乳腺癌内乳区淋巴结治疗现状

乳腺癌内乳区淋巴结（IMN）是否需要治疗存争议,多数学者认为,对淋巴结造影证明有初始IMN引流的早期乳腺癌及原发灶位于乳腺内侧或中央区伴腋淋巴结阳性和因局部晚期伴淋巴结转移行乳腺切除术后的病人给予IMN照射是必要的。     

乳腺癌内乳区淋巴结诊疗的研究进展

内乳区淋巴结（internal mammary lymph node,IMLN）引流整个乳腺约25%的淋巴液,其转移状况为乳腺癌预后指标之一,也是确定分期和制定治疗方案的重要依据。内乳区前哨淋巴结活检术（internal mammary-sentinel lymph node biopsy,IM-SLNB）作为微创诊断技术实现对IMLN的评估,有助于为患者制定更为准确的个体化治疗方案。在乳晕周围腺体内增加注射部位和注射剂量的新型注射技术显著提高内乳区前哨淋巴结（internal mammary sentinel lymph node,IMSLN）检出率,使得常规开展IM-SLNB成为可能。随着内乳区淋巴引流规律的深入研究,新型注射技术引导下的IM-SLNB的准确性目前已得到初步验证。本文将对乳腺癌内乳区淋巴结诊疗的研究进展进行综述。      

乳腺癌术后内乳淋巴结放射治疗研究进展

近年来发表的几个有关乳腺切除术后放射治疗的随机分组研究发现，放射治疗可以增加有高危因素患者的生存率，引起了人们对乳腺癌术后局部或区域放射治疗的更大关注，目前认为，对于早期患者，内乳淋巴结照射的价值并不明确，而对内象和中央区病变、腋窝淋巴结阳性的患者，内乳淋巴结的术后放疗仍有争议。减少内乳区的照射范围，改进照射技术，可以减少心血管等系统的放射并发症。     

乳腺癌术中光动力辅助清除内乳区淋巴结的临床意义

乳腺癌内乳区淋巴结转移进行局部放射治疗,容易导致肺部的损伤;如果是左侧乳腺癌,局部放射治疗还会对心脏血管系统产生影响.为了探讨对乳腺癌内乳区淋巴结转移更加有效,副作用更小的方法,我们术中采用光动力疗法（photodynamic therapy,PDT）治疗有内乳区淋巴结转移的乳腺癌15例,获得了良好的临床效果,报告如下.     

乳腺癌内乳区淋巴结转移研究进展

 内乳区淋巴结的转移状况是乳腺癌的独立预后指标,也是乳腺癌分期的重要依据之一。内乳区淋巴结转移的患者预后较差。内乳区淋巴结的总体转移率为18 %～33 %,仅有内乳区淋巴结转移而无腋窝淋巴结转移的发生率为2 %～11 %,其转移受腋窝淋巴结状况、患者年龄、原发肿瘤的位置和特点等多因素影响。随着前哨淋巴结活检技术的不断发展,内乳区前哨淋巴结活检术可能以最小的风险评估内乳区淋巴结状况,并进一步完善乳腺癌的淋巴结分期,有助于为患者制定更为准确的个体化治疗方案。     

