乳腺癌再次腋窝淋巴结清扫36例分析

目的探讨乳腺癌手术后腋窝淋巴结转移以及不规范性手术后残留实施再手术的可行性。方法制定纳入标准,回顾性分析我院2001年6月至2010年8月间再次腋窝淋巴结清扫手术的36例乳腺癌患者的临床病理资料,再次手术围手术期综合性治疗措施及其术后1、3、5年随访资料。结果全组非规范性手术19例占52.78%(原腋窝残留包块再次清扫11例,胸壁复发包块切除及腋窝淋巴结清扫8例)。原改良根治术11例、Halsted术6例患者术后单纯腋窝复发12例(33.33%),腋窝及胸壁复发性包块5例(13.89%);实施腋窝淋巴结清扫或加胸壁包块切除术。全组病例腋下共检出346枚淋巴结,平均17.78枚(7～35枚),阳性淋巴结58枚占16.76%(1～13枚),部分病例有淋巴结融合。再次手术后均给予4～6疗程化疗或放疗,少数辅以免疫治疗等综合性治疗措施。术后1年内死亡2例,3年内10例,5年15例其1,3,5年生存率分别为94%、72%、58%。结论规范性手术是防止乳腺癌术后复发转移的关键措施,对局部复发、腋窝淋巴结转移可切除患者再次手术有助于控制局部病情的发展,再次手术围手术期规范性治疗可以改善患者的生存质量。     

A case of non-palpating breast cancer with huge lymph node metastasis

We report a case of non-palpating breast cancer with huge lymph node metastasis. The patient was a 58-year-old woman who had a huge tumor at her right armpit. The tumor was 4 cm in diameter. Aspiration biopsy cytology for the tumor was performed. The diagnosis is Class V. Mammography showed an ill-defined mass at her right breast. Ultrasonography revealed a low echoic mass at the C area of her right breast. A core needle biopsy for the breast tumor led to a diagnosis of an invasive ductal carcinoma positive for estrogen receptor and progesterone receptor, and negative for HER2/neu protein expression. She received 4 cycles of CEF (E: 60 mg/tri-weekly) plus 12 cycles of paclitaxe (l80 mg/weekly). After chemotherapy, she received muscle preserving mastectomy plus axillary lymph nodes dissection. In histopathology, there were no carcinoma cells in resected breast tissue and resected lymph nodes. Therefore, the effect of chemotherapy was diagnosed as a pathological complete response. After operation, she was administered aromatase inhibitor. The patient has been well and remained disease-free during a follow-up period of 6 years.     

Unknown primary carcinoma, diagnosed as inflammatory breast cancer,and successfully treated with trastuzumab and vinorelbine

Occult breast cancer presenting with axillary lymph node metastases is uncommon, and inflammatory breast cancer (IBC), as a subtype, is quite rare. Here we describe a case of IBC, which arose as an unknown primary carcinoma; the patient presented with axillary lymph node metastasis, and was successfully treated with trastuzumab and vinorelbine. Specifically, a 55-year-old woman presented with right axillary lymphadenopathy. Although she underwent various examinations, the primary site of the disease was not revealed. Axillary lymph node dissection was performed, and the lesion was diagnosed as a poorly differentiated adenocarcinoma. The patient chose to be treated by alternative medicine. About 6 months later, she was referred to our hospital, due to marked bilateral neck and axillary lymph node swelling. She presented withdiffuse right breast enlargement, redness, and peau d’orange. Computed tomography (CT) of the breast showed skin thickening and swelling of the right breast.F-18 Fluorodeoxyglucose positron emission tomography (FDG-PET) showed FDG uptake in the right breast. The patient was clinically diagnosed with IBC. Because overexpression of the human epidermal growth factor receptor 2 (HER2) was found in the specimen from her right axillary lymph node, she was treated with trastuzumab and vinorelbine. Two months after the start of chemotherapy, CT revealed a complete response in the lymph nodes, and the skin thickening and parenchymal edema of the right breast had improved. FDG-PET was also performed at this time, and revealed no FDG uptake in either the right breast or the lymph nodes.     

