乳腺癌患者腋窝淋巴结清扫术中保留肋间臂神经的临床意义

Clinical significance of preserving intercostobrachial nerve in axillary lymph node dissection for breast cancer patients

目的：探讨乳腺癌患者腋窝淋巴结清扫术（ ALND）中保留肋间臂神经（ ICBN）的临床意义。方法前瞻性研究2011年1月至2013年6月石家庄市第一医院收治的228例乳腺癌患者的临床资料。其中,乳腺癌ALND中保留 ICBN的患者有90例（ ICBN 保留组）,切除 ICBN 的患者有138例（ ICBN切除组）。并对两组患者术后1、6、12个月时上臂内侧及腋窝皮肤的感觉进行观察。两组患者间感觉异常发生率和上肢水肿发生率的比较采用χ2检验,淋巴结检出数目的比较采用t检验。结果术后1、6、12个月时,ICBN保留组患者感觉异常的发生率分别为42.2%（38/90）、43.3%（39/90）和33.3%（30/90）,明显低于 ICBN 切除组的84.1%（116/138）、81.2%（112/138）和80.4%（111/138）（χ2=43.491、34.847、51.214,P均〈0.001）。术后1个月时,ICBN保留组患者的主观感觉异常发生率明显低于ICBN切除组[27.8%（25/90）比46.4%（64/138）,χ2=7.918,P=0.005]；而在术后6个月和12个月时,两组患者的主观感觉异常发生率相似[13.3%（12/90）比21.0%（29/138）,χ2=2.179,P=0.140；8.9%（8/90）比15.2%（21/138）,χ2=1.965,P=0.161]。术后1、6、12个月时,ICBN保留组患者的客观感觉异常发生率均明显低于 ICBN 切除组[35.6%（32/90）比76.8%（106/138）,41.1%（37/90）比76.8%（106/138）,31.1%（28/90）比76.8%（106/138）,χ2=38.807、29.693、46.953, P均〈0.001）。并且,ICBN保留组与ICBN切除组患者间淋巴结的检出数目相似[（19±4）枚比（18±3）枚,t=1.848,P=0.066],术后上肢水肿的发生率也相似[术后1个月：11.1%（10/90）比15.2%（21/138）,χ2=0.782,P=0.377；术后6个月：15.6%（14/90）比15.9%（22/138）,χ2=0.006,P=0.938；术后12个月：16.7%（15/90）比15.9%（22/138）,χ2=0.021,P=0.885]。中位随访14个月（12~41个月）时,两组患者均未出现局部复发及死亡病例。结论乳腺癌ALND中保留ICBN在术后早期可以明显降低感觉异常的发生率,在一定程度上提高了患者的生存质量。并且,手术6个月以后,保留ICBN者的客观感觉异常得到明显改善,而主观感觉异常的改善并不明显。

Objective To investigate the clinical significance of preserving intercostobrachial nerve （ ICBN） in axillary lymph node dissection （ ALND） for breast cancer patients. Methods The clinical data of 228 cases of breast cancer in the First Hospital of Shijiazhuang City from 2011 January to 2013 June were prospectively analyzed. ICBN was preserved in 90 cases （ ICBN preservation group） and was resected in the other 138 cases （ ICBN dissection group） in ALND. The skin sensation inside the affected upper arm and at axillary fossa was recorded at 1, 6 and 12 months after surgery. The rates of skin paresthesia and edema of the upper extremity between two groups were compared usingχ2 test, the number of detected axillary nodes using t＆amp;nbsp;test. Results At 1,6 and 12 months after surgery,the incidence of skin paresthesia in ICBN preservation group was 42. 2%（38/90）,43. 3%（39/90）and 33. 3%（30/90）respectively, which was significantly lower than that in ICBN dissection group [84. 1%（116/138）,81. 2%（112/138）,80. 4%（111/138）;χ2=43. 491,34. 847, 51. 214;all P〈0. 001 ] . The incidence of subjective paresthesia in ICBN preservation group was significantly lower than that in ICBN dissection group at one month after surgery [ 27. 8%（ 25/90 ） vs 46. 4%（ 64/138 ） ,χ2=7. 918,P=0. 005]. There was no significant difference in the incidence of subjective paresthesia between the two groups at 6 and 12 months after surgery （13. 3%（12/90） vs 21. 0%（29/138）,χ2=2. 179,P=0. 140;8. 9%（8/90） vs 15. 2%（21/138）,χ2=1. 965,P= 0. 161）. The incidence of objective paresthesia in ICBN preservation group was significantly lower than that in ICBN dissection group at 1,6 and 12 months after surgery [35. 6%（32/90） vs 76. 8%（106/138）, 41. 1%（37/90） vs 76. 8%（106/138）, 31. 1% （28/90） vs 76. 8%（106/138）;χ2=38. 807, 29. 693, 46. 953,all P〈0. 001]. No significant difference was found in the numbers of detected axillary nodes [（19±4） vs （18±3）,t=1. 848,P=0. 066] and in the incidences of the upper extremity edema between ICBN preservation group and ICBN dissection group [ one month after surgery：11. 1%（10/90） vs 15. 2%（21/138）,χ2=0. 782,P=0. 377;6 months after surgery：15. 6% （14/90）vs 15. 9%（22/138）,χ2=0. 006,P=0. 938;12 months after surgery：16. 7%（15/90） vs 15. 9%（22/138）,χ2=0. 021,P=0. 885]. No case of local recurrence or death was observed in both groups in the follow-up of 12-41 months （ median 14 months） . Conclusions Preserving the intercostobrachial nerve in ALND can decrease the incidence of the skin paresthesia significantly at early stage after surgery and improve the quality of life of breast cancer patients to some extent. However, at postoperative 6 months, the patients with ICBN preservation show a significant improvement in objective paresthesia, but not in subjective paresthesia.