乳腺癌术后上肢淋巴水肿预防措施及治疗原则

前瞻性研究显示乳腺癌术后上肢淋巴水肿的发生率为21.4%,且全球其发生率存在地域差异。乳腺癌病人预防淋巴水肿的理念应贯串始终。预防措施包括规范化手术与放疗、功能锻炼及日常注意事项。淋巴水肿可采取保守治疗、药物及手术治疗。术式可包括降低淋巴系统负荷如病变组织切除术、负压抽吸术等,促进淋巴引流如筋膜条引流、网膜引流及带蒂皮瓣引流术等,重建淋巴通道如淋巴-静脉系统吻合术、淋巴管移植术 、静脉代替淋巴管移植术、淋巴结移植术等。上述治疗虽取得一定疗效,但未能从根本上解决问题,疗效难以持久且个体差异较大。治疗原则强调早期、长期、综合、个体化。     

毫米波治疗乳腺癌术后上肢淋巴水肿患者的护理

对46例乳腺癌术后上肢水肿患者用毫米波(频率36 GHz,输出功率120 mW)治疗.结果 治疗2个疗程后患者主观症状如上肢沉重感、烧灼感及肢体活动度有明显的改善,优良29例,良好6例.有效5例,无效6例,治疗总有效率87.0%(40/46).随访6个月,无1例加重.提示毫米波治疗乳腺癌术后轻、中度上肢淋巴水肿简便有效,治疗期间做好患者的心理护理、患侧上肢水肿的护理,合理选择照射方位、频率、功率、时间,做好饮食护理及密切观察病情变化,能有效促进淋巴液回流,减轻患肢水肿,从而提高患者的生活质量.     

毫米波治疗乳腺癌术后上肢淋巴水肿患者的护理

对46例乳腺癌术后上肢水肿患者用毫米波（频率36GHz，输出功率120mW）治疗。结果治疗2个疗程后患者主观症状如上肢沉重感、烧灼感及肢体活动度有明显的改善，优良29例，良好6例，有效5例，无效6例，治疗总有效率87．0％（40／46）。随访6个月，无1例加重。提示毫米波治疗乳腺癌术后轻、中度上肢淋巴水肿简便有效，治疗期间做好患者的心理护理、患侧上肢水肿的护理，合理选择照射方位、频率、功率、时间，做好饮食护理及密切观察病情变化，能有效促进淋巴液回流，减轻患肢水肿，从而提高患者的生活质量。     

乳腺癌术后上肢淋巴水肿危险因素的临床观察

目的：调查乳腺癌术后淋巴水肿患者的发生情况,分析其危险因素,为临床工作提供参考。方法回顾分析本院近10年接受乳腺癌根治术并行淋巴清扫的患者513例,通过多因素相关分析,探讨年龄、体重指数、肿瘤大小、淋巴结病理分期、临床分期、前哨淋巴结情况、腋窝淋巴结清扫数量、腋窝淋巴结清扫范围、放疗与否、化疗与否、术后愈合情况及并发症等因素与淋巴水肿的发生关系。结果513例患者中发生淋巴水肿102例,其中轻度水肿占51.96%（53例）,中度水肿占40.20%（41例）,重度水肿占7.84%（8例）;通过Logistic多因素逐步回归分析对所收集的12个可能相关因素进行研究,笔者发现年龄、体重指数、放疗与否、腋窝淋巴结清扫范围和术后愈合情况及并发症等5因素与淋巴水肿的发生密切相关（P＜0.05）。结论乳腺癌根治并淋巴结清扫的乳腺癌术后患者发生上肢淋巴水肿的危险因素主要有：年龄、体重指数、放疗、腋窝淋巴结清扫范围、术后愈合情况及并发症。     

空气波压力治疗乳腺癌术后患者上肢淋巴水肿效果观察

目的探讨应用空气波压力治疗乳腺癌术后患者上肢淋巴水肿的治疗效果。方法对22例上肢淋巴水肿患者采用空气波压力治疗2个疗程。结果治疗后患者普遍反映肢体轻松，活动灵便，皮肤张力下降。治疗前后患肢4个测试点周径比较，差异有显著性意义（均P〈0．05）。结论空气波压力治疗乳腺癌术后上肢淋巴水肿，效果较好，操作简便，使用安全、无痛苦。     

