浸润性乳腺癌腋窝淋巴结活检：FNAB与CNB的诊断价值比较

发布时间：2018-07-05 17:10

本文选题：乳腺癌 + 超声　；参考：《山东大学》2016年博士论文

【摘要】：目的：乳腺癌是女性常见的恶性肿瘤之一,也是女性恶性肿瘤致死的主要原因。超声是筛查或诊断乳腺疾病常用的影像学检查手段,其诊断技术不断地改进和提高。超声引导的干预措施,增加了确切的腋窝淋巴结转移的检出率,但是,超声诊断可能受限于医生的主观因素从而影响诊断效果。由于超声检查非常低的敏感性和特异性,不能足够准确的进行乳腺癌患者术前的腋窝淋巴结分期。病理结果是确定肿瘤是否恶性的最准确的依据,病理检查技术不断发展,在前哨淋巴结活检和微创活检技术尚未被应用到临床实践前,医师通常都会选择手术活检及快速冰冻病理的方式以确诊乳腺癌后行改良根治术,但会带给患者巨大身心痛苦。随着广大女性对生活质量要求的提高,微创活检技术应运而生。对于乳腺原发肿瘤,细针穿刺和空芯针穿刺是应用最为广泛的乳腺微创活检技术,其主要特点体现在准确率高、速度快、伤口小、并发症少、成本低等,因此受到临床医师的广泛欢迎并迅速普及开来。随着超声引导下腋窝淋巴结活检技术的引进,无论是细针穿刺活检(fine-needle aspiration biopsy,FNAB)还是空芯针穿刺活检(core-needle biopsy,CNB),均提高了腋窝淋巴结超声检查的敏感性。超声引导下腋窝淋巴结细针穿刺活检(FNAB)和空芯针穿刺活检(CNB)也可提高超声检查在腋窝淋巴结方面的特异度。本研究拟探讨超声引导下初次诊治的浸润性乳腺癌患者腋窝淋巴结细针穿刺活检(FNAB)和空芯针穿刺活检(CNB)的诊断价值。同时,分析判断术前CNB及FNAB腋窝淋巴结标本能否反映术后手术切除乳腺原发肿瘤组织标本的雌激素受体(ER)、孕激素受体(PR)、人表皮生长因子受体-2(Her-2)表达状况。材料与方法：本课题选取我院2009年09月至2015年8月符合纳入标准的所有初诊浸润性乳腺癌患者参加我们的研究。最终共184例患者入组,188例腋窝进行腋窝超声评价(四例为双侧乳腺病变)。超声检查特别注意位于腋尾部的前哨淋巴结的典型位置。从最可疑的腋窝淋巴结获取活检样本,并对其进行组织病理学评价。以术后病理结果为诊断金标准,比较两种方法对腋窝淋巴结术前分期的诊断价值。收集47例CNB、FNAB及原发灶病理均有免疫组织化学(IHC)结果的病例,并进行术前腋窝淋巴结与术后原发灶ER、PR、HER-2的IHC结果比较。结果：对188例腋窝进行超声检查,共有66例(35.1%)腋窝淋巴结符合纳入标准并同时进行了FNAB和CNB。行CNB者,45例腋窝淋巴结为阳性转移,21例为阴性或者取样不足。而行FNAB者,37例腋窝淋巴结为阳性转移,29例为阴性或取样不足。其中8例腋窝淋巴结CNB正确识别阳性转移,而FNAB显示为阴性。无FNAB结果阳性而CNB结果阴性的病例。所有患者中,45例活检提示阳性淋巴结转移的直接行腋窝淋巴结清扫手术(axillary lymph node dissection,ALND)或行新辅助化疗后行保乳治疗,其余143例则行前哨淋巴结活检(Sentinel lymph node biopsy, SLNB),最终另外38例仍需行腋窝淋巴结清扫手术,最终结果显示淋巴结转移阳性患者共为83例。最终的组织病理学分析表明,83/188(44.1%)腋窝淋巴结转移(72例宏转移,11例微转移)。超声引导CNB确定了45/83的腋窝淋巴结转移,FNAB确定了37/83的腋窝淋巴结转移,前哨淋巴结活检则确定了剩余的38例阳性转移。CNB含有6个假阴性结果,FNAB则为14个。两种方法之间差异显著(P0.05)。有微转移的腋窝中,仅有1例进行了上述术前超声引导下腋窝淋巴结活检,结果使用两种腋窝淋巴结活检技术均提示腋窝淋巴结转移阴性。如果再次统计分析,把微转移解释为转移阴性,FNAB和CNB的敏感性会略有增加,分别为74%和90%,但方法之间的差异仍然显著(P0.05)。对腋窝淋巴结行CNB后检测ER、PR、Her-2与术后原发灶检测结果比较,诊断一致率分别为93.6%、91.5%、97.9%。对腋窝淋巴结进行FNAB后检测ER、PR、 Her-2与术后原发灶检测结果比较,诊断一致率分别为97.9%、95.7%、97.9%。结论：对新诊断的乳腺癌患者腋窝淋巴结行准确术前分期时,CNB比FNAB更敏感,提倡作为乳腺癌腋窝淋巴结一线的活检方法,从而减少或替代不必要的前哨淋巴结活检,指导进一步治疗的选择,具有很高的临床应用价值。对腋窝淋巴结行CNB后检测ER、PR、Her-2与术后原发灶检测结果有较好的一致性(p0.05)。对腋窝淋巴结进行FNAB后检测ER、PR、Her-2与术后原发灶检测结果也有较好的一致性(p0.05)。
[Abstract]:Objective: breast cancer is one of the common malignant tumors in women and the main cause of death in female malignant tumors. Ultrasound is a common imaging method for screening or diagnosis of breast diseases. Its diagnostic techniques are constantly improved and improved. Ultrasound guided interventions increase the detection rate of axillary lymph node metastases, but, super Acoustic diagnosis may be limited to the subjective factors of the doctor and affect the diagnosis. Due to the very low sensitivity and specificity of ultrasound examination, the preoperative axillary lymph node staging is not accurate enough for breast cancer patients. The pathological results are the most accurate basis for determining the malignancy of the tumor, and the pathological examination technology is developing continuously and in the outpost. Before the application of knot biopsy and minimally invasive biopsy to clinical practice, physicians usually choose surgical biopsy and rapid frozen pathology to make modified