影像学检查内乳淋巴结阴性乳腺癌患者内乳淋巴结转移风险评估与内乳淋巴引流区照射取舍

目的探讨影像学检查内乳淋巴结(IMN)阴性的乳腺癌患者IMN转移的独立危险因素和术前IMN转移风险评估方法, 以指导不同IMN转移风险分层患者的内乳淋巴引流区放疗。方法 2012年1月至2019年10月山东省肿瘤医院手术治疗的301例乳腺癌患者, 术前CT和MRI均显示无IMN转移且行内乳前哨淋巴结活检和(或)内乳淋巴结清扫, 回顾性分析其临床病理资料。通过单因素分析和多因素logistic回归分析明确IMN转移的独立危险因素, 利用IMN转移的独立危险因素对患者进行IMN转移风险分层。结果 301例患者中, 43例检出IMN转移, IMN转移率为14.3%。单因素分析显示, 脉管瘤栓、孕激素受体(PR)表达状态、T分期和N分期与IMN转移有关(均P<0.05)。多因素logistic回归分析显示, 肿瘤位于内侧象限、PR阳性、腋窝淋巴结转移是IMN转移的独立危险因素(均P<0.05)。按照患者存在独立危险因素的情况进行IMN转移风险评估:有0个危险因素为低危组, 有1个危险因素为中危组, 同时有2～3个危险因素为高危组。按照此评估标准, 将301例乳腺癌患者分为低危组(有...     

乳腺癌内乳区淋巴结转移危险因素的Meta分析

目的 运用系统评价方式探讨乳腺癌内乳区淋巴结转移的危险因素,为内乳区放疗的决策提供循证依据。方法 在Medline、Embase以及Cochrane library数据库中检索截至2021年1月29日发表的与内乳区淋巴结转移相关文献。采用Review Manager 5.3软件进行统计分析。结果 涉及5 484例乳腺癌患者的13项研究纳入Meta分析。与内乳区淋巴结转移相关的因素为：年龄≤35岁(OR=1.83,95%CI=1.33～2.51)、年龄≤40岁(OR=2.93,95%CI=1.16～7.41)、内侧或中央肿瘤(OR=1.32,95%CI=1.11～1.57)、肿瘤>2 cm(OR=1.65,95%CI=1.14～2.41)、肿瘤>5 cm(OR=1.58,95%CI=1.25～2.00)、腋窝淋巴结转移(OR=5.27,95%CI=3.72～7.47)、≥4枚阳性腋窝淋巴结(OR=6.49,95%CI=5.12～8.23)、PR阴性(OR=1.35,95%CI=1.00～1.84)。结论 年轻女性、内侧或中央区肿瘤、较大肿瘤、腋窝淋巴结转移和PR阴性是乳腺癌内...     

乳腺癌内乳区淋巴结照射研究进展

乳腺癌内乳区淋巴结照射能够降低局部和远处复发并改善患者的生存,NCCN指南也在内乳区淋巴结照射方面进行了相应的更新,但由于内乳区淋巴结照射造成的心肺损伤不容忽视,因此需要提供更为准确的个体化内乳区放疗指征。内乳区前哨淋巴结活检能够以微创的方法评估内乳区淋巴结的转移情况,为内乳区淋巴结照射提供准确的放疗指征,使乳腺癌患者获得更大的生存获益。本文主要从内乳区放疗获益、不良反应控制及内乳区前哨淋巴结活检指导放疗的探讨等方面进行了综述。     

乳腺癌术后内乳淋巴结放射治疗研究进展

近年来发表的几个有关乳腺切除术后放射治疗的随机分组研究发现，放射治疗可以增加有高危因素患者的生存率，引起了人们对乳腺癌术后局部或区域放射治疗的更大关注。目前认为，对于早期患者，内乳淋巴结照射的价值并不明确。而对内象限和中央区病变、腋窝淋巴结阳性的患者，内乳淋巴结的术后放疗仍有争议。减少内乳区的照射范围，改进照射技术，可以减少心血管等系统的放射并发症。     

