超声技术用于乳腺癌相关淋巴水肿研究进展

乳腺癌相关淋巴水肿（BCRL）是乳腺癌治疗后常见并发症,早期诊断BCRL并有效管理极为重要。超声现已逐渐用于临床诊断及评估BCRL。本文对超声技术针对BCRL的应用进展进行综述。     

乳腺癌相关淋巴水肿的评估与治疗方法

<正>乳腺癌相关淋巴水肿(Breast Cancer Related Lymph edema,BCRL)是乳腺癌患者术后最常见的并发症之一,常伴随上肢功能受限、疼痛、疲乏及焦虑等症状,严重影响患者的身、心、社会功能和生活质量~([1])。大多数研究认为BCRL是由于手术、放疗等治疗手段阻碍或中断上肢淋巴回流,导致大量高蛋白含量的淋巴液在组织间隙滞留,最终形成高蛋白水肿~([2]),BCRL的发病率从0~94%不等~([3])。早期发现BCRL至关重要,关     

乳腺癌病人乳腺癌相关淋巴水肿发生风险及其与发病情况的关联效应分析

目的:分析乳腺癌病人乳腺癌相关淋巴水肿（BCRL）发生风险、发病情况及两者之间的关联效应。方法:选取2019年1月—2020年12月广西医科大学附属肿瘤医院因乳腺癌住院治疗的1 441例病人为研究对象,采用一般资料调查表、Additive风险评分系统、Norman电话问卷对病人进行调查。结果:1 441例乳腺癌术后病人中,BCRL高风险病人751例（52.12%）,BCRL低风险病人690例（47.88%）。BCRL高风险病人年龄≥60岁、体质指数（BMI）≥25 kg/m2、居住地为城市、行化疗或放疗、术后发生感染的比例均高于BCRL低风险病人,且BCRL高风险病人和BCRL低风险病人婚姻状况、医疗付费方式、临床分期、肿瘤部位、放疗区域、腋窝淋巴结清扫级别、手术方式、手术切口类型、治疗方式、腋窝淋巴结清扫类型、术后时长比较,差异均有统计学意义（P<0.05）。751例BCRL高风险病人中,283例（37.68%）患BCRL,468例（62.32%）未患BCRL;690例BCRL低风险病人中,85例（12.32%）患BCRL,605例（87.68%）未患BCRL。与患BCRL的低...     

乳腺癌手术病人术后并发上肢淋巴水肿的相关危险因素分析

目的:探讨乳腺癌手术病人术后并发上肢淋巴水肿(BCRL)的危险因素。方法:选取医院收治的86例乳腺癌病人,所有病人均行手术治疗,术后随访3个月,统计病人并发BCRL情况,根据结果分为发生组与未发生组,详细统计病人基线资料并比较,重点分析乳腺癌手术病人术后并发BCRL的危险因素。结果:术后随访3个月,86例乳腺癌病人并发BCRL 17例;发生组与未发生组病人的体质指数(BMI)、肿瘤直径、腋窝清扫范围、合并高血压情况比较差异有统计学意义(P<0.05);经Logistic回归分析结果显示,BMI高、肿瘤直径长、腋窝清扫范围大、合并高血压均是乳腺癌手术病人术后并发BCRL的危险因素(OR>1,P<0.05)。结论:乳腺癌手术病人术后并发BCRL的风险较高,BMI高、肿瘤直径长、腋窝清扫范围大、合并高血压均是乳腺癌手术病人术后并发BCRL的危险因素,应根据危险因素给予针对性护理。     

