Хирургия аксиллярных лимфатических узлов при раке молочной железы в современной онкологии

В лечении рака молочной железы понимание состояния регионарных аксиллярных лимфатических узлов является значимым фактором в определении стадии и прогноза заболевания, а также играет ведущую роль при выборе терапевтической стратегии лечения пациента. Однако в настоящее время продолжается деэскалация объема хирургического воздействия на аксиллярный лимфоколлектор с перспективой в будущем отказа от какого-либо лечения подмышечной области для отдельных групп пациентов. В статье рассматриваются текущие исследования, посвященные определению объема хирургического лечения на аксиллярных лимфатических узлах в разных клинических ситуациях.

1. Beck A.C., Morrow M. Axillary lymph node dissection: Dead or still alive? Breast 2023;69:469–75. DOI: 10.1016/j.breast.2023.01.009

2. Heidinger M., Knauer M., Tausch C., Weber W.P. Tailored axillary surgery – a novel concept for clinically node positive breast cancer. Breast 2023;69:281–9. DOI: 10.1016/j.breast.2023.03.005

3. Fisher B., Jeong J.H., Anderson S. et al. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med 2002;347(8):567–75. DOI: 10.1056/NEJMoa020128

4. Louis-Sylvestre C., Clough K., Asselain B. et al. Axillary treatment in conservative management of operable breast cancer: Dissection or radiotherapy? Results of a randomized study with 15 years of follow-up. J Clin Oncol 2004;22:97–101. DOI: 10.1200/JCO.2004.12.108

5. Wu T., Long Q., Zeng L. et al. Axillary lymph node metastasis in breast cancer: From historical axillary surgery to updated advances in the preoperative diagnosis and axillary management. BMC Surg 2025;25(1):81. DOI: 10.1186/s12893-025-02802-2

6. Krag D.N., Anderson S.J., Julian T.B. et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: Overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol 2010;11:927–33. DOI: 10.1016/S1470-2045(10)70207-2

7. Krag D.N., Anderson S.J., Julian T.B. et al. Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymphnode dissection in patients with clinically node-negative breast cancer: Results from the NSABP B-32 randomised phase III trial. Lancet Oncol 2007;8:881–8. DOI: 10.1016/S1470-2045(07)70278-4

8. Giuliano A.E., Ballman K.V., McCall L. et al. Effect of axillary dissection vs no axillary dissection on 10-year overall survival among women with invasive breast cancer and sentinel node metastasis: The ACOSOG Z0011 (Alliance) randomized clinical trial. JAMA 2017;318:918–26. DOI: 10.1001/jama.2017.11470

9. Bartels S.A.L., Donker M., Poncet C. et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer: 10-year results of the randomized controlled EORTC 10981-22023 AMAROS trial. J Clin Oncol 2022. DOI: 10.1200/JCO.22.01565

10. Sávolt Péley G., Polgár C., Udvarhelyi N. et al. Eight-year follow up result of the OTOASOR trial: The optimal treatment of the axilla – surgery or radiotherapy after positive sentinel lymph node biopsy in early-stage breast cancer: a randomized, single centre, phase III, non-inferiority trial. Eur J Surg Oncol 2017;43:672–9. DOI: 10.1016/j.ejso.2016.12.011

11. Tinterri C., Gentile D., Gatzemeier W. et al. Preservation of axillary lymph nodes compared with complete dissection in T1–2 breast cancer patients presenting one or two metastatic sentinel lymph nodes: The SINODAR-ONE multicenter randomized clinical trial. Ann Surg Oncol 2022;29:5732–44. DOI: 10.1245/s10434-022-11866-w

12. Heidinger M., Weber W.P. Axillary surgery for breast cancer in 2024. Cancers (Basel) 2024;16(9):1623. DOI: 10.3390/cancers16091623

13. Gentilini O.D., Botteri E., Sangalli C. et al. Sentinel lymph node biopsy vs no axillary surgery in patients with small breast cancer and negative results on ultrasonography of axillary lymph nodes: the SOUND randomized clinical trial. JAMA Oncol 2023;9:1557–64. DOI: 10.1001/jamaoncol.2023.3759

14. Hughes K.S., Schnaper L.A., Bellon J.R. et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol 2013;31:2382–7. DOI: 10.1200/JCO.2012.45.2615

15. Henke G., Knauer M., Ribi K. et al. Tailored axillary surgery with or without axillary lymph node dissection followed by radiotherapy in patients with clinically node-positive breast cancer (TAXIS): Study protocol for a multicenter, randomized phase-III trial. Trials 2018;19:667. DOI: 10.1186/s13063-018-3021-9