radical mastectomy for the diagnosis of breast cancer, but it will bring great physical and mental pain to the patients. With the improvement of the quality of life for women, minimally invasive biopsy technique arises at the historic moment. Adenocarcinoma, fine needle puncture and hollow needle puncture are the most widely used minimally invasive biopsy techniques. The main features are high accuracy, fast speed, small wound, less complications and low cost. Therefore, it is widely welcomed by clinicians and is popularized rapidly. With the introduction of axillary lymph node biopsy technique under ultrasound guidance, Both fine needle biopsy (fine-needle aspiration biopsy, FNAB) or hollow needle aspiration biopsy (core-needle biopsy, CNB) enhanced the sensitivity of axillary lymph node ultrasonography. Ultrasound guided fine needle aspiration biopsy of axillary lymph nodes (FNAB) and hollow needle puncture biopsy (CNB) can also improve the axillary lymph nodes. The purpose of this study is to explore the diagnostic value of axillary lymph node biopsy (FNAB) and hollow needle aspiration biopsy (CNB) for the first diagnosis of invasive breast cancer under ultrasound guidance. At the same time, the analysis of CNB and FNAB axillary lymph nodes before operation can reflect the estrogen of the primary breast tumor tissue specimen after operation. The expression of receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor -2 (Her-2). Materials and methods: this subject selected all of the first diagnosed invasive breast cancer patients in our hospital from 09 months to August 2015 2009 to participate in our study. A total of 184 patients were enrolled in the group, and 188 axillary fossa were evaluated by axillary ultrasound (four cases). Ultrasound examination paid special attention to the typical position of the sentinel lymph nodes located at the tail of the axillary. Biopsy samples were obtained from the most suspected axillary lymph nodes, and the histopathological evaluation was made. The diagnostic value of the two methods for the preoperative staging of axillary lymph node was compared with the postoperative pathological results. 47 cases of CNB, F were collected. NAB and primary pathology have immunohistochemical (IHC) results, and the preoperative axillary lymph node and the primary focus of ER, PR, HER-2 IHC results. Results: 188 cases of axillary ultrasound examination, a total of 66 cases (35.1%) of axillary lymph nodes conformed to the inclusion criteria and simultaneous FNAB and CNB. CNB, 45 cases of axillary lymph nodes For positive metastasis, 21 cases were negative or lack of sampling. In FNAB, 37 cases of axillary lymph nodes were positive, 29 cases were negative or lack of sampling. Among them, 8 cases of axillary lymph nodes were correctly identified with positive metastasis, and FNAB showed negative. No FNAB positive but negative CNB results. 45 cases with positive lymph node biopsy suggested positive lymph nodes. The metastatic direct axillary lymph node dissection (axillary lymph node dissