目的

探讨荧光法腋窝反向制图(ARM)技术(即逆向腋窝淋巴结示踪)在乳腺癌腋窝手术中的可行性、ARM 淋巴结(示踪剂显示的引流上肢淋巴液的淋巴结)在腋窝的分布规律以及保留ARM 淋巴结的肿瘤学安全性。

方法

采用前瞻性研究方法,对2014年4 ～11月期间在南京医科大学附属杭州医院就诊的40 例浸润性乳腺癌患者,经知情同意后,在乳腺癌前哨淋巴结活组织检查(SLNB)术或腋窝淋巴结清扫(ALND)术开始前15 min,将2 ml(5 mg)吲哚菁绿注射于患侧上肢内侧肌间沟皮下以示踪ARM 淋巴结,术中用红外荧光定位观察相机观察、记录腋窝有无荧光ARM 淋巴结显影及其在腋窝的分布情况,切除分布在手术区域内的荧光ARM 淋巴结送病理学检查,评估其受肿瘤侵犯的情况。

结果

35 例患者行SLNB+ARM 术,ARM 淋巴结示踪成功8 例,SLNB 中ARM 淋巴结示踪成功率为22.9%(8/35);5 例患者行ALND+ARM 术,ARM 淋巴结示踪成功3 例,另有25 例行SLNB+ARM 术的患者在完成SLNB 后转而行ALND,且ARM 淋巴结示踪均获成功,因此,在所有行ALND 术的患者中ARM淋巴结示踪成功率为93.3%(28/30)。 全组共发现119 枚荧光ARM 淋巴结,其中57.1%(68/119)的荧光ARM 淋巴结分布于腋静脉下方、第2 肋间臂神经上方及胸背血管神经束外侧的区域。 ARM-SLN 共干率(即引流乳腺淋巴液的淋巴结与引流上肢淋巴液的淋巴结在解剖上存在共同通路的概率)为17.1%(6/35)。 24 例患者的ARM 淋巴结被切除送病理学检查,其中20 例pN_0～1患者无ARM 淋巴结受累,4 例pN_2～3患者中有2 例ARM 淋巴结受累,ARM 淋巴结受累率为8.3%(2/24)。

结论

吲哚菁绿荧光法在ALND 中是一种成功率高的ARM 淋巴结示踪方法;ARM 淋巴结在腋窝分布存在一定的规律;腋窝淋巴结肿瘤负荷重的患者不适合行ARM 手术。

Objective

To explore the feasibility of fluorescent axillary reverse mapping (ARM), the distribution of ARM lymph nodes (the lymph nodes which drained lymphatic fluid in upper extremities indicated by dye tracer) in axilla and the safety to spare the ARM lymph nodes in breast cancer surgery.

Methods

Forty invasive breast cancer patients who received treatment in the Affiliated Hangzhou Hospital of Nanjing Medical University from April to November in 2014 were included in the prospective study. After obtaining the informed consent, ARM procedure was carried out with a subcutaneous injection of 2 ml fluorescent dye indocyanine green (5 mg) into the medial bicipital sulcus in the ipsilateral upper arm about 15 min before the patients underwent breast cancer sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND). During surgery,photodynamic eye was used to detect any fluorescent lymph nodes and the distribution pattern of such nodes in the axilla. The fluorescent nodes in the surgical region were dissected out and sent for pathological examination to investigate node metastasis.

Results

ARM was successful in 8 out of 35 patients who underwent SLNB + ARM (ARM identification rate 22.9%). ARM was also successful in 3 out of 5 patients who underwent ALND + ARM. Twenty five patients shifted to ALND after accomplishing SLNB +ARM, and ARM was successful in these 25 patients. Totally, ARM identification rate was 93.3% (28/30) in patients who underwent ALND. 119 fluorescent ARM lymph nodes were detected, and 57.1 % (68/119) of nodes were located under the axillary vein, above the 2nd intercostobrachial nerve and in the lateral area of thoraco-dorsal neurovascular bundle. The crossover rate of ARM-SLN (the anatomical possibility of shared pathway between lymph nodes draining lymphatic fluid from breast and lymph nodes draining lymphatic fluid from upper extremities) was 17.1% (6/35). Among the 24 patients whose ARM lymph nodes were dissected and sent for pathology, no node metastasis was found in 20 patients who were in pN_0-1 and node metastasis was found in 2 of the other 4 patients who were in pN_2-3. The involvement rate of ARM lymph nodes was 8.3%(2/24).

Conclusions

Fluorescent ARM using indocyanine green was sensitive for identification of ARM lymph nodes in ALND. ARM lymph nodes have a certain distribution pattern in the axilla. ARM should not be performed in the patients with heavy tumor load in the axilla.