NCCN乳腺癌指南2023年第1版

电镀铜

2023年1月27日，时隔220天，美国国家综合癌症网络（NCCN）悄然将乳腺癌临床实践指南由2022年第4版麻醉药品五专更新至2023年第1版，全文由232页增加至255页，免费注册登录后仍可免费下载。

NCCN为非国立、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32个：

NCCN乳腺癌临床实践指南2020年更新了6版、2021年更新了8版、2022年只更新了4版。2023年第1版架构仍为临床路径＋循证解读＋参考文献，其依据主要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。此次更新内容较多，具体如下（中划线为删除，管锥编下划线为新增）

DCIS-1

∙主要，修改：乳房局部快速放疗/乳房局部放疗（APBI/PBI）

∙Primary treatment, modified: Accelerated partial breast irradiation/partial breast radiation (APBI/PBI运动磁场)

∙脚注j，修改：乳腺导管原位癌（DCIS）低风险患者如果符合RTOG 9804试验关于DCIS低风险定义全部条件（包括筛查发现的DCIS、核分级低或中、肿瘤大小≤2.5厘米、手术切缘阴性且距离肿瘤的边距>3mm）可以考虑接受APBI/PBI。

∙Footnote j, modified: Select patients with low-risk DCIS may be considered suitable for APBI/PBI if they meet all aspects of the definition of low-risk DCIS from the RTOG 9804 trial, including screen-detected DCIS, low to intermediate nuclear grade, tumor size ≤2.5 cm, and surgical resection with margins negative at >3 mm.

DCIS-2

∙DCIS手术后，第1点第1小点修改：接受保乳手术和放疗（1类），尤其对于雌激素受体（ER）阳性DCIS患者。

∙DCIS postsurgical treatment, 1st bullet, 1st sub-bullet modified: Treated with BCS and R

T (category 1), especially for patients with ER-positive DCIS.

∙新增脚注n：对于接受芳香化酶抑制剂辅助的绝经后（自然或诱发）患者，双膦酸盐（口服或静脉注射）或地舒单抗可以维持或改善骨矿密度并降低骨折风险。两种疗法的最佳持续时间尚未确定。持续时间超过3年的获益或超过3年的最佳持续时间未知。抗骨质疏松持续时间考虑因素包括骨矿密度、效果、持续骨质流失或骨折的风险因素。停用地舒单抗后有自发骨折的病例报告。对于接受双膦酸盐或地舒单抗的患者，开始前应接受预防性牙科检查，并应补充钙和维生素D。

∙Footnote n added: The use of a bisphosphonate (PO/IV) or denosumab is acceptable to maintain or improve bone mineral density and reduce risk of fractures in postmenopausal (natural or induced) patients receiving adjuvant aromatase inhibitor therapy. Optimal duration of either therapy has not been established. Benefits from duration beyond 3 years or optimal duration beyond 3 years is not known. Factors to consider for duration of antiosteoporosis therapy include bone mineral density, response to therapy, and risk factors for continued bone loss or fracture. There are case reports of spontaneous fractur

es after denosumab discontinuation. Patients treated with a bisphosphonate or denosumab should undergo a dental examination with preventive dentistry prior to the initiation of therapy, and should take supplemental calcium and vitamin D.

BINV-2

∙cT1-3、cN0或cN+、M0乳腺癌的局部区域，修改：保乳手术＋腋窝手术分期（1类）± 肿瘤整形重建

∙Locoregional treatment of cT1-3, cN0 or cN+, M0 Disease, modified: BCS with surgical axillary staging (category 1) ± oncoplastic reconstruction男子喝水银被救治

∙腋窝淋巴结阴性：

∙Negative axillary nodes:

∙修改：对于乳房中心或内侧肿瘤、病理T3期肿瘤、病理T2期肿瘤且<10枚腋窝淋巴结切除并有以下高风险特征之一的患者：3级、广泛淋巴血管浸润（LVI）或ER阴性，给予全乳放疗（WBRT）± 瘤床加量o，并考虑全身区域淋巴结放疗（RNI）。

∙Modified: WBRT ± boosto to tumor bed, and consider comprehensive regional nodal irradiation (RNI) in patients with central/medial tumors, pT3 tumors, or pT2 tumors with <10 axillary nodes removed and one of the following high-risk features: grade 3, extensive lymphovascular invasion (LVI), or ER-negative.

∙修改：对于某些低风险患者，考虑行APBI/PBI（1类）

∙格伦莱斯Modified: Consideration of APBI/PBI in selected low-risk patients (category 1)

∙新增脚注m：局部组织重排、局部皮瓣、区域皮瓣、乳房缩小和乳房固定术等技术可以实现更大体积的切除，同时优化保乳手术患者的美观结局。

∙Footnote m added: Includes techniques such as local tissue rearrangement, local flaps, regional flaps, breast reduction and mastopexy to allow for greater volumes of resection while optimizing aesthetic outcomes in patients undergoing BCS.

BINV-3

∙脚注t，修改：对于伴有多个高风险复发因素的患者，包括乳房中心或内侧肿瘤或肿瘤≥2厘米且<10枚腋窝淋巴结切除并至少符合以下一项：3级、ER阴性或LVI，可以考虑乳房切除术后放疗。

∙Footnote t 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.

BINV-5

∙病理淋巴结阳性（≥1个同侧转移灶>2毫米），修改：辅助化疗＋曲妥珠单抗＋帕妥珠单抗（1类，首选）和内分泌

∙pN+ ((≥1 ipsilateral metastases >2 mm), modified: Adjuvant chemotherapy with trastuzumab + pertuzumab (category 1, preferred) and endocrine therapy.

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