临床腋窝淋巴结阳性乳腺癌患者内乳区前哨淋巴结活检术研究*

目的：评估临床腋窝淋巴结阳性乳腺癌患者行内乳区前哨淋巴结活检术（IM-SLNB）的临床意义。方法：2013年6 月至2014年10月对山东省肿瘤医院乳腺病中心就诊的64例临床腋窝淋巴结阳性的原发性乳腺癌患者行前瞻性单臂入组研究,采取腋窝淋巴结清扫术,同时均应用新的核素注射技术进行IM-SLNB。结果：64例患者中内乳区前哨淋巴结（IM-SLN）显像为38例,显像率为59.4%（38/ 64）。 38例IM-SLN 显像患者中IM-SLNB 成功率为100%（38/ 38）,并发症发生率为7.9%（3/ 38）,IM-SLN 转移率为21.1%（8/ 38）。 肿瘤位于内上象限和腋窝淋巴结转移数目较多的患者,其IM-SLN 转移率较高（P < 0.001 和P = 0.017）。 患者临床获益率为59.4%（38/ 64）,其中12.5%（8/ 64）另接受了内乳区放疗、46.9%（30/ 64）避免了不必要的内乳区放疗。结论：临床腋窝淋巴结阳性的乳腺癌应进行IM-SLNB,尤其对于肿瘤位于内上象限及怀疑存在较多腋窝淋巴结转移数目的患者,以获得内乳区淋巴结的转移状态,指导乳腺癌患者内乳区放疗。     

胸腔镜内乳淋巴结清扫:一种针对乳腺癌内乳淋巴结的分期技术(英文)

Objective  

The aim of our study was to investigate the feasibility and safety of thoracoscopic internal mammary lymphadenectomy as a method to refine and thereby improve nodal staging in breast cancer.     

Distribution and depth of internal mammary lymph nodes in breast cancer

Lymphoscintigraphy was performed in 50 cases of breast cancer using 99mTc-colloid as a tracer. The results indicated that 277 lymph nodes, 128 on the right side and 149 on the left, were imaged. Most of the lymph nodes were located in the second and third intercostal spaces. The mean distance between these lymph nodes and mid line was 1.93 +/- 1.05 cm-2.70 +/- 0.93 cm. The mean depth was 2.42 +/- 0.52 cm-3.07 +/- 0.72 cm. It was over 4.0 cm in isolated cases. The lymph nodes which were not showed after repeated examination could have been involved by the cancer. Radionuclide lymphoscintigraphy, being safe, easily repeated and having low radiation dose and good image, is very useful for radiotherapy.     

Radiotherapy of MRI-detected involved internal mammary lymph nodes in breast cancer

Background

The internal mammary (IM) lymph node chain, along with the axillary nodal basin, is a first-echelon breast lymphatic draining site. A growing body of evidence supports irradiation of this region in node-positive breast cancer. This study evaluated the effectiveness of radiotherapy in treating magnetic resonance imaging (MRI)-detected abnormal IM lymph nodes in newly-diagnosed non-metastatic breast cancer.

Methods

A structured query was performed on an electronic institutional database to identify women with radiographic evidence of abnormal IM node(s) on breast MRI from 2005 to 2013. Manual review narrowed inclusion to patients with a primary diagnosis of non-metastatic breast cancer with abnormal IM node(s) based on pathologic size criteria and/or abnormal enhancement.

Results

Of the 7070 women who underwent pre-treatment MRI, 19 (0.3%) were identified on imaging to have a total of 25 abnormal pre-treatment IM lymph nodes, of which 96% were located in the first two intercostal spaces and 4% in the third space. A majority of the primary tumors were high-grade (94.7%) and hormone-receptor negative (73.7%), while 47.4% overexpressed HER-2/neu receptor. Axillary nodal disease was present in 89.5% of patients, while one patient had supraclavicular involvement. At a median follow-up of 38 months, 31.6% of patients had developed metastatic disease and 21.1% had died from their disease. Of the patients who received IM coverage, none had progressive disease within the IM lymph node chain.

Conclusions

Radiologic evidence of pre-treatment abnormal IM chain lymph nodes was associated with advanced stage, high grade, and negative estrogen receptor status. The majority of positive lymph nodes were located within the first two intercostal spaces, while none were below the third. Radiation of the IM chain in combination with modern systemic therapy was effective in achieving locoregional control without surgical resection in this cohort of patients.

