乳腺癌相关淋巴水肿发病风险的研究进展

介绍乳腺癌相关淋巴水肿的危险因素,对Cox回归模型、列线图模型、Logistic回归模型3种发病风险预测模型进行综述,并总结乳腺癌相关淋巴水肿的预防措施,旨在为医护人员早期识别乳腺癌相关淋巴水肿患者及采取有效预防措施提供参考。     

女性乳腺癌患者术后上肢水肿的危险因素分析及其列线图预测模型的构建

目的:分析女性乳腺癌术后上肢水肿(LE)的危险因素,构建女性乳腺癌术后上肢水肿的列线图预测模型。方法:回顾性分析2013年1月—至2020年12月行手术治疗的女性乳腺癌患者的相关临床资料,采用χ^(2)检验或t检验初步分析与LE相关的因素,再进一步采用Logistic回归分析筛选出导致LE的独立危险因素,应用R软件构建列线图预测模型,通过绘制校准曲线评价模型预测结局概率与实际概率的一致程度,以C-index表示。绘制受试者工作特征(ROC)曲线,以曲线下面积(AUC)评估列线图预测模型对LE的预测能力。结果:489例女性乳腺癌患者纳入研究,术后LE发生率为16.2%。单因素分析结果显示,术后LE与体重指数(BMI)(t=-3.716,P<0.001)、糖尿病(χ^(2)=36.784,P<0.001)、高血压病(χ^(2)=4.525,P=0.033),肿瘤TNM分期(χ^(2)=3.955,P=0.047)、术后功能锻炼依从性(χ^(2)=7.011,P=0.030),新辅助化疗(χ^(2)=4.025,P=0.045),腋窝淋巴结清除(χ^(2)=5.197,P=0.023),放疗(χ^(2)=8.068,P=0.005)有关。Logistic多因素分析结果表明,BMI(OR=1.182,95%CI:1.083~1.291,P<0.001),糖尿病(OR=5.126,95%CI:2.924~8.989,P<0.001),术后功能锻炼依从性(OR=0.242,95%CI:0.083~0.701,P=0.009),新辅助化疗(OR=2.181,95%CI:1.101~4.319,P=0.025),行腋窝淋巴结清除(OR=1.996,95%CI:1.156~3.447,P=0.013),放疗(OR=1.986,95%CI:1.109~3.556,P=0.021)是LE发生的独立危险因素,基于此构建出列线图预测模型,模型总分220分,通过校准曲线可见该列线图模型的预测概率与实际概率有较好的一致性,C-index值为0.775(95%CI:0.716~0.833),所绘制的ROC曲线显示其曲线下面积为0.775,提示该列线图预测模型对LE有较强的预测能力。结论:BMI、糖尿病、术后功能锻炼依从性、新辅助化疗、腋窝淋巴结清除、放疗是LE发生的独立危险因素,基于这6项独立危险因素构建的列线图模型,可以直观地预测术后出现LE的风险。     

BRCA1/2基因突变对乳腺癌保乳术后局部复发的影响及相关预后模型的构建

背景与目的 保乳手术现已成为乳腺癌的标准手术方式之一,保乳手术能够保留患者的乳房外形,极大地改善患者术后的心理状态和生活质量。BRCA1/2基因是与乳腺癌密切相关的易感基因,BRCA1/2基因突变对保乳术后乳腺癌患者局部复发的影响目前尚有争议。因此,本研究分析BRCA1/2基因突变与乳腺癌保乳术后局部复发的关系,并构建相关预测模型,预测保乳术后乳腺癌患者的无局部复发生存（LRFS）率,为乳腺癌患者保乳手术适应证的选择提供可靠的依据。方法 回顾性分析2014年6月—2016年6月于中国人民解放军空军军医大学第一附属医院进行保乳手术的189例乳腺癌患者临床资料,并比较不同临床病理特征下患者BRCA1/2基因突变的差异,通过单因素及多因素Cox等比例回归模型分析BRCA1/2基因突变及其它临床病理因素对乳腺癌患者保乳术后局部复发的影响,并构建列线图来预测患者的LRFS率。通过一致性指数（C-index）、受试者工作特征（ROC）曲线及曲线下面积（AUC）对模型进行内部验证,通过校准曲线评估模型的准确性,并通过临床决策曲线分析（DCA）评价模型的临床获益和应用价值。结果 BRCA1/2基因突变组和未突变组的年龄和分子分型进行差异有统计学意义（均P<0.05）。单因素Cox等比例回归模型分析结果显示,BRCA1/2突变、肿瘤分级、肿瘤大小、N分期及分子分型是保乳术后乳腺癌患者LRFS率的影响因素（均P<0.1）。多因素Cox等比例回归模型分析结果显示,BRCA1/2基因突变、肿瘤大小、N分期及分子分型是保乳术后乳腺癌患者局部复发的独立影响因素（P<0.05）。将这些因素纳入并建立LRFS率的列线图预测模型。模型的C-index为0.86,内部验证C-index为0.81。ROC曲线分析结果显示,模型的3、5年LRFS率预测的AUC分别为0.89、0.85;校准曲线显示列线图预测的LRFS率与实际LRFS率接近;DCA分析显示模型的临床获益及应用价值较高。结论 BRCA1/2基因突变与保乳术后乳腺癌患者的局部复发相关,基于BRCA1/2基因突变列线图模型能够准确地预测保乳术后乳腺癌患者的LRFS率,并为乳腺癌患者手术方式的选择提供有效的科学依据。     

