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...     

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。     

锁骨上血管化淋巴结移植治疗淋巴水肿的研究进展

目的 对锁骨上血管化淋巴结移植（vascularized lymph node transfer,VLNT）的研究进展作一综述。方法 广泛查阅近年国内外锁骨上VLNT相关研究文献,从锁骨上淋巴结解剖、锁骨上VLNT临床应用及并发症方面进行归纳总结。结果 锁骨上淋巴结解剖位置恒定,位于颈后三角区域,血供主要来自于颈横动脉。锁骨上淋巴结数量存在个体差异,术前可进行超声检查以明确淋巴结数量。临床研究表明锁骨上VLNT能改善淋巴水肿患者的肢体肿胀、减少感染发生率和提高生活质量,同时也能联合淋巴管静脉吻合、切除手术以及抽脂术,提高治疗效果。结论 锁骨上淋巴结数量较多,血供丰富,锁骨上VLNT已被证实对任何时期的淋巴水肿均有效,联合治疗效果更显著。但是需更多临床研究来明确锁骨上VLNT单独或联合应用的治疗效果以及联合治疗的手术方式、手术时机选择。     

乳腺癌腋窝淋巴结清扫术中选择性保留上肢淋巴结对预防上肢淋巴水肿的作用

目的探讨乳腺癌腋窝淋巴结清扫(ALND)过程中保留上肢淋巴结的可行性及其对术后上肢淋巴水肿的预防作用。方法 2007年8月至2010年1月期间124例早期乳腺癌患者按手术时间被分为两期进行临床研究。患者均于淋巴结清扫前于患侧前臂皮下注射亚甲蓝5 ml进行上肢淋巴定位。一期(2007年8月至2008年7月)患者22例行常规ALND,术中分检出上肢淋巴结和水平Ⅱ淋巴结,水平Ⅱ淋巴结进行术中印片细胞学和冰冻切片病理检查。术后分别对水平Ⅰ、Ⅱ、Ⅲ和上肢淋巴结进行常规病理检查,以评估ALND过程中保留上肢淋巴结的可行性。二期(2008年8月至2010年1月)患者102例,用抽签法随机分为对照组和选择性保留上肢淋巴结组(保留组)。对照组患者30例,所有操作同一期患者;保留组患者72例,术中印片细胞学检查和冰冻切片病理学检查确定无水平Ⅱ淋巴结转移且可见蓝染者施行保留上肢淋巴结的ALND。观察记录二期的2组患者术后上肢淋巴水肿发生情况。结果 124例患者术中可见上肢淋巴结蓝染者119例(96.0%),术中水平Ⅱ淋巴结联合病理学检查与术后常规病理学检查的符合率为99.2%(123/124)。一期患者及二期对照组患者术后病理学检查无水平Ⅱ淋巴结转者均未发现上肢淋巴结转移。术后6个月时对照组和保留组患者中施行腋窝水平Ⅰ、Ⅱ淋巴结清扫者的上肢淋巴水肿发生率分别为18.2%(4/22)和2.0%(1/51),差异有统计学意义(2χ=6,34,P<0.05)。结论亚甲蓝上肢淋巴定位可有效显示腋窝上肢淋巴结。术中可选择无水平Ⅱ淋巴结转移的患者施行保留上肢淋巴结的ALND,可有效预防上肢淋巴水肿的发生。     

染料法腋窝反向淋巴作图与前哨淋巴结活检在乳腺癌术中应用研究

目的 研究染料法腋窝反向淋巴作图（axillary reverse mapping,ARM）结合前哨淋巴结活检（sentinel lymph nodebiopsy,SLNB）在乳腺癌术中的应用。方法 回顾性分析2011年6月至2013年6月蚌埠医学院第一附属医院肿瘤外三科收治的共363例乳腺癌病人资料,均行乳腺癌腋窝淋巴结清扫术（ALND）,其中联合行ARM+SLNB者78例（ARM+SLNB组）,单纯行ALND者285例（ALND组）,比较两组术后疗效。结果 ALND组病人术后带管时间为（12.3±1.5）d,而ARM+SLNB组为（9.6±1.9）d,二者差异有统计学意义（t=11.74,P<0.05）。ARM+SLNB组术后第1～7天的引流量均较ALND组明显减少,差异有统计学意义（P<0.05）。随访12个月,两组均未发现Ⅲ级水肿,第12个月ALND组与ARM+SLNB组水肿发生率差异有统计学意义（P<0.05）。结论 ARM可保护患侧上肢淋巴通道,减少术后上肢水肿的发生。     

