染料法腋窝反向淋巴作图在早期乳腺癌手术中的应用及分析

目的 研究影像学检查腋窝阴性的浸润性乳腺癌患者,行染料法腋窝反向淋巴作图（axillaryreverse mapping, ARM）,探讨影响其成功率的影响因素,并比较保留ARM淋巴结的腋窝淋巴结清扫术(axillary lymph node dissection, ALND)与常规ALND术后上肢淋巴水肿的发生率,分析其危险因素。方法 对50例确诊为浸润性乳腺癌,并且术前影像检查腋窝阴性的患者,于术中向患侧上臂内侧皮下及肌肉内注射亚甲蓝染料约2 ml。观察上肢的淋巴管道及淋巴结的显影情况,并对显影的淋巴管道及淋巴结予以保留,比较保留ARM淋巴结的ALND与ARM失败后的ALND术后上肢的淋巴水肿发生率,并且对其潜在因素,如年龄及体质量指数,做正态性检验、t检验及多因素Logistic回归分析。结果 50例中ARM成功的有34例(68%),ARM未成功的有16例(32%)。术中观察保留ARM淋巴结的患者体质量指数及上肢淋巴水肿程度均低于术中ARM失败的患者（P均=0.01）,而与年龄无关（P=0.56）。去除混杂因素后的多因素分析表明,术中是否能显示并保留ARM淋巴结,是影响上肢淋巴水肿的独立危险因素（P=0.02,OR=16.39）,ARM失败的ALND,术后上肢淋巴水肿发生的危险度是保留ARM淋巴结的ALND的16.4倍。结论 乳腺癌术中保留ARM淋巴结,可以有效降低ALND后上肢淋巴水肿的发生。     

腋窝逆向淋巴示踪的临床实践及争议

前哨淋巴结活组织检查术(SLNB)是腋窝淋巴结阴性乳腺癌患者标准的腋窝处理术式,而腋窝淋巴结清扫术(ALND)则应用于腋窝淋巴结阳性的乳腺癌患者,两者均可能破坏患侧上肢的淋巴回流,从而导致乳腺癌相关淋巴水肿(BCRL),后者在一定程度上降低了患者术后的生活质量。腋窝逆向淋巴示踪(ARM)旨在通过在SLNB或ALND中显示并保留引流上肢淋巴液的淋巴结/淋巴管(ARM LN/LV),以预防BCRL发生。然而,将ARM应用于临床工作前,仍有几个问题亟待解决,如其预防BCRL的有效性,以及因引流上肢和乳腺的淋巴通道存在交通所致的肿瘤学安全性问题。近期的研究表明,对于腋窝淋巴结临床阴性、前哨淋巴结(SLN)阳性及SLN与ARM LN不重叠的患者而言,ARM在肿瘤学方面是安全的。淋巴回流通道的重建不仅避免了SLN与ARM LN重叠而必须将其切除时所面临的尴尬,而且能有效预防BCRL的发生。ARM作为乳腺癌手术家族中新兴的一员,其应用前景值得期待。     

术前淋巴显像在乳腺癌前哨淋巴结活检中的作用

目的探讨术前淋巴显像在乳腺癌前哨淋巴结活检（sentinel lymph node biopsy，SLNB）中的作用。方法回顾性分析了716例联合术前淋巴显像与术中1探测仪和蓝染料检测乳腺癌SLNB的结果。结果全组SLNB成功率98．2％（703／716），验证组SLNB的假阴性率16．0％（15／94）。淋巴显像共成功地确定出620例患者（86．6％）的前哨淋巴结（sentinel lymph node，SLN），并在36例患者（5．0％）中发现了腋窝以外的前哨淋巴结。淋巴显像确定SLN的失败率与原发肿瘤的部位、肿瘤的病理类型和注射同位素到显像的时间无显著相关性（均P〉0．05）。注射示踪剂前已进行肿瘤切除活检的患者，其淋巴显像成功率低于未行肿瘤切除活检者；淋巴结转移患者淋巴显像的成功率低于淋巴结阴性患者。术中确定SLN的成功率在术前淋巴显像成功组和失败组之间存在显著的统计学差异（99．5％ vs 91．0％，P〈0．01）。术前淋巴显像是否成功确定SLN与SLNB的假阴性率无显著相关性（P=0．731）。结论乳腺癌SLN术前淋巴显像可以预测术中SLNB的成功率，同时术前淋巴显像有助于确定腋窝以外的SLN，但术前淋巴显像并非乳腺癌SLNB所必需。     