乳腺癌术后上肢淋巴水肿的预防及应用改良后静脉淋巴管吻合技术的疗效分析

目的对乳腺癌相关上肢淋巴水肿(BCRL)的危险因素进行分析,探讨应用改良静脉淋巴管吻合技术治疗BCRL的疗效。方法选取2010年3月至2015年2月200例乳腺癌患者,对BCRL的危险因素进行分析,对术后已发生上肢淋巴水肿的106例BCRL患者,采用改良后静脉淋巴管吻合术,于术后3、6、12个月测量上手臂和前臂周径,判定疗效。结果 TNM分期(Ⅲ~Ⅳ)患者更易发生BCRL,术后锁骨上区淋巴结照射者BCRL发生率更高,TNM分期是发生上肢水肿的独立危险因素。经改良静脉淋巴管吻合技术治疗后,患侧上臂和前臂周径较治疗前明显缩小,肿胀减轻较为显著,上臂、前臂总有效率分别为89.62%、93.40%。中、重度BCRL患者93例,经治疗后,上臂、前臂均达到治愈的共8例,总有效率占89.25%。未见术后吻合口血栓形成、感染、肢体坏死、丹毒、皮下积液以及复发等不良事件发生。结论 TNM分期是发生BCRL的独立危险因素,在有效预防BCRL发生的同时,对已发的BCRL患者采用改良静脉淋巴管吻合技术具有有效性。     

基于CiteSpace对乳腺癌相关淋巴水肿研究的可视化分析

目的:分析2011年—2020年乳腺癌相关淋巴水肿(BCRL)的研究热点和发展趋势。方法:以Web of Science (WOS)数据库核心集为数据源,利用CiteSpaceV.5.8.R1软件对近10年BCRL的研究进行可视化分析,对相关研究的作者、国家/机构分布状况及对关键词进行可视化分析。结果:共获得2011年—2020年发表的英文BCRL研究文章2 038篇。最多产的国家、机构和作者分别是美国、德克萨斯大学MD安德森癌症中心和Jame M Armer。“手臂淋巴水肿”“继发性淋巴水肿”“放射”和“腋窝淋巴结清扫术”是主要关键词。BCRL领域的主要研究热点是BCRL的发病机制、诊断标准及其防治方法。结论:BCRL的预防和新的治疗方法仍然是BCRL领域的主要热点,相关研究质量有很大的提升空间,要加强国家、机构以及作者之间的合作,从而提高研究的广度和深度。     

二维超声和剪切波弹性成像对乳腺癌相关淋巴水肿的评估价值

目的 探讨二维超声和剪切波弹性成像(SWE)诊断乳腺癌相关淋巴水肿(BCRL)和评估康复治疗效果的价值。方法 基于临床评估结果,将102例乳腺癌术后患者分为正常组、亚临床淋巴水肿组和临床淋巴水肿组。使用二维超声、SWE分别检测患者双上肢皮肤和皮下组织,获得相应厚度、硬度值。分析水肿组(亚临床淋巴水肿组和临床淋巴水肿组)患者皮肤、皮下组织的厚度和硬度与国际淋巴学会(ISL)分期的相关性;比较3组患者患肢与对侧肢皮肤、皮下组织的厚度与硬度;比较二维超声、SWE诊断亚临床淋巴水肿的效能;比较周径测量法、二维超声和SWE评估治疗效果的价值。结果 亚临床淋巴水肿组中,患肢前臂皮肤厚度、硬度和前臂皮下组织硬度均大于对侧肢,差异有统计学意义(P<0.05);临床淋巴水肿组中,患肢前臂、上臂皮肤和皮下组织的厚度、硬度均大于对侧肢,差异有统计学意义(P<0.05)。水肿组患者前臂皮肤厚度(r=0.443,P<0.001)、前臂皮肤硬度(r=0.275,P=0.024)均与ISL分期呈显著正相关。受试者工作特征曲线显示,二维超声、SWE诊断亚临床BCRL的曲线下面积分别为0.808、0....     