皮瓣转移结合负压抽吸治疗乳腺癌术后上肢淋巴水肿

目的 探讨一种治疗乳腺癌根治术后上肢淋巴水肿的手术方法。方法 2001～2002年我们采用侧胸壁皮瓣或背阔肌肌皮瓣转移结合上肢负压抽吸治疗10例单侧乳腺癌根治术后上肢淋巴水肿患者。结果 术后所有患者上肢周径均有不同程度减小，核素淋巴管造影显示淋巴回流有显著改善。术后随访3～18个月，疗效稳定。结论 皮瓣转移结合负压抽吸可以有效地治疗乳腺癌根治术后淋巴水肿。     

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。     

外科治疗转移性肝癌值得关注的若干问题

转移性肝癌在当今已不再被认为是毫无治疗希望的晚期癌症,其中部分病人可行肝切除术或辅助性综合治疗并能获得满意的治疗效果及5年存活率。为此,需要医生改变观念并与病人沟通为之共同努力,需要多学科合作采取最佳方案及组合。无论何种办法,如能手术切除才是最佳选择,选择手术时要权衡手术的安全性及有效性,否则会事与愿违。     

Safety of elective hand surgery following axillary lymph node dissection for breast cancer

The development of lymphedema is the most feared complication shared by breast cancer survivors undergoing hand surgery after prior axillary lymph node dissection (ALND). Traditionally, these patients are advised to avoid any interventional procedures in the ipsilateral upper extremity. However, the appropriateness of some of these precautions was recently challenged by some surgeons claiming that elective hand operations can be safely performed in these patients. The purpose of this study was to evaluate our experience and determine the safety of elective hand operations in breast cancer survivors. The medical records of patients operated for different hand conditions after prior breast surgery and ALND at our institution between 1983 and 2002 were reviewed. The techniques and preventive measures performed, use of antibiotics, and upper extremity complications associated with the operations were analyzed. Overall, we operated on 27 patients after prior ALND performed for breast cancer. Follow-up was available for 25 patients. Four patients had pre-existing lymphedema. The surgical technique used was similar to that performed in patients without prior ALND and antibiotic prophylaxis was not given. Delayed wound healing was observed in one patient and finger joint stiffness in another. Two patients with pre-existing lymphedema developed temporary worsening of their condition. None of the patients developed new lymphedema. The results of the present study support the few previous studies, suggesting that hand surgery can be safely performed in patients with prior ALND. Based on these findings, the appropriateness of the rigorous precautions and prohibitions regarding the care and use of the ipsilateral upper extremity may need to be reconsidered.     

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.     

美蓝染色法检测乳腺癌前哨淋巴结的临床研究

目的 寻找检测乳腺癌前哨淋巴结(SLN)方法，研究前哨淋巴结活检(SLNB)预测腋窝淋巴结状况的准确性。方法 对40例乳腺癌患者行美蓝染色法检测SLN，并行腋窝淋巴结清扫术(ALND)后，将腋窝淋巴结转移状况与SLN进行对比分析，分析SLN检出率及临床特征。结果 40例患者中成功检测出SLN35例，成功率为87．5％。检出SLN60个，平均每例检出SLNl．7个。2例出现假阴性，假阴性率为10.5％，无假阳性。35例患者中有16例SLN阳性，阳性率为45.7％。SLNB预测腋窝淋巴结(ALN)的敏感性为88．8％，特异性为100％，准确性为94．4％。结论 美蓝染色法检测乳腺癌SLN经济实用，可以较准确地预测腋窝淋巴结的转移状况。     