降低乳腺癌术后淋巴水肿新技术——腋窝反向淋巴制图的研究进展

腋窝反向淋巴制图(axillary reverse mapping, ARM)技术是指在腋窝淋巴结切除术(axillary lymph node dissection, ALND)和/或前哨淋巴结切除术(sentinel lymph node dissection, SLND)中显示上肢淋巴管道并对其予以保护, 从而降低术后上肢淋巴水肿发生率, 是针对乳腺癌手术治疗的一项新兴技术, 目前仍处于临床试验阶段。本文回顾了近年来国外相关临床试验, 分析ARM淋巴结和淋巴管的显示方法, 评估保留ARM淋巴结和淋巴管的可行性, 评价ARM技术对降低乳腺癌术后上肢淋巴水肿发生率的临床意义。      

前哨淋巴结活检指导保留乳房手术患者行选择性腋窝淋巴结清除术的研究

目的研究通过前哨淋巴通道（SLC）行前哨淋巴结活检（SLNB）以指导保留乳房手术（breast—conservingtherapy,BCT）患者行选择性腋窝淋巴结清除术（ALND）的可行性。方法采用非随机对照研究,在BCT患者中采用联合示踪法通过SLC行SLNB。对术中检出的前哨淋巴结（SLN）行细胞印片和冰冻切片检查,根据SLN的术中病理结果行选择性ALND,其中SI。N阳性、行ALND者为A组,SI。N阴性仅行SLNB者为B组。定性资料的比较选用Y。检验,两组均数的比较采用t检验。结果2009年1月至2009年12月采用联合示踪法行SLNB的BCT患者共43例,检出42例,A组28例,B组14例。两组患者的SLC均被显影。每例患者被检出SLN1～3枚,平均1．4枚,共被检出59枚。SLNB检出率为97．7％（42／43）。术后病理检查共检出阳性SI,N29例,其中术中细胞印片、冰冻切片及二者联合病理检测分别检出阳性淋巴结27、27、28例。A组ALND相关并发症发生率明显高于B组（P=0．003）。结论通过SLC行SLNB有助于准确定位SLN,能够指导BCT患者行选择性ALND,降低术后并发症。     

早期乳腺癌前哨淋巴结活检术的临床应用

目的探讨应用前哨淋巴结活检（SLNB）技术预测腋窝淋巴结状态的准确性。方法应用同位素示踪法联合亚甲蓝染料示踪法对68名临床腋窝阴性的早期乳腺癌患者行前哨淋巴结活检术,然后行腋窝淋巴结清扫术（ALND）。对照前哨淋巴结情况与腋窝淋巴结状态的关系,分析SLNB的临床意义。结果68例患者中检出前哨淋巴结（SLN）66例,检出率为97．06％,共检出SLN192枚,平均每例2．91枚。66例中,34例SLN阴性患者中,2例为假阴性,假阴性率为5．88％。当SLN阴性时,SLNB预测腋窝淋巴结状态的准确率为94．12％。SLNB检测腋窝淋巴结转移情况的灵敏度为94．12％,特异度为94．12％,SLNB与ALND结果的一致率为77．27％。结论联合应用染料示踪法和同位素示踪法行SLNB具有较高的检出率,SLNB能较准确的预测腋窝淋巴结的转移情况。     