臂围测量和水置换法评估乳腺癌相关淋巴水肿的一致性

目的观察臂围(AC)测量和上肢体积(ULV)测量评估乳腺癌相关淋巴水肿(BCRL)的相关性。方法 2013年11月至2015年2月,连续收集女性单侧乳腺癌术后放疗患者281例。以肘关节鹰突中心水平下5cm和上10 cm处臂围测量值的均值为AC;以上肢浸没水面至鹰突中心上15 cm处的排水体积为ULV。对AC和ULV进行单因素和多因素线形回归,计算Kappa系数。结果放疗前后,两侧AC与In(ULV)的Pearson和Spearman相关系数均 0.959 (P 0.001)。线性回归方程R~20.90。两者对BCRL诊断一致率 90%(Kappa系数 0.492, P 0.001)。结论 AC和In(ULV)线性关系显著。单独利用AC诊断和评估术后放疗BCRL可靠实用。     

等速肌力训练联合穴位按摩对乳腺癌术后上肢淋巴水肿及肢体功能的影响

目的：探讨等速肌力训练联合穴位按摩对乳腺癌术后上肢淋巴水肿（BCRL）及肢体功能的影响。方法：按随机数字表法，将2021年3月至2023年3月于医院治疗的82例乳腺癌患者分为两组，每组41例。对照组采用常规康复训练，观察组于对照组基础上采用等速肌力训练联合穴位按摩。比较两组上肢功能、握力、生活质量、患肢肩关节活动度及BCRL发生率。结果：干预后，两组上肢功能障碍评分均低于干预前，握力、生活质量评分及患肢肩关节内收、外展、前屈、后伸活动度均高于干预前，且观察组上肢功能障碍评分低于对照组，握力、生活质量评分及患肢肩关节内收、外展、前屈、后伸活动度高于对照组（P＜0.05）；观察组BCRL发生率低于对照组（P＜0.05）。结论：等速肌力训练联合穴位按摩能够降低乳腺癌患者术后BCRL发生率，提高患者握力、患肢肩关节活动度，改善患者生活质量，促进患者肢体功能恢复。     

女性乳腺癌术后上肢淋巴水肿危险因素调查分析

目的:探讨女性乳腺癌术后上肢淋巴水肿(BCRL)的发生率和危险因素。方法:选择本院乳腺外科诊断为单侧、单病灶乳腺癌并行手术治疗的女性患者246例。查阅相关病史资料,完成科研病历的填写,内容包括患者的一般资料(诊断时年龄、体质量、付费方式、文化程度、是否有并发症等)、肿瘤情况(病理类型、术后分期、激素受体情况、Her-2情况、淋巴结清扫数目、阳性淋巴结数目等)、治疗情况(外科手术方式、腋窝淋巴结处理方式、是否接受放疗、是否接受术后化疗、化疗方案、化疗周期数,是否接受内分泌治疗、内分泌治疗药物和用药时间等),建立乳腺癌BCRL的临床资料数据库。通过随访并采用Norman中文版问卷对患者双侧手掌、前臂和上臂等部位自我症状的感知判断BCRL及其严重程度。结合患者的临床资料进行回顾性分析,统计可能与BCRL相关的因素,包括发病年龄、术前BMI、随访时BMI、手术方式、手术侧、淋巴结清扫数目、阳性淋巴结、高血压、糖尿病、化疗、放疗、内分泌治疗等,采用χ2检验进行单因素分析和logistic回归分析方法进行多因素分析。结果:在246例患者中,有47例被诊断为BCRL,199例未发生上肢淋巴水肿,患者术后1～3年BCRL发生率为19.11%。所有病例均经病理明确诊断,ER阳性136例,PR阳性113例,Her-2阳性161例,整组患者中仅31例接受保乳手术。BCRL影响因素的单因素分析中术前和随访时的BMI、高血压、术后化疗、术后放疗、术后内分泌治疗、淋巴结清扫数目、阳性淋巴结、发病年龄共9个因素,水肿组和非水肿组组间比较差异均有统计学意义(P0.05)。多因素分析发现高血压(OR=11.868)、化疗(OR=6.669)、放疗(OR=3.408)、阳性淋巴结(OR=3.838)是BCRL的危险因素。结论 :BCRL是乳腺癌术后严重的并发症之一,对于有高血压、阳性淋巴结以及术后行化疗、放疗的患者,应积极进行健康宣教和采取预防措施,及早干预,避免淋巴水肿发生。     

