腋窝逆向淋巴示踪预防乳腺癌患者上肢淋巴水肿的研究

目的：探讨乳腺癌前哨淋巴结活组织检查（ SLNB）或腋窝淋巴结清扫（ ALND）过程中,进行腋窝逆向淋巴示踪（ ARM）以保留引流上肢淋巴液的腋窝淋巴结的可行性,及其对术后上肢淋巴水肿的预防作用。方法选择2012年1月至2013年6月本科71例全乳房切除术＋前哨淋巴结活组织检查术患者（ SLNB组）和134例乳腺癌改良根治术患者（ ALND组）进行临床研究。将SLNB组和ALND组分别随机分为对照组和示踪组,即：SLNB对照组36例,SLNB示踪组35例；ALND对照组64例,ALND示踪组70例。 SLNB示踪组和ALND示踪组的手术方式除与其对照组相同外,还需进行ARM以保留引流上肢淋巴液的腋窝淋巴结（ ARM淋巴结）。前哨淋巴结和ARM淋巴结定位方法如下：术前2 h,在患者乳房肿块周围及患侧上臂内侧皮下注射^99Tc^m-Dx标记的同位素,并于术前5 min在患侧上臂内侧皮下注射2 ml亚甲蓝进行ARM淋巴结显色,术中用同位素γ探测仪探测放射性核素热点进行前哨淋巴结定位,并用γ探测仪结合蓝色染料定位ARM淋巴结。术中注意观察ARM淋巴结蓝染情况及其与前哨淋巴结有无重合,若无重合则保留所有蓝染的ARM淋巴结,若有重合则同时切除前哨淋巴结和ARM淋巴结；术后统计切除的淋巴结数量、术中出血量、置管时间、引流液体量及手术时间。术后6个月随访两组患者上肢淋巴水肿的发生情况。定量资料分析采用 t检验,定性资料比较采用秩和检验或χ^2检验。结果在SLNB示踪组35例患者中,26例（74．29%,26/35）术中检测到ARM淋巴结,其中1例患者前哨淋巴结与ARM淋巴结重合,此患者在SLNB过程中也接受了ARM淋巴结切除,因此SLNB示踪组ARM淋巴结保留率为71．43%（25/35）。在ALND示踪组70例患者中,67例（95．71%,67/70）术中检测到ARM淋巴结,其中5例患者前哨淋巴结与ARM淋巴结重合,此部分患者在ALND过程中同时接受ARM淋巴结切除,因此ALND示踪组ARM淋巴结保留率为88．57%（62/70）。在SLNB对照组与SLNB示踪组之间以及ALND对照组与ALND示踪组之间,腋窝淋巴结切除数量、术中出血量、术后引流液体量及置管时间的差异均无统计学意义（ t=-1．136、-0．570、0．032、0．903,P=0．264、0．570、0．975、0．370；t=1．149、0．416、1．405、-0．547,P=0．253、0．678、0．162、0．585）,但是SLNB示踪组和ALND示踪组的手术时间均长于其对照组[（90．26±6．04） min比（86．61±5．62） min,t=-2．616,P=0．011；（112．24±7．94） min比（92．33±6．88） min,t=-15．399,P=0．000]。术后随访6个月：SLNB对照组与SLNB示踪组上肢淋巴水肿发生率分别为11．11%（4/36）和8．00%（2/25）,两者间差异无统计学意义（P=1．000）；ALND对照组与ALND示踪组上肢淋巴水肿发生率分别为31．25%（20/64）和6．45%（4/62）,两者间差异有统计学意义（χ2=12．560,P=0．000）。结论乳腺癌患者行SLNB或ALND的过程中可以行ARM。 SLNB过程中保留ARM淋巴结对降低术后上肢淋巴水肿发生率无意义,而ALND过程中保留ARM淋巴结可有效降低术后上肢淋巴水肿发生率。

