点穴分筋拨络法治疗乳腺癌术后腋网综合征的疗效观察

目的:拟采用点穴分筋拨络法治疗乳腺癌术后腋网综合征,运用中医临床理论为该病的认识及防治提供临床依据。方法:将2019年10月至2021年10月我院乳腺外科存在腋网综合征的患者82例随机分为两组,治疗组41例,对照组41例。治疗组由专门从事传统康复的治疗师予以点穴分筋拨络法进行治疗,并提供健康教育;对照组不进行手法治疗,仅给予健康教育,两组患者分别在干预前和干预后3周、6周进行随访,对比两组患者在肩关节活动度、视觉模拟评分（visual analogue scale/score,VAS）、上肢残疾功能评分(disabilities of arm,shoulder and hand scale,DASH)以及Barthel指数方面的改变情况。结果:治疗组患者在3周、6周随访时肩关节外展、前屈活动度,DASH评分与对照组相比均有明显改善,且具有统计学差异（P＜0.05）;治疗组肩关节后伸、内收以及Barthel指数评分、VAS评分在3周随访时与对照组相比无统计学差异（P＞0.05）,6周随访时差异具有统计学意义（P＜0.05）。结论:点穴分筋拨络法能够改善乳腺癌术后腋网综合征患者肩关节活动受限,缓解患肢疼痛,提高上肢功能及生活自理能力。     

分子分型与乳腺癌新辅助化疗腋窝降阶梯手术的研究

  目的  探讨临床淋巴结阴性患者新辅助化疗（neoadjuvant chemotherapeutic,NAC）与前哨淋巴结活检（sentinel lymph node biopsy,SLNB）的最佳时机,评估临床淋巴结阳性患者行NAC后腋窝降阶梯手术可能获益人群。  方法  回顾性分析2010年10月至2017年11月山东大学附属山东省肿瘤医院收治206例行NAC患者的临床病理资料,分析分子分型与腋窝淋巴结病理完全缓解（axillary nodal pathologic complete response,apCR）的关系。  结果  206例行NAC患者中183例为临床淋巴结阳性,apCR为33.3%（61/183）。Luminal型HER-2阴性患者apCR为19.8%（17/86）,与HER-2阳性行靶向治疗患者apCR的62.1%（18/29）、HER-2阳性未行靶向治疗的34.5%（10/29）及三阴性乳腺癌（triple-negative breast cancer,TNBC）的41.0%（16/39）相比显著降低,差异具有统计学意义（P < 0.001）。23例临床淋巴结阴性患者行NAC后前哨淋巴结阳性率为26.1%（6/23）,Luminal型HER-2阴性、TNBC和HER-2阳性患者前哨淋巴结阳性率分别为36.4%（4/11）、25.0%（1/4）和12.5%（1/8）。  结论  分子分型与行NAC后的apCR相关。对临床淋巴结阴性的Luminal型HER-2阴性患者,NAC前行SLNB可避免腋窝淋巴结清扫,对临床淋巴结阴性的TNBC和HER-2阳性患者,建议NAC后行SLNB。临床淋巴结阳性且行NAC降期转阴的TNBC和HER-2阳性患者,从NAC后的腋窝降阶梯手术中可能获益更多。      

Incidence and risk factors for Chyle leak after pancreatic surgery for cancer: A comprehensive systematic review

BackgroundChyle leak (CL) is a clinically relevant complication after pancreatectomy. Its incidence and the associated risk factors are ill defined, and various treatments options have been described. There is no consensus, however, regarding optimal management. The present study aims to systematically review the literature on CL after pancreatectomy.MethodsA systematic review from PubMed, Scopus and Embase database was performed. Studies using a clear definition for CL and published from January 2000 to January 2021 were included. The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score was used to assess methodological quality.ResultsLiterature search found 361 reports, 99 of which were duplicates. The titles and abstracts of 262 articles were finally screened. The references from the remaining 181 articles were manually assessed. After the exclusions, 43 articles were thoroughly assessed. A total of 23 articles were ultimately included for this review. The number of patients varied from 54 to 3532. Incidence of post pancreatectomy CL varied from 1.3% to 22.1%. Main risk factors were the extent of the surgery and early oral or enteral feeding. CL dried up spontaneously or after conservative management within 14 days in 53% to 100% of the cases.ConclusionsThe extent of surgery is the most common predictor of risk of CL. Conservative treatment has been shown to be effective in most cases and can be considered the treatment of choice. We propose a management algorithm based on the current available evidence.     

