探讨经皮注射对比增强超声(CEUS)在乳腺癌前哨淋巴结(SLN)术前定位及转移风险评估中的临床应用价值。

根据纳入及排除标准，选择2019年5～9月在江苏大学附属人民医院乳腺外科行手术治疗的21例女性乳腺癌患者进行前瞻性研究。术前根据经皮CEUS示踪结果，在皮肤表面标记SLN位置及数目，根据其增强模式评估SLN转移风险，并在术中联合亚甲蓝共同确认SLN的位置及数目。以亚甲蓝染色的病理检查结果为金标准，计算经皮CEUS预测SLN状态的敏感度、特异度、阳性预测值、阴性预测值及准确率。用Kappa一致性检验分析CEUS与SLN常规病理检查结果的一致性及2名超声科医师对SLN增强模式判读的一致性。用Fisher精确概率法分析不同临床病理特征患者CEUS评估SLN结果的差异。

21例患者中，经皮CEUS共检出32枚SLN，亚甲蓝染色共检出71枚。经皮CEUS体表定位的SLN均为术中亚甲蓝染色的SLN,患者经皮CEUS检出(1.6±0.9)枚SLN,低于亚甲蓝染色检出的(3.4±1.4)枚(t＝5.017, P<0.001)。CEUS预测SLN转移风险：判定有SLN转移患者9例(病理证实SLN有转移7例，无转移2例)，判定无转移患者12例(病理证实SLN无转移11例，有转移1例)。CEUS评估SLN状态的敏感度7/8，特异度11/13，阳性预测值7/9，阴性预测值11/12，准确率85.7%(18/21)。CEUS与病理诊断结果具有较高一致性(Kappa ＝0.704，P＝0.001)。2名超声科医师对CEUS中32枚SLN增强模式的判读结果一致性较好(Kappa＝0.829，P<0.001)。不同组织学分级的患者，其CEUS预测结果比较，差异有统计学意义(P＝0.046)。

经皮CEUS是乳腺癌患者SLN术前定位及转移风险评估的一种有效方法。

To explore clinic value of contrast enhanced ultrasound (CEUS) for preoperative sentinel lymph node (SLN) localization and metastasis risk evaluation in patients with breast cancer.

According to the inclusion and exclusion criteria, 21 female breast cancer patients who underwent surgical treatment in the Department of Breast Surgery, People’s Hospital of Jiangsu University from May to September 2019 were enrolled for a prospective study. Before surgery, the position and number of SLN were marked on the skin surface according to the results of percutaneous CEUS and the risk of SLN metastasis was evaluated based on the enhancement mode. The location and number of SLNs was confirmed by intraoperative methylene blue staining. The pathological results after methylene blue staining were used as the gold standard, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of percutaneous CEUS in predicting SLN status were calculated. The Kappa consistency test was used to analyze the consistency between CEUS and pathological examination and the consistency of the interpretation of SLN enhancement mode on CEUS by two sonographers. Fisher’s exact test was used to analyze the differences in CEUS assessment of SLN in patients with different clinicopathological characteristics.

Among the 21 patients, 32 SLNs were detected by percutaneous CEUS and 71 SLNs were detected by methylene blue staining. All SLNs detected by percutaneous CEUS were confirmed by methylene blue staining during the operation. The number of detected SLNs was 1.6±0.9 by CEUS, significantly lower than 3.4±1.4 by methylene blue staining (t=5.017, P<0.001). Nine patients were diagnosed with SLN metastasis by CEUS (7 with SLN metastasis confirmed by pathology and 2 without). CEUS demonstrated 12 patients with no metastasis, in which 11 cases confirmed by pathology, but one had metastasis. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of percutaneous CEUS in the diagnosis of SLN were 7/8, 11/13, 7/9, 11/12 and 85.7 % (18/21), respectively. The results of CEUS and pathology showed a high consistency (Kappa=0.704, P=0.001). The interpretation of 32 SLNs on CEUS showed a high consistency between two sonographers (Kappa=0.829, P<0.001). There was a significant difference in the results of CEUS among patients with different histological grades (P=0.046).

Percutaneous CEUS is feasible for preoperative SLN localization and metastasis risk evaluation in patients with breast cancer.