美国乳腺癌临床实践指南更新（上）

　　时隔129天，美国国家综合癌症网络NCCN于2021年1月15日悄然将乳腺癌临床实践指南更新至2021年第1版，全文由238页增至240页，免费注册登录后仍可免费下载：

NCCN为非国立、非营利、全国综合癌症中心联盟组织，1993年11月成立，1995年1月31日正式宣布成为全国联盟，最初由13个美国知名综合癌症中心组成，目前已经增至30个：

前情提要

• NCCN乳腺癌临床实践指南2020年第6版（简体中文版）

• NCCN乳腺癌临床实践指南2020年第3版（简体中文版）

　　NCCN乳腺癌临床实践指南2021年第1版架构仍为临床路径＋循证解读＋参考文献，其依据仍来自权威学术期刊或学术会议最新发表的大样本多中心随机对照三期临床研究结果。由于本版更新内容太多，故分两集进行简介，以下为上集（下划线为新增内容，中划线为删除内容）

整体修改（General）

• “女性”全部改为“患者”

• "Women" changed to "patients."

• “激素受体”全部改为“HR”

• "Hormone receptor" changed to "HR."

• “淋巴结阳性”和“淋巴结阴性”全部改为“N+”和“N0”

• "Node positive" and "node negative" changed to "N+" and "N0"

乳腺导管原位癌（DCIS-1）

• 初步治疗：4个初步治疗选项重新排列组合为3个保乳治疗选项＋1个全切治疗选项；推荐意见内容不变。

• Primary treatment options rearranged; no change to recommendations.

• 修改脚注j：如果患者和医师认为个体风险“低”，那么某些患者可以仅仅接受切除治疗，尤其对于ER阳性患者，将接受内分泌治疗。

• Footnote modified: If the patient and physician view the individual risk as "low," some patients may be treated by excision alone, particularly if they are ER positive and will be receiving endocrine therapy.

乳腺导管原位癌（DCIS-2）

• 乳腺导管原位癌术后治疗，删除：对于雌激素受体阴性乳腺导管原位癌，内分泌治疗的获益尚不明确

• DCIS postsurgical treatment, sub-bullet removed: The benefit of endocrine therapy for ER-negative DCIS is uncertain.

• 新增脚注n：他莫昔芬标准剂量为每天20毫克连续5年。低剂量他莫昔芬（每天5毫克连续3年）仅可选用于患者对每天20毫克有症状、不愿或不能服用标准剂量他莫昔芬。

• Footnote added: The standard dose of tamoxifen is 20 mg/day for 5 years. Low-dose tamoxifen (5 mg/day for 3 years) is an option only if patient is symptomatic on the 20-mg dose or if patient is unwilling or unable to take standard-dose tamoxifen.

乳腺浸润癌（BINV-1）

• 该页整体调整并重新排列组合：由“临床分期与检查”调整并重新排列组合为“诊断、检查与临床分期”

• Page significantly revised and reorganized.

• 修改脚注f：关于生育和节育（参见BINV-C）NCCN青少年（AYA）肿瘤指南和NCCN生存指南针对特定人群概述的生育和性健康/功能总体注意事项适用于被诊断为乳腺癌的全部患者。

• Footnote modified: For Fertility and Birth Control (see BINV-C). The general considerations for fertility and sexual health/function outlined for specific populations in NCCN Guidelines for Adolescent and Young Adult (AYA) Oncology and NCCN Guidelines for Survivorship are applicable to all patients diagnosed with breast cancer.