A retrospective study on the clinical and biological prediction of axillary lymph node metastasis in breast cancer

If axillary lymph node metastases were able to be accurately predicted, dissection could be avoided in some patients with breast cancer whose axillary nodes are clinically negative. In this study, we assessed the relationships between histological axillary lymph node metastases and clinical axillary nodal status, tumor size, DNA-ploidy, c-erbB-2 expression, and the score of the argyrophilic nucleolar organizer region. We then attempted to evaluate their predictive values for axillary lymph node metastasis in 173 patients with invasive breast cancer, retrospectively. The clinical and biological variables were significantly correlated with the presence and degree of axillary lymph node metastases. A metastatic index, calculated from the clinical and biological variables, proved especially useful for predicting axillary lymph node metastases in patients whose axillary nodes were clinically negative. However, the predictive abilities were still limited and thus it was concluded that as yet, only axillary dissection can provide accurate information on axillary lymph node metastases.Recipient of a fellowship from the Japanese-Germany Center Berlin, Germany     

Surgical approach to pulmonary metastases from breast cancer

Abstract: One of the main characteristics of breast cancer is its capability to disseminate. Solitary pulmonary metastases from breast cancer occur rarely (0.4%). The aim of this study is to check whether or not the outcome following the surgical treatment of pulmonary metastases in patients with breast cancer is in accordance with the data in the literature and based on it to identify prognostic factors. We have reviewed retrospectively data for 33 patients who underwent 43 curative resections of breast cancer pulmonary metastases between 1997 and 2002 at our department. Potential prognostic factors affecting survival, namely survival after lung metastasectomy, assessed were disease‐free interval (DFI), the number and location of lung metastases, the diameter in mm of metastases and the extent of pulmonary resection. The median survival for 33 patients with pulmonary breast cancer metastatic lesions after metastasectomy was 73.2 months. Mean 5‐year survival was 54.5%. There was a statistically significant difference in survival time with better prognosis for patients with DFI > 36 months (p = 0.0007), complete metastasectomy (p = 0.0153), unilateral pulmonary metastases (p = 0.0267) and for patients who underwent multiple operations (p = 0.0211). In multivariate analysis there was significant influence for long‐term prognosis for patients with DFI > 36 months (p = 0.0446) and for complete resection of the metastases (p = 0.0275). Analysis of the survival rates for patients with solitary pulmonary metastasis, with different size of tumors and after different types of pulmonary resection showed no significant differences. It was concluded that resection of lung metastases from breast cancer may offer a significant survival benefit for selected patients. The identified prognostic factor for survival after metastasectomy is DFI longer than 36 months and complete resection of the metastases. In our group of patients, DFI longer than 36 months, unilateral pulmonary metastases and number of operations significantly influenced survival. Also, the results showed that lung metastasectomy by conventional surgery is a safe procedure with low perioperative morbidity and mortality rate.     

Incidence of axillary lymph node metastases in T1a and T1b breast carcinoma

Background: We investigated the incidence of axillary lymph node metastases in patients with T1a (0.5 cm) and T1b (>0.5 cm and 1.0 cm) breast cancers. Methods: The charts of 2000 patients who underwent axillary lymph node dissection for breast cancer at our institution from 1989 to 1991 were reviewed. Of these, 81 patients had T1a and 166 had T1b primary breast cancers. Results: Among the 247 patients with T1a and T1b breast cancers, nodal metastases were present in 30 (12.1%), with a 7.4% positivity rate for patients with T1a and 14.5% positivity rate for T1b tumors. Of the 212 patients who had 10 nodes dissected, 29 (13.7%) had positive nodes. Of those, 6 of 60 (10.0%) patients with T1a and 23 of 152 (15.1%) with T1b tumors had positive nodes. The presence of lymphovascular invasion (LVI) predicted a significantly higher nodal positivity rate (27.8% vs. 10.9%,p=0.05). Conclusions: Of patients with adequately evaluated axillae, 10% with T1a and 15% with T1b cancers were found to have nodal metastases. Although LVI was significantly associated with a higher risk of lymph node metastases, we could not characterize any subgroup at acceptably low risk of nodal positivity. Until a more useful prognostic indicator is discovered, axillary dissection should continue to be part of the mainstay of management for small breast cancers.Presented at the 50th Annual Cancer Symposium of the Society of Surgical Oncology, Chicago, IL, March 1997.     

