单孔非溶脂荧光腔镜技术在早期乳腺癌腋窝前哨淋巴结活组织检查中的应用

doi:10.3877/cma.j.issn.1674-0807.2023.05.002

目的

探讨单孔非溶脂荧光腔镜技术在早期乳腺癌腋窝前哨淋巴结活组织检查(SLNB)中的应用效果。

方法

回顾性收集2020年6月至2022年5月华南理工大学附属第六医院乳腺外科收治的30例早期乳腺癌患者临床病理资料。所有患者均采用吲哚菁绿联合纳米碳双染法经胸外侧入路单孔非溶脂荧光腔镜行腋窝SLNB。采用t检验、χ²检验或Fisher确切概率法比较不同BMI组患者的手术相关指标及术后并发症。采用McNemar检验比较不同染色方法对前哨淋巴结(SLNs)的检出率，采用χ²检验比较检出淋巴结病理阳性率的差异。

结果

30例患者均顺利完成单孔非溶脂荧光腔镜腋窝SLNB。手术时间为(35.4±3.4) min。BMI >24.0 kg/m²的患者手术时间和腋窝总引流量均高于BMI为18.5~24.0 kg/m²的患者[(37.36±9.45) min比(30.29±6.15) min，t＝2.480，P＝0.019; (155.62±4.29) ml比(132.53±7.65)ml；t＝9.748，P<0.001]；而术中出血量、拔管时间及术后并发症比较，差异无统计学意义(t＝－0.869，P＝0.388；t＝1.193，P＝0.238；P＝1.000)。30例患者共检出SLNs 121枚，每例检出(4.89±1.73)枚，病理阳性SLNs 15枚，阳性率12.39%(15/121)。其中，发光SLNs 106枚，染色SLNs 88枚，吲哚菁绿和纳米碳的检出率分别为87.6%(106/121)和72.7%(88/121)，差异有统计学意义(P＝0.013)。106枚发光SLNs的病理阳性率为14.15%(15/106)；88枚染色SLNs的病理阳性率为14.77%(13/88)，二者差异无统计学意义(χ²＝0.015，P＝0.902)。30例患者中位随访15个月，无1例肿瘤局部复发或远处转移。

结论

单孔非溶脂荧光腔镜技术用于早期乳腺癌腋窝SLNB临床可行，并发症少，SLNs的检出率高，是一项适宜开展的临床新技术。

关键词: 乳腺肿瘤, 前哨淋巴结, 腹腔镜, 吲哚菁绿, 纳米碳

Objective

To investigate the application of single-port non-lipolysis fluorescence-guided laparoscopy in axillary sentinel lymph node biopsy (SLNB) of early breast cancer.

Methods

We retrospectively collected the clinicopathologic data of 30 early breast cancer patients in the Department of Breast Surgery, Sixth Affiliated Hospital of South China University of Technology from June 2020 to May 2022. They all underwent axillary SLNB by indocyanine green and nanocarbon staining and single-port non-lipolysis fluorescence-guided laparoscopy through the lateral thoracic approach. The surgical parameters and postoperative complications were compared using t test, χ² test and Fisher exact test. The detection rates of sentinel lymph nodes (SLNs) were compared between different staining methods by McNemar test and the pathological positivity rates of detected lymph nodes were compared by χ² test.

Results

All 30 patients successfully underwent axillary SLNB by single-port non-lipolysis fluorescence-guided laparoscopy. The operation time was (35.4±3.4) min. The operation time and total axillary drainage volume in patients with BMI >24.0 kg/m² were significantly higher compared with the patients with BMI of 18.5~24.0 kg/m²[(37.36±9.45) min vs (30.29±6.15) min, t=2.480, P=0.019; (155.62±4.29) ml vs(132.53±7.65)ml; t=9.748, P<0.001]. There was no significant difference in intraoperative blood loss, extubation time and postoperative complications (t=-0.869, P=0.388; t=1.193, P=0.238; P=1.000). A total of 121 SLNs were detected in 30 patients, (4.89±1.73) nodes per person. Fifteen nodes were confirmed as pathologically positive SLNs(12.39%, 15/121). Among 121 detected SLNs, 106 were luminescent (indocyanine green-positive) and and 88 were stained (nanocarbon positive); the detection rates of two methods were 87.6% (106/121) and 72.7% (88/121), respectively, indicating a significant difference (P=0.013). Fifteen nodes were pathologically positive out of 106 luminescent SLNs, with a positive rate of 14.15% (15/106); 13 nodes were pathologically positive out of 88 stained SLNs, with a positive rate of 14.77% (13/88); there was no significant difference between the two (χ²=4.081, P=0.130). All 30 patients were followed up for median 15 months, and no recurrence or distant metastasis of breast cancer was observed.

