乳腺癌腋窝淋巴结清扫术中保留上肢淋巴结的可行性研究

A clinical study on upper limb lymph-node-conserving surgery in axillary lymph node dissection for early breast cancer

目的探讨乳腺癌腋窝淋巴结清扫术（ALND）中保留上肢淋巴结的可行性。方法52例早期乳腺癌在施行ALND前于患侧前臂皮下注射亚甲蓝5ml进行上肢淋巴结定位，术中分检出上肢淋巴结和水平Ⅱ淋巴结，水平Ⅱ淋巴结进行印片细胞学和冰冻切片病检。术后所有淋巴结分组进行常规病检。结果52例术中可见上肢淋巴结蓝染50例（96．2％）；术后病检，上肢淋巴结蓝染者腋窝淋巴结转移31例（62．0％，31／50）；其中单独水平Ⅱ转移1例（2．0％，10／50），水平Ⅰ转移者30例（60．0％，）；水平Ⅰ转移的患者中同时具有水平Ⅱ转移者10例（22．0％，10／50），水平Ⅱ转移者并上肢淋巴结转移者3例（6．0％，3／50）。3例上肢淋巴结转移者均同时具有水平Ⅱ转移，单独水平Ⅰ转移而无水平Ⅱ转移者均未发现腋窝蓝染淋巴结转移。11例水平Ⅱ淋巴结转移，术中印片细胞学检出8例，冰冻切片检出9例，2者联合检出10例。术中淋巴结印片细胞学检查联合冰冻切片病检与术后常规病检的符合率为98．0％（49／50）。结论乳腺癌患者术前前臂皮下注射亚甲蓝可有效进行上肢淋巴结定位。经术中快速病检确定水平Ⅱ淋巴结无转移者，可施行保留上肢淋巴结的ALND。

Objective To evaluate the feasibility of upper limb lymph node conservation in axillary lymph node dissection （ALND） for early breast cancer patients. Methods This study involved 52 patients. Before ALND, they were injected 5 ml of methylene blue subcutaneouly in ipsilateral upper limb for upper limb lymphatic mapping. Level Ⅱ lymph nodes and upper limb lymph nodes were respectively separated from axillary lymph nodes during operation. Level Ⅱ lymph nodes were given intraoperative imprint cytology and frozen section. All lymph nodes were given routine pathological examination after operation. Results Of the 52 patients, 50 cases showed blue stained lymphatic vessels or lymph nodes in the axillary region. The rate of blue dye under naked eyes was 96. 2% （50/52）. The postoperative pathological examination showed there were 31 cases of axillary lymph nodes metastasis in patients with blue stained lymph nodes. There was Ⅰ case with metastasis to level Ⅱlymph nodes only （2.0%） and 30 cases with metastasis to level Ⅰ lymph nodes （60. 0% ）. There were 10 cases with metastasis to both level Ⅱ and level Ⅰ lymph nodes （22.0%）. There were 3 cases with metastasis to both level Ⅱ and upper limb lymph nodes. 3 patients with metastasis to upper limb lymph nodes all had metastasis to level Ⅱ lymph nodes. For cases with metastasis to level Ⅰ lymph nodes only, pathological examination showed there was no metastasis to the blue stained lymph nodes removed from the axillary region. For the 11 cases with metastasis to level Ⅱ lymph nodes, 8 cases were successfully detected by intraoperative imprint cytology, 9 cases were detected by frozen section and 10 were detected by the combination of imprint cytology and frozen section. Comparing the combining method （ intraoperative imprint cytology and frozen section） and postoperative routine pathological examination, the concordant rate was 98.0% （49/50）. Conclusions Subcutaneous methylene blue injection in ipsilateral upper limb can effectively map lymph nodes of upper limb in the axillary region. The upperlimb lymph-node-conserving surgery in ALND can be performed if the patients don＇t have level Ⅱ lymph node metastasis identified by intraoprative rapid pathological examination.