乳腺癌保守手术治疗后同侧局部复发危险因素的探讨

目的 探讨临床、病理因素及辅助治疗对乳腺癌保守手术合并放疗后同侧局部复发的影响。方法 应用Kaplan-Meier方法和Cox比例风险模型对126例保乳术合并放疗的早期乳腺癌患者进行回顾性分析。结果 多因素条件下56岁以上乳腺癌患者保乳手术合并放疗后同侧局部复发的风险比为2.17,EIC阳性的风险比为3.46,病灶切缘不净为1.68,无辅助TAM治疗组的风险比为1.52。结论 年龄、EIC及切缘情况对保乳术合并放疗后同侧局部复发有重要的影响,同时辅助TAM治疗可以减少局部复发的风险。     

Advances in axillary surgery for breast cancer 2019

Over the last 25 years, modifications in systemic and radiation therapy for breast cancer have led to significant reductions in the risk of regional recurrence. During the same time, surgeons have demonstrated that it is safe to forego axillary dissections for patients with low burdens of axillary lymph node disease. When these advances are added to those by reconstructive microsurgeons, the promise of reducing morbidity rates from posttreatment lymphedema seems within our grasp.     

The upper‐limb volumetric changes in breast cancer survivors with axillary web syndrome

Whether upper‐limb swelling is associated with axillary web syndrome (AWS) is unknown. We recruited unilateral breast cancer (BC) patients who were scheduled for surgical intervention and lymph node dissection. The pre‐operative assessment and post‐operative assessment 3–4 weeks after surgery evaluated the upper‐limb circumferential measurements, segmental limb volume, pain scores, grasp, shoulder range of motion (ROM), shoulder muscle power and quality‐of‐life scores. In the control group, the peri‐elbow volume and upper‐arm volume were significantly higher post‐operatively than pre‐operatively. In the AWS group, no significant difference was found. In comparison with the control group, the AWS group had significantly more pain, less active ROM in shoulder abduction and a lower upper‐limb volume at 0–10 cm proximal to the lateral epicondyle. The incidence of lymphedema was 9.9% and was not associated with AWS. AWS is a common morbidity of lymph node dissection and causes significant pain and restricted shoulder abduction in the affected limb in BC survivors. This study is the first to investigate post‐operative upper‐limb volumetric changes in BC survivors with and without AWS. Our findings are of great value for the clinical effect of AWS in BC survivors, for patient education, and for developing diagnostic tools for detecting AWS.     

Development of a screening instrument for risk factors of persistent pain after breast cancer surgery

Background:

Persistent postsurgical pain can have a significant effect on the quality of life of women being treated for breast cancer. The aim of this prospective study was to develop a screening tool to identify presurgical demographic, psychological and treatment-related factors that predict persistence of significant pain in the operated area after 6 months from surgery.

Methods:

Background and self-reported questionnaire data were collected the day before surgery and combined with treatment-related data. Pain in the operated area was assessed 6 months after surgery with a questionnaire. The Bayesian model was used for the development of a screening tool.

Results:

Report of preoperative chronic pain, more than four or more previous operations, preoperative pain in the area to be operated, high body mass index, previous smoking and older age were included in the six-factor model that best predicted significant pain at the follow-up in the 489 women studied.

Conclusion:

A six-factor risk index was developed to estimate the risk of developing significant pain after breast cancer surgery. Neither treatment- nor mood-related variables were included in the model. Identification of risk factors may lead to prevention of persistent postsurgery pain. This tool could be used for target prevention to those who are at the highest risk of developing persistent postsurgery pain.     