空气波压力治疗乳腺癌术后患者上肢淋巴水肿效果观察

目的 探讨应用空气波压力治疗乳腺癌术后患者上肢淋巴水肿的治疗效果.方法 对22例上肢淋巴水肿患者采用空气波压力治疗2个疗程.结果 治疗后患者普遍反映肢体轻松,活动灵便,皮肤张力下降.治疗前后患肢4个测试点周径比较,差异有显著性意义(均P＜0.05).结论 空气波压力治疗乳腺癌术后上肢淋巴水肿,效果较好,操作简便,使用安全、无痛苦.     

乳腺癌术后上肢淋巴水肿的临床分析及康复治疗

目的研究乳腺癌术后上肢淋巴水肿发病机制及防治措施。方法回顾分析61例上肢淋巴水肿的治疗情况。结果治愈59例,缓解2例。结论乳腺癌术后上肢淋巴水肿的发病与淋巴结清扫不当、腋窝积液、皮瓣坏死及感染、放疗、化疗等有关。向心性体位按摩、理疗、中西药联合是有效治疗方法。     

乳腺癌术后预防上肢淋巴水肿专用软枕的研制与应用

目的预防乳腺癌术后病人患侧上肢淋巴水肿的发生.方法选择临床诊断(经病理证实)为乳腺癌行乳腺癌改良根治术后病人70例,随机分为观察组和对照组,各35例.观察组术后给予自制专用软枕,抬高患侧上肢;对照组按常规方法抬高患肢.比较两组病人术后患侧上肢淋巴水肿发生率.结果观察组病人术后患侧上肢淋巴水肿11例(占31.43%),对照组20例(占57.14%),两组比较,差异有显著性意义(P＜0.05).结论乳腺癌术后病人使用自制专用软枕,能降低术后患侧上肢淋巴水肿发生率,病人感觉舒适,易接受.     

乳腺癌外科治疗中值得关注的若干问题

伴随乳腺癌基础研究的进步,涉及肿瘤化疗、内分泌治疗和靶向药物治疗已经获得共识。作为重要的治疗手段之一,外科手术同样有原则,也存在争议需要讨论。笔者复习文献介绍了包括NSABP试验及NCCN有关的外科治疗指南。并重点针对锁骨上淋巴结活检与清扫的适应证与危险、前哨淋巴结检测的规范方法、乳腺癌手术后上肢淋巴水肿的诊治、乳腺癌肝脏及肺转移灶的外科手术切除现状以及乳腺癌术后即刻重建合并症等问题进行了讨论。     

乳腺癌术后上肢淋巴水肿患者自我管理体验的质性研究

目的 了解乳腺癌术后上肢淋巴水肿患者自我管理中的体验和感受,为临床制订解决方案提供参考。方法 采用质性研究方法对15例乳腺癌术后上肢淋巴水肿患者进行半结构式访谈,采用Colaizzi7步分析法分析资料。结果 提炼出6个主题,包括缺乏自我管理知识、思想上未引起足够重视、管理方式的差异化、自我管理过程中存在诸多障碍、自我管理中的情绪问题和社会支持不足。结论 乳腺癌术后上肢淋巴水肿患者在自我管理过程中存在较多问题,医护人员应帮助患者纠正对疾病的错误认知及处理方式,树立良好的自我管理行为与习惯,重视患者由自我管理产生的心理问题,联合家庭和社会共同提高患者的自我管理能力。     

Lymphedema of the arm and breast in irradiated breast cancer patients: risks in an era of dramatically changing axillary surgery