乳腺癌患者术后早期上肢淋巴水肿的发生率及影响因素分析

目的 探讨乳腺癌患者术后上肢淋巴水肿发生率、淋巴水肿分期以及相关危险因素。方法 回顾性分析2019年9月1日至2019年12月31日期间128例接受腋窝淋巴结清扫术的乳腺癌患者资料。患者均为女性,年龄29～81岁（平均49.0±6.8岁）。术后6个月、12个月、24个月及36个月时随访,采用诺曼问卷和臂围测量,从主观和客观两个角度评估乳腺癌患者术后上肢淋巴水肿情况及淋巴水肿治疗情况。采用Logistic二元回归模型分析乳腺癌术后上肢淋巴水肿的影响因素。结果 乳腺癌术后6个月、12个月、24个月和36个月的上肢淋巴水肿比例分别为9.4%(12/128)、25.0%(32/128)、23.4%(30/128)、23.4%(30/128),诺曼问卷得出的结果为12.5%、26.6%、25.0%、25.0%。128例患者中,最终30例诊断为乳腺癌术后上肢淋巴水肿,其中,Ⅰ、Ⅱ、Ⅲ期淋巴水肿的发生比例分别为15.6%、6.3%和1.6%。体重指数（BMI）、放疗、淋巴结阳性数目及手术方式在淋巴水肿及对照组中存在差异。乳腺癌术后的CDT治疗及淋巴外科手术均对淋巴水肿有积极的治疗效果。结论 乳腺癌术...     

乳腺癌改良根治术后上肢淋巴水肿与腋窝淋巴结阳性率的相关性分析

目的探讨分析乳腺癌改良根治术后上肢淋巴水肿与腋窝淋巴结阳性率的相关性。 方法对2014年11月至2016年11月进行改良根治术治疗的112例乳腺癌患者进行回顾性研究,依据周径测量法对患者淋巴水肿状况进行测量,将未出现水肿患者作为对照组,出现水肿患者列入水肿组,应用SPSS18.0进行分析,对两组患者上肢淋巴水肿与腋窝淋巴结阳性率进行Logistic单因素与多因素分析,两组患者术后上肢淋巴水肿症状对比采用χ²检验,P<0.05差异有统计学意义。 结果经单因素分析结果显示,患者体质指数、淋巴结转移、术后并发症、瘤体大小、放射治疗与上肢淋巴水肿、腋窝淋巴结阳性率有关(P<0.05);经多因素分析上肢淋巴水肿的独立危险因素为：体质指数、年龄、放射治疗(P<0.05);通过对比,水肿组上肢肿胀感与沉重感发生率显著高于对照组(P<0.05)。 结论导致乳腺癌患者术后出现上肢淋巴水肿的独立危险因素诸多,应当对出现的危险因素给予高度重视,采取相应措施来降低上肢淋巴水肿的发生率。     