上肢淋巴系统功能保护在乳腺癌腋窝淋巴结清扫中的应用

腋窝淋巴结清扫(ALND)是腋窝淋巴结阳性乳腺癌患者的标准治疗,用于腋窝局部控制、淋巴结分期、辅助治疗方案制定及预后评估,常见并发症包括上肢淋巴水肿、肩关节功能障碍、疼痛、麻木、乏力等,其中乳腺癌相关上肢淋巴水肿是非常困扰患者的并发症,与ALND破坏了上肢淋巴引流有关。基于上肢淋巴引流与乳腺淋巴引流互相独立的假说,腋窝逆向示踪(ARM)技术被用于ALND术中识别并保护上肢淋巴系统,从而预防或减轻水肿。但ARM技术在有效性和肿瘤安全性上仍有争议。近年来,高级别循证医学证据的前瞻性临床试验结果相继发表,证实了ARM技术的有效性,部分解决了肿瘤安全性问题。笔者总结了ARM技术在乳腺癌腋窝处理中的研究进展,为ARM技术的临床实践提供参考与借鉴。     

荧光法腋窝反向制图技术在乳腺癌手术中的可行性

目的探讨荧光法腋窝反向制图(ARM)技术(即逆向腋窝淋巴结示踪)在乳腺癌腋窝手术中的可行性、ARM淋巴结(示踪剂显示的引流上肢淋巴液的淋巴结)在腋窝的分布规律以及保留ARM淋巴结的肿瘤学安全性。方法采用前瞻性研究方法,对2014年4~11月期间在南京医科大学附属杭州医院就诊的40例浸润性乳腺癌患者,经知情同意后,在乳腺癌前哨淋巴结活组织检查(SLNB)术或腋窝淋巴结清扫(ALND)术开始前15 min,将2 ml(5 mg)吲哚菁绿注射于患侧上肢内侧肌间沟皮下以示踪ARM淋巴结,术中用红外荧光定位观察相机观察、记录腋窝有无荧光ARM淋巴结显影及其在腋窝的分布情况,切除分布在手术区域内的荧光ARM淋巴结送病理学检查,评估其受肿瘤侵犯的情况。结果 35例患者行SLNB+ARM术,ARM淋巴结示踪成功8例,SLNB中ARM淋巴结示踪成功率为22.9%(8/35);5例患者行ALND+ARM术,ARM淋巴结示踪成功3例,另有25例行SLNB+ARM术的患者在完成SLNB后转而行ALND,且ARM淋巴结示踪均获成功,因此,在所有行ALND术的患者中ARM淋巴结示踪成功率为93.3%(28/30)。全组共发现119枚荧光ARM淋巴结,其中57.1%(68/119)的荧光ARM淋巴结分布于腋静脉下方、第2肋间臂神经上方及胸背血管神经束外侧的区域。ARM-SLN共干率(即引流乳腺淋巴液的淋巴结与引流上肢淋巴液的淋巴结在解剖上存在共同通路的概率)为17.1%(6/35)。24例患者的ARM淋巴结被切除送病理学检查,其中20例p N0~1患者无ARM淋巴结受累,4例p N2~3患者中有2例ARM淋巴结受累,ARM淋巴结受累率为8.3%(2/24)。结论吲哚菁绿荧光法在ALND中是一种成功率高的ARM淋巴结示踪方法;ARM淋巴结在腋窝分布存在一定的规律;腋窝淋巴结肿瘤负荷重的患者不适合行ARM手术。     