Recurrent breast cancer successfully treated with a weekly dose of paclitaxel--a case report

The patient was a 46-year-old women who was treated for axillary lymph node recurrence of breast cancer by a variety of methods, including surgery, chemotherapy, and radiotherapy, but who experienced recurrences in the cervical and mediastinal lymph nodes and skin, and developed hydrothorax and ascites. Although the recurrent foci responded to 4 cycles of CAF chemotherapy, there was concern that the foci would become refractory or resistant to chemotherapy. The administration of paclitaxel was therefore initiated. The patient received a dose of paclitaxel once a week for 5 consecutive weeks followed by a 1-week recovery period (one cycle). After two cycles of the paclitaxel treatment, a marked shrinkage of the lymph nodes and complete resolution of the hydrothorax and ascites were observed. Even though the patient exhibited bone marrow suppression and G-CSF was administered twice for neutropenia, there were no adverse effects except mild alopecia, again suggesting the possibility that paclitaxel is effective chemotherapy for recurrent breast cancer.     

A case of breast cancer with postoperative metastasis to the supraclavicular lymph nodes-recurrence-free survival achieved by surgical excision following chemotherapy

The patient, a 58-year-old woman, underwent a partial excision of the right breast and an axillary lymph node dissection in October 2004. The histopathological findings were: solid tubular carcinoma with metastasis to 17 axillary lymph nodes; triple negative-type breast cancer. As adjuvant therapy, FEC60 was administered 6 times, followed by radiotherapy applied to the residual breast and the right supraclavicular fossa. In Novermber 2007, she noted a tumorous growth above the right clavicle. The pathological diagnosis via fine needle biopsy was adenocarcinoma. An oral antineoplastic agent was given for about 6 months, but did not alter the lymph nodes. No distant recurrence was noted during this time. In August 2008, the right supraclavicular lymph nodes were dissected. The patient has been under observation without treatment, but no signs of recurrence have been noted. It was thought that excision of the recurrent supra-clavicular lymph nodes should be considered after careful examination in some individual cases.     

A case of breast cancer diagnosed by inguinal lymph node metastasis

We describe a case of a 58-year-old woman with right inguinal lymph node swelling and a T1 tumor in the right breast. She was referred with an 18-month history of the former complaint and a six-month history of the latter. Excisional biopsy of the inguinal lymph node revealed breast cancer metastasis. Radiographical examination showed no metastases to the lungs, liver or bone. Modified radical mastectomy was performed. Histological examination revealed solid tubular carcinoma, PT2, PM (axillary lymph node metastases 4/16), stage IV. Estrogen and progesterone receptors were negative. Three cycles of postoperative cyclophosphamide, adriamycin and 5-fluorouracil (CAF) chemotherapy were given, and the right inguinal area was irradiated with 40 Gy. The patient complained of swelling in both legs three years after surgery. Computed tomography revealed marked lymph node swellings in the pelvic cavity. She died six months later. Inguinal lymph node metastasis from breast cancer is very rare, although distant lymph node metastasis in the cervix occurs frequently. This case should help clarify how breast cancer metastasizes to distant lymph nodes.     

女性乳腺癌患者229例新辅助化疗的影响因素

目的 分析女性乳腺癌患者实施新辅助化疗的临床影响因素,为是否进行新辅助化疗及化疗方案选择提供依据.方法 根据229例女性乳腺癌患者术后雌激素受体(ER)、C-erhB-2、p53蛋白表达状态,分为阳性组和阴性组,对相关临床因素分别进行多因素非条件的Logistic回归分析.结果 月经状况为影响乳腺癌ER表达状态的临床因素;腋窝淋巴结转移、月经状况、乳腺增生史是影响乳腺癌C-erbB-2表达的临床因素;年龄、肿块大小、腋窝淋巴结转移、月经状况是影响乳腺癌p53表达状态的临床因素.结论 月经状况、腋窝淋巴结转移、年龄、肿块大小、乳腺增生史对决定乳腺癌患者是否进行新辅助化疗以及选择何种化疗方案具有一定的指导价值.     