乳腺癌非前哨淋巴结转移的预测模型构建

目的探讨乳腺癌非前哨淋巴结(NSLN)转移的危险因素并构建非前哨淋巴结转移的预测模型。 方法回顾性分析2016年1月至2019年6月接受前哨淋巴结活检(SLNB)且确诊前哨淋巴结(SLN)阳性,行腋窝淋巴清扫术(ALND)的95例乳腺癌患者的临床资料。应用SPSS 20.0软件对数据进行处理,计数资料用[例(%)]描述,其中连续变量使用秩和检验,分类变量使用χ²检验。对与NSLN转移相关的临床病理因素进行多因素Logistic回归分析,根据Logistic回归分析各变量的回归系数建立非前哨淋巴结转移风险预测模型计算每例患者NSLN转移的预测概率,通过描绘受试者工作特征曲线(ROC)并计算曲线下面积(AUC)从而来评估模型的预测能力。 结果通过单因素分析显示乳腺癌患者NSLN转移与肿瘤大小、肿瘤位置、淋巴血管是否受侵犯、SLN转移灶大小及SLN阳性率相关(P<0.05);将相关因素纳入多因素Logistic回归分析中,结果显示,肿瘤大小、淋巴血管是否受侵犯、SLN阳性率为乳腺癌患者NSLN转移的独立危险因素。根据Logistic回归分析建立NSLN转移风险预测模型,绘制研究对象的ROC曲线,计算AUC为0.792(95%CI为0.651～0.934);Hosmer-Lemeshow拟合优度检验P＝0.603。 结论肿瘤大小、淋巴血管是否受侵犯、SLN阳性率为乳腺癌患者非前哨淋巴结转移的独立危险因素,NSLN转移风险预测模型对NSLN转移患者具有较高的预测价值,可辅助临床医师术前判断,选择合理的术式。     

乳腺癌术后上肢淋巴水肿因素分析与外科治疗进展

上肢淋巴水肿是乳腺癌术后的常见并发症,乳腺癌根治术后早期常有上肢不同程度的肿胀,在数月甚或20年后可出现淋巴水肿,但75%发生在术后第1年内,1个月以内发生率为28%[1]。淋巴水肿可导致上肢功能障碍和患者精神紧张,轻者随着侧支循环的建立而缓解,严重者可影响术后生活质量,甚至导致无法正常生活和工作[2]。临床处理较为棘手,其治疗方法可分为保守治疗和外科治疗,目的均是改善淋巴液生成与回流之间平衡,减小上肢周径。本文就乳腺癌术后上肢淋巴水肿产生的因素进行分析,探讨其预防措施和外科治疗。1乳腺癌术后上肢淋巴水肿形成的机制1.1腋窝淋巴结清扫手术腋窝淋巴结清扫是大部分乳腺癌手术的必要步骤,淋巴结被彻底清扫干净,可有效预防术后复发和转移。乳腺癌术后上肢淋巴水肿主要由淋巴回流障碍引起,其可能形成的机制为:由于腋窝淋巴的清扫切断了上肢的淋巴回流通路,使上肢的淋巴不能充分引流,导致上肢淋巴液中的蛋白浓度增高,滤过压增加,由于血浆蛋白减少,使液体渗透压降低,同时,毛细血管渗透压增加,所以可出现程度不等的上肢水肿,随后上肢组织出现纤维化及炎症的淋巴水肿[3]。Pain等[4]认为乳腺癌腋窝淋巴清扫改变腋静脉血流动力学,使之易发生...     

术前桡静脉压测定预测乳腺癌患者术后淋巴水肿的临床研究及其对胸大肌肌瓣转移术的理论价值

目的研究术前上肢桡静脉压的测定对乳腺癌患者术后上肢淋巴水肿的预测能力。方法第一阶段对我院2009年9月至2015年6月期间75例术后出现淋巴水肿的行乳腺癌改良根治术的患者进行双上肢桡静脉压的测定和上臂围的测量。第二阶段再对我院2015年7月至2017年5月期间157例行乳腺癌改良根治术的患者在术前、术后6个月、术后12个月分别进行双侧上肢桡静脉压检测和双侧上臂围的测量,记录两臂桡静脉压差值及上臂围的变化,同时记录患者淋巴结阳性数目。结果经过随访和统计分析,在第一阶段75例淋巴水肿患者中,术后上臂围差值与桡静脉压差明显正相关,P=0. 000。第二阶段中患者术前桡静脉压差值与术后淋巴结阳性数目存在正相关,P=0. 000;且术前桡静脉压差值较大的患者,术后6个月和12个月的上臂围差与术前比较,其差异具有统计学意义,P=0. 000;而术前桡静脉压差值较小的患者,术后6个月和12个月的上臂围差与术前比较,其差异没有统计学意义,P 0. 05。同时发现,术前桡静脉压差值越高,术后淋巴水肿的程度越重,两者呈正相关,P=0. 000。结论术前桡静脉压的检测可以提前筛选出术后淋巴水肿发生风险较高的乳腺癌患者,从而在手术时可以通过行乳腺癌改良根治术加胸大肌肌瓣转移术,来降低乳腺癌术后患侧上肢淋巴水肿的发生,避免盲目加行胸大肌肌瓣转移术,从而造成不必要的损伤。     

胸大肌肌瓣转移术预防乳腺癌术后上肢淋巴水肿的临床研究

目的 探讨胸大肌肌瓣转移术对乳腺癌改良根治术后患侧上肢淋巴水肿的预防效果。方法 自2013年9月至2014年6月,将68例乳腺癌患者分成2组,35例行乳腺癌改良根治术+胸大肌肌瓣转移术(干预组),33例单纯行乳腺癌改良根治术(对照组),术后随访观察,分别在术后2周、1个月、3个月、6个月和9个月测量双侧臂围,判断有无上肢淋巴水肿的发生及程度。结果 随访结果表明,干预组和对照组相比,术后患侧上肢淋巴水肿发生率明显减少,差异具有统计学意义(P<0.05)。结论 乳腺癌改良根治术后行胸大肌肌瓣转移术,可显著减少乳腺癌术后患侧上肢淋巴水肿的发生率,提高患者的生活质量。     

口腔负压吸引预防乳腺癌术后上肢淋巴水肿和皮下积液30例

目的：探讨口腔负压吸引对乳腺癌术后上肢淋巴水肿和皮下积液的影响和治疗作用。方法：对30例乳腺癌术后患者进行口腔负压吸引治疗,比较与对照组患者上肢淋巴水肿和皮下积液的发生情况及完全拔除引流管的时间。结果：实验组3例患者术后发生上肢淋巴水肿,对照组10例术后发生上肢淋巴水肿（χ^2=4.812,P〈0.05）;实验组患者较早完全拔除引流管（χ^2=16.530,P〈0.05）,皮下积液发生率未增加（χ^2=1.298,P〉0.05）。结论：口腔负压吸引可以显著降低乳腺癌术后上肢淋巴水肿的发生率,并缩短持续皮下负压引流的时间,同时不增加皮下积液的发生率,为临床预防和治疗乳腺癌术后近期的上肢淋巴水肿和皮下积液提供了新的思路和方法。     

Erysipelas of the upper extremity following locoregional therapy for breast cancer

Cellulitis is a well-known complication of lymphedema of the lower extremities. Erysipelas of the upper extremity complicating breast cancer therapy has never been reported in the English-language literature. We describe seven breast cancer patients with erysipelas of the upper extremity. Five had a predisposing injury to the extremity. All patients responded very well to intravenous antibiotics without any sequelae. They had rapid resolution with typical desquamation. No long-term sequelae were seen except for mild increase of lymphedema. Erysipelas should be listed as a rare complication after locoregional therapy for breast cancer. Intravenous penicillin should be used as the initial therapy. Prevention of arm lymphedema and avoidance of any trauma to the arm are important prophylactic measures. Sentinel lymph node biopsy reduces the rate of axillary lymph node dissection and thus should reduce the incidence of lymphedema and erysipelas.     

Safety of elective hand surgery following axillary lymph node dissection for breast cancer

The development of lymphedema is the most feared complication shared by breast cancer survivors undergoing hand surgery after prior axillary lymph node dissection (ALND). Traditionally, these patients are advised to avoid any interventional procedures in the ipsilateral upper extremity. However, the appropriateness of some of these precautions was recently challenged by some surgeons claiming that elective hand operations can be safely performed in these patients. The purpose of this study was to evaluate our experience and determine the safety of elective hand operations in breast cancer survivors. The medical records of patients operated for different hand conditions after prior breast surgery and ALND at our institution between 1983 and 2002 were reviewed. The techniques and preventive measures performed, use of antibiotics, and upper extremity complications associated with the operations were analyzed. Overall, we operated on 27 patients after prior ALND performed for breast cancer. Follow-up was available for 25 patients. Four patients had pre-existing lymphedema. The surgical technique used was similar to that performed in patients without prior ALND and antibiotic prophylaxis was not given. Delayed wound healing was observed in one patient and finger joint stiffness in another. Two patients with pre-existing lymphedema developed temporary worsening of their condition. None of the patients developed new lymphedema. The results of the present study support the few previous studies, suggesting that hand surgery can be safely performed in patients with prior ALND. Based on these findings, the appropriateness of the rigorous precautions and prohibitions regarding the care and use of the ipsilateral upper extremity may need to be reconsidered.     