识别并保护上肢淋巴系统技术预防乳腺癌患者术后上肢淋巴水肿的前瞻性随机对照研究

目的评估腋窝淋巴结清扫术(ALND)中施行识别并保护上肢淋巴系统技术(DEPART)对预防或减轻乳腺癌患者术后上肢淋巴水肿的效果。方法采用随机对照研究方法。纳入2017年11月至2018年6月在武汉大学中南医院甲乳外科拟行乳腺癌手术的265例患者, 通过随机数字表法, 将患者随机分为ALND+DEPART组(132例)和标准ALND组(133例)。ALND+DEPART组患者术前注射示踪剂吲哚菁绿和亚甲蓝, 术中清扫腋窝淋巴结时, 采用分级显影方法示踪上肢淋巴系统, 对长径>1 cm、质硬可疑转移的上肢淋巴结做1/4部分冰冻切片, 选择性保留上肢淋巴结及淋巴管。标准ALND组患者行标准ALND。术后分别采用5点周径测量体积法和Norman问卷调查, 对患者的上肢淋巴水肿情况进行客观和主观指标评估。结果 ALND+DEPART组132例乳腺癌患者中, 121例(91.7 %)完成DEPART。ALND+DEPART组和标准ALND组患者的年龄、体质指数、病理类型、腋窝淋巴结清扫数目、N分期、TNM分期、分子分型、区域放疗差异均无统计学意义(均P>0.05)。中位随访24个月,...     

早期乳腺癌前哨淋巴结活检在简化腋清扫中的应用研究

[目的]探讨早期乳腺癌患者行前哨淋巴结活检（SLNB）为阴性,行简化腋窝淋巴结清扫替代腋窝淋巴结清扫术（ALND）的临床效果。[方法]采用1%亚甲蓝染色法对65例早期乳腺癌患者行SLNB,60例成功行SLNB,其中40例SLN无转移者行简化腋窝淋巴结清扫术（简化组）;20例SLN有转移者行ALND（标准组）,比较两组患者术后上肢并发症的发生情况、腋窝复发及全身转移情况。[结果]简化组手术时间和腋窝引流时间比标准组明显缩短,有统计学差异（P〈0.01）;简化组术后患侧上肢的疼痛、肿胀、麻木症状明显较标准组少（P〈0.01）。两组生存曲线没有差异。[结论]亚甲蓝染色法能够比较准确地定位乳腺癌的前哨淋巴结。简化ALND替代ALND手术时间和术后引流时间缩短,方便可行,并发症明显减少,腋窝复发率低,是早期乳腺癌患者的安全分期手术。     

乳腺癌新辅助化疗后前哨淋巴结活检的临床意义

目的探讨新辅助化疗后乳腺癌前哨淋巴结活检的可行性。方法对57例行^99Tc联合亚甲蓝示踪前哨淋巴结活检术和腋窝淋巴结清扫术乳腺癌患者的资料进行分析,其中31例ⅡB、Ⅲ期患者先行2～3个疗程新辅助化疗后再行前哨淋巴结活检及腋窝淋巴结清扫术,另26例Ⅰ、Ⅱ期患者直接行前哨淋巴结活检及腋窝淋巴结清扫术。结果新辅助化疗组和非新辅助化疗组平均腋窝淋巴结数、前哨淋巴结（sentinel lymph node,SLN）数、SLN检出率、SLN假阴性率均无显著差异（P均〉0．05）。新辅助化疗纽化疗前临床分期在N2以上者,SLN检出率均显著下降（P〈0．05）。结论新辅助化疗后前哨淋巴结活检能准确预测腋窝淋巴结的状况。化疗前的N分期是SLNB检出率的影响因素。     