Two cases of recurrent breast cancer with regional lymph node metastases showing a complete response to trastuzumab and paclitaxel treatment

We report two cases of recurrent breast cancer with regional lymph node metastases that responded completely to treatment with trastuzumab and paclitaxel. Case 1: A 52-year-old woman, who presented with left breast cancer, underwent mastectomy and axillary lymph node dissection in July 2002. Pathological findings were as follows: invasive ductal carcinoma (scirrhous type), 2.2 cm in size, histological grade 3, positive invasion to the lymphatic and blood vessels, negative nodal status (0/11), negative ER/PgR status, and overexpression of HER 2/neu. Left axillary lymph node metastasis was noted after five months, ie, in December 2002. Four cycles of chemotherapy with doxorubicin and cyclophosphamide were administered from January 2003; however, they were not effective. The patient showed a complete response after three months of chemotherapy with trastuzumab and paclitaxel. This treatment was stopped in September 2003. She has maintained a complete response for two and a half years and was not administered any further treatment as of February 2006. Case 2: A 59-year-old woman, who presented with right breast cancer, underwent mastectomy and axillary lymph node dissection in May 2002. Pathological findings were as follows: invasive ductal carcinoma (scirrhous type), 1.8 cm in size, histological grade 2, positive invasion to the lymphatic and blood vessels, negative nodal status (0/5), positive ER and uncertain PgR status, and overexpression of HER 2/neu. She had received adjuvant hormonal therapy with tamoxifen; however, a right supraclavicular lymph node metastasis was noted in October 2004. Treatment with exemestane was not effective. However, a complete response was observed with trastuzumab and paclitaxel for four months. She has maintained a complete response for six months and was not administered any further treatment as of February 2006.     

Complete axillary conversion after neoadjuvant chemotherapy in locally advanced breast cancer: a step towards conserving axilla?

OBJECTIVES: This study was designed to assess the clinical, sonographic and histopathological response of axillary lymph node metastasis to neoadjuvant chemotherapy in patients with locally advanced breast cancer. MATERIAL AND METHODS: Forty patients with locally advanced breast cancer (LABC) with clinically palpable or sonographically detectable axillary nodes were studied. FNAC of the primary tumor and axillary nodes was done and patients were started on neoadjuvant chemotherapy. Axillary nodes were assessed clinically and sonographically for response after 3 cycles of chemotherapy. All patients underwent total mastectomy with axillary clearance and the lymph nodes in the specimen were examined for metastasis. RESULTS: 47% patients had complete clinical nodal response, while 19% showed complete sonographic response. Complete pathological nodal response was documented in 22% of patients. Ultrasonography was found to be more sensitive than clinical examination in assessing complete nodal response. 10% of the patients had complete pathological response of both primary tumor and axillary nodes. There was significant correlation between pathological response of primary tumor and lymph nodes (P=0.004). Patients with complete sonographic or clinical response were found to have no or minimal residual disease in axilla and hence axillary dissection may be avoided in them.     

A case of advanced gastric cancer resistant to S-1 successfully treated with weekly administration of paclitaxel

A 62-year-old female was diagnosed with type 2 advanced gastric cancer in May 2003. Pathological examination showed a poorly differentiated carcinoma. Computed tomography (CT) revealed paraaortic lymph node metastasis, duodenal metastasis and ascites due to peritoneal dissemination. Chemotherapy with CDDP+S-1 was started and continued. After the chemotherapy, there were progressive diseases. Therefore, paclitaxel (PTX) was administered at a dose of 80 mg/m2/day for 3 weeks followed by a week rest. Clinical symptoms were relieved, and CT scan revealed metastatic lymph nodes were reduced after 4 cycles. After 13 cycles, MRI revealed a solitary brain mass was detected. She was resected for a right temporal-occipital brain metastatic tumor, and local cerebral irradiation was performed. After this operation, she was diagnosed with brain metastasis from advanced gastric cancer. The procedure was interrupted for about 6 months. After rehabilitation, PTX treatment was restarted as 14th cycle. She has survived without recurrence more than 30 cycles after the resection. A weekly administration of PTX may be a promising regimen as second-line chemotherapy for S-1 resistant recurrent gastric cancer.     

