早期乳腺癌腋窝淋巴结清扫和检测程度的临床意义

腋窝淋巴结清扫有重要的临床意义,但目前仍缺乏判断腋窝淋巴结清扫和检测是否彻底的统一标准;淋巴结阳性率及阳性个数随腋窝淋巴结清扫和检测数目的增加而增加,故淋巴结清扫和检测不彻底常导致低估腋窝淋巴结的转移状态,使一部分患者得不到应有的放疗,导致局部复发率相对升高;术后放疗是腋窝淋巴结清扫不彻底患者的有效挽救手段,可以达到与腋窝淋巴结彻底清扫相同的疗效.     

乳腺癌淋巴化疗与静脉化疗后腋窝淋巴结药物浓度的比较

背景和目的:淋巴结状态是乳腺癌重要的预后因素之一,区域淋巴组织靶向化疗是近几年出现的针对高淋巴转移倾向肿瘤的治疗方法。本研究检测乳腺癌患者淋巴化疗(lymphaticchemotherapy,LC)后腋窝淋巴结内的药物浓度,并与静脉化疗(intravenouschemotherapy,VC)作对比,以确定LC能否有效提高区域淋巴结内抗癌药物的聚积。方法:60例乳腺癌患者随机分为LC组和VC组,每组30例,所有患者均于术前穿刺活检明确诊断。LC组在癌灶周围皮下注射卡铂鄄活性炭混悬液5mg/ml,VC组给予同等剂量卡铂水溶液静脉化疗。给药后1、12、24、36、48h分别行乳腺癌改良根治术,每组每个时间点各6例患者。术中常规清扫腋窝淋巴结并送病理检查,原子吸收光谱法(AAS)测定淋巴结内卡铂浓度。结果:术中共切除淋巴结275枚,其中LC组154枚,VC组121枚。共有23例(38.3%)患者的146枚(53.1%)淋巴结发现癌转移。LC组给药后1、12、24、36、48h腋窝淋巴结中卡铂浓度分别为(11.82±3.50)、(23.58±7.34)、(18.22±4.93)、(16.70±5.15)、(14.62±4.29)μg/g,VC组在给药后1、12、24、36h分别为(0.06±0.02)、(0.11±0.05)、(0.10±0.02)、(0.05±0.02)μg/g,给药后48h淋巴结内未检测出卡铂,两组间差异有极显著性(P<0.001)。淋巴结药物浓度与癌转移之间无明显     

乳腺癌新辅助化疗后腋窝淋巴结状态的评估

新辅助化疗或新辅助化疗联合生物靶向治疗日趋成为局部晚期乳腺癌(Ⅱb~Ⅲ)的标准治疗方式,除了能降低原发肿块的临床分期,约有40%的患者能达到腋窝淋巴结的病理完全缓解,从而实现了腋窝淋巴结的降期。而对于经过新辅助化疗或化疗联合靶向治疗后经影像学评估达到腋窝淋巴结临床完全缓解的患者,其腋窝淋巴结缓解情况的预测及新辅助化疗后腋窝前哨淋巴结活检等,仍存在诸多争议,成为临床治疗选择上的难题。本文拟对近年来新辅助化疗后腋窝淋巴结处理的相关研究及临床试验进行分析和解读,并对新近开展的临床研究进行梳理,以期为临床提供更多参考信息。     

Drug concentrations in axillary lymph nodes after lymphatic chemotherapy on patients with breast cancer

Background  

Lymph node status is one of the decisive prognostic factors in breast cancer. Chemotherapy targeting regional lymphatic tissues has emerged as a promising therapy for the treatment of malignancies with a high tendency to disseminate lymphatically. The present study determined the drug concentrations in axillary lymph nodes after lymphatic chemotherapy (LC) in patients with breast cancer and compared the results with those receiving intravenous chemotherapy (VC) to investigate whether LC could improve the accumulation of anticancer drug in regional lymph nodes.     