乳腺癌术后发生下肢深静脉血栓的危险因素及血栓风险评估

  目的   研究乳腺癌患者术后发生下肢深静脉血栓(deep venous thrombosis,DVT)的危险因素,分析血栓风险评估模型的临床价值。  方法  回顾性分析2013年1月至2016年6月天津医科大学肿瘤医院703例术后发生血栓的患者为血栓组,通过系统抽样法选取对照组706例,分析乳腺癌患者术后发生下肢DVT的危险因素,并比较Khorana及Caprini血栓风险评估模型的预测价值。  结果  比较血栓组与对照组的年龄、BMI≥30 kg/m2、手术切除活检确诊、接受新辅助化疗、手术时间>2 h、治疗前脂蛋白a(Lpa)>475.5 mg/L、血浆蛋白C(PC) < 102.5%、血浆凝血因子Ⅷ(FⅧ)>129.8%及D-二聚体(D-D)>289.99 ng/mL,差异具有统计学意义(P < 0.05)。两组患者的Khorana风险评估模型进行比较,差异无统计学意义(P = 0.207);两组患者的Caprini风险评估模型进行比较,差异具有统计学意义(P < 0.001)。  结论   年龄、BMI≥30 kg/m2、手术切除活检确诊、接受新辅助化疗、手术时间>2 h、治疗前Lpa>475.5 mg/L、PC < 102.5%、FⅧ>129.8%及D-D>289.99 ng/mL是乳腺癌术后发生下肢DVT的独立危险因素,Caprini评估模型可能导致乳腺癌患者血栓风险评估偏高,应进一步探究更加适合乳腺癌患者血栓的风险评估模型。      

结直肠癌腹腔镜手术患者术后肠梗阻发生率及影响因素分析

目的分析腹腔镜根治术治疗结直肠癌后的肠梗阻发生率并探讨其影响因素。方法回顾性分析北京市第一中西医结合医院2010年3月至2018年9月收治的923例接受腹腔镜根治术的结直肠癌患者的资料。计算患者术后肠梗阻发生率,并按照其肠梗阻发生情况,将患者分为梗阻组和未梗阻组,比较两组患者的临床资料,采用多因素Logistic回归分析影响患者术后肠梗阻的因素。结果923例患者中有45例术后30 d内发生肠梗阻,占488％,为梗阻组;未梗阻组878例。两组患者的年龄、性别、肿瘤部位、TNM分期、肿瘤分化程度、手术方式、吸烟史、术前低蛋白血症及腹部手术史比较差异均有统计学意义。Logistic多因素回归分析示年龄≥65岁、男性、直肠肿瘤、TNM分期Ⅲ～Ⅳ期、术中中转开腹、术前低蛋白血症是影响结直肠癌患者行腹腔镜手术后发生肠梗阻的独立危险因素。结论结直肠癌患者行腹腔镜手术后肠梗阻的发生受患者年龄、性别、肿瘤部位、TNM分期、手术方式及术前合并症等多种因素影响。     

Patients' and surgeons' perspectives on axillary surgery for breast cancer.

AIMS: The objectives of this study were to compare the postoperative morbidity of Sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) and to compare the views of surgeons and patients regarding postoperative morbidity. METHODS: A prospective and comparative study was initiated to evaluate, 1 year after surgery, morbidity and sequelae after SLNB in 231 patients. Group I (n=141) underwent SLNB without ALND, group II (n=90) underwent SLNB followed by ALND when SLN where involved. Morbidity analysis was performed, respectively, by surgeons and patients. RESULTS: One hundred and eighty-five patients (80.5%) completed the questionnaire including 113 with SLNB alone, and 72 with ALND. One year after surgery, SLNB produced less morbidity than ALND for symptoms and function. There were significantly different assessments between surgeons and patients for pain, arm mobility and sensitiveness. CONCLUSIONS: One-year postoperative morbidity after SLNB is significantly lower than after ALND but views of surgeons and patients appears to be significantly different. Additional data are required to assess late consequences of axillary surgery.     