A case of malignant epithelioid schwannoma in the triceps muscle of the arm

A patient with malignant epithelioid schwannoma in the right triceps muscle of the arm is reported. This tumor was mainly composed of plump epithelioid cells, which showed focal necrosis and nuclear arrangement in palisades. The structures and the presence of long cytoplasmic processes, discrete basal lamina, and long spaced collagen on electron microscopic examination suggested schwannian derivation of the tumor. The tumor exhibited metastasis to the axillary lymph nodes. However, no recurrence was observed a year after surgical removal, irradiation, and chemotherapy.     

前哨淋巴结活检术在早期乳腺癌保乳术中的应用

目的探讨前哨淋巴结活检术（sentinellymph node biopsy,SLNB）在早期乳腺癌保乳术中的应用效果。方法回顾性分析56例pT1.2N0M0期乳腺癌行保乳术＋前哨淋巴结活检术的临床资料。56例SLN阴性,未行腋窝淋巴结清扫术（axillary lymph node dissection,ALND）。术后辅以化疗、放疗,激素受体阳性患者行内分泌治疗。结果56例成功施行保乳手术,保乳术后双乳对称。SLNB替代ALND者各项术后并发症少。中位随访时间36个月（1～72个月）,1例发现局部复发,行乳腺癌改良根治术时发现腋窝淋巴结转移;1例发现腋窝淋巴结复发转移。结论SLNB可以缩小手术范围,减少术后并发症,保留腋窝形态,提高保乳质量。     

Surgical treatment of carcinoma of the breast. V. Changes in patient population and therapeutic modalities at a metropolitan hospital (1971-1980)

This is a retrospective study of 408 patients who had mastectomy for carcinoma of the breast during 1971-1980. Over these 10 years, we have had a significant increase in Hispanic patients. Although the mean size of breast tumors among the Hispanic patients was smaller than that of our black patients, Hispanic patients are more likely to have higher numbers of positive axillary lymph nodes. Similar to the nationwide trend, over 90% of the patients had modified radical mastectomy in recent years, and adjuvant systemic chemotherapy has replaced postoperative radiotherapy for patients with axillary metastasis. Postmastectomy actuarial 5-year relapse rates of our patients with none or 1-3 positive axillary nodes were quite similar. Among patients with 1-3 positive axillary nodes, year of diagnosis and whether postoperative radiotherapy or chemotherapy was added or not did not affect disease-free probability. However, among patients who had four or more positive axillary nodes, those who were admitted after 1976 and who received systemic chemotherapy (90% had CMF) had a much lower probability of developing recurrence.     

Metaplastic carcinoma with predominant chondrosarcoma of the right breast

A 45-year-old female presented with complaint of a lump in the right breast for the last 6 months. Excisional biopsy had been performed outside our institution, which was suggestive of a pure mammary chondrosarcoma. Modified radical mastectomy of the right breast was performed and histopathology was suggestive of a pure mammary chondrosarcoma of the right breast. One axillary lymph node was positive for metastasis, the rest of the lymph nodes were free of metastasis. Immunohistochemistry was suggestive of a metaplastic carcinoma with a predominant chondrosarcoma in the right breast. Postoperative radiotherapy was given to the patient with a further plan of chemotherapy.     

