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减少乳腺癌术后淋巴水肿的新技术

  腋窝逆行淋巴显影可以显示上肢的淋巴结和淋巴管,用于乳腺癌腋窝淋巴结清扫的作用尚存争议,可能由于其对上肢淋巴系统识别不全及其对肿瘤学安全性的影响。上肢淋巴系统识别保留技术有助于完全识别上肢淋巴系统,有助于减少乳腺癌腋窝清扫术后上肢淋巴水肿的发生。

  2019年6月25日,美国乳腺外科医师学会和肿瘤外科学会《肿瘤外科学报》在线发表武汉大学中南医院、华中科技大学同济医学院附属同济医院、芝加哥大学普利茨克医学院的研究报告,分析了将上肢淋巴系统识别保留技术用于腋窝淋巴结清扫的上肢淋巴水肿率、局部区域远处复发率以及可行性。

  该多中心随机对照研究于2013年2月~2017年10月从两个三级转诊中心(武汉中南医院、武汉同济医院)入组早期乳腺癌淋巴结阳性患者1354例,随机分为两组。其中,研究组689例,通过吲哚菁绿和亚甲蓝识别上肢前哨淋巴结,并将0.1毫升亚甲蓝注入上肢前哨淋巴结显示引流区域淋巴结和淋巴管。通过术中部分冷冻切片对所有上肢淋巴结进行检查,若阳性则切除。根据不同随访检查记录上肢淋巴水肿、局部复发、引流区域复发、远处转移。

  结果,上肢前哨淋巴结被识别于573例(83.2%)患者,其中558例(97.4%)患者可显示引流区域淋巴结和淋巴管,其中38例(6.8%)患者发现上肢淋巴结转移。

  中位随访37个月,剔除未接受研究方案治疗和失访患者后,研究组与对照组相比:

  • 淋巴水肿率较低:3.3%比15.3%(P<0.001)

  • 局部复发率相似:1.5%比1.4%(P=0.903)

  • 区域复发率相似:1.4%比1.2%(P=0.392)

  • 远处复发率相似:5.0%比4.6%(P=0.783)

  因此,该研究结果表明,对于乳腺癌腋窝淋巴结清扫患者,上肢淋巴系统识别保留技术可以减少上肢淋巴水肿率不显著影响复发率

  对此,阿肯色医科大学发表同期评论:腋窝淋巴评估有助于解决复杂问题。

Ann Surg Oncol. 2019 Jun 25. [Epub ahead of print]

Identification and Preservation of Arm Lymphatic System in Axillary Dissection for Breast Cancer to Reduce Arm Lymphedema Events: A Randomized Clinical Trial.

Qianqian Yuan, Gaosong Wu, Shu-Yuan Xiao, Jinxuan Hou, Yuqi Ren, Hongying Wang, Kun Wang, Dan Zhang.

Zhongnan Hospital of Wuhan University, Wuhan, China; Wuhan University Center for Pathology and Molecular Diagnostics, Wuhan, China; University of Chicago Pritzker School of Medicine, Chicago, USA; Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China.

BACKGROUND: Controversy in axillary reverse mapping in axillary lymph node dissection (ALND) possibly results from incomplete recognition of the arm lymphatic system (ALS) and its compromise to oncological safety. The iDEntification and Preservation of ARm lymphaTic system (DEPART) technique facilitates complete identification of ALS; therefore, its use may decrease the occurrence of arm lymphedema. This study aimed to examine the arm lymphedema rate, locoregional recurrence, and feasibility to perform DEPART in ALND.

METHODS: Patients from February 2013 to October 2017 from two tertiary referral centers were randomly assigned to two groups. In the study group, indocyanine green and methylene blue (MB) were utilized to identify arm sentinel nodes, and 0.1 ml MB was injected into the arm sentinel nodes to reveal the subsequent-echelon nodes and lymphatics. Gross arm lymph nodes were examined by intraoperative partial frozen section and were removed if positive. Arm lymphedema, local recurrence, regional recurrence, and distant metastasis were recorded at different follow-up examinations.

RESULTS: Arm sentinel nodes were identified in 573 (83.2%) patients. Subsequent-echelon nodes and lymphatics were visualized in 558 (97.4%) patients. Metastatic arm nodes were identified in 38 (6.8%) patients. The arm lymphedema rate was 3.3% (18/543) in the study group versus 15.3% (99/648) in the control group (p<0.001) after 37-month median follow-up. Regional recurrence showed no difference between the two groups (1.4% and 1.2%, respectively) (p=0.392).

CONCLUSIONS: DEPART can benefit breast cancer patients who undergo ALND, reducing the arm lymphedema rate without adversely affecting the morbidity of regional recurrence.

DOI: 10.1245/s10434-019-07569-4


Ann Surg Oncol. 2019 Jun 25. [Epub ahead of print]

Axillary Lymphatic Evaluation: A Solution to a Complex Problem.

Daniela A. Ochoa.

University of Arkansas for Medical Sciences, Little Rock, USA.

DOI: 10.1245/s10434-019-07570-x

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