Surgical treatment of solitary metastasis in the male breast from non-small cell lung cancer

Detection of metastases in the breast from extramammary neoplasms is rare. We present a case of metastases in breast tissue from surgically treated non-small cell bronchogenic carcinoma. A histologic and immunohistologic study was essential for choosing the appropriate treatment for the patient. The patient is alive and disease-free 18 months after the breast surgery.     

New technique to assess the axilla for breast cancer metastases using cell separation technology

Introduction: Accurate staging of the axilla for metastatic disease is critical in deciding on the optimal management of patients with breast cancer. Lymph node status is the most powerful prognostic factor. Current standard surgical management of breast cancer involves axillary dissection for staging. Pathological staging by routine histology, however, is known to understage the disease extent because only one or two sections are taken from each node, a sampling of less than 1% of most nodes. Sentinel node biopsy is currently under trial to determine if thorough pathological staging of the most likely involved node is more accurate than standard pathological assessment of all nodes. The present pilot study was undertaken to investigate an alternative method of assessing all axillary nodes for cancer cells. Methods: After routine material was taken from lymph nodes for standard pathological assessment, discarded parts of nodes were used for the study technique. These node parts were mechanically disaggregated, and the cell suspension centrifuged on a density gradient to separate any tumour cells (into the pellet) from lymphocytes (at the top of the gradient). The pellet was then assessed by haematoxylin and eosin and immunohistochemistry. Results: The results of the present study proved highly significant. The technique detected metastatic cells in three nodes which were negative on routine pathology, in one case changing the status of the patient from node‐negative to node‐positive. Discussion: It is concluded that the technique examined in the present paper has the potential to reduce sampling error, may offer far more accurate axillary staging than routine histopathology, and should be further evaluated in a controlled trial.     

乳腺癌行腋窝淋巴结清扫规范、争议与共识

乳腺癌的有效治疗方法很多,但外科手术是公认的乳腺癌治疗的基础。手术成功与否的最根本标志是肿瘤手术区域的局部控制。腋窝淋巴结受累的程度是预测乳腺癌术后复发和生存,指导进一步个体化治疗的最为重要指标。规范的腋窝淋巴结清扫和病理检查对乳腺癌的治疗至关重要。术前判断存在腋窝淋巴结转移的乳腺癌病人,腋窝淋巴结清扫是乳腺癌手术的规范和要求。术前临床诊断无腋窝淋巴结转移（cN0）的早期乳腺癌病人,如果前哨淋巴结活检阴性可不做进一步的腋窝淋巴结清扫也已成为共识。对于前哨淋巴结1或2枚阳性的乳腺癌病人可以不行腋窝淋巴结的清扫的观点仍然存在争论。     

乳腺癌根治术保留肋间臂神经临床价值分析

目的 探讨乳腺癌手术腋窝淋巴结清扫时保留肋间臂神经（ICBN）的临床意义。 方法 甘肃省定西市人民医院2002年1月至2006年1月对122例Ⅰ、Ⅱ、Ⅲa期乳腺癌病人行手术治疗。将其随机分为两组：治疗组（56例）行腋窝清扫术时保留ICBN,对照组（66例）行腋窝清扫术时常规切除ICBN,两组病人术后均按乳腺癌治疗,进行严密随访观察。 结果 治疗组及对照组术后1个月上臂内侧感觉障碍发生率分别为7.14%、56.06%（P＜0.01）,差异有统计学意义,经1～5年随访均无局部复发。 结论 对于Ⅰ、Ⅱ、Ⅲa期乳腺癌病人行腋窝淋巴结清扫术时,保留ICBN可明显减少病人术后患侧上臂内侧感觉障碍,提高生活质量。