Variability in axillary lymph node dissection for breast cancer

BACKGROUND: The axillary nodal status may influence the prognosis and the choice of adjuvant treatment of individual breast cancer patients. The variation in number of reported axillary lymph nodes and its effect on the axillary nodal stage were studied and the implications are discussed. METHODS: Between 1994 and 1997, a total of 4,806 axillary dissections for invasive breast cancers in 4,715 patients were performed in hospitals in the North-Netherlands. The factors associated with the number of reported nodes and the relation of this number with the nodal status and the number of positive nodes were studied. RESULTS: The number of reported nodes varied significantly between pathology laboratories, the median number of nodes ranged from 9 to 15, respectively. The individual hospitals explained even more variability in the number of nodes than pathology laboratories (range in median number 8-15, P < 0.0001). The number of reported nodes increased gradually during the study period. A decreasing trend was observed with older patient age. A higher number of reported nodes was associated with a markedly increased chance of finding tumor positive nodes, especially more than three nodes. The frequency of node positivity increased from 28% if less than six nodes to 54% if >/=20 nodes were examined, the percentage of tumors with >/=4 positive nodes increased from 4 to 31%. Multivariate analysis confirmed these results. CONCLUSIONS: This population-based study showed a large variation in the number of reported lymph nodes between hospitals. A more extensive surgical dissection or histopathological examination of the specimen generally resulted in a higher number of positive nodes. Although the impact of misclassification on adjuvant treatment will have varied, the impact with regard to adjuvant regional radiotherapy may have been considerable.     

Tuberculosis of axillary lymph nodes with primary breast cancer

A rare case of tuberculosis of axillary lymph nodes occurring with primary breast cancer is presented. A 78-year-old woman with no history of pulmonary tuberculosis was admitted to our hospital to undergo examination for a lump in her right breast. The tumor was in the upper outer quadrant of the right breast. On palpation, the tumor was 1.2 cm in diameter and axillary lymph node swelling was noted. Mammography disclosed a spiculated mass and swelling and calcification of the axillary lymph nodes. Sonography showed an irregular hypoechoic mass in the right breast and lymph node swelling in the right axilla, indicating breast cancer with axillary lymph nodes metastases. Chest X-ray showed clustered calcifications in the right axilla and a granular shadow in the right upper lobe. Breast conserving therapy was carried out. Invasive papillotubular carcinoma of the right breast and granulomas with calcification of lymph nodes, compatible with tuberculosis, was diagnosed. Tubercle bacillis were detected by culture of lymph nodes. This case suggests that X-ray is useful for diagnosing lymph node tuberculosis. Lymph node tuberculosis should be suspected when lymph node swelling is noted and X-ray shows clustered calcifications in axillary lymph nodes.     

Statistical distribution of involved axillary lymph nodes in breast cancer

Our aim is to characterize the statistical distribution of the number of involved lymph nodes in breast cancer. The material uses a sample of 109618 women from the US SEER (Surveillance, Epidemiology, and End Results). In a first analysis, we observed a log-concave distribution with overdispersion which excluded a Poisson stochastic process. A Negative Binomial (NB) provided an acceptable fit. Overdispersion implies that there are patients who are more at risk than expected, and/or cascade processes in which the variability increases when there are more involved lymph nodes. In a second series of analyses, we applied predictive models taking into account or not the NB. Logistic models, commonly used, allow only the prediction of nodal status, and we found a poor predictive value. A NB generalized linear regression (NBGLR) allowed us to model the number of involved nodes. We argued that the approach of modeling the number of nodes, and not merely the nodal status, allows a grading of nodal involvement risk and might identify patients for whom neoadjuvant treatment would be justified. Incidentally, the NBGLR found in our sample a seasonal factor affecting the numbers of nodes, suggesting the variability of medical practice, which might warrant further investigation.     

Presence of breast cancer antigens in uninvolved axillary lymph nodes

Monoclonal antibodies which bind to breast cancer have been used to evaluate the detection of metastatic disease in axillary lymph nodes. Three monoclonal antibodies (H59, H71, and H72) were reacted with tissue sections of primary tumors and axillary nodes from 24 mastectomy specimens and four specimens from glandular mastectomies for benign disease. All three antibodies had been shown to react with subsets of normal and malignant breast tissue; did not bind erythroid, myeloid, or lymphoid tissue; and recognized antigens in paraffin-embedded tissue. The antibodies recognized cell surface antigens, and H59 and H72 bound to glycoproteins which are either sloughed or secreted. Primary tumors and tumors in lymph nodes from the same specimen were always bound by the same antibodies. Antibodies detected unrecognized microscopic tumor in nodes from one previously node-negative specimen and two specimens with positive nodes. This suggests that monoclonal antibodies may be useful for detecting metastatic breast cancer in nodes which by light microscopy are negative. Moderate binding of H59 and H72 antibodies to sinus histiocytes and perivascular cells was observed in all uninvolved nodes with sinus hyperplasia obtained from benign and malignant specimens. Thus, breast antigens can be identified in hyperplastic nodes in patients with no evidence of breast cancer. The antigens are detected predominately in the lymphoid sinuses and are bound to nonneoplastic cells. Therefore, breast antigens are regularly being processed and presented by normal lymphoid cells within the sinus. The binding of these monoclonal antibodies to axillary lymph nodes does not necessarily indicate the presence of metastatic disease. Dense binding to paracortical single cells was observed in tumor-containing lymph nodes and in uninvolved nodes obtained from mastectomy specimens with breast cancer. These cells are infrequent, and their number in an uninvolved node correlates with the pathological stage. They represent either binding to isolated lymphoid cells or metastatic tumor. Studies are under way to determine the origin of these cells.     

新辅助化疗对腋窝淋巴结数量影响随机对照临床研究

目的：探讨新辅助化疗（neoadjuvant chemotherapy,NAC）对乳腺癌患者腋窝淋巴结数量的影响。方法：2010—03—02—2012—06—30临沂市人民医院乳腺外科收治82例临床Ⅱ～Ⅲ期乳腺癌患者,随机数字表法分为化疗组40例和手术组42例,化疗组以蒽环类CEF或EC方案行3～4个周期NAC,手术组直接接受乳腺癌改良根治术,比较两组患者的腋窝淋巴结数量。结果：40例经NAC的乳腺癌患者中,目标病灶完全缓解（CR）6例,部分缓解（PR）19例,病情稳定（SD）15例,无患者出现疾病进展（PD）。腋窝淋巴结清除以后,化疗组平均检出淋巴结总数为16．7枚（8～28枚）,手术组为20．4枚（12～37枚）;平均阳性淋巴结数化疗组为2．1枚（0～13枚）,手术组为6．5枚（0～20枚）,两组间差异均有统计学意义,P值均〈0．001。结论：乳腺癌患者接受NAC以后,进行腋窝淋巴结清除时,不仅阳性淋巴结减少,得到的淋巴结总数也减少。     

Sequelae following axillary lymph node dissection for breast cancer

Axillary lymph node dissection (ALND) has a central role in the surgical management of breast cancer; however, it is associated with a potentially significant morbidity. Although post-ALND complications are often minor, in some cases they can persist for a long time following surgery, thereby affecting the quality of life of breast cancer survivors. Seroma formation and altered sensation of the upper limb are the two most common complications following ALND. Lymphedema is the most common potentially severe long-term complication following ALND. Major post-ALND complications (such as injury or thrombosis of the axillary vein and injury to the motor nerves of the axilla) are extremely rare. Meticulous surgical technique and careful selection of patients for postoperative radiation therapy are mandatory to prevent significant morbidity following ALND. The introduction of the technique of sentinel lymph node biopsy in clinical practice has resulted in a significant reduction in the incidence of post-ALND complications.     

Sequelae following axillary lymph node dissection for breast cancer

Axillary lymph node dissection (ALND) has a central role in the surgical management of breast cancer; however, it is associated with a potentially significant morbidity. Although post-ALND complications are often minor, in some cases they can persist for a long time following surgery, thereby affecting the quality of life of breast cancer survivors. Seroma formation and altered sensation of the upper limb are the two most common complications following ALND. Lymphedema is the most common potentially severe long-term complication following ALND. Major post-ALND complications (such as injury or thrombosis of the axillary vein and injury to the motor nerves of the axilla) are extremely rare. Meticulous surgical technique and careful selection of patients for postoperative radiation therapy are mandatory to prevent significant morbidity following ALND. The introduction of the technique of sentinel lymph node biopsy in clinical practice has resulted in a significant reduction in the incidence of post-ALND complications.     

Lymphedema following axillary lymph node dissection for breast cancer

Lymphedema is a relatively common, potentially serious and unpleased complication after axillary lymph node dissection (ALND) for breast cancer. It may be associated with functional, esthetic, and psychological problems, thereby affecting the quality-of-life (QOL) of breast cancer survivors. Objective measurements (preferentially by measuring arm volumes or arm circumferences at predetermined sites) are required to identify lymphedema, but also subjective assessment can help to determine the clinical significance of any volume/circumference differences. Lymphedema per se predisposes to the development of other secondary complications, such as infections of the upper limb, psychological sequelae, development of malignant tumors, alterations of the QOL, etc. The risk of lymphedema is associated with the extent of ALND and the addition of axillary radiation therapy. Treatment involves the application of therapeutic measures of the so-called decongestive lymphatic therapy. Prevention is of key importance to avoid lymphedema formation. The application of the sentinel lymph node biopsy in the management of breast cancer has been associated with a reduced incidence of lymphedema formation.     

