腋窝逆行淋巴显影联合术中细针穿刺活检预防腋窝淋巴清扫术后上肢淋巴水肿

Combined therapy of axillary reverse mapping and fine needle aspiration cytology for postoperative lymphedema in axillary lymph node dissection

目的：探讨乳腺癌腋窝淋巴清扫术（axillary lymph node dissection,ALND）中腋窝逆行淋巴显影（axillary reverse mapping,ARM）联合细针穿刺活检（fine needle aspiration cytology,FNAC）预防术后上肢淋巴水肿的作用。方法 ：选取2013年1月~12月乳癌患者,随机分为对照组与选择组,均行ARM与FNAC。对照组切除ARM淋巴结;选择组ARM淋巴结如为阳性、可疑或无法确定则予以切除,阴性则予以保留。结果：入组乳腺癌72例,对照组35例,选择组37例,均在腋区成功显影ARM淋巴结。对照组细针穿刺ARM淋巴结阳性1例（2.9%）,可疑3例（8.6%）,无法确定6例（17.1%）,术后组织病理示阳性2例（5.7%）;选择组细针穿刺阳性2例（8.1%）,可疑2例（5.4%）,无法确定9例（24.3%）,术后组织病理阳性3例（8.1%）。术后2周内上肢淋巴水肿发生率对照组88.6%（31/35）、选择组中切除者84.6%（11/13）、选择组中保留者12.5%（3/24）;完成6个月随访后水肿发生率对照组31.4%（11/35）、选择组中切除者30.8%（4/13）,选择组中保留者未发现上肢淋巴水肿。结论：ARM联合FNAC可安全有效地鉴别上肢淋巴引流,可用于预防ALND后上肢淋巴水肿的发生。

Objective：To explore the effect of combined ARM and FNAC on postoperative lymphedema in ALND. Methods：This study was performed from Jan 2013 to Dec 2013 and patients undergoing ALND were enrdled. The patients were devided into control and treatment groups. One ml of Carbon Nanopartieles intradermally was injected in the ipsilateral upper extremity. FNAC was performed in both groups. All the dyed nodes were dissected in the control group. ARM nodes which were positive for malignancy, suspicious, or inadequate for diagnosis were dissected,while negative ARM nodes were spared. Data were collected with successful identification and protection of the arm lymphatlcs,and occurrence of ]ymphedcma. Results：Of the 72 patients undergoing ALND,in 100% of patients, all ARM lymphatics and nodes were identified in the axilla. One, 3,6 patients in control group and 2,2,9 with selective group had positive ,suspicious and Unidentified ARM nodes by FNAC, respectively. Two in control group and 3 with the other had positive ARM nodes by histological diagnosis. Lymphedema in two weeks and postoperative 6 months happened in 88.6% and 31.4% of control, 84.6% and 30.8% in the selective patients whose ARM nodes were removed,but 12.5% and none in the selective patients whose ARM nodes were preserved, other 8 cases whose blue lymphatics and nodes were preserved. Conclusion：ARM and FNAC can safely and effectively identify the upper extremity lymph drainage, so may be used to prevent the ]ymphedema after ALND.