薄层血管化腹股沟淋巴结皮瓣移植联合反向淋巴显影在继发性上肢淋巴水肿手术中的应用

目的 探讨薄层血管化腹股沟淋巴结皮瓣移植联合反向淋巴显影在继发性上肢淋巴水肿手术中的应用效果.方法 2019年7月至2020年9月,应用吲哚菁绿、美蓝双染法引导的反向淋巴显影术,制备薄层游离血管化腹股沟淋巴结皮瓣,切取后移植于患侧上肢,治疗乳腺癌术后继发性淋巴水肿患者5例.皮瓣约10 cm×5 cm大小,平均厚度约0....     

综合康复对乳腺癌术后患者癌性疲乏及上肢淋巴水肿的影响分析

目的研究综合康复对乳腺癌术后患者癌性疲乏及上肢淋巴水肿的影响。方法选取2012年2月至2015年2月期间76例术后癌性疲乏及上肢淋巴水肿患者,按照随机数表法分为综合康复组和压力循环治疗组,每组为38例。压力循环治疗组采取压力循环治疗法,综合康复组患者在压力循环治疗的基础上加以综合康复。观察两组患者治疗前后的淋巴结水肿、上肢功能及癌性疲乏改善程度。实验数据通过SPSS 11.5软件分析,计量资料采用t检验,计数资料采用χ~2检验,等级资料采用秩和检验,P0.05具有统计学意义。结果治疗后综合康复组患者的水肿为轻、中度97.37%(37/38)明显高于压力循环治疗组78.95%(30/38)(u=3.842,P0.05);综合康复组患者的癌性疲乏评分(3.87±0.64)分与上肢功能评分(8.33±1.49)分明显低于压力循环治疗组(t=5.887,14.337,P0.05),差异均有统计学意义。结论综合康复能明显改善乳腺癌术后患者的癌性疲乏状态,对缓解患者的上肢淋巴水肿具有着较好的疗效。     

Treatment of upper limb lymphedema with combination of liposuction, myocutaneous flap transfer, and lymph-fascia grafting: a preliminary study

Treatment of obstructive extremity lymphedema remains a challenge in reconstructive surgery, since none of the varieties of procedures have been demonstrated a reliable resolution for the lymphedema. In this report, we present the preliminary results of treatment of severe upper extremity lymphedema with combined liposuction, latissimus myocutaneous flap transfer, and lymph-fascia grafting in 11 patients. All patients had histories of radical mastectomy, irradiation therapy for breast cancer, and frequent onsets of erysipelas. Postoperative measurements in an average of 26 months follow up showed that significant decrease of circumferences of the arms on all levels at surgery side were achieved. The onsets of erysipelas were also reduced. There was no chronic lymphedema found in the donor leg after harvest of the lymph-fascia graft. The results suggest the strategy of liposuction, latissimus myocutaneous flap transfer, and lymph-fascia grafting may provide a useful method for treatment of the chronic upper extremity lymphedema with severe axillary scar contracture.     

Time-course of arm lymphedema and potential risk factors for progression of lymphedema after breast conservation treatment for early stage breast cancer

Abstract: The objective of this study was to describe the progression of arm lymphedema (ALE) after the initial presentation among patients receiving breast conservation therapy for early stage breast cancer and to identify potential risk factors contributing to ALE progression. The study sample was the 266 stage I or II breast cancer patients with documented ALE who underwent breast conservation therapy that included lumpectomy, axillary staging followed by radiation therapy. ALE were graded according to a difference of 0.5–2 cm (mild), 2.1–3 cm (moderate), and >3 cm (severe) in the circumference between the upper extremities for the treated and untreated sides. ALE at presentation was scored as mild, moderate, and severe in 109 (41%), 125 (47%), and 32 (12%) patients, respectively. One third of patients with ALE progressed to a more severe grade of lymphedema at 5 years of follow‐up. Age older than 65 years at the time of breast cancer treatment was associated with higher risk of ALE progression when compared 65 year age or younger (p = 0.04). The patients who had regional lymph node irradiation including posterior axillary boost were at higher risk of lymphedema progression than the patients treated with whole breast irradiation only (p = 0.001). Progression of ALE is a common occurrence. The current study provides support for the utility of routine arm measurements after breast cancer treatment to facilitate timely diagnosis and treatment of ALE.