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中华乳腺病杂志(电子版) ›› 2024, Vol. 18 ›› Issue (05) : 308 -314. doi: 10.3877/cma.j.issn.1674-0807.2024.05.010

综 述

乳腺癌内乳淋巴结的诊断和治疗
潘荔生1, 刘忠强1, 周莹莹1, 陈勃1, 李晏宁1, 徐金锋1, 蔡隆梅1, 王宏梅1,()   
  1. 1.510515 广州,南方医科大学南方医院放射治疗科
  • 收稿日期:2023-11-19 出版日期:2024-10-01
  • 通信作者: 王宏梅

Diagnosis and treatment of internal mammary lymph nodes in breast cancer

Lisheng Pan, Zhongqiang Liu, Yingying Zhou, Bo Chen, Yanning Li, Jinfeng Xu, Longmei Cai, Hongmei Wang()   

  • Received:2023-11-19 Published:2024-10-01
  • Corresponding author: Hongmei Wang
引用本文:

潘荔生, 刘忠强, 周莹莹, 陈勃, 李晏宁, 徐金锋, 蔡隆梅, 王宏梅. 乳腺癌内乳淋巴结的诊断和治疗[J]. 中华乳腺病杂志(电子版), 2024, 18(05): 308-314.

Lisheng Pan, Zhongqiang Liu, Yingying Zhou, Bo Chen, Yanning Li, Jinfeng Xu, Longmei Cai, Hongmei Wang. Diagnosis and treatment of internal mammary lymph nodes in breast cancer[J]. Chinese Journal of Breast Disease(Electronic Edition), 2024, 18(05): 308-314.

内乳淋巴结(IMN)是指位于胸骨外侧缘约0.5 cm 的淋巴结链。 与IMN 阴性患者相比,IMN 阳性患者远处转移风险增高、预后较差。 由于IMN 的解剖学位置特殊、体积小及其检出率受各项检查技术敏感度及特异度的限制,目前在临床实践中缺乏准确检测IMN 转移的方法和指导乳腺癌患者IMN 个体化治疗的规范。 基于此,本文主要从乳腺癌IMN 的解剖学特点、阳性IMN 的影像学和病理学诊断、IMN 转移和复发的影响因素、IMN 的治疗策略等方面进行总结,以期为乳腺癌患者内乳区精准规范化治疗提供参考。

表1 内乳淋巴结的局部治疗技术
治疗方式 优点 局限 适用对象
放射治疗
非调强放射治疗[43] 斜电子线野技术:电子线的使用最大限度地减少了对深层结构的剂量(特别是心脏和肺);宽切线野技术:治疗计划简单,乳房靶区剂量覆盖率好 斜电子线野技术:IMN靶区剂量覆盖不足、剂量不均匀;治疗计划复杂;宽切线野技术:IMN靶区剂量过高;心肺剂量高 在未开展调强放射治疗的医院经影像或临床诊断为转移性IMN的患者,且放射治疗计划能基本满足临床要求
调强放射治疗[43] 目标靶区剂量均匀性、覆盖率好;心肺剂量较低(尤其在使用DIBH技术后);有改善患者远期生存的趋势 对IMN阴性及低危IMN转移患者的长期随访结果暂不明确 影像学或临床诊断为转移性IMN,或有放射治疗指征的IMN高危转移患者
质子治疗[44] 目标靶区体积覆盖率、危及器官剂量及心脏平均剂量优于光子治疗;唯一能使对侧乳房平均剂量<1 Gy的疗法 与自由呼吸相比,DIBH技术不会带来额外的剂量学获益 影像学或临床诊断为转移性IMN,或有放射治疗指征的IMN高危转移患者
IMN清扫
传统开放性手术[45] 协同诊断和治疗 术野受限,手术并发症多,未能改善患者生存 已不适用于当前临床实践
传统胸腔镜手术[46] 创伤较传统术式小,并发症少;适用于右侧IMN转移 由于毗邻心脏、主动脉,左侧IMN操作难度高 拟评估IMN状态以明确分期的IMN转移患者,完全清扫右侧IMN存在一定困难,其适应证未完全明确
视频辅助胸腔镜手术[47-48] 术野清晰、放大;无明显并发症;微创、无需切除肋软骨;进一步优化肿瘤分期 可能出现胸膜粘连,在早期乳腺癌患者中不易推广 拟评估IMN状态以明确分期的患者,适应证未完全明确
达·芬奇机器人手术[36] 美容效果好;术野更加清晰、立体、放大 例数少,操作时间长,设备费用昂贵,对术者操作能力要求较高 肿瘤直径≥5cm、腋窝淋巴结阳性、手术切缘阳性或影像学可疑的IMN转移
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