16. Weber W.P., Heidinger M., Hayoz S. et al. Impact of imaging-guided localization on performance of tailored axillary surgery in patients with clinically node-positive breast cancer: Prospective cohort study within TAXIS (OPBC-03, SAKK 23/16, IBCSG 57-18, ABCSG53, GBG 101). Ann Surg Oncol 2023;31:344–55. DOI: 10.1245/s10434-023-14404-4

17. Weber W.P., Matrai Z., Hayoz S. et al. Association of axillary dissection with systemic therapy in patients with clinically nodepositive breast cancer. JAMA Surg 2023;158:1013–21. DOI: 10.1001/jamasurg.2023.2840

18. Mittendorf E.A., Zhang H., Barrios C.H. et al. Neoadjuvant atezolizumab in combination with sequential nab-paclitaxel and anthracycline-based chemotherapy versus placebo and chemotherapy in patients with early-stage triple-negative breast cancer (IMpassion031): A randomised, double-blind, phase 3 trial. Lancet 2020;396:1090–100. DOI: 10.1016/S0140-6736(20)31953-X

19. Schmid P., Cortes J., Pusztai L. et al. Pembrolizumab for early triple-negative breast cancer. N Engl J Med 2020;382:810–21. DOI: 10.1056/nejmoa1910549

20. Samiei S., Simons J.M., Engelen S.M.E. et al. Axillary pathologic complete response after neoadjuvant systemic therapy by breast cancer subtype in patients with initially clinically node-positive disease: A systematic review and meta-analysis. JAMA Surg 2021;156. DOI: 10.1001/jamasurg.2021.0891

21. Yan M., Abdi M.A., Falkson C. Axillary management in breast cancer patients: A comprehensive review of the key trials. Clin Breast Cancer 2018;18(6):e1251–9.

22. Galimberti V., Ribeiro Fontana S.K., Maisonneuve P. et al. Sentinel node biopsy after neoadjuvant treatment in breast cancer: Five-year follow-up of patients with clinically node-negative or node-positive disease before treatment. Eur J Surg Oncol 2016;42(3):361–8. DOI: 10.1016/j.ejso.2015.11.019

23. Kuehn T., Bauerfeind I., Fehm T. et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): A prospective, multicentre cohort study. Lancet Oncol 2013;14(7):609–18.

24. Classe J.M., Loaec C., Gimbergues P. et al. Sentinel lymph node biopsy without axillary lymphadenectomy after neoadjuvant chemotherapy is accurate and safe for selected patients: The GANEA 2 study. Breast Cancer Res Treat 2019;173(2):343–52. DOI: 10.1007/s10549-018-5004-7

25. Van Loevezijn A.A., van der Noordaa M.E.M., Stokkel M.P.M. et al. Three-year follow-up of de-escalated axillary treatment after neoadjuvant systemic therapy in clinically node-positive breast cancer: The MARI-protocol. Breast Cancer Res Treat 2022;193(1):37–48. DOI: 10.1007/s10549-022-06545-z

26. Donker M., Straver M.E., Wesseling J. et al. Marking axillary lymph nodes with radioactive iodine seeds for axillary staging after neoadjuvant systemic treatment in breast cancer patients: The MARI procedure. Ann Surg 2015;261:378–82. DOI: 10.1097/sla.0000000000000558

27. Donker M., van Tienhoven G., Straver M.E. et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981–22023 AMAROS): A randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol 2014;15:1303–10. DOI: 10.1016/s1470-2045(14)70460-7

28. Андреев Д.А., Кашурников А.Ю., Завьялов А.А. Анализ объема хирургического лечения рака молочной железы в странах с низким ассоциированным индексом «смертность/ заболеваемость» (обзор). Злокачественные опухоли 2021;11(1):9–19.

29. GlobalSurg Collaborative and National Institute for Health Research Global Health Research Unit on Global Surgery. Global variation in postoperative mortality and complications after cancer surgery: A multicentre, prospective cohort study in 82 countries. Lancet 2021;397:387–97. DOI: 10.1016/S0140-6736(21)00001-5

30. Mansel R.E., Fallowfield L., Kissin M. et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst 2006;98:599–609. DOI: 10.1093/jnci/djj158

31. Armer J.M., Ballman K.V., McCall L. et al. Factors associated with lymphedema in women with node-positive breast cancer treated with neoadjuvant chemotherapy and axillary dissection. JAMA Surg 2019;154:800–9. DOI: 10.1001/jamasurg.2019.1742