Site-specific risk factors for local recurrence after rectal cancer surgery

BackgroundQuite few studies examined risk factors for local recurrence after rectal cancer surgery with respect to local recurrence sites.MethodsLocal recurrence sites were categorized into axial, anterior, posterior, and lateral (pelvic sidewall), and axial, anterior, and posterior type were combined as the “other” type of local recurrence. Among 76 patients enrolled into our prospective randomized controlled trial to determine the indication for pelvic autonomic nerve preservation (PANP) in patients with advanced lower rectal cancer (UMIN000021353), multivariate analyses were conducted to elucidate risk factors for either lateral or the “other” type of local recurrence.ResultsUnivariate analyses showed that tumor distance from the anal verge was significantly (p = 0.017), and type of operation (sphincter preserving operation (SPO) vs. abdominoperineal resection (APR)) was marginally (p = 0.065) associated with pelvic sidewall recurrence. Multivariate analysis using these two parameters showed that tumor distance from the anal verge was significantly and independently correlated with pelvic sidewall recurrence (p = 0.017). As for the “other” type of local recurrence, univariate analyses showed that depth of tumor invasion (p = 0.011), radial margin status (p < 0.001), and adjuvant chemotherapy (p = 0.037) were significantly associated, and multivariate analysis using these three parameters revealed that depth of tumor invasion (p = 0.004) and radial margin status (p < 0.001) were significantly and independently correlated with the “other” type of local recurrence.ConclusionRisk factors for local recurrence after rectal cancer surgery were totally different with respect to the intra-pelvic recurrent sites. Site-specific probability of local recurrence can be inferred using these risk factors.Trial registration numberUMIN000021353.     

Ipsilateral hemodialysis access after axillary dissection for breast cancer

Breast cancer survivors who have had axillary lymph node dissection (ALND) and who later develop end-stage renal failure may eventually require hemodialysis access. If veins available for access in the contralateral arm have been exhausted, especially after chemotherapy, the ipsilateral arm will have to be considered for access construction. There are no evidence-based guidelines for lymphedema prevention, but there are sweeping recommendations to avoid physical injury to the ipsilateral limb, including needle puncture, after ALND with or without radiotherapy. Three studies have shown little or no effect of hand surgery in producing or exacerbating lymphedema after ALND. Dialysis access guidelines recommend the use of autogenous accesses over synthetic grafts whenever possible. Three patients after ALND were referred for hemodialysis access construction in our center. Pre-operative duplex ultrasound confirmed that patent veins appropriate for autogenous access construction were only present in the ipsilateral arm. Autogenous arteriovenous fistulas were constructed in the ipsilateral arm in the three patients. All the three entered our access surveillance program and were regularly examined. All had more than 20 lymph nodes removed. One had axillary radiotherapy and anthracycline-based chemotherapy, one had anthracycline-based chemotherapy without axillary radiotherapy and one had neither treatment. The access was established 4–10 years after ALND. No patient developed significant lymphedema at two, 20 and 76 months respectively after access construction, with cannulation for dialysis occurring three times a week. Autogenous hemodialysis access construction does not seem to contribute to lymphedema development after ALND. Physicians and other medical personnel caring for patients with breast cancer should not oppose the use of the ipsilateral arm if it is the only arm with vasculature suitable for autogenous access construction. Recommendations for lymphedema prevention may exaggerate the extent of risk attributable to interventions in the ipsilateral arm.     

The risk of local recurrence after breast-conserving surgery for breast cancer

Recently, the rates of early stage breast cancers involving breast-conserving therapy have increased due to use of mammography screening. Morever, a patient's desire to keep the breast is now considered to be a factor which determines the surgery tactics. However, there has been so far no consensus on optimal extent of surgery capable of preventing local recurrence. In order to precisely estimate such risk it is essential to take into account factors such as tumor size, surgical margin status and age. Besides, correlations between certain subtypes of breast cancer and various associated risks of local recurrence are to be established. Another important factor is to devise the necessary subsequent radiotherapy.     