A radical resection of non-small cell lung cancer invading chest wall with ipsilateral axillary lymph node metastases

A 41-year-old man who had non-small cell lung cancer invading his right 3rd, 4th and 5th ribs with hilum lymph node swelling(cT3N1M0, cStage III A), received chemoradiation therapy, cisplatin(CDDP)/docetaxel, and 2 Gy/Fr of irradiation prior to surgery. But the therapy was discontinued due to interstitial pneumonitis on day 24, during 28 Gy of radiation. At that time, a PET-CT scan revealed the accumulation of FDG in the primary tumor, hilar lymph node, and one of the ipsilateral axillar lymph nodes, in which cancer cell presence was proven by aspiration needle cytology. We organized a radical operation even though the node status was classified to cStage IV, because ipsilateral axillary lymph nodes may be regarded as regional nodes for tumors invading the chest wall. Right upper lobectomy and chest wall resection were performed, and the ipsilateral hilar, mediastinal, and axillary lymphnode were dissected. Pathological findings showed no active cancer cell in the primary lesion and hilar lymph nodes(Ef. 3), but obvious metastasis in one of the axillary lymph nodes(pT0N0M1b, pStage IV). The patient received adjuvant chemotherapy(CDDP/vinorelbine), and is alive and tumor-free 10months after the resection.     

Metachronous secondary primary occult breast cancer initially presenting with metastases to the contralateral axillary lymph nodes: report of a case

We report a rare case of a 64-year-old female with metachronous secondary primary left occult breast cancer initially presenting right axillary lymph node metastases. The patient, who had received breast-conserving therapy for left breast cancer at another hospital about 4.5 years ago, came to our hospital complaining of right axillary node swelling. After both breast and systemic examination, she received complete right axillary lymph node dissection. Just after the operation, she was diagnosed with right occult breast cancer by a review of the right axillary lymph nodes and previous left breast cancer. She was followed by radiation and systemic chemoendocrine therapies. One year after axillary lymph node dissection, mammography and ultrasonography showed a new lesion in her left breast. Core needle biopsy revealed similar findings to right axillary lymph node metastasis. After salvage surgery, the diagnosis was revised. We recommend that patients without clinical findings except for axillary lymph node metastasis, especially post-breast-conserving surgery followed by radiation therapy, should be considered not only as having ipsilateral but also contralateral occult breast cancer. If there is no evidence of a primary lesion, axillary lymph node dissection needs to be carried out, and the patient should be offered the choice of radiation therapy or mastectomy followed by proper systemic therapy.     

Axillary metastasis as first symptom of occult breast cancer: a case report

Axillary lymph node metastasis from an occult breast carcinoma is a rare occurrence. We report this condition in a 59-year-old woman who presented with a swelling in the right axilla. No breast mass was clinically evident. Mammography, ultrasonography and multiple random fine-needle breast biopsies yielded no pathological findings. No extramammary primary lesions were present. Axillary sampling was performed and histological examination revealed the presence of metastatic adenocarcinoma in three of the 12 dissected lymph nodes. Estrogen receptors were positive and immunohistochemistry pointed to a breast origin. All these data were suggestive of occult breast cancer. The patient refused any further treatment but accepted clinical and radiological follow-up. Eight years later mammography revealed in the same breast a 10-mm nodule containing microcalcifications, which was not evident at physical examination. The patient underwent a lumpectomy. Intraoperative histology was positive for breast carcinoma and complete axillary clearance was performed. Histological examination revealed a lobular invasive breast carcinoma and the presence of micrometastasis in one of the 23 removed lymph nodes. The patient was given radiotherapy to the breast and axilla and tamoxifen. At present, one year after the appearance of the primary tumor, she is free of disease. Based on this case report we suggest an eclectic approach in the management of patients with axillary metastasis from occult breast cancer, depending on the clinical, pathological and biological findings.     