The purpose of this study was to assess risk for lymphedema of the breast and arm in radiotherapy patients in an era of less extensive axillary surgery. Breast cancer patients treated for cure were reviewed, with a minimum follow-up of 1.5 years from the end of treatment. Clinical, surgical, and radiation-related variables were tested for statistical association with arm and breast lymphedema using regression analyses, t-tests, and chi-squared analyses. Between January 1998 and June 2001, 240 women received radiation for localized breast cancer in our center. The incidence of lymphedema of the ipsilateral breast, arm, and combined (breast and arm) was 9.6%, 7.6%, and 1.8%, respectively, with a median follow-up of 27 months. For breast edema, t-test and multivariate analysis showed body mass index (BMI) to be significant (p = 0.043, p = 0.0038), as was chi-squared and multivariate testing for site of tumor in the breast (p = 0.0043, p = 0.0035). For arm edema, t-test and multivariate analyses showed the number of nodes removed to be significant (p = 0.0040, p = 0.0458); the size of the tumor was also significant by multivariate analyses (p = 0.0027). Tumor size appeared significant because a number of very large cancers failed locally and caused cancer-related obstructive lymphedema. In our center, even modern, limited level 1-2 axillary dissection and tangential irradiation carries the risk of arm lymphedema that would argue in favor of sentinel node biopsy. For breast edema, disruption of draining lymphatics by surgery and radiation with boost to the upper outer quadrant increased risk, especially for the obese. Fortunately both breast and arm edema benefited from manual lymphatic drainage.     

携带淋巴组织的横行腹直肌皮瓣移植乳房再造治疗上肢淋巴水肿1例附文献复习

目的  总结采用携带淋巴组织的横行腹直肌皮瓣移植进行乳房再造并治疗上肢淋巴水肿的临床经验。方法  中国医学科学院整形外科医院收治的1例乳腺癌根治术后7年右侧上肢淋巴水肿的患者, 经术前淋巴造影证实为腋窝淋巴回流障碍。应用携带淋巴组织的横行腹直肌皮瓣移植进行胸壁修复、乳房再造及淋巴回流重建, 并彻底松解腋窝严重挛缩瘢痕。术后对该病例双侧上肢周径进行长期监测。结果  该病例术后出现移植皮瓣严重水肿, 术后引流量达755 mL/d, 长达5 d, 伴随心房颤动、低蛋白血症、低钾血症及切口延迟愈合等术后并发症。经过及时引流及规范综合治疗, 术后转归良好, 患侧上肢周径逐渐缩小, 术后3周趋于稳定。术后随访5年效果较好。结论  应用携带淋巴组织的横行腹直肌皮瓣移植进行乳房再造同时治疗乳腺癌根治术后上肢淋巴水肿, 可取得良好的临床效果。     

Role of tranexamic acid in axillary lymph node dissection in breast cancer patients

Axillary lymph node dissection (ALND) is an important step in the management of node‐positive operable breast cancer. It is associated with large amount of axillary drainage and increased risk of wound‐related infection. Tranexamic acid (TA) has antifibrinolytic property and is being extensively used in controlling blood loss. However, its role in reducing axillary drainage after ALND is still not well‐established. The aim of this study is to evaluate the effectiveness of TA in reducing the axillary drainage, early removal of the drain, and decreasing the wound‐related infection in breast cancer patients undergoing ALND. This is a prospective nonrandomized double‐armed cohort study. Total of 47 patients were included in the TA group and 46 in the nontranexamic (NTA) group. All the patients in TA group received a single dose of intravenous (IV) TA at the time of induction followed by oral TA for five days after surgery. Both TA and NTA groups had similar proportions of locally advanced breast cancers (57.4% vs 56.5%, P = .90). Majority of them underwent modified radical mastectomy (MRM) (70.2% vs 67.4%, P = .76). Patients in TA group had significantly lower axillary drainage (440 ml vs 715.5 ml, P = .003) with earlier removal of the drain (8 vs 11 days, P = .046). Seroma formation (19.1% vs 32.6%, P = .13) and wound‐related infection (4.3% vs 8.7%, P = .43) were nonsignificantly lower in the TA group. Tranexamic acid reduces axillary drainage and facilitates early removal of the drain after axillary lymph node dissection.     