乳腺癌术后上肢淋巴水肿风险因素的研究进展

上肢淋巴水肿是乳腺癌术后常见而又顽固的并发症,由于手术或放射治疗等损伤了腋窝淋巴管,导致淋巴液回流障碍,造成上肢浅层软组织内淋巴液积聚引起组织水肿.其临床治疗一直是世界性难题,至今尚无根治的方法.     

Postoperative extremity compartment syndrome in a cancer center: Incidence and risk factors

ObjectivePostoperative compartment syndrome is a reported complication with known patient- and treatment-specific risk factors. Cancer patients carry unique risk factors associated with their underlying disease and long, complex procedures. While elevated serum lactate in traumatic and intensive care settings portends higher risk, no laboratory parameter has demonstrated utility in postoperative risk stratification. Postoperative extremity compartment syndrome in the study institution's cancer population was examined and whether intraoperative serum lactate correlates with postoperative compartment syndrome risk was investigated.MethodsA 1:2 case-control study was performed, which compared cancer patients with postoperative compartment syndrome to those who underwent similar surgical procedures without this complication. Twelve patients were matched to 24 controls by sex, age, surgical procedures, and duration of surgery. Patient and operative variables were analyzed for prognostic significance.ResultsThe compartment syndrome rate was 0.09% of all cases (n = 13,491); 0.12% of cases ≥ 3 h’ duration (n = 9,979), and 0.25% of cases ≥ 5 h (n = 4,811). Compared with controls, the case group had higher median BMI (31.7 kg/m2 vs. 25.4 kg/m2, P = 0.001), and median intraoperative lactate level (4.05 mmol/L vs. 1.5 mmol/L, P = 0.047).ConclusionOur institutional incidence of postoperative compartment syndrome was similar to that of non-oncologic institutions. While many traditional risk factors did not prove to be influential in our patients, elevated median body mass index and intraoperative serum lactate were identified as risk factors for postoperative compartment syndrome in a cancer population.     

HER2阳性和三阴性乳腺癌新辅助化疗后选择性避免腋窝手术分期的研究

背景与目的：新辅助化疗（neoadjuvant chemotherapy,NAC）目前已成为局部晚期乳腺癌患者的标准治疗模式。探讨人表皮生长因子受体2（human epidermal growth factor receptor 2,HER2）阳性和三阴性乳腺癌（triple-negative breast cancer,TNBC）患者NAC后选择性避免腋窝手术分期的可行性及可能获益人群。方法：回顾性分析2010年1月—2018年8月山东省肿瘤防治研究院（山东省肿瘤医院）收治的865例行NAC患者的临床病理学资料,其中184例（21.3%）为HER2阳性和TNBC患者,分析其临床病理学特征与NAC后腋窝淋巴结病理学阴性（ypN ₀ ）的相关性。结果：NAC前肿瘤分期、淋巴结分期及Ki-67,NAC后腋窝淋巴结临床阴性（ycN ₀ ）、乳房影像学完全缓解（breast radiologic complete response,brCR）及乳房病理学完全缓解（breast pathologic complete response,bpCR）均与NAC后ypN ₀ 显著相关（P<0.05）,其中NAC前临床淋巴结分期（OR=0.363,P<0.001）、bpCR（OR=11.285,P<0.001）及ycN ₀（OR=4.995,P<0.001）是NAC后ypN ₀ 的独立预测因素。cN ₀ →ycN ₀ 组37例,NAC后bpCR、未达bpCR患者ypN ₀ 率分别为100.0%（17/17）、90.0%（18/20）（P=0.178）。cN ₁ →ycN ₀ 组42例,NAC后bpCR、未达bpCR患者ypN ₀ 率分别为95.8%（23/24）、55.6%（10/18）（P<0.001）。NAC后未达bpCR的cN 1 患者腋窝淋巴结残留转移的相对风险是bpCR患者的10.56倍（95% CI：2.720~41.003;P<0.001）。结论：在HER2阳性和TNBC患者中,NAC后bpCR与腋窝淋巴结状态具有高度相关性。NAC后bpCR的cN ₀ 及部分cN ₁ 患者（NAC后降期为ycN ₀ ）腋窝淋巴结残留转移的风险<5%,使其选择性避免腋窝手术分期成为可能。