乳腺癌前哨淋巴结活检术假阴性及转移淋巴结新辅助化疗反应的研究

发布时间：2018-08-02 18:53

【摘要】：1、前哨淋巴结活检术的假阴性分析目的:队列分析不同示踪方法在乳腺浸润性导管癌前哨淋巴结探查活检中的假阴性,进一步探究影响假阴性的相关因素。方法:收集2010年到2016年我中心行前哨活检术并行腋窝淋巴结清扫术的患者588例,分析不同示踪方法的效果,比较假阴性率,并分析年龄、分期、分子分型及是否新辅助化疗等因素对乳腺癌前哨淋巴结活检假阴性的影响。结果:4种示踪方法中,乳腺癌前哨淋巴结假阴性共计50例,其中美兰染料组假阴性率11.0%,核素+美兰染料组假阴性6.1%,美兰染料+荧光组假阴性10%,前3种示踪方法检测乳腺癌前哨的假阴性率无统计学差别(P=0.2130.05);美兰染料+核素+荧光组假阴性为0%。针对所有假阴性患者,分析其与年龄、分子分型的关系,P值分别为0.879、0.580;分级及是否行辅助化疗后检测乳腺癌前哨的假阴性率结果间存在统计学意义,P㩳0.05。结论:不同示踪方法的假阴性无统计学差异,但染料+荧光假阴性比例较低,且无放射污染,适于全面推广,故推荐使用染料+荧光法示踪。美兰染料+核素+荧光组病例数较少,需要进一步扩大病例研究。进一步分析发现分级及是否进行辅助化疗的检测结果间存在统计学差异(P0.05),即T2组假阴性率明显高于T1组;前哨淋巴结活检术前行新辅助化疗的患者的假阴性比例较高,前哨淋巴结活检术前未行新辅助化疗的患者假阴性比例较低,其临床意义有待进一步研究。年龄和分子分型之间的检测结果间无统计学差异(P0.05)。2、乳腺浸润性导管癌患者1~2枚前哨淋巴结阳性时非前哨淋巴结状况分析目的:前瞻性研究乳腺浸润性导管癌1~2枚SLN阳性的者NSLN转移状况。方法:研究纳入2010年1月至2015年10月于第三军医大学西南医院乳腺外科的乳腺浸润性导管癌共220例,SLNB确诊为1~2枚SLN转移,均行乳腺癌改良根治术,术后病理分析NSLN的转移情况。同时分析乳腺癌原发灶分级、分子亚型、是否行新辅助化疗及ER、PR、HER-2、Ki67与NSLN转移的关系。计量资料用c2检验,分析年龄与NSLN转移的关系用非参数检验。结果:220例乳腺浸润性导管癌行ALND后非前哨淋巴结(NSLN)阳性91例,占41.4%(91/220),其中90例均为腋窝Ⅰ水平淋巴结转移,仅1例同时有Ⅰ、Ⅱ水平淋巴结转移;NSLN阴性者129例,占58.6%(129/220)。原发灶分级、分子分型、是否新辅助化疗、ER、PR、Ki67表达及年龄等指标对NSLN转移的影响,差异无统计学意义(c2=1.830、1.336、0.918、0.074、0.000、1.766,Z=-1.369;P=0.608、0.248、0.338、0.786、0.986、0.184、0.171)。57例HER-2阳性患者中,NSLN阳性的患者30例,阳性率为52.6%(30/57);在163例HER-2阴性患者中,NSLN阳性的患者61例,阳性率仅为37.4%(61/163)。HER-2阳性患者中NSLN阳性率明显高于HER-2阴性患者(c2=4.027,P=0.045)。结论:1~2枚SLN阳性的乳腺浸润性导管癌患者,其NSLN仍然存在较高的转移风险,尤其在HER-2阳性的患者中更易出现NSLN转移。故1-2枚SLN阳性的乳腺癌患者仍需接受进一步腋窝淋巴结清扫等治疗。3、乳腺癌转移淋巴结新辅助化疗反应及相关因素探讨目的:队列分析乳腺癌转移淋巴结新辅助化疗后化疗反应,探讨影响其化疗反应的相关因素。方法:本研究纳入2012年-2016年我中心收治病例中临床查体及影像学检查提示腋窝淋巴结转移可能的患者64例,其中女性63例,男性1例。除原发灶病理活检外,行超声引导下腋窝淋巴结穿刺病理学检查以确诊为乳腺癌转移性淋巴结,其中61例使用粗针穿刺,2例使用麦默通旋切活检,1例为外院手术并化疗后来我院行机器人辅助内乳淋巴链切除术。对确诊为乳腺癌淋巴结转移者行新辅助化疗后,病理学评价转移淋巴结的化疗反应。参考2015年《乳腺癌新辅助化疗后的病理诊断专家共识》,建立乳腺癌转移淋巴结新辅助化疗反应评价标准。结果:63例乳腺癌经新辅助化疗后乳腺癌化疗反应情况:原发灶化疗反应I级2例,淋巴结全为有反应,未转阴。原发灶化疗反应II级12例,其中9例淋巴结为有反应,未转阴;2例淋巴结为无反应,未转阴;1例淋巴结为有反应,已转阴。原发灶化疗反应III级19例,其中14例淋巴结为有反应,未转阴;1例淋巴结为无反应,未转阴;3例淋巴结为有反应,已转阴;1例淋巴结为无反应,已转阴。原发灶化疗反应IV级18例,其中8例淋巴结为有反应,未转阴;1例淋巴结为无反应,未转阴;5例淋巴结为有反应,已转阴;4例淋巴结为无反应,已转阴。原发灶化疗反应V级12例,其中3例淋巴结为有反应,未转阴;6例淋巴结为有反应,已转阴;3例淋巴结为无反应,已转阴。经新辅助化疗后,原发病灶化疗后反应与转移淋巴结化疗后反应并不一致。64例经化疗后原发灶达到化疗反应V级12例中有3例患者经新辅助化疗后淋巴结未转阴,原发灶未达到化疗反应V级51例中有14例患者经新辅助化疗后淋巴结转阴。结论:本研究建立了乳腺浸润性导管癌转移淋巴结新辅助化疗反应的评价分类方法,能够对乳腺癌淋巴结转移病灶化疗后反应和缓解进行评价。其临床意义有待进一步深入研究。新辅助化疗对转移淋巴结疗效与原发灶疗效并非完全一致,Luminal A乳腺癌病例新辅助化疗后淋巴结转阴的比例为0。三阴性乳腺癌病例新辅助化疗后淋巴结转阴比例达到75%,转移淋巴结内癌灶未达到完全缓解的其他淋巴结中均可见化疗反应。
[Abstract]:1, the false negative analysis of sentinel lymph node biopsy: a cohort analysis of different tracers in the false negative of sentinel lymph node biopsy in invasive ductal carcinoma of the breast, and further explore the related factors affecting false negative. Methods: 588 cases of the sentinel biopsy and axillary lymph node dissection were collected from 2010 to 2016. We analyzed the effect of different tracer methods, compared the false negative rate, and analyzed the effect of age, staging, molecular typing and new adjuvant chemotherapy on the false negative of sentinel lymph node biopsy in breast cancer. Results: among the 4 tracer methods, 50 cases of false negative negative lymph nodes of the sentinel lymph nodes in the breast cancer, of which the false negative rate of the methylene blue dye group was 11%, and the nuclide + Meilan was used in the methylene blue dye group. The false negative of the dyestuff group was 6.1%, the methylene blue dye + fluorescence group was false negative 10%. The false negative rate of the first 3 tracers was not statistically different (P=0.2130.05); the false negative of the methylene blue dye + nuclide + fluorescence group was 0%. against all the false negative patients, and the relationship