• 修改脚注h：常规全身分期不适用于没有全身症状的早期乳腺癌未转移癌（M0）。如果怀疑疾病转移，参见BINV-17的检查。（同BINV-11）

• Footnote modified: Routine systemic staging is not indicated for early breastnon-metastatic (M0) cancer in the absence of systemic symptoms. If metastatic disease is suspected, see workup on BINV-17. (Also on BINV-11)

• 新增脚注i：对于已知或怀疑乳腺癌易感基因突变患者，保乳治疗的同侧乳腺癌或对侧乳腺癌风险可能增加。为了减少风险，可考虑对这些患者进行预防性双侧乳房切除术。参见NCCN遗传/家族高风险评定指南：乳腺癌、卵巢癌和胰腺癌。（同BINV-3）

• Footnote added: Patients with a known or suspected genetic predisposition to breast cancer may have an increased risk of ipsilateral breast recurrence or contralateral breast cancer with breast-conserving therapy. These patients may be considered for prophylactic bilateral mastectomy for risk reduction. See NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic. (Also on BINV-3)

乳腺浸润癌（BINV-2）

• 标题修改：cT1-3, cN0或N+-1, M0期病变局部区域治疗：保乳治疗”

• Heading modified: Locoregional Treatment of cT1-3, cN0 or N+ -1, M0 Disease: Breast-Conserving Therapy

• 腋窝淋巴结阴性治疗选项修改：

• Negative axillary nodes, options modified:

• 选项修改：对于乳房中心或内侧肿瘤、肿瘤>2厘米并伴其他高风险特征（年轻或广泛淋巴血管浸润）患者，全乳放疗±瘤床加量，并考虑对腋窝清扫部位以外进行区域淋巴结放疗。

• Option modified: Whole breast RT (WBRT) ± boost to tumor bed, and consider regional nodal irradiation with exclusion of the dissected portion of the axilla in patients with central/medial tumors or tumors >2 cm with other high-risk features (young age or extensive lymphovascular invasion [LVI]).

• 新增选项，原为脚注u：对于年龄≥70岁、ER阳性、cN0、T1期肿瘤接受术后辅助内分泌治疗患者考虑免除乳房放疗（1类证据）

• Option added (previously in a footnote): Consider omitting breast irradiation in patients ≥70 y of age with ER-positive, cN0, T1 tumors who receive adjuvant endocrine therapy (category 1)

• 删除并移至BINV-I：如有化疗指征，通常先化疗、后放疗。（同BINV-3）

• Line moved to BINV-I: It is common for RT to follow chemotherapy when chemotherapy is indicated. (Also on BINV-3)

• 对于1～3枚腋窝淋巴结阳性，新增选项：对于符合ACOSOG Z0011全部标准者，全乳放疗±瘤床（±腋窝）加量（1类证据）

• 1-3 positive axillary nodes, options added for those who meet all ACOSOG Z0011 criteria: WBRT ± boost (with or without intentional axillary coverage) (category 1)

• 该选项移至BINV-3：全乳切除＋腋窝手术分期（1类证据）±重建

• Option moved to BINV-3: Total mastectomy with surgical axillary staging (category 1) ± reconstruction

乳腺浸润癌（BINV-3）

• 标题修改：cT1-3, cN0或N+-1, M0期病变局部区域治疗：乳房切除→术后放疗”

• Heading modified: Locoregional Treatment of cT1-3, cN0 or N+ -1, M0 Disease: Mastectomy Followed by RT

• 放疗推荐意见：修改措辞以保持一致

• RT recommendations, language modified for consistency.

• 修改脚注s：乳房切除术后放疗可考虑用于具有多种高风险复发因素的患者，包括乳房中心或内侧肿瘤、肿瘤>2厘米并有其他高风险特征，例如年轻和/或广泛淋巴血管浸润且腋窝淋巴结切除<10枚并有以下至少之一：3级、ER阴性或淋巴血管浸润。

• Footnote modified: Postmastectomy RT may be considered for patients with multiple high-risk recurrence factors, including central/medial tumors or tumors ≥2 cm with <10 axillary nodes removed and at least one of the following: grade 3, ER-negative, or LVI. other high-risk features such as young age and/or extensive LVI.

