术前活检诊断的乳腺导管原位癌前哨淋巴结活检45例分析

Preoperative biopsy diagnosis of breast ductal carcinoma in situ sentinel lymph node biopsy in 45 cases

目的分析由空芯针穿刺（CNB）或微创旋切活检（VAB）诊断的乳腺导管原位癌（DCIS）的临床及病理特征与前哨淋巴结（SLN）阳性的关系,探讨术前诊断DCIS患者实施美蓝示踪前哨淋巴结活检（SLNB）的准确性、可行性,为临床工作提供理论依据。方法回顾性分析我院2011年3月至2015年3月45例术前活检诊断的DCIS患者,采用美蓝示踪进行SLNB。麻醉后切皮前,于病灶周围或活检残腔以及乳晕周围各分4点皮下注2%美蓝共2m L。10-15 min后进行SLNB。取病灶同侧腋窝胸大肌外侧缘沿腋皱襞长约4 cm弧形切口,切除蓝染淋巴结及淋巴管送术中印片细胞学＋冰冻组织学病理检查。再行保留乳房手术或乳房切除手术。结果 1 45例患者均成功检出SLN,共144枚。SLN检出率100%（45/45）,准确率98%（44/45）。其中4例患者SLN阳性,阳性率9%（4/45）,3例患者后续进行腋窝淋巴结清扫。42例仅行SLNB患者术后随访7-5个月（中位30个月）,无一例患者出现患肢肿胀、麻木、疼痛等不适。随访期间无复发、转移及死亡病例。2同时分析SLN阳性与临床及病理特征的关系：患者年龄、肿瘤大小、首发症状、活检方式、检出SLN数目,差异均无统计学意义（P均〉0.05）。可能与DCIS患者SLN阳性有关的因素为：肿瘤大小〉3.0 cm、首发症状为可触及肿块、术前诊断方式为CNB,行乳房切除手术,最终病理诊断为导管原位癌伴微浸润（DCIS-MI）及浸润性导管癌（IDC）。结论 1术前诊断的DCIS行美蓝示踪SLNB安全、可行;2以下因素对预测DCIS患者可能出现SLN阳性提供帮助：病灶范围〉3 cm、可触及肿块、同时伴有雌激素受体（ER）低表达、人表皮生长因子受体过表达。对于此类患者推荐进行SLNB。

Objective To analyze the clinicopathologic characteristics of the patients pretoperative diagnosed with breast ductal carcinoma in situ（DCIS） using core needle biopsy（CNB） or vacuum-assisted biopsy（VAB） as the initial diagnostic method, and the relationship with the positive sentinel lymph nodes （SLN）. To explore the accuracy and feasibility of using methylene blue staining method for sentinel lymph node biopsy of the patients diagnosed with breast ductal carcinoma in situ using CNB or VAB as the initial diagnostic method. Providing a theoretical basis for clinical work. Methods A retrospective study was performed of 45 patients with an initial diagnosis of DCIS between March 2011 and March 2015 in our hospital. The patients were treated with methylene blue staining method for sentinel lymph node biopsy （SLNB）. During the surgery, 10-15 minutes before skin incision, we injected 2 mL 2% methylene blue （total dose） around four points of the tumor and the areola in 45 cases of DCIS, and then underwent sentinel lymph node biopsy. We made an arc incision along skin texture in the axillary folds, resection the blue-stained lymph tube and the blue-stained lymph node for intraoperative cell imprint and frozen section. Then perform breast conserving surgery or mastectomy. Results ①One hundred and forty-four SLNs of 45 cases were successfully detected;the success rate was 100%（45/45）. SLNB accuracy rate was 98%（44/45）. Four of 45 patients （9%） had a positive SLN. Three of 4 patients underwent axillary node dissection（ALND）, but had no other axillary lymph node metastasis. The median follow-up of 42 cases only undergoing SLNB was 30 months （7-55 months）, no limb edema, anesthesia or painess was found in this group. No metastasis and local relapse was found in total 45 cases. No patient dead during follow-up. ② The results of multiple logistic regression analysis showed that there was no statistically significant difference about these factors , including age, tumor size, first symptom, biopsy method, number of SLN excised（P〉0.05）. However, there were still some factors that might be correlative to the node positive of DCIS patients, which are size of tumor 〉3.0 cm, palpable mass, inicial diagnosis by core needle biopsy（CNB）, mastectomy, the final diagnosis upstaged to DCIS with microinvasion（DCI-MI） or invasive breast cancer（IBC）. Conclusion ①Methylene blue staining method for SLNB of the patients preto-perative diagnosed with DCIS is safety and feasible. ② It is suggested that the following factors could help to predict the DCIS for patients who were treated with the positive SLN, size of tumor 〉3.0 cm, palpable mass, with negative ER, or Her-2 overexpression. SLNB should be performed.