Prevention of lymphedema of upper limb by axillary reverse mapping

Objective To explore the feasibility of conserving the axillary lymph nodes draining lymph from upper limb during axillary reverse mapping （ ARM） in the process of sentinel lymph node biopsy （ SLNB） or axillary lymph node dissection （ ALND） and its function in preventing upper limb lymphedema after breast cancer operation. Methods Totally 71 patients who underwent total mastectomy plus sentinel lymph node biopsy （SLNB group） and 134 patients who underwent modified radical mastectomy of breast cancer （ALND group） in our department from January 2012 to June 2013 were enrolled. SLNB group and ALND group were randomly subdivided into SLNB control group （n=36）, SLNB tracer group （n=35）, ALND control group （n=64） and ALND tracer group （n=70）, respectively. The operation of SLNB tracer group and ALND tracer group is similar to its control group, and additionally all patients in the tracer group underwent ARM to retain the axillary lymph nodes draining lymph from upper limb（ ARM lymph nodes） . The SLN and ARM lymph nodes were located as follows： ^99 Tc^m-Dx labeled isotope was subcutaneously injected around the mass of breast and in the medial side of affected upper limb 2 h before surgery, then 2 ml methylene blue was injected into affected upper limb 5 min before surgery for lymph node coloring of ARM. During the operation, isotope gamma probe was used to detect the radionuclide hot spots and locate sentinel lymph node. The gamma probe combined with methylene blue staining was applied to locate ARM lymph nodes. During the operation, the surgeon should pay attention to whether the blue stained lymph node and lymph duct by ARM were coincided with the stained sentinel lymph nodes, if not, preserve all dyed ARM lymph nodes and lymphatic vessels, otherwise sentinel lymph nodes and ARM lymph nodes are removed. After the operation, the number of resected lymph nodes, intraoperative blood loss, postoperative drainage volume, drainage time and operation time were compared between groups. The patients were followed up for 6 months for the prevention of upper limb lymphedema. Quantitative data was analyzed by t-test, qualitative data by chi-square test. Results In SLNB tracer group, ARM lymph nodes were identified in 26 （74. 29%, 26/35） of 35 patients who underwent SLN biopsy, and the coincidence of ARM lymph nodes with sentinel lymph nodes was seen in one patient whose ARM lymph nodes were resected in the process of SLNB. Therefore, the preservation rate of ARM lymph nodes in SLNB tracer group was 71. 43%（25/35）. In ALND tracer group, ARM lymph nodes were identified in 67 （95. 71%, 67/70） of 70 patients who underwent ALND, and the coincidence of ARM lymph nodes with sentinel lymph nodes was seen in 5 patients whose ARM lymph nodes were resected in the process of ALND. So the preservation rate of ARM lymph nodes in ALND tracer group was 88. 57%（ 62/70 ） . Comparing SLNB control group and SLNB tracer group, ALND control group and ALND tracer group, there was no significant difference in the number of resected axillary lymph nodes, intraoperative blood loss, postoperative drainage volume and drainage time （ t=-1. 136,-0. 570,0. 032,0. 903,P=0. 264,0. 570,0. 975,0. 370;t=1. 149,0. 416,1. 405,-0. 547,P=0. 253, 0. 678,0. 162,0. 585）. But the operation time in SLNB tracer group and ALND tracer group were longer than its control group [（90.26±6.04） min vs（86.61±5.62）min,t=-2.616,P=0.011;（112.24±7.94） min vs （92. 33±6. 88） min,t=-15. 399,P=0. 000]. After 6 months, follow-up, the incidence rate of upper limb lymphedema was 11. 11% （ 4/36 ） in the SLNB control group and 8. 00% （ 2/25 ） in SLNB tracer group respectively, and there was no statistically significant difference （P=1. 000）;the incidence rate of upper limb lymphedema was 31. 25% （ 20/64 ） in the ALND control group and 6. 45% （ 4/62 ） in ALND tracer group respectively, and there was statistically significant difference （χ^2=12. 560,P=0. 000）. Conclusions ARM is feasible during the process of SLNB or ALND in breast cancer patients. Preserving ARM lymph nodes in SLNB cannot reduce the incidence of postoperative upper limb lymphedema, while preserving ARM lymph nodes during ALND can effectively reduce postoperative upper limb lymphedema.