乳腺浸润癌（BINV-4）

• 良好的组织学类型，新增：腺样囊性癌、其他唾液腺癌；分泌性癌；罕见的低分级化生性癌。

• Favorable histologic types added: Adenoid cystic and other salivary carcinomas; Secretory carcinoma; Rare low-grade forms of metaplastic carcinoma.

• 修改脚注v：为了与良好的预后相关，良好的组织学类型不应为高分级，应为单纯（>90%，按手术切除而非仅粗针活检进行分类），不应为高分级且应为HER2阴性。

• Footnote modified: To be associated with favorable prognosis, the favorable histologic type should not be high grade, should be pure (>90% as classified on the surgical excision, not core biopsy alone), not high grade and should be HER2 negative. If atypical...

• 修改脚注y：因此，其他辅助治疗和总体治疗路径决策时应予考虑应该个体化考虑内分泌治疗和其他辅助治疗的风险和获益。参见生物标志检测原则（BINV-A）

• Footnote modified: Although patients with cancers...ER-negative cancers; thus, individualized consideration of risks and benefits of endocrine therapy and additional adjuvant therapies should be incorporated into This should be considered in decision-making for other adjuvant therapy and overall treatment pathway. See Principles of Biomarker Testing (BINV-A).

• 新增脚注w：不伴明确浸润的包被乳头状癌由于生物学行为与乳腺导管原位癌相似，被美国癌症联合委员会分期为病理原位癌。实体乳头状癌应该按世界卫生组织乳腺肿瘤组织学分类指定为原位癌或浸润癌，不过两种类型的结局都良好。

• Footnote added: Encapsulated papillary carcinoma (EPC) without associated conventional invasion is staged as pTis because behavior is similar to DCIS (per AJCC). Solid papillary carcinoma (SPC) should be specified as in situ or invasive based on WHO criteria but both forms have favorable outcomes.

乳腺浸润癌（BINV-5）

• 修改脚注aa：证据表明支持HR阳性乳腺癌绝经前患者激素受体阳性乳腺癌绝经前女性对卵巢手术切除或放射抑制的获益程度与单用CMF化疗方案相似。参见术后辅助治疗（BINV-K）（同BINV-10）

• Footnote modified: Evidence suggests supports that the magnitude of benefit from surgical or radiation ovarian ablation in premenopausal patients with HR-positive breast cancer those who are premenopausal women with hormone receptor-positive breast cancer is similar to that achieved with CMF alone. See Adjuvant Endocrine Therapy (BINV-K). (Also on BINV-10)

乳腺浸润癌（BINV-7）

• 对病理淋巴结微转移（pN1mi）根据肿瘤特征初步决策后：

• pN1mi, after initial decision-making based on tumor:

• 新增：如果根据肿瘤特征可能适合化疗，那么应该考虑体力状态和合并症。

• Added: If potential candidate for chemotherapy based on tumor characteristics, then consider performance status and comorbities.

• 阐明：适合化疗：考虑基因表达测定，以评定对预后和化疗获益。

• Clarified: Candidate for chemotherapy: Consider gene expression assay to assess prognosis and chemotherapy benefit.

乳腺浸润癌（BINV-10）

• 组织学修改/新增：腺样囊性癌和其他唾液腺癌；唾液腺分泌性癌；其他罕见低分级类型形式化生性癌。

• Histologies modified/added: Adenoid cystic and other salivary carcinomas; Salivary Secretory carcinoma; Other Rare low-grade types forms of metaplastic carcinoma.

乳腺浸润癌（BINV-11）

• 临床分期改为：c≥T2或cN+和M0和考虑术前全身治疗（参见BINV-M术前全身治疗标准）

• Clinical stage modified: c≥T2 or cN+ and M0 and Considering preoperative systemic therapy (see criteria for preoperative systemic therapy on BINV-M, 1 of 2)

• “检查”改为“其他检查”并删除BINV-1已推荐的检查

• Changed "Workup" to "Additional Workup" and removed duplicates recommended on BINV-1.

• 乳腺磁共振成像，新增“如果既往未做”

• Breast MRI, added "if not previously done."

• 脚注i和脚注j修改/合并为脚注ss：FDG PET/CT可与CT同时进行。PET或PET/CT不适用于临床I、II期或可手术III期乳腺癌的分期。FDG PET/CT对于标准分期研究不明确或可疑的情况可能最有用，尤其对于局部晚期或转移病变。除标准分期研究外，FDG PET/CT还可用于确定局部晚期乳腺癌未知区域淋巴结病变和/或远处转移。（同BINV-17和IBC-1）

• Footnotes combined/modified: FDG PET/CT can may be performed at the same time as diagnostic CT. The use of PET or PET/CT is not indicated in the staging of clinical stage I, II, or operable stage III breast cancer. FDG PET/CT is most and may be helpful in situations where standard staging studies are equivocal or suspicious. especially in the setting of locally advanced or metastatic disease. FDG PET/CT may also be helpful in identifying unsuspected regional nodal disease and/or distant metastases in locally advanced breast cancer when used in addition to standard staging studies. (Also on BINV-17 and IBC-1)

• 新增脚注qq：如果考虑术前治疗，那么考虑对cN0期可手术ER阳性HER2阴性乳腺癌绝经后患者进行基因表达测定。

• Footnote added: If considering preoperative therapy, consider use of a gene expression assay during workup for postmenopausal patients with cN0, operable ER-positive, HER2-negative disease. (Iwata H, et al. Breast Cancer Res Treat 2019;173,123-133; Pease AM, et al. Ann Surg Oncol 2019:26;366-371.)

乳腺浸润癌（BINV-12）

• 修改第一项：乳房粗针活检应该放置成像可检测的夹子或标记，如果既往未做过，那么应于术前治疗之前进行以便为术前全身治疗后根治手术区分瘤床

• First bullet modified: Core biopsy of breast with placement of image-detectable clips or marker(s), if not previously performed, should be performed prior to preoperative therapy to demarcate the tumor bed for definitive surgical management after preoperative systemic therapy

• 修改第三项：活检±放置夹子

• Third bullet modified: Biopsy ± clip placement of suspicious...

• 删除脚注vv：如果确定淋巴结状态将影响手术和/或全身治疗的选择，那么可于术前全身治疗之前考虑进行前哨淋巴结活检。

• Footnote removed: Sentinel node biopsy can be considered prior to preoperative systemic therapy if the determination of nodal status will influence surgical and/or systemic therapy choices.

乳腺浸润癌（BINV-13）

• 第一项“完全缓解或部分缓解，乳房肿块切除术可行”之后新增箭头指向乳房切除术选项

• Following complete response or partial response, lumpectomy possible, added arrow to mastectomy option.

• 新增脚注vv：对于高风险特征（例如高分级病变或年龄<50岁）强烈考虑放疗加量。

• Footnote added: Strongly consider RT boost for high-risk features (eg, high-grade disease, or age <50 years).

乳腺浸润癌（BINV-14）

• 疗效第二项修改：术前全身治疗无效和/或肿瘤仍不可手术

• Bottom response modified: No response to preoperative systemic therapy and/or tumor remains inoperable

乳腺浸润癌（BINV-15）

• 由于冗余，删除“或残留病变”和“或淋巴结阳性病变”。

• Removed "or residual disease" and "or node positive disease" due to redundancy.

• 新增脚注z：对于接受辅助治疗的绝经后（自然或诱发）患者，考虑辅助双膦酸盐治疗。

• Footnote added: Consider adjuvant bisphosphonate therapy in postmenopausal (natural or induced) patients receiving adjuvant therapy.

• 修改脚注yy：如果HER2靶向治疗和/或内分泌治疗可与放疗同时进行，卡培他滨应于放疗完成后给药有指征，可与放疗同时进行。如有指征，卡培他滨应于放疗完成后给药。

• Footnote modified: If HER2-targeted therapy and/or endocrine therapy may be delivered concurrently with RT, while capecitabine should follow completion of RT. is indicated, it may be administered concurrently with radiation. If indicated, capecitabine should follow completion of RT.

