乳腺癌腋窝各组淋巴结转移相关性的研究
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摘要
乳腺癌是一种全身性疾病。随着研究的进展,乳腺癌早期的远处微小转移灶与远处转移灶之间的联系越来越明显。这就要求乳腺疾病专科医生相比局部治疗手段更为重视乳腺癌的全身治疗,同时也应尽量减少局部治疗所带来的副损伤。由术后病理结果我们可以了解到,绝大多数早期乳腺癌患者仍承受了腋窝淋巴结清扫术中的一定程度的过度治疗。这与当前在保证治疗效果的前提下尽可能减少手术创伤的理念背道而驰。因而要想进一步缩小腋窝淋巴结清扫的手术范围必须对乳腺癌腋窝转移的规律有更深层次的探讨。前一阶段学术界对腋窝淋巴结转移规律的探讨主要集中在年龄、月经状况、原发灶大小、位置、病理类型等宏观统计学因素对腋窝淋巴结转移几率的影响。而当前对腋窝淋巴结转移规律的研究热点转向对淋巴结转移的分子预测因子的研究以及各组淋巴结转移之间的量化关系更为细化的探讨。
在以往与本研究类似的课题中,研究者更着重于对Ⅲ组淋巴结转移规律的探讨。其得出的结论使得大部分早期乳腺癌患者可以免受第Ⅲ组淋巴结清扫。但是对于我国大部分腋窝阴性的早期患者,仍有进一步减少过度治疗的可能性。因此本研究就以此为着眼点,对腋窝各组淋巴结转移之间的规律进行研究,并着重研究早期乳腺癌更为常见的Ⅰ、Ⅱ组转移间的相关性,以期找到对部分早期患者进一步缩小腋窝手术范围的可能性。
Breast cancer is one of the most harmful disease to the health of women..The morbidity of breast cancer increases year by year under the influence of some extrinsic factor such as living habit and so on. Lymph-path is the main way of metastasis for the early stage breast cancer. The axillary lymph-path drains nearly 70% of the lymph fluid in breast. It’s also the most common place where the local metastasis of braest cancer takes place. Axillary lymphnodes contain plenty of information which is of great importance to the treatment of breast cancer. The statue of axillary lymphnodes have great value for the doctors in getting the procedure of the disease ,estimating prognosis and making decision in treatment.It plays a role of“road sign”to the surgeons and oncologists.And that was the main reason for the researchers’keeping studying the regularity of the lymphnodes metastasis in breast cancer.
In surgery , we usually take the upper and lower edges of pectoralis minor as the boundary of the three levels of axllary lymohnodes. The lymphnodes beneath the lower edge of pectoralis minor are the levelⅠlymphnodes . The one behind the deeper side of pectoralis minor are the levelⅡlymphnodes. And the one above the upper edge of pectoralis minor are the levelⅢ.The lymphnodes between the deeper side of pectoralis major and the upper side of pectoralis minor are called Rotter’s lymphnodes.This group of lymphnodes has a special meaning as another path of lymphnodes metastasis of breast cancer. They can be reached in the axillary lymphnodes dissection(ALND), so they are usually one group of the levels of lymphnodes being removed in ALND. The basic principle on the circumscription of ALND is that: if the result of sentinel lymphnode biopsy(SLNB) was negative,ALND could be avoided. If the result of SLNB was positive,or in the case that a patient didn’t accept SLNB,the ALND must be done. If there was no finding of positive nodes in the operation,or there were positive nodes in levelⅠonly, the lymphnodes being removed should include levelⅠand levelⅡlymphnodes. If there were positive nodes in levelⅡ, the lymphnodes being removed should include levelⅢand Rotter’s lymphnodes. As the increasing of people’s awareness of health,and the progressing of the diagnostic technique, the diagnose rate of early stage breast cancer rise continually. Most early stage breast cancer patients are node-negtive or merely have positive nodes in the minor parts of levelⅠlymphnodes.Patients and doctors usually have the same request in curative effect of disease. In the meanwhile, they begin to pay more attention to the post-operation life quality. The tendency of reducing the circumscription of operation not only is showed in the changing of operation method from mastectomy to modified mastectomy and to lumtectomy, but also showed in minimizing the injury in ALND in the premise of getting exact axillary imformation..
Nevertheless,the operation method we use today will cause some degree of overtreatment to the early stage breast cancer patients.For example,most early stage patients with node-negtive or 1-3 nodes positive in levelⅠonly will still accept a levelⅡdissection at least according to the routine. It was reported in both domestic and abroad documents that enlarging the circumscription of ALND didn’t benefit the patients. On the contrary, it increased the possibility of arm complication . So our research set target on studying the regularity between the levels of axillary nodes metastasis to find the opportunity to minimize the circumscription for some early stage patients.
