乳腺癌保乳手术和改良根治术保留肋间臂神经的对比研究

目的:比较乳腺癌保留乳房手术和改良根治术保留肋间臂神经(ICBN)的解剖入路、成功率和术后患侧腋窝及上臂内侧皮肤的感觉状态。方法:121例保留ICBN的乳腺癌患者,按手术方式分为保留乳房手术组(简称保乳组,48例)和改良根治术组(简称改良组,73例),前者行1/4乳房切除或肿瘤广泛切除加腋窝淋巴结清扫术,后者采用乳腺癌改良根治术,两组术中均保留ICBN;评价两组ICBN的解剖入路和保留成功率以及术后患侧腋窝及上臂皮肤感觉状态的差异。结果:保乳组经顺行法、中间法或逆行法解剖ICBN各有5、35和8例,改良组分别有33、38和2例(P<0.01);两组ICBN保留成功率分别为64.6%(31/48)和87.7%(64/73)(P<0.01),保乳组失败的主要原因是暴露不佳引起的误伤和逆行解剖的不足,改良组是淋巴结固定并与ICBN粘连或侵犯该神经;两组术后患侧腋窝及上臂内侧皮肤感觉异常发生率分别为37.5%(18/48)和15.1%(11/73)(P<0.01)。结论:乳腺癌保留乳房手术和改良根治术解剖ICBN入路存在差异,保乳组以中间法为主,改良组以中间法和顺行法为主;改良组ICBN保留成功率高于保乳组;两组失败的主要原因分别是误伤和淋巴结粘连或侵犯ICBN。

Outcomes of preserving intercostobrachial nerves by conservation surgery or modified radical mastectomy for patients with breast cancer

Objective： To compare the outcomes of preserving the intercostobrachial nerves（ ICBN） during axillary dissection on sensory change by conservation surgery or modified radical mastectomy for breast cancer patients. Methods： 121 patients with breast cancer were divided into the breast conservation surgery group（ BCS group,n = 48） and the modified radical mastectomy group（ MRM group,n = 73） according to surgical manner. Patients in BCS group were treated with conservative surgery plus axillary lymph node dissection. MRM group were treated with modified radical mastectomy. ICBNs were designed to be reserved in the two groups,in which the patients were evaluated on the successful rate of ICBN preservation,postoperative skin sensation of armpit and upper arm regarding two different approaches. Results： Successful preservation of ICBN in two groups were 64. 6%（ 31 /48） and 87. 7%（ 64 /73）（ P〈0. 01）,respectively. The primary causes of failure were associated with accidental injury of the nerve due to bad exposure and shortcoming of retrograde dissection in BCS group and lymph node adherence or involvement in MRM group. The incidences of postoperative paresthesia of armpit and upper arm were 37. 5%（ 18 /48） and 15. 1%（ 11 /73）（ P〈0. 01）,respectively. Conclusion： The dissection can be different to preserve the ICBN by conservation surgery or modified radical mastectomy,and MRM has a higher successful rate of preservation than BCS. The failure procedure is involved in accidental injury of the nerve and lymph node adherence or involvement.