早期乳腺癌腋窝亚LevelⅡ淋巴结清扫的初步研究

目的：探索基层医院早期乳腺癌腋窝淋巴结外科处理的适宜方法。方法：对9例符合研究条件的病例先美兰染色（meythylene blue staining）实施前哨淋巴结活检（sentinel lymph node biopsy,SLNB）,再补充实施腋窝淋巴结清扫术（axillary lymph node dissection,ALND）;ALND术中显露腋静脉,以腋静脉下2cm为界缝线标记,术后将标本从缝线处分离,对淋巴结进行分组取材,将前哨淋巴结、腋静脉下2cm内淋巴结（亚levelⅡ淋巴结）、腋窝其余淋巴结（其余淋巴结）分组送病理检查,观察各组淋巴结数量及肿瘤细胞腋淋巴结转移规律。结果：找到前哨淋巴结6例;5例前哨淋巴结、亚levelⅡ淋巴结、其余淋巴结均为阴性;1例前哨淋巴结、亚levelⅡ淋巴结、其余淋巴结均为阳性;另有1例患者前哨淋巴结未找到,而亚levelⅡ淋巴结检出阳性。结论：基层医院对于早期乳腺癌腋窝淋巴结清扫,可以用美兰染色行前哨淋巴结活检,若前哨淋巴结阳性或未找到前哨淋巴结,行ALND;若前哨淋巴结阴性,行亚levelⅡ淋巴结清扫。     

Axillary reverse mapping in patients undergoing axillary dissection -a short review of the literature

Axillary lymph node dissection (ALND) can be avoided not only in patients with negative sentinel lymph nodes (SLNs) but also in those with one or two positive SLNs receiving breast or axillary radiation. However, ALND has remained the standard treatment for patients with clinically positive nodes (cN+). Although axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND, it could not be indicated for cN + patients because metastatic rate of ARM nodes is high. However, a new type of conservative ALND with ARM attempts to preserve ARM lymphatics and nodes except SLNs and other suspicious palpable nodes, including suspicious ARM nodes. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients received postoperative chemotherapy and high-risk patients underwent axillary radiation. Thus, a traditional full ALND may not be necessary for cN + patients in the era of effective multimodality therapy.     

A patient- and assessor-blinded randomized controlled trial of axillary reverse mapping (ARM) in patients with early breast cancer

BackgroundAxillary lymph node dissection (ALND) in breast cancer patients is infamous for its accompanying morbidity. Selective preservation of upper extremity lymphatic drainage and accompanying lymph nodes crossing the axillary basin - currently resected during a standard ALND - has been proposed as a valuable surgical refinement.MethodsPeroperative Axillary Reversed Mapping (ARM) was used for selective preservation of upper extremity lymphatic drainage. A multicentre patient- and assessor-blinded randomized study was performed in clinical node negative, sentinel node positive early breast cancer patients. Patients were randomized to undergo either standard-ALND or ARM-ALND. Primary outcome was the presence of surgery-related lymphedema at six, 12 and 24 months post-operatively. Secondary outcomes included patient reported and objective signs and symptoms of lymphedema, pain, paraesthesia, numbness, loss of shoulder mobility, quality of life and axillary recurrence risk.ResultsNo significant differences were found between both groups using the water displacement method with respect to measured lymphedema. ARM-ALND resulted in less reported complaints of lymphedema at six, 12 and 24 months postoperatively (p < 0.05). No axillary recurrence was found in both groups.ConclusionsIn contrast to results of volumetric measurement, patient reported outcomes support selective sparing of the upper extremity lymphatic drainage using ARM as valuable surgical refinement in case of ALND in clinically node negative, sentinel node positive early breast cancer. If completion ALND in clinically node negative, sentinel node positive early breast cancer is considered, selective sparing of upper extremity axillary lymphatics by implementing ARM should be carried out in order to reduce morbidity.     

前哨淋巴结活检在早期乳腺癌患者腋窝管理中的研究进展

传统的观点认为腋窝淋巴结清扫(axillary lymph node dissection,ALND)是前哨淋巴结(sentinellymph node,SLN)阳性乳腺癌患者的标准治疗方法,而ALND容易引起上肢水肿、功能障碍等术后并发症,影响患者生活质量.近几年研究显示,对于SLN阳性的早期乳腺癌,并非所有患者都需...     

