吲哚菁绿联合亚甲蓝在乳腺癌前哨淋巴结活组织检查中的应用价值

doi:10.3877/cma.j.issn.1674-0807.2016.02.005

目的

探讨吲哚菁绿联合亚甲蓝在乳腺癌前哨淋巴结活组织检查(SLNB)中的应用价值。

方法

根据纳入、排除标准,选取2015年5 ～12月在第三军医大学西南医院乳腺外科住院行术前检查提示腋窝淋巴结阴性的104 例乳腺癌患者进行前瞻性研究。按照随机数字表法将患者分成2 组(每组均为52 例),分别采用吲哚菁绿联合亚甲蓝(试验组)或者核素联合亚甲蓝(对照组)作为淋巴示踪剂对患者进行SLNB,术中根据冰冻检查结果决定是否行腋窝淋巴结清扫。比较两种方法在乳腺癌SLNB 中检出率的差别。偏态分布的计量资料用M(P₂₅ ～P₇₅)表示。两组患者间前哨淋巴结(SLN)和转移性SLN 检出率及检出数目的比较,采用χ² 检验、Fisher 确切概率检验或非参数检验。

结果

试验组52 例患者中,皮肤淋巴管荧光显影者49 例(94.2%,49/52),SLN 荧光显影者52 例(100%,52/52),SLN 检出率为100%(52/52),而对照组的检出率为96.2%(50/52)。试验组转移性SLN 检出率为32.7%(17/52),明显高于对照组的15.4%(8/52)(χ²=4.27,P=0.039)。试验组共检出SLN190 枚,中位数为3(2 ～4)枚,对照组共检出SLN 158 枚,中位数为2(1 ～4)枚,两组患者SLN 检出数目相似(Z=-1.58,P=0.113)。试验组共检出转移性SLN 26 枚,中位数为0(0 ～1)枚,而对照组共检出转移性SLN 9 枚,中位数为0(0 ～0)枚,两组相比,差异有统计学意义(Z=-2.15,P=0.032)。

结论

在乳腺癌SLNB 术中应用吲哚菁绿联合亚甲蓝法示踪,其SLN 检出率与核素联合亚甲蓝双标法相当,且能提高转移性SLN 的检出率,并可协助术者精准定位SLN 的位置,降低手术难度,具有较高的临床应用价值。

关键词: 乳腺肿瘤, 前哨淋巴结活组织检查, 吲哚花青绿

Objective

To evaluate the application value of indocyanine green (ICG) combined with methylene blue (MB) for sentinel lymph node biopsy(SLNB) in breast cancer patients.

Methods

Totally 104 breast cancer patients with axillary node negative indicated by preoperative examination in Department of Breast Surgery, Southwest Hospital, Third Military Medical University, from May 2015 to December 2015 were enrolled for a prospective study. They were randomly divided into two groups (n=52) by the random number table method: experimental group with MB combined with ICG as lymph tracer, control group with nuclide combined with MB as lymph tracer for SLNB. During operation, the surgeon decided whether to perform axillary lymph node dissection according to the result of intraoperative frozen section examination. The detection rates in SLNB were compared between two groups. Skewed distribution data were described as M(P₂₅-P₇₅).χ² test and Fisher's exact probability test or non-parametric test were used to compare the number of detected sentinel lymph nodes (SLNs) and metastatic SLNs,and the detection rates of the two in two groups.

Results

In 52 patients of experimental group, subcutaneous lymphatic vesselsc were visualized in 49 patients(94.2%,49/52) and SLNs were visualized in 52 (100%). The detection rate of SLNs was 100% (52/52) in experimental group, 96.2% (50/52) in control group. The detection rate of metastatic SLNs was 32.7%(17/52) in experimental group, significantly higher than 15.4% (8/52) in control group (χ²= 4.27, P=0.039). Totally 190 SLNs [median 3(2-4)] were detected in experimental group,158 [median 2 (1-4)]in control group, indicating no significant difference (Z=-1.58,P=0.113). Twenty-six metastatic SLNs[median 0 (0-1)] were detected in experimental group,Nine[median 0 (0-0)] in control group, indicating significant difference (Z=-2.15,P=0.032).

Conclusion

Compared with nuclide plus methylene blue,indocyanine green combined with methylene blue for intraoperative SLNB in breast cancer patients has similar detection rate of SLNs and higher detection rate of metastatic SLNs, with the advantages of precise positioning of SLNs, reducing the difficulty of operation, worthy of clinical application.