Number of lymph nodes identified at axillary dissection

BACKGROUND:

Several reports have shown a significantly lower number of axillary lymph nodes (AxLNs) found at axillary lymph node dissection (ALND) after neoadjuvant chemotherapy. The objective of the current study was to investigate the factors affecting the number of AxLNs identified at ALND.

METHODS:

Medical records of patients seen at the study institution, a tertiary center, from 2004 to 2007 who underwent ALND for breast cancer were reviewed.

RESULTS:

Among the 698 patients who met study criteria, the mean number of AxLNs resected was 20.4. There were 649 (93%) patients with at least 10 AxLNs recovered. Seventy‐one (10%) patients received neoadjuvant chemotherapy and 627 (90%) underwent surgical resection first. The mean number of AxLNs in the patients treated with neoadjuvant chemotherapy was 21.9 (range, 4‐56 AxLNs) compared with 20.2 (range, 5‐65 AxLNs) in the group treated with surgical resection first (P = .13). The number of patients with <10 AxLNs found at ALND was 44 of 627 (7.0%) in the surgical resection first group and 5 of 71 (7.0%) in the neoadjuvant chemotherapy group (P = 1.0). The mean number of AxLNs was higher in the 599 (86%) ALNDs performed at the study center compared with the 99 cases from outside institutions (21.2 vs 15.2 AxLNs; P <.001). Among the cases performed at the study institution, 367 (61%) were performed by surgeons with oncologic training and 232 (39%) were not. Surgical oncologists recovered an average of 23 AxLNs, which was significantly higher than the 18.4 resected by the remaining surgeons (P <.001).

CONCLUSIONS:

The number of AxLNs recovered at ALND does not appear to be affected by neoadjuvant chemotherapy. Surgeons with oncologic training appear to retrieve more AxLNs. Cancer 2010. © 2010 American Cancer Society.     

乳腺癌腋窝淋巴结转移规律的回顾性分析

目的 :确定与乳腺癌腋窝淋巴结转移相关因素及转移规律 ,探讨淋巴结状况作为乳腺癌预后因素的意义。方法 :通过对在我院手术治疗、有完整病理资料的 60 3例的淋巴结情况进行归纳、总结 ,建立数据库。将数据库内的数据使用SPSS 10 0统计学软件分析处理。结果 :与乳腺癌腋窝淋巴结转移相关因素为临床分期、肿瘤大小、术前化疗、原发瘤化疗效果、腋窝转移性淋巴结化疗效果、病理类型 ,与患者的年龄和病期无关。术前化疗方案和化疗时间的长短对淋巴结转移的状况也有一定影响 ,肿瘤的个数与腋窝淋巴结转移有相关性 ,且差异有统计学意义。结论 :乳腺癌腋窝淋巴结转移相关因素对淋巴结状况判别正确率为 67 3 % ,淋巴结转移与否对患者生存判别正确率为 75 5 %。     

腋窝微小淋巴结在乳腺癌分期中的作用

目的探讨乳腺癌腋窝微小淋巴结对乳腺癌分期的影响。方法127例乳腺癌不同根治性手术清除的腋窝组织经专人按常规方法寻找淋巴结后，把腋窝脂肪组织切1cm厚浸泡于溶脂液（Carnoy＇s solution）6～12h，取出腋窝脂肪组织置于玻璃板上寻找微小淋巴结，检出的淋巴结行常规病理检查。结果依靠常规方法检出淋巴结2483枚（平均每例19．55&#177;7．95枚）；腋窝组织经溶脂液浸泡后检出1—6mm的淋巴结878枚（平均每例6．9&#177;5．31枚），其中3mm以下的淋巴结781枚。使平均腋窝淋巴结检出数量增加到26，47&#177;9．69枚。7例患者的pN改变，其中4例pN0升为pN1，2例pN1升为pN2，1例pN2升为pN3。结论该溶脂法能简捷地检出腋窝微小淋巴结，有助于乳腺癌的精确分期。     

Treatment of breast carcinoma in patients with clinically negative axillary lymph nodes using radiotherapy versus axillary dissection