Direct evidence of lymphatic function improvement after advanced pneumatic compression device treatment of lymphedema

Lymphedema affects up to 50% of all breast cancer survivors. Management with pneumatic compression devices (PCDs) is controversial, owing to the lack of methods to directly assess benefit. This pilot study employed an investigational, near-infrared (NIR) fluorescence imaging technique to evaluate lymphatic response to PCD therapy in normal control and breast cancer-related lymphedema (BCRL) subjects. Lymphatic propulsion rate, apparent lymph velocity, and lymphatic vessel recruitment were measured before, during, and after advanced PCD therapy. Lymphatic function improved in all control subjects and all asymptomatic arms of BCRL subjects. Lymphatic function improved in 4 of 6 BCRL affected arms, improvement defined as proximal movement of dye after therapy. NIR fluorescence lymphatic imaging may be useful to directly evaluate lymphatic response to therapy. These results suggest that PCDs can stimulate lymphatic function and may be an effective method to manage BCRL, warranting future clinical trials.     

Lymphatic abnormalities in the normal contralateral arms of subjects with breast cancer-related lymphedema as assessed by near-infrared fluorescent imaging

Current treatment of unilateral breast cancer-related lymphedema (BCRL) is only directed to the afflicted arm. Near-infrared fluorescent imaging (NIRF) of arm lymphatic vessel architecture and function in BCRL and control subjects revealed a trend of increased lymphatic abnormalities in both the afflicted and unafflicted arms with increasing time after lymphedema onset. These pilot results show that BCRL may progress to affect the clinically "normal" arm, and suggest that cancer-related lymphedema may become a systemic, rather than local, malady. These findings support further study to understand the etiology of cancer-related lymphedema and lead to better diagnostics and therapeutics directed to the systemic lymphatic system.     

A systematic review of the effect of low-level laser therapy in the management of breast cancer-related lymphedema

Purpose

The purpose of this study was to review the effect of low-level laser therapy (LLLT) in the management of breast cancer-related lymphedema (BCRL).

Methods

A systematic review of seven databases for clinical trials for LLLT in the management of BCRL published between 1990 and 2011 was performed.

Results

A total of eight studies on 230 patients were found. The methodological qualities of the selected studies were assessed with the Physiotherapy Evidence Database scale, and the studies were categorized according to Sackett’s levels of evidence. Five studies were graded at evidence level II. Two studies were graded at evidence level III, and the remaining study was graded at evidence level V.

Conclusions

There is moderate to strong evidence for the effectiveness of LLLT for the management of BCRL from five small studies of acceptable methodological quality. A dose of 1–2?J/cm² per point applied to several points covering the fibrotic area can reduce limb volume following BCRL. Further well-designed, large-scale studies are required to determine more precisely how effective LLLT may be in BCRL.     

淋巴结病变影像学研究的新进展

淋巴结病变主要包括淋巴结增生、淋巴结转移及淋巴瘤.影像学对淋巴结病变的定性诊断,主要依靠淋巴结的大小(>1.0 cm为异常).如何对淋巴结病变作出准确的定性和定量诊断,一直是影像学医生棘手的难题.目前研究得较多的有MR特异性造影剂成像、磁共振频谱分析(MRS)、CT淋巴结造影术和各种灌注成像.     