Time-course of arm lymphedema and potential risk factors for progression of lymphedema after breast conservation treatment for early stage breast cancer

Abstract: The objective of this study was to describe the progression of arm lymphedema (ALE) after the initial presentation among patients receiving breast conservation therapy for early stage breast cancer and to identify potential risk factors contributing to ALE progression. The study sample was the 266 stage I or II breast cancer patients with documented ALE who underwent breast conservation therapy that included lumpectomy, axillary staging followed by radiation therapy. ALE were graded according to a difference of 0.5–2 cm (mild), 2.1–3 cm (moderate), and >3 cm (severe) in the circumference between the upper extremities for the treated and untreated sides. ALE at presentation was scored as mild, moderate, and severe in 109 (41%), 125 (47%), and 32 (12%) patients, respectively. One third of patients with ALE progressed to a more severe grade of lymphedema at 5 years of follow‐up. Age older than 65 years at the time of breast cancer treatment was associated with higher risk of ALE progression when compared 65 year age or younger (p = 0.04). The patients who had regional lymph node irradiation including posterior axillary boost were at higher risk of lymphedema progression than the patients treated with whole breast irradiation only (p = 0.001). Progression of ALE is a common occurrence. The current study provides support for the utility of routine arm measurements after breast cancer treatment to facilitate timely diagnosis and treatment of ALE.     

生活希望计划干预对中老年乳腺癌放疗患者上肢功能锻炼的影响

目的探讨生活希望计划干预对中老年乳腺癌患者放疗期间上肢功能锻炼的影响。方法将行放疗的92例中老年乳腺癌患者随机均分为两组,对照组实施常规健康教育和康复护理,观察组在此基础上实施生活希望计划护理干预。比较两组结束放疗出院时上肢功能活动度、生活质量评分和希望水平。结果观察组的上肢活动度、生活质量总分、希望总体评分显著优于对照组(均P0.01)。结论生活希望计划干预能够增强中老年乳腺癌患者放疗期间上肢活动度,提高生活质量和希望水平。     

Lymphaticovenular anastomosis improves quality of life and limb volume in patients with secondary lymphedema after breast cancer treatment

Secondary lymphedema is a common side effect of breast cancer treatment, with significant impact on patients' physical and psychological well‐being. Conservative therapies are the gold standard treatment, however surgical options are becoming more popular. Lymphaticovenular anastomosis (LVA) is a supermicrosurgical procedure that aims to restore lymphatic flow by anastomosing damaged lymphatics to subcutaneous venules. We aimed to assess the effects of LVA on patients' limb volume and quality of life. Pre‐ and postoperative limb volumes and LYMQOL scores were collected for patients undergoing LVA for lymphedema secondary to breast cancer. Thirty‐seven patients underwent LVA. A significant reduction was seen in median excess limb volume postoperatively (13.3%‐6.6%, P < 0.005), with volumetric improvement seen in 78% of patients. Thirteen patients were able to discontinue compression garment use. Eighty‐six percent of patients reported improved quality of life postoperatively with median LYMQOL score increasing from 90 to 104 points (P < 0.005). LVA is a minimally invasive surgical option for patients with early stage lymphedema. It can lead to significant volumetric improvements and in select patients, freedom from compression therapy. LVA can also lead to significant improvements in quality of life, in particular patients' mood and perception of their appearance.     

芳香化酶与乳腺癌的相关研究

雌激素在乳腺癌的发生发展中起着重要作用。绝经后妇女的雌激素主要由肾上腺分泌的雄激素前体转化而来,芳香化酶是这一转变过程的关键酶、限速酶。因此,深入研究芳香化酶和乳腺癌的关系具有重要的临床意义。现就芳香化酶在乳腺癌组织中的表达、调控及芳香化酶抑制剂在乳腺癌内分泌治疗中的临床进展作一综述。     

The acceptable delay between biopsy and radical mastectomy in breast cancer patients

The effects on the prognosis of breast cancer, of the delay between biopsy and radical mastectomy were studied in 394 patients. No delay had been experienced by 148 cases (no delay group), no biopsy had been performed in 166 cases (no biopsy group) and 80 cases had experienced a delay of 1 day or longer after having had a biopsy taken at a different institution (delay group). The recurrence rate of the no delay group was 10.8 per cent (16/148), whereas that of the delay group was 18.8 per cent (15/80). The relapse free survival rate of the no delay group was superior to that of the delay group (Kaplan Meier’s method: p<0.05). The delay group was further divided into two groups according to the duration of delay, namely: a group whose delay was less than 7 days and another whose delay was longer than 8 days. There was no significant difference between the relapse free survival rates of the no delay group and the less than 7 days group, however, a significant difference was observed between the no delay group and the longer than 8 days delay group (p<0.05). The acceptable delay between biopsy and radical mastectomy may therefore be concluded as less than 7 days.