Our research selected operable breast cancer patients without any new neoadjuvant treatment as target,gave them a standard modified mastectomy and a total axillary lymphnodes dissection to get more intact and accurate axillary information. The lymphnodes sample were divided into four group as level I , level II, levelⅢand Rotter’s lymphnodes,then sent to pathologic examination separately. In the imformation we got, we emphasized analyzing the regularity between the level I and level II metastasis ,and tried to find the opportunity to minimize the circumscription for the early stage patients. The detail data shows as below: there is 55 (63.2%)patients with negative nodes and 32(36.8%) patients with positive nodes in total 87 patients. There is one patient with Rotter’s lymphnodes skip metastasis in the level I negative patients.24 patients have 1-3 positive nodes in level I, in which there are 22(91.7%) patients with negative level II nodes , one patient with positive level II nodes and one with Rotter’s lymphnode skip metastasis(8.3% together). 7 patients have more than 3 positive nodes in level I, in which there are 2(28.6%) patients with negative level II nodes , one patient(14.3%) with 1-3 positive level II nodes ,3 patient(42.9%) with 4-9 positive level II nodes, one patient(14.3%) with more than 9 positive level II nodes and 4 (57.1%)with levelⅢmetastasis. By ananlysing the data, we can see that the level I negative and 1-3 positive patients have a relative low rate of level II nodes metastasis.But the possibility of the Rotter’s lymphnode skip metastasis can not be neglected. According to the documents, level I 1-3 positive patients have more opportunity of level II nodes metastasis and skip metastasis than level I negative patients. So we gained the conclusion as below: 1.It dose exist in abstracto the feasibility of giving level I dissection to the patients with no clinical evidence of nodes-positive and no findings of positive nodes in the procedure of operation. 2.The patients which were found 1-3 level I nodes positive should accept a at least level II dissection.3.Detecting Rotter’s lymphnodes during operation is a necessary step to determine wether a low level dissection should be done or the circumscription of axillary dissection.
The result of our research suggests a more rational circumscription of ALND to early stage breast cancer patients.It will reduce the injury caused by overtreatment. And it meet the view that we should consider breast cancer as a systemic disease , emphasize general treatment more than local treatment, and reduce the unnecessary injury of local treatment as much as possible. The shortage of our research is that the conclusion stays in the category of a theory. It still take a long way to go to realize a modification of operation method. In our next research ,we will enlarge the number of samples,and set negative control group in order to compare the possibility of complications, RFS and OS. It can be expected that ,as the research progressing, our research would suggest a more reasonable circumscription of ALND and contribute to the improving of the post-operating living quality of early stage breast cancer patients.
在以往与本研究类似的课题中,研究者更着重于对Ⅲ组淋巴结转移规律的探讨。其得出的结论使得大部分早期乳腺癌患者可以免受第Ⅲ组淋巴结清扫。但是对于我国大部分腋窝阴性的早期患者,仍有进一步减少过度治疗的可能性。因此本研究就以此为着眼点,对腋窝各组淋巴结转移之间的规律进行研究,并着重研究早期乳腺癌更为常见的Ⅰ、Ⅱ组转移间的相关性,以期找到对部分早期患者进一步缩小腋窝手术范围的可能性。
Breast cancer is one of the most harmful disease to the health of women..The morbidity of breast cancer increases year by year under the influence of some extrinsic factor such as living habit and so on. Lymph-path is the main way of metastasis for the early stage breast cancer. The axillary lymph-path drains nearly 70% of the lymph fluid in breast. It’s also the most common place where the local metastasis of braest cancer takes place. Axillary lymphnodes contain plenty of information which is of great importance to the treatment of breast cancer. The statue of axillary lymphnodes have great value for the doctors in getting the procedure of the disease ,estimating prognosis and making decision in treatment.It plays a role of“road sign”to the surgeons and oncologists.And that was the main reason for the researchers’keeping studying the regularity of the lymphnodes metastasis in breast cancer.
In surgery , we usually take the upper and lower edges of pectoralis minor as the boundary of the three levels of axllary lymohnodes. The lymphnodes beneath the lower edge of pectoralis minor are the levelⅠlymphnodes . The one behind the deeper side of pectoralis minor are the levelⅡlymphnodes. And the one above the upper edge of pectoralis minor are the levelⅢ.The lymphnodes between the deeper side of pectoralis major and the upper side of pectoralis minor are called Rotter’s lymphnodes.This group of lymphnodes has a special meaning as another path of lymphnodes metastasis of breast cancer. They can be reached in the axillary lymphnodes dissection(ALND), so they are usually one group of the levels of lymphnodes being removed in ALND. The basic principle on the circumscription of ALND is that: if the result of sentinel lymphnode biopsy(SLNB) was negative,ALND could be avoided. If the result of SLNB was positive,or in the case that a patient didn’t accept SLNB,the ALND must be done. If there was no finding of positive nodes in the operation,or there were positive nodes in levelⅠonly, the lymphnodes being removed should include levelⅠand levelⅡlymphnodes. If there were positive nodes in levelⅡ, the lymphnodes being removed should include levelⅢand Rotter’s lymphnodes. As the increasing of people’s awareness of health,and the progressing of the diagnostic technique, the diagnose rate of early stage breast cancer rise continually. Most early stage breast cancer patients are node-negtive or merely have positive nodes in the minor parts of levelⅠlymphnodes.Patients and doctors usually have the same request in curative effect of disease. In the meanwhile, they begin to pay more attention to the post-operation life quality. The tendency of reducing the circumscription of operation not only is showed in the changing of operation method from mastectomy to modified mastectomy and to lumtectomy, but also showed in minimizing the injury in ALND in the premise of getting exact axillary imformation..
Nevertheless,the operation method we use today will cause some degree of overtreatment to the early stage breast cancer patients.For example,most early stage patients with node-negtive or 1-3 nodes positive in levelⅠonly will still accept a levelⅡdissection at least according to the routine. It was reported in both domestic and abroad documents that enlarging the circumscription of ALND didn’t benefit the patients. On the contrary, it increased the possibility of arm complication . So our research set target on studying the regularity between the levels of axillary nodes metastasis to find the opportunity to minimize the circumscription for some early stage patients.
Our research selected operable breast cancer patients without any new neoadjuvant treatment as target,gave them a standard modified mastectomy and a total axillary lymphnodes dissection to get more intact and accurate axillary information. The lymphnodes sample were divided into four group as level I , level II, levelⅢand Rotter’s lymphnodes,then sent to pathologic examination separately. In the imformation we got, we emphasized analyzing the regularity between the level I and level II metastasis ,and tried to find the opportunity to minimize the circumscription for the early stage patients. The detail data shows as below: there is 55 (63.2%)patients with negative nodes and 32(36.8%) patients with positive nodes in total 87 patients. There is one patient with Rotter’s lymphnodes skip metastasis in the level I negative patients.24 patients have 1-3 positive nodes in level I, in which there are 22(91.7%) patients with negative level II nodes , one patient with positive level II nodes and one with Rotter’s lymphnode skip metastasis(8.3% together). 7 patients have more than 3 positive nodes in level I, in which there are 2(28.6%) patients with negative level II nodes , one patient(14.3%) with 1-3 positive level II nodes ,3 patient(42.9%) with 4-9 positive level II nodes, one patient(14.3%) with more than 9 positive level II nodes and 4 (57.1%)with levelⅢmetastasis. By ananlysing the data, we can see that the level I negative and 1-3 positive patients have a relative low rate of level II nodes metastasis.But the possibility of the Rotter’s lymphnode skip metastasis can not be neglected. According to the documents, level I 1-3 positive patients have more opportunity of level II nodes metastasis and skip metastasis than level I negative patients. So we gained the conclusion as below: 1.It dose exist in abstracto the feasibility of giving level I dissection to the patients with no clinical evidence of nodes-positive and no findings of positive nodes in the procedure of operation. 2.The patients which were found 1-3 level I nodes positive should accept a at least level II dissection.3.Detecting Rotter’s lymphnodes during operation is a necessary step to determine wether a low level dissection should be done or the circumscription of axillary dissection.
The result of our research suggests a more rational circumscription of ALND to early stage breast cancer patients.It will reduce the injury caused by overtreatment. And it meet the view that we should consider breast cancer as a systemic disease , emphasize general treatment more than local treatment, and reduce the unnecessary injury of local treatment as much as possible. The shortage of our research is that the conclusion stays in the category of a theory. It still take a long way to go to realize a modification of operation method. In our next research ,we will enlarge the number of samples,and set negative control group in order to compare the possibility of complications, RFS and OS. It can be expected that ,as the research progressing, our research would suggest a more reasonable circumscription of ALND and contribute to the improving of the post-operating living quality of early stage breast cancer patients.
引文
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【3】马榕,孙靖中,张凯等.乳腺癌腋淋巴结转移规律的临床病理研究
【4】苏新良,任国胜,吴凯南.乳腺癌第Ⅲ组淋巴结转移的探讨.内分泌外科,2007,1(1):28-31
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【2】王根本,洛树东,崔慧先主编.医用局部解剖学.人民卫生出版社.2003.7第5版
【3】马榕,孙靖中,张凯等.乳腺癌腋淋巴结转移规律的临床病理研究
【4】苏新良,任国胜,吴凯南.乳腺癌第Ⅲ组淋巴结转移的探讨.内分泌外科,2007,1(1):28-31
【5】Gregory M Senofsky, Frederick L Moffat, Kevin Davis,et al.Total axillary lymphadenectomy in the management of breast cancer[J].Arch Surg, 1991, 126:1336-1342
【6】Aaron H Chevinsky, John Ferrara, Arthur G James,et al.Prospective evaluation of clinical and pathologic detection of axillary metastases in patients with carcinoma of breast[J].Surgery 1990,108(4):612-618
【7】Umberto Veronesi, Franco Rilke, Albert Luini,et al.Distribution of axillary node metastases by level of invasion:an analysis of 539 cases[J].Cancer 1987,59:682-687
【8】Robert S.Boova MD, Roseann Bonanni,et al.Patterns of axillary nodal involvement in breast cancer:predictability of level one dissection[J].Ann Surgery 1982,196(6):642-644
【9】Gaglia P, Bussone R, Caldarola B,et al.The correlation between the spread of metastases by level in axillary nodes and disease-free-survival in breast cancer.A multifactorial analysis[J].Eur J Cancer Clin Oncol,1987,23(6):849-854
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