• 新增脚注xx：该推荐意见不适用于残留乳腺导管原位癌（ypTis）。

• Footnote added: Recommendations do not apply to residual DCIS (ypTis).

乳腺浸润癌（BINV-16）

• 影像学检查，新增：

• Imaging, bullets added:

• 参见NCCN遗传/家族高风险评定指南：乳腺癌、卵巢癌和胰腺癌

• See NCCN Guidelines for Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic

• 对于接受蒽环类治疗患者，参见NCCN生存指南超声心动图推荐意见

• For patients receiving anthracycline-based therapy, see NCCN Guidelines for Survivorship for echocardiogram recommendations.

• 内分泌治疗

• Endocrine therapy

• 他莫昔芬用药患者，新增：不推荐常规每年盆腔超声检查

• Patients on tamoxifen, sub-bullet added: Routine annual pelvic ultrasound is not recommended.

• 修改脚注aaa：对于接受辅助内分泌芳香酶抑制剂治疗的绝经后（自然或诱发）患者，双膦酸盐（口服或静脉注射）或地舒单抗可维持或改善骨密度并减少骨折风险。

• Footnote modified: The use of a bisphosphonate (oral/IV) or denosumab is acceptable to maintain or to improve bone mineral density and reduce risk of fractures in postmenopausal (natural or induced) patients receiving adjuvant endocrinearomatase inhibitor therapy.

乳腺浸润癌（BINV-17）

• 对检查项目进行归类

• Workup reorganized.

• 新增项目：全身分期影像学检查

• Bullet added: Imaging for systemic staging

• 新增项目：生物标志检测

• Bullet added: Biomarker testing

• 修改项目：确定肿瘤评估ER/PR和HER2状态以区分复发病变与新发原发病变

• Bullet modified: Determination of tumor Evaluation of ER/PR and HER2 status to differentiate recurrent disease from new primary

• 修改项目：【生物标志检测】【种系和体细胞突变全面分析】以确定其他靶向治疗的候选者，参见复发或IV期（M1）病变其他靶向治疗及其生物标志检测（BINV-R）

• Bullet modified: Biomarker testing Comprehensive germline and somatic profiling to identify candidates for additional targeted therapies, see Additional Targeted Therapies and Associated Biomarker Testing for Recurrent or Stage IV (M1) Disease (BINV-R)

• 新增项目：对心理痛苦（苦恼）进行评定

• Bullet added: Assess for distress.

乳腺浸润癌（BINV-18）

• 初步治疗方法为乳房切除术且未先放疗：如有可能手术切除＋放疗补标脚注iii。

• Initial treatment with mastectomy and no prior RT: Footnote iii added after surgical resection if possible + RT.

乳腺浸润癌（BINV-19）

• 修改脚注kkk：常规手术切除原发乳腺肿瘤通常不适用于首发IV期（M1）病变患者。虽然生存获益不大，但是可考虑用于原发肿瘤局部控制。关于该情况下原发肿瘤管理的讨论必须个体化。首发IV期（M1）患者手术切除原发肿瘤的作用和时机是当前研究热点并且必须个体化。对于初步全身治疗有效的筛选患者，乳房局部手术和/或放疗是合理的。

• Footnote modified: Routine surgical resection of the primary breast tumor is generally not indicated in the management of patients presenting with de novo stage IV (M1) disease. Although there is no survival benefit, it may be considered for local control of the primary tumor. Discussion regarding management of the primary tumor in this setting must be individualized. The role and timing of surgical removal of the primary tumor in patients presenting with de novo stage IV (M1) is the subject of ongoing investigations and must be individualized. Performance of local breast surgery and/or RT is reasonable in select patients responding to initial systemic therapy.

