染料法乳腺癌前哨淋巴通道的研究

The study on sentinel lymphatic channels by using methylene blue in breast cancer patients

目的通过研究前哨淋巴通道（SLCs）及其与前哨淋巴结（SLN）之间的解剖关系,探讨乳腺癌前哨淋巴结活检（SLNB）出现假阴性的机制.方法62例乳腺癌患者术前作外侧角即θe标记.全身麻醉后于乳晕内侧缘注入美蓝3 ml.取改良根治术标本仔细解剖连接乳晕和SLN之间的SLCs,观察其走行方向、走行途径、数量及与SLN之间的关系.结果52例（83.9%）成功解剖SLCs及其连接的SLN,其中49例（94.2%）SLCs的θe角为31°～90°,36例（69.2%）θe角为61°～90°.1枚SLN者48例（92.3%）,2枚者4例（7.7%）.SLCs与SLN有3种连接方式：2条独立的SLCs各连接1枚SLN;1条SLCs进入腋窝前后分成若干分支连接1枚SLN;1条SLCs进入腋窝前分成2条各连接1枚SLN,且2枚SLN可位于腋窝的不同群.沿SLCs解剖出的SLN,病理结果未发现有假阴性和假阳性.结论尚未发现乳腺癌腋窝“跳跃式”淋巴转移模式,推测SLNB假阴性的产生是技术问题,可能与手术者对SLCs和SLN行走路线和数量的复杂性认识不足有直接关系.

Objective To explore why sentinel lymph node biopsies （SLNB） produce false negative results in breast cancer patients by studying the anatomical origin of sentinel lymphatic channels （ SLCs）, as well as the relationship between SLCs and sentinel lymph node （SLN）. Methods Sixty-two breast cancer patients consenting to modified radical mastectomies were marked by exit angle （ θe ） preoperatively and were injected with 3 ml of methylene blue （MB） into the inner edge of the areolae under general anesthesia. SLCs were carefully dissected to retain connections between the areolae and SLN to define the direction, route and number of SLCs and their relationship with the SLN. Results SLCs and SLN were identified in 52 cases （83. 87% ） successfully. In 49 of these 52 cases （94. 23% ） the SLCs exited from the areolae and terminated in axilla with an θe =31°～90°, and in 36 of 52 cases （69. 23% ） with an θe =61°-90°. The majority of the time, one SLN was identified （92. 31%, n = 48 ） with two identified SLNs occurring only 7. 69% （n =4） of the time. There were three patterns of connectivity： 1） Two SLCs could connect to one SLN separately; 2） One SLC could divide into several branches before or after entering axilla, which ultimately connected to one SLN; or 3 ） One SLC could divide into two branches before entering axilla, which connected to one SLN separately and these two SLNs could be located in different parts of axilla. No false negative or false positive was demonstrated by pathological ananlysis of SLN which was identified according to SLCs. Conclusions No evidence showed that the mechanism of axillary lymph node metastasis is skip metastasis. We conclude that false negative results from SLNB seems to be associated with the technique used, which may be caused by the incomplete knowledge of the anatomical relationship between SLCs and SLN.