     

Internal mammary lymph nodes and sentinel node biopsy in breast cancer.

The long-term follow-up of patients treated with extended radical mastectomy has proved that the internal mammary node (IMN) status is an important prognosticator of breast cancer. Patients with isolated IMN involvement seem to have the same outcome as those with limited axillary disease, and these patients may therefore be overstaged in the TNM system. Sentinel node biopsy (SNB) of IMNs may be an ideal staging procedure, but lymphatic mapping studies demonstrate that data from extended radical mastectomy series cannot be extrapolated to patients suitable for SNB, where the IMN involvement is <5% overall, and around 1% for IMN metastases without axillary disease. Current evidence does not allow internal mammary SNB to be recommended as a standard procedure, but as patients with IMN involvement may benefit from adjuvant systemic treatment, internal mammary SNB should be further studied in this context.     

The significance of the internal mammary lymph nodes in medially located breast cancer

The efficacy of adjuvant radiotherapy for medial breast cancers in Stage I or II disease was studied with a retrospective clinical analysis. All cases of breast cancer free of axillary node metastases at the time of standard or modified radical mastectomy were included. These were grouped by location and size of the primary tumor. There were 76 medial lesions, including those in the 6:00 or 12:00 axis. Seventeen of these had received postoperative radiation. Lateral tumors included 59. The size was based on the largest linear dimension and grouped less than or equal to 2 cm or greater than 2 cm. At the time of initial recurrence, all areas of metastases were determined. The data suggests that: (1) medial breast cancers have a greater rate of recurrence than lateral ones; (2) adjuvant radiation for medial lesions decreases that recurrence rate to the range of lateral tumors; (3) large lesions may have a greater chance for local recurrence as well as medial lesions of all sizes; and (4) the potential problems with local recurrence may be diminished with adequate radiotherapy as an adjunctive measure. When recurrence does occur, prior radiotherapy seems to delay the appearance of that recurrence.     

Adjuvant therapy for breast cancer patients with negative lymph nodes

Although approximately 50,000 cases of axillary node-negative breast cancer are diagnosed in the United States annually, the natural history of this heterogeneous disease is incompletely defined. Several series have reported 5-year relapse-free and overall survival ranging from 56% to 89% and 74% to 92%, respectively. Tumor necrosis and anaplastic morphology correlate with early treatment failure. The estrogen receptor and size of the primary tumor are probably also predictive of clinical course. Thus far, perioperative cyclophosphamide is the only systemic treatment demonstrated to prolong survival in a statistically significant fashion. Several ongoing studies are investigating the role of tamoxifen or cytotoxic chemotherapy, or both, in prospective randomized trials. However, too few patients with insufficient follow-up have been analyzed to permit definitive conclusions or recommendations.     

Extra-axillary sentinel lymph nodes in breast cancer

Background  Extra-axillary locations are known sites of lymph node metastases in patients with carcinoma of the breast. Methods  A technique utilizing a gamma probe was used to identify hot spots representing sentinel nodes residing in either axillary or extra-axillary locations in 680 patients with operable, clinically node-negative breast cancer. All identified sentinel nodes were excised. Results  Results showed that extra-axillary hot spots were found in 6.5% of patients. This rate increased to 14.8% if patients were injected with 8.0 ml unfiltered Technetium-99m-Sulfur colloid. Extra-axillary metastatic disease was identified in 6.8% of patients with extra-axillary hot spots. In patients with extra-axillary drainage, pathologically-positive nodes were exclusive to extra-axillary sites (ie, no axillary metastases) in 4.5% of cases. Factors found to increase the likelihood of identifying extra-axillary hot spots included; an increased volume of injection, medial or central tumor locations and T3 primary tumors. Conclusion  Gamma probe-guided techniques can identify extra-axillary sentinel nodes, which are at risk for harboring metastatic disease. Removal of these nodes can be done with little morbidity and may improve staging in the individual patient.