• 新增脚注mmm：对接受芳香酶抑制剂且有骨质疏松风险（例如，年龄>65岁、家族病史、长期用类固醇）患者进行骨密度基线评定。（同BINV-K）

• Footnote added: Baseline assessment of bone density recommended for patients receiving an aromatase inhibitor who are at risk of osteoporosis (eg, age >65, family history, chronic steroids). (Also on BINV-K)

乳腺浸润癌（BINV-22）

• BINV-P和BINV-Q已列出的方案和脚注已从该页删除。（同BINV-23和BINV-24）

• Regimens and footnotes that are listed on BINV-P and BINV-Q have been removed from this page. (Also on BINV-23 and BINV-24)

乳腺浸润癌（BINV-A 1 of 2）

• 脚注a参考文献更新：“Hammond EH”改为“Hammond MEH”，“J Clin Oncol 2018;36:2105-2122”改为“J Clin Oncol 2018;36(20):2105-2122”

• Footnote a, reference updated: Wolff AC, Hammond MEH, Allison KH, et al. Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer: American Society of Clinical Oncology/College of American Pathologists Clinical Practice Guideline Focused Update. J Clin Oncol 2018;36(20):2105-2122.

乳腺浸润癌（BINV-A 2 of 2)

• 脚注f参考文献更新：“Hammond EH”改为“Hammond MEH”，“Estrogen and progesterone receptor testing in breast cancer. American Society of Clinical Oncology/College of American Pathologists Guideline Update. Arch Pathol Lab Med. doi: 10.5858/arpa.2019-0904-SA”改为“Estrogen and Progesterone Receptor Testing in Breast Cancer: ASCO/CAP Guideline Update. J Clin Oncol 2020;38(12):1346-1366; Arch Pathol Lab Med 2020;144(5):545-563.”

• Reference updated: Allison KH, Hammond MEH, Dowsett M, et al. Estrogen and Progesterone Receptor Testing in Breast Cancer: ASCO/CAP Guideline Update. J Clin Oncol 2020;38(12):1346-1366; Arch Pathol Lab Med 2020;144(5):545-563.

乳腺浸润癌（BINV-B）

临床适应证及其应用，第三项修改：可能有助于发现腋窝淋巴结转移（cT0, cN+）患者的其他临床隐匿病变，腋窝淋巴结腺癌和隐匿（或不明）原发癌患者的原发癌

Bullet modified: May be useful in identifying otherwise clinically occult disease in patients presenting with axillary nodal metastases (cT0, cN+), primary cancer in patients with axillary nodal adenocarcinoma and occult (or unidentified) primary cancer

乳腺浸润癌（BINV-D）

• 第一列，标准修改：

• First column, criteria modified:

• 诊断时无可触及的淋巴结，或成像发现可疑淋巴结≤2枚，或穿刺活检±放置夹子确认阳性淋巴结≤2枚诊断时临床发现淋巴结阴性±可疑淋巴结1～2枚（未计划术前全身治疗）

• No palpable lymph node at diagnosis or ≤2 suspicious nodes on imaging or or ≤2 positive nodes confirmed by needle biopsy and No preoperative systemic therapy planned

• 临床发现可疑（可触及）淋巴结，或成像发现可疑淋巴结≥3枚，或正考虑术前全身治疗且诊断时体检或成像发现可疑淋巴结诊断时临床发现淋巴结阳性（体检和/或成像发现阳性淋巴结≥3枚）或≥T2或≥N1且计划术前全身治疗或T2-4, N1-3, M0

• Clinically suspicious (palpable) lymph nodes or ≥3 suspicious nodes on imaging or Preoperative systemic therapy being considered and suspicious lymph nodes at diagnosis on exam or imaging.

• 新增：超声引导细针抽吸或粗针活检±放置夹子

• Added: US-guided FNA or core biopsy ± clip placement

• 前哨淋巴结阳性，修改：乳房切除术后前哨淋巴结仅可见微转移

• Sentinel node positive, modified: Only Micrometastases seen in SLN post-mastectomy.