BACKGROUND: The role of axillary lymph node dissection (AxD) for patients with breast carcinoma who have clinically negative lymph nodes (cN0) and undergo breast-conserving therapy has been controversial. If patients do not undergo AxD, then it is uncertain whether specific lymph node irradiation should be given. The authors compared the results obtained from patients w ho underwent AxD with the results from patients who received axillary irradiation (AxR) using one of two radiotherapy techniques. METHODS: Patients with T1-T2cN0 breast carcinoma were treated from 1983 to 2002 with either AxD (80 patients) or AxR (1134 patients received tangential-field [2-field] irradiation, and 303 patients received 3-field irradiation). The median follow-up was 161 months for the AxD group and 66 months for the AxR group (55 months for patients who received tangential-field irradiation, and 122 months for patients who received 3-field irradiation). RESULTS: One patient in the AxD group and 35 patients in the AxR group had axillary recurrences. The 10-year cumulative axillary recurrence rates were 1.3% and 4.6% for the AxD group and the AxR group, respectively (P = 0.21). For patients with T1 tumors, the 10-year overall survival rates for the two groups were 94.7% and 92.7%, respectively (P = 0.34); and, for patients with T2 tumors, the 10-year overall survival rates were 92.5% and 89.1%, respectively (P = 0.34). In the AxR group, the 5-year axillary recurrence rates were 2.5% for patients who received tangential-field irradiation and 1.7% for patients who received 3-field irradiation (P = 0.18), and the 5-year regional recurrence rates for the two groups were 4.8% and 2.4%, respectively (P = 0.048). On multivariate analysis, positive lymphovascular invasion, outer tumor location, and larger tumor size were significant risk factors for regional failure. CONCLUSIONS: For patients with cN0 breast carcinoma, AxD and AxR yielded the same overall survival rates. Most patients can be treated safely with tangential-field irradiation alone. Patients who are at increased risk of regional failure may benefit from three-field irradiation.     

The number of tumor-free axillary lymph nodes removed as a prognostic parameter for node-negative breast cancer

Recently, there has been controversy about the relationship between the number of lymph nodes removed and survival of patients diagnosed with lymph node-negative breast cancer. To assess this relationship, 603 cases of lymph node-negative breast cancer with a median of 126 months of follow-up data were studied. Patients were stratified into two groups（Group A, 10 or fewer tumor-free lymph nodes removed; Group B, more than 10 tumor-free lymph nodes removed）. The number of tumor-free lymph nodes in ipsilateral axillary resections as well as 5 other disease parameters were analyzed for prognostic value. Our results revealed that the risk of death from breast cancer was significantly associated with patient age, marital status, histologic grade, tumor size, and adjuvant therapy. The 5- and 10-year survival rates for patients with 10 or fewer tumor-free lymph nodes removed was 88.0% and 66.4%, respectively, compared with 69.2% and 51.1%, respectively, for patients with more than 10 tumor-free lymph nodes removed. For patients with 10 or fewer tumor-free lymph nodes removed, the adjusted hazard ratio（HR） for risk of death from breast cancer was 0.579（95% confidence interval, 0.492-0.687, P 〈 0.001）, independent of patient age, marital status, histologic grade, tumor size, and adjuvant therapy. Our study suggests that the number of tumor-free lymph nodes removed is an independent predictor in cases of lymph node-negative breast cancer.     

Minimal risk of macrometastases in the non-sentinel axillary lymph nodes in breast cancer patients with micrometastatic sentinel lymph nodes and preoperatively ultrasonically uninvolved axillary lymph nodes

Micrometastases in the sentinel lymph node (SLN) carry a considerable risk of macrometastases in the non-sentinel lymph nodes (NSLN), resulting in axillary lymph node dissection (ALND). Preoperative ultrasound (US) examination of the axillary lymph nodes combined with a fine-needle aspiration biopsy (FNAB) has been proved to discover metastases in the axillary lymph nodes. The aim of our study was to assess the risk of macrometastases in NSLN in patients with micrometastatic SLN after a preoperative US examination of the axillary lymph nodes. The study included 36 patients in whom, after preoperative axillary US, micrometastases in the SLN were revealed and ALND was subsequently performed. At final histopathology, no macrometastases were discovered in the NSLN. In four patients, additional micrometastases were discovered in the NSLN. In conclusion, the risk of macrometastases in the NSLN in patients with preoperatively ultrasonically uninvolved axillary lymph nodes is minimal.