乳腺癌前哨体淋巴结活检的研究

前哨淋巴结(SLN)的概念和前哨淋巴结活检(SLNB)的应用是在1977年被提出的,但由于当时淋巴结检测设备和技术尚不先进,使SLN的研究未能得到足够的重视.乳腺癌SLNB是在20世纪90年代兴起的,现已成为乳腺癌外科领域的研究热点,有望在早期乳腺癌治疗中取代常规的腋窝淋巴结解剖(ALND),降低上肢淋巴水肿和功能障碍的发生率.我国该项目研究起步较晚,目前已逐渐成为人们关注的热点.该项目还将继续进行多中心、大样本、前瞻性研究,最终达成共识,将给乳腺癌病人带来福音.     

Association between Number of Retrieved Sentinel Lymph Nodes and Breast Cancer-related Lymphedema

PurposeSentinel lymph node biopsy (SLNB) has become a standard axillary staging surgery for early breast cancer, and the proportion of patients requiring axillary lymph node dissection (ALND) is decreasing. We aimed to evaluate the association between the number of sentinel lymph nodes (SLNs) retrieved and the risk of lymphedema of the ipsilateral arm.MethodsProspectively collected medical records of 910 patients were reviewed. Lymphedema was defined as a difference in circumference > 2 cm compared to the contralateral arm and/or having clinical records of lymphedema treatment in the rehabilitation clinic.ResultsTogether with an objective and subjective assessment of lymphedema, 36 patients (6.1%) had lymphedema in the SLNB group and 85 patients (27.0%) had lymphedema in the ALND group (p < 0.001). In a multivariate analysis of the whole cohort, risk factors significantly associated risk with the development of lymphedema were body mass index, mastectomy (vs. breast-conserving surgery), ALND, and radiation therapy. In logistic regression models in the SLNB group only, there was no correlation between the number of retrieved SLNs and the incidence of lymphedema. In addition, in the Pearson correlation analysis, no correlation was observed between the number of retrieved SLNs and the difference in circumference between the ipsilateral and contralateral upper extremities (correlation coefficients = 0.067, p = 0.111).ConclusionThe risk of lymphedema in breast cancer surgery and adjuvant treatments is multifactorial. The number of retrieved lymph nodes during sentinel biopsy was not associated with the incidence of lymphedema.     

Axillary reverse lymphatic mapping in breast cancer surgery: a comprehensive review

Axillary reverse lymphatic mapping (ARM) is a surgical technique that was first described in 2007 as a method for preserving the lymphatic drainage of the arm during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) for breast cancer. We found that the ARM technique had several limitations that include a poor success rate for identification of arm lymph nodes (ARM nodes) and lymphatics. The occurrence of common lymphatic drainage pathways of the arm and the breast in a subset of patients also raises concerns regarding its oncological soundness. Furthermore, the effectiveness of the ARM procedure in reducing lymphedema risk in breast cancer patients that undergo a variety of treatments, has yet to be clearly defined.     

1枚前哨淋巴结阳性早期乳腺癌保腋窝的可行性分析

目的探讨1枚前哨淋巴结（sentinel lymph node,SLN）阳性的早期乳腺癌患者保腋窝（omitting axillary dissection,OAD）的可行性。方法用美蓝作为示踪剂先行乳腺癌前哨淋巴结活检术（sentinel lymph node biopsy,SLNB）,根据快速冰冻病理结果分为SLN阴性组与1枚SLN阳性组,随后两组均行常规腋窝淋巴结清扫（axillary lymph node dissection,ALND）以解剖出非前哨淋巴结（non—sentinellymphnode,NSLN）,比较两组间NSLN的阳性率。结果SLN阴性组30例,1例NSLN阳性,阳性率为3．3％,准确性为96．7％（29／30）;1枚SLN阳性组30例,仅3例NSLN阳性,阳性率为10．0％;两组阳性率差异无统计学意义（X^2=1．071,P=0．612）。全组随访1～48个月,均无区域淋巴结复发。结论1枚SLN阳性的早期乳腺癌患者可考虑OAD。