A long-surviving patient with Stage IV breast cancer with no recurrence after combined therapy of medroxy progesterone acetate (MPA) and intra-arterial infusion chemotherapy

The patient is a 42-year-old woman who had advanced (Stage IV) right breast cancer with contralateral supraclavicular lymph node metastasis. She was treated with the combined use of MPA and the intra-arterial infusion chemotherapy. We administered EPI into the left subclavian artery and the right internal thoracic artery. Total dose of EPI was 210 mg. MPA was administered po at 1,200 mg/day daily. During the chemotherapy, she experienced only grade 2 alopecia. After the chemotherapy, the regressive change was noted in the primary lesion. The clinical response was evaluated CR. She underwent right modified mastectomy and the resection of contralateral supraclavicular lymph nodes. Although the clinical response was very good, the pathological effect was only Grade 1b. Eight years have passed since the operation, and the patient is still alive with no sign of recurrence. It is suggested that this combination therapy may be useful for advanced breast cancer and the like.     

Axillary sentinel lymph node biopsy after neoadjuvant chemotherapy for carcinoma of the breast

BACKGROUND:

The timing and accuracy of axillary sentinel lymph node biopsy (SLNB) in patients who are receiving neoadjuvant chemotherapy (NACT) for breast cancer are controversial. To examine the accuracy of SLNB after NACT, the authors performed SLNB after chemotherapy on all of patients who received NACT at their institution starting in January 1997.

METHODS:

Seventy‐nine women who underwent NACT between 1997 and 2008 comprised this study and were divided as follows: 4 women had stage I disease, 60 women had stage II disease, and 15 women had stage III disease, including 10 women who had multicentric disease. Thirty‐nine women (49.4%) had clinical evidence of axillary metastasis (N1‐N2) at the time of diagnosis. The regimen, the duration of treatment, and the number of cycles of NACT depended on clinical response. The choice of breast conservation therapy or mastectomy was based on the patient's response to treatment and patient preference. All patients underwent SLNB after NACT.

RESULTS:

Seventy‐three patients underwent breast conservation therapy, and 6 patients underwent mastectomy. Sentinel lymph nodes were identified in 98.7% of patients (in 1 patient, SLNB failed to capture 1 proven axillary metastasis), and 29 patients underwent full axillary lymph node dissection. Fourteen patients (17.7%) had no residual carcinoma (invasive or ductal carcinoma in situ) in their breast, 5 patients (6.3%) had residual ductal carcinoma in situ (only), and 60 patients (75.9%) had residual invasive carcinoma. One false‐negative SLNB was reported in the group of 23 patients who underwent full axillary dissection after a negative SLNB. No patient had a subsequent axillary recurrence.

CONCLUSIONS:

SLNB after NACT was feasible in virtually all patients and accurately selected patients who required complete level I and II axillary dissection. NACT frequently downstaged the axilla, converting patients with N1‐N2 lymph node status to N0 status and also avoiding full axillary dissection in these patients. Cancer 2010. © 2010 American Cancer Society.     

右肺PN2非小细胞肺癌术后无复发转移及预后因素探讨

 目的分析影响右肺PN2非小细胞肺癌术后无复发转移及预后的因素,探讨最佳治疗方案。方法分析1999年9月～2002年3月24例术后病理确诊的右肺PN2非小细胞肺癌,随机分为辅助化疗组(术前或术后)与直接手术组,手术均为完全性切除,采用右肺叶或右全肺+系统性纵隔淋巴结清扫术。术后标本采用免疫组化法行抑癌基因p53,癌基因HER2,表皮生长因子受体(EGFR)等基因表达检测。分析病理分型,手术方式,术前辅助治疗,基因表达,淋巴结转移区域,肺门淋巴结转移,最高纵隔淋巴结转移等因素对预后的影响。结果24例患者2年生存率46%。辅助化疗,EGFR为影响术后无复发转移的重要因素。KaplanMeier生存分析显示辅助化疗与生存有影响,多变量COX回归分析未发现影响预后的独立因素。结论以手术为主的综合治疗是右肺PN2非小细胞肺癌较好的治疗模式。EGFR高表达与术后复发转移有关,对此类患者术后是否应加用靶点治疗需进一步的研究。