between the age and sub typing was analyzed, the P value was 0.879,0.580, classification and whether or not. There was statistical significance between the false negative rates of detecting breast cancer sentinel after adjuvant chemotherapy. P? 0.05. conclusion: there is no statistical difference in the false negative of different tracer methods, but the ratio of the false negative of the dye + fluorescence is low, and there is no radiation pollution, it is suitable for the comprehensive promotion. Therefore, it is recommended to use the dye + fluorescence method. Further analysis was needed to further expand the case study. Further analysis found that there was a statistical difference between the classification and the results of the adjuvant chemotherapy (P0.05), that is, the false negative rate in the T2 group was significantly higher than that in the T1 group; the false negative proportion of the patients with the sentinel lymph node biopsy before the neoadjuvant chemotherapy was higher and the sentinel lymph node biopsy was not new before the biopsy. The false negative proportion of patients with adjuvant chemotherapy is low, and the clinical significance needs further study. There is no statistical difference between the results of age and molecular typing (P0.05).2. The non sentinel lymph node status analysis of 1~2 sentinel lymph nodes in patients with invasive ductal carcinoma of the breast: a prospective study of 1~2 SLN in invasive ductal carcinoma of the breast Methods: 220 cases of invasive ductal carcinoma of breast in the breast surgery of Southwest Hospital of Third Military Medical University from January 2010 to October 2015 were included in 220 cases. SLNB was diagnosed as 1~2 SLN metastasis. All of them were treated with modified radical mastectomy, postoperative pathological analysis of NSLN metastasis. Subtype, the relationship between neoadjuvant chemotherapy and ER, PR, HER-2, Ki67 and NSLN metastasis. Measurement data using C2 test, analysis of the relationship between age and NSLN metastasis by nonparametric test. Results: 220 cases of invasive ductal carcinoma of the mammary gland were 91 cases of non sentinel lymph node (NSLN) positive after ALND, accounting for 41.4% (91/220), of which 90 cases were all axillary I level lymph node metastasis, Only 1 cases had level I, II level lymph node metastasis, 129 cases of NSLN negative, 58.6% (129/220). The effects of primary lesion classification, molecular typing, neoadjuvant chemotherapy, ER, PR, Ki67 expression and age on NSLN metastasis were not statistically significant (c2= 1.830,1.336,0.918,0.074,0.000,1.766, Z=-1.369; P=0.608,0.248,0.338,0.786,0.986,0.1). 84,0.171) in.57 cases with HER-2 positive, 30 cases of NSLN positive were positive, the positive rate was 52.6% (30/57); in 163 cases of HER-2 negative patients, 61 cases were positive for NSLN, and the positive rate was only 37.4% (61/163) in.HER-2 positive patients. The positive rate of NSLN was significantly higher than that of HER-2 negative patients. In cancer patients, NSLN still has a high risk of metastasis, especially in patients with HER-2 positive. NSLN metastasis is more likely to occur in patients with positive HER-2. Therefore, 1-2 SLN positive breast cancer patients still need further axillary lymph node dissection to treat.3, breast cancer metastatic lymph node neoadjuvant chemotherapy and related factors: cohort analysis of breast cancer metastasis Methods: This study included 64 cases of axillary lymph node metastases in 64 cases, including 63 women and 1 male cases, which were diagnosed by clinical examination and imaging examination