Key words: Breast neoplasms, Sentinel lymph node biopsy, Indocyanine green

表1 两组乳腺癌患者一般情况及肿瘤病理特征比较(例)

组别	例数	年龄		绝经状态		体质指数			肿瘤大小		肿瘤部位
组别	例数	≤50岁	＞50岁	绝经前	绝经后	18.5～23.9	24.0～27.9	≥28.0	T₁	T₂	左乳	右乳
对照组	52	31	21	30	22	29	20	3	27	25	22	30
试验组	52	33	19	36	16	29	20	3	24	28	21	31
检验值		χ²=0.16		χ²=1.49		Z=0.00			χ²=0.35		χ²=0.04
P值		0.687		0.222		1.000			0.556		0.842
组别	例数	肿瘤分布的象限					病理类型				临床分期		新辅助化疗
组别	例数	外上	外下	内上	内下	乳头乳晕区	浸润性导管癌	浸润性小叶癌	原位癌	其他	Ⅰ	Ⅱ	有	无
对照组	52	22	10	14	2	4	41	0	7	4	27	25	20	32
试验组	52	33	7	6	3	3	43	0	5	4	24	28	16	36
检验值		χ²=6.27					χ²=0.46				χ²=0.35		χ²=0.68
P值		0.180					0.931				0.556		0.410

表1 两组乳腺癌患者一般情况及肿瘤病理特征比较(例)

组别	例数	年龄		绝经状态		体质指数			肿瘤大小		肿瘤部位
组别	例数	≤50岁	＞50岁	绝经前	绝经后	18.5～23.9	24.0～27.9	≥28.0	T₁	T₂	左乳	右乳
对照组	52	31	21	30	22	29	20	3	27	25	22	30
试验组	52	33	19	36	16	29	20	3	24	28	21	31
检验值		χ²=0.16		χ²=1.49		Z=0.00			χ²=0.35		χ²=0.04
P值		0.687		0.222		1.000			0.556		0.842
组别	例数	肿瘤分布的象限					病理类型				临床分期		新辅助化疗
组别	例数	外上	外下	内上	内下	乳头乳晕区	浸润性导管癌	浸润性小叶癌	原位癌	其他	Ⅰ	Ⅱ	有	无
对照组	52	22	10	14	2	4	41	0	7	4	27	25	20	32
试验组	52	33	7	6	3	3	43	0	5	4	24	28	16	36
检验值		χ²=6.27					χ²=0.46				χ²=0.35		χ²=0.68
P值		0.180					0.931				0.556		0.410

图1 吲哚菁绿对乳腺癌患者腋窝淋巴引流示踪的效果注:a 图为淋巴管走行及SLN 潜在位点直视图;b 图为淋巴管走行及SLN 潜在位点荧光视图;c 图为切开皮肤探查SLN 的荧光视图;SLN 代表前哨淋巴结。 A 点为吲哚菁绿皮内注射点;B 点为显影淋巴管走行;C 点为吲哚菁绿显影的SLN

表2 试验组52 例乳腺癌患者中吲哚菁绿与亚甲蓝对前哨淋巴结的检出效果比较(例)

亚甲蓝	吲哚菁绿		合计
亚甲蓝	检出	未检出	合计
检出	44	0	44
未检出	8	0	8
合计	52	0	52

表2 试验组52 例乳腺癌患者中吲哚菁绿与亚甲蓝对前哨淋巴结的检出效果比较(例)

亚甲蓝	吲哚菁绿		合计
亚甲蓝	检出	未检出	合计
检出	44	0	44
未检出	8	0	8
合计	52	0	52

表3 试验组52 例乳腺癌患者中吲哚菁绿与亚甲蓝对转移性前哨淋巴结的检出效果比较(例)

亚甲蓝	吲哚菁绿		合计
亚甲蓝	转移	未转移	合计

转移	11	0	11
未转移	6	35	41
合计	17	35	52

表3 试验组52 例乳腺癌患者中吲哚菁绿与亚甲蓝对转移性前哨淋巴结的检出效果比较(例)

亚甲蓝	吲哚菁绿		合计
亚甲蓝	转移	未转移	合计

转移	11	0	11
未转移	6	35	41
合计	17	35	52

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Indocyanine green combined with methylene blue for sentinel lymph node biopsy in breast cancer patients

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Indocyanine green combined with methylene blue for sentinel lymph node biopsy in breast cancer patients