• 细针抽吸或粗针活检阳性

• FNA or core biopsy positive

• 术前未化疗，删除该选项：如果满足ACOSOG Z011研究全部标准且肿瘤负荷低，那么考虑前哨淋巴结活检

• If no preoperative chemotherapy was given, option removed: Consider sentinel lymph node biopsy if meets ALL the ACOSOG Z011 trial criteria listed above and low tumor burden

• 术前已化疗，修改第二项：对筛选病例考虑进行前哨淋巴结活检

• If preoperative chemotherapy was given, modified second option: Consider SLNB in selected cases...

• 删除脚注a：对临床阳性淋巴结考虑超声引导细针抽吸或粗针活检进行病理检查确认恶性肿瘤。

• Footnote removed: Consider pathologic confirmation of malignancy in clinically positive nodes using ultrasound-guided FNA or core biopsy.

• 新增脚注a：如果活检时阳性淋巴结被放置夹子，那么手术时应该尽可能切除全部被放置夹子的淋巴结。

• Footnote added: If a positive lymph node is clipped at biopsy, every effort should be made to remove the clipped node at the time of surgery.

• 删除脚注f：腋窝肿瘤负荷低代表淋巴结病变：1）为成像检出病变而临床检查不明显；和2）仅限于1或2枚腋窝淋巴结。

• Footnote removed: Low tumor burden in the axilla means nodal disease that 1) is image-detected disease not apparent on clinical exam; and 2) appears to be limited to one or two axillary nodes.

• 修改脚注f：对于最初cN0、前哨淋巴结活检阳性、未行腋窝淋巴结清扫的患者，乳房切除术后放疗应该包括胸壁、锁骨上±内乳淋巴结和整个腋窝。

• Footnotes modified: In the mastectomy setting, in patients who were initially cN0, who have positive nodes on SLNB, and have no axillary dissection, RT should include chest wall, supraclavicular ± internal mammary nodes and full axilla.

• 修改脚注h：对于术前全身治疗之前淋巴结阳性患者，术前全身治疗之后前哨淋巴结活检假阴性率>10%。通过双示踪剂标记活检淋巴结以记录其切除，并切除超过2枚≥3枚前哨淋巴结（靶向腋窝淋巴结清扫）可减少假阴性率。

• Among patients shown to be N+ prior to preoperative systemic therapy, SLNB has a >10% false-negative rate when performed after preoperative systemic therapy. This rate can be improved by marking biopsied lymph nodes to document their removal, using dual tracer, and by removing more than 2 ≥3 sentinel nodes (targeted axillary lymph node dissection). (Caudle AS, et al. J Clin Oncol 2016;34(10):1072-1078.)

乳腺浸润癌（BINV-F 1 of 2）

• 标题修改：乳腺浸润癌和乳腺导管原位癌和浸润癌保乳术后切缘状态推荐意见

• Title modified: Margin Status Recommedations After Breast-Conserving Surgery for Invasive Cancers and DCIS and Invasive Breast Cancer

• 第二项修改：对于乳腺钼靶发现的乳腺导管原位癌伴微钙化，应该通过标本影像检查和切缘分析记录完整切除情况。如果不确定，可考虑切除术后乳腺钼靶只要对于切除是否充分仍不确定，也可进行切除术后乳腺钼靶

• Second bullet modified: For mammographically detected DCIS with microcalcifications, complete resection should be documented by analysis of margins and specimen radiography. Post-excision mammography could also be performed whenever can be considered if there is uncertainty about adequacy of excision remains.

• 乳腺导管原位癌，第一项修改：对于单纯乳腺导管原位癌……临床判断应被用于权衡个别患者再次切除风险和复发风险可被用于确定个别病例能否避免再次切除。

• DCIS, first bullet modified: For patients with pure DCIS... clinical judgment can should be utilized to weigh the risks of re-excision with risk of recurrence for an individual patient.be applied to determine if re-excision might be avoided in individual cases.

未完待续……