Conclusion

Single-port non-lipolysis fluorescence-guided laparoscopy for axillary SLNB of early breast cancer is clinically feasible, with few complications and high detection rate of SLNs, worth of clinical application.

Key words: Breast neoplasms, Sentinel lymph nodes, Laparoscopy, Indocyanine green, Carbon nanoparticles

表1 30例早期乳腺癌患者的临床病理特征

临床病理特征	例数
月经状况
未绝经	18
已绝经	12
体质指数
18.5~24.0 kg/m²	17
>24.0 kg/m²	13
肿瘤长径
≤2 cm	14
>2 cm且≤3 cm	16
病理类型
浸润性导管癌	28
非浸润性导管癌	2
TNM分期
Ⅰ期	14
Ⅱ_A期	16
分子分型
Luminal型	15
HER-2过表达型	10
三阴型	5

表1 30例早期乳腺癌患者的临床病理特征

临床病理特征	例数
月经状况
未绝经	18
已绝经	12
体质指数
18.5~24.0 kg/m²	17
>24.0 kg/m²	13
肿瘤长径
≤2 cm	14
>2 cm且≤3 cm	16
病理类型
浸润性导管癌	28
非浸润性导管癌	2
TNM分期
Ⅰ期	14
Ⅱ_A期	16
分子分型
Luminal型	15
HER-2过表达型	10
三阴型	5

图1 单孔非溶脂近红外荧光腔镜腋窝前哨淋巴结活组织检查　a图所示荧光脉管成像仪显示乳腺皮下荧光的淋巴管(蓝色箭头)；b图所示高清近红外荧光腔镜显示乳腺皮下荧光的淋巴管(蓝色箭头)；c图所示经胸外侧腋中线手术入路置入单孔腔镜牵开器进行手术操作；d图所示近红外荧光腔镜荧光模式下显示荧光的淋巴管(蓝色箭头)；e图所示荧光模式下显示发光SLN(蓝色箭头)、单纯染色-SLN(黑色箭头)和N-SLNs(红色箭头)；f图所示术中切除的淋巴结(1、2为既发光又染色的SLNs，3、5为单纯发光SLNs，4为单纯染色SLNs)注：SLNs为前哨淋巴结，N-SLNs为非前哨淋巴结

表2 30例早期乳腺癌患者手术指标及术后并发症与体质指数的关系

体质指数	例数	手术时间(min)	术中出血量(ml)	总引流量(ml)	腋窝拔管时间(d)	术后并发症(例)
体质指数	例数	手术时间(min)	术中出血量(ml)	总引流量(ml)	腋窝拔管时间(d)	切口愈合不良	患侧上肢水肿
>24.0 kg/m²	13	37.36±9.45	5.13±3.78	155.62±4.29	5.16±1.95	2	0
18.5~24.0 kg/m²	17	30.29±6.15	5.76±1.23	132.53±7.65	4.61±1.63	1	1
t值		2.480	－0.869	9.748	1.193
P值		0.019	0.388	<0.001	0.238	1.000^a

表2 30例早期乳腺癌患者手术指标及术后并发症与体质指数的关系

体质指数	例数	手术时间(min)	术中出血量(ml)	总引流量(ml)	腋窝拔管时间(d)	术后并发症(例)
体质指数	例数	手术时间(min)	术中出血量(ml)	总引流量(ml)	腋窝拔管时间(d)	切口愈合不良	患侧上肢水肿
>24.0 kg/m²	13	37.36±9.45	5.13±3.78	155.62±4.29	5.16±1.95	2	0
18.5~24.0 kg/m²	17	30.29±6.15	5.76±1.23	132.53±7.65	4.61±1.63	1	1
t值		2.480	－0.869	9.748	1.193
P值		0.019	0.388	<0.001	0.238	1.000^a

表3 采用吲哚菁绿荧光和纳米碳染色法检出的121枚SLNs的分布情况(枚)

纳米碳染色法	荧光法		合计
纳米碳染色法	发光SLNs	非发光SLNs	合计
染色SLNs	73	15	88
非染色SLNs	33	0	33
合计	106	15	121

表3 采用吲哚菁绿荧光和纳米碳染色法检出的121枚SLNs的分布情况(枚)

纳米碳染色法	荧光法		合计
纳米碳染色法	发光SLNs	非发光SLNs	合计
染色SLNs	73	15	88
非染色SLNs	33	0	33
合计	106	15	121

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Single-port non-lipolysis fluorescence-guided laparoscopy for axillary lymph node biopsy in early breast cancer

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Single-port non-lipolysis fluorescence-guided laparoscopy for axillary lymph node biopsy in early breast cancer