in -2016 2012. The pathological examination of the nest lymph node puncture was used to diagnose the metastatic lymph nodes of breast cancer, of which 61 cases were treated with rough needle puncture, 2 with maimoral circumflex biopsy, 1 for external hospital surgery and after chemotherapy by robot assisted internal mammary lymphadenectomy. After the neoadjuvant chemotherapy for the lymph node metastases of the breast cancer, the pathological evaluation was changed. A new adjuvant chemotherapy evaluation standard for metastatic lymph nodes of breast cancer was established by the consensus of the 2015 "new adjuvant chemotherapy for breast cancer". Results: 63 cases of breast cancer chemotherapy response to breast cancer after neoadjuvant chemotherapy: 2 cases of primary chemotherapy reaction at grade I, the lymph nodes were all reacted and not turned negative. There were 12 cases of primary chemotherapy reaction at grade II, of which 9 lymph nodes were reacted and not turned negative; 2 cases were not reacted and not turned negative; 1 lymph nodes were reacted and turned negative. 19 cases of III grade in primary chemotherapy reaction, 14 lymph nodes were reacted and not turned negative; 1 lymph nodes were not reacted and negative; 3 lymph nodes had reacted and turned negative; 1 cases had turned negative; 1 cases had turned negative; 1 cases had turned negative; 1 cases had turned negative; 1 cases had turned negative; 1 cases had turned Yin; 1 cases had turned Yin; 1 cases had turned Yin; 1 cases had turned Yin; 1 cases had turned Yin; 1 cases had turned Yin; 1 cases had turned Yin; 1 cases had turned Yin; 1 cases had turned Yin; 1 cases had turned Yin The lymph nodes were not reacted and turned negative. 18 cases of primary chemotherapy response to IV grade, 8 cases of lymph nodes were reacted and not turned negative; 1 cases were not reacted, not turned negative; 5 lymph nodes were reacted and turned negative; 4 lymph nodes were negative, 12 cases of primary chemotherapy reaction, 3 cases of lymph nodes were reacted, not turned negative, and 6 cases were lymph nodes. After the neoadjuvant chemotherapy, the primary focus after chemotherapy was not consistent with the metastatic lymph node chemotherapy after chemotherapy. After chemotherapy, the primary focus of the primary focus after chemotherapy in the 3 cases was not consistent with the chemotherapy reaction after chemotherapy. In the 3 cases, 12 of the 12 cases of chemotherapy after chemotherapy, 3 cases of the lymph nodes were not turned negative after the neoadjuvant chemotherapy, and the primary focus did not reach the chemotherapy reaction V. In the 51 cases, 14 patients were treated with neoadjuvant chemotherapy. Conclusion: This study established an evaluation classification method for the neoadjuvant chemotherapy of lymph node metastasis of invasive ductal carcinoma of the breast. It can evaluate the response and remission of breast cancer lymph node metastases after chemotherapy. Its clinical significance needs further study. The curative effect of chemotherapy on metastatic lymph nodes was not exactly the same as that of the primary focus. The proportion of lymph nodes turned negative after neoadjuvant chemotherapy in Luminal A breast cancer cases was 0. three negative breast cancer cases after neoadjuvant chemotherapy, the proportion of lymph nodes turned negative to 75%, and the chemotherapy reaction was found in other lymph nodes that had not reached complete remission in the metastatic lymph nodes.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R737.9

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