乳腺癌术后上肢淋巴水肿病人自我感受负担与自我护理能力的相关性研究

目的:了解乳腺癌术后上肢淋巴水肿病人的自我感受负担、自我护理能力,并探讨二者的相关性。方法:采用方便抽样方法选取在中山大学肿瘤防治中心就诊的187例乳腺癌术后上肢淋巴水肿病人进行问卷调查。结果:乳腺癌术后上肢淋巴水肿病人自我感受负担总分为(30.40±7.65)分,自我护理能力总分为(109.36±18.57)分。自我感受负担与自我护理能力呈负相关(P<0.05)。结论:多数乳腺癌术后上肢淋巴水肿病人存在中重度自我感受负担,且自我护理能力有待提高。护理人员应关注病人的心理问题,及时进行心理疏导,同时提高病人的自我护理能力,减轻其心理负担。     

Breast cancer-related lymphedema: comparing direct costs of a prospective surveillance model and a traditional model of care

Secondary prevention involves monitoring and screening to prevent negative sequelae from chronic diseases such as cancer. Breast cancer treatment sequelae, such as lymphedema, may occur early or late and often negatively affect function. Secondary prevention through prospective physical therapy surveillance aids in early identification and treatment of breast cancer-related lymphedema (BCRL). Early intervention may reduce the need for intensive rehabilitation and may be cost saving. This perspective article compares a prospective surveillance model with a traditional model of impairment-based care and examines direct treatment costs associated with each program. Intervention and supply costs were estimated based on the Medicare 2009 physician fee schedule for 2 groups: (1) a prospective surveillance model group (PSM group) and (2) a traditional model group (TM group). The PSM group comprised all women with breast cancer who were receiving interval prospective surveillance, assuming that one third would develop early-stage BCRL. The prospective surveillance model includes the cost of screening all women plus the cost of intervention for early-stage BCRL. The TM group comprised women referred for BCRL treatment using a traditional model of referral based on late-stage lymphedema. The traditional model cost includes the direct cost of treating patients with advanced-stage lymphedema. The cost to manage early-stage BCRL per patient per year using a prospective surveillance model is $636.19. The cost to manage late-stage BCRL per patient per year using a traditional model is $3,124.92. The prospective surveillance model is emerging as the standard of care in breast cancer treatment and is a potential cost-saving mechanism for BCRL treatment. Further analysis of indirect costs and utility is necessary to assess cost-effectiveness. A shift in the paradigm of physical therapy toward a prospective surveillance model is warranted.     

Comparison of diagnostic accuracy of clinical measures of breast cancer-related lymphedema: area under the curve

Smoot BJ, Wong JF, Dodd MJ. Comparison of diagnostic accuracy of clinical measures of breast cancer–related lymphedema: area under the curve.

Objective

To compare diagnostic accuracy of measures of breast cancer–related lymphedema (BCRL).

Design

Cross-sectional design comparing clinical measures with the criterion standard of previous diagnosis of BCRL.

Setting

University of California San Francisco Translational Science Clinical Research Center.

Participants

Women older than 18 years and more than 6 months posttreatment for breast cancer (n=141; 70 with BCRL, 71 without BCRL).

Interventions

Not applicable.

Main Outcome Measures

Sensitivity, specificity, receiver operator characteristic curve, and area under the curve (AUC) were used to evaluate accuracy.

Results

A total of 141 women were categorized as having (n=70) or not having (n=71) BCRL based on past diagnosis by a health care provider, which was used as the reference standard. Analyses of ROC curves for the continuous outcomes yielded AUC of .68 to .88 (P<.001); of the physical measures bioimpedance spectroscopy yielded the highest accuracy with an AUC of .88 (95% confidence interval, .80–.96) for women whose dominant arm was the affected arm. The lowest accuracy was found using the 2-cm diagnostic cutoff score to identify previously diagnosed BCRL (AUC, .54–.65).

Conclusions

Our findings support the use of bioimpedance spectroscopy in the assessment of existing BCRL. Refining diagnostic cutoff values may improve accuracy of diagnosis and warrant further investigation.     

乳腺癌相关淋巴水肿患者自我护理的研究进展

乳腺癌相关淋巴水肿患者自我护理是实现成功治疗的关键,但自我护理过程长且受多种因素的影响。该文介绍了乳腺癌相关淋巴水肿患者自我护理依从性的研究现状,分析了影响乳腺癌相关淋巴水肿患者自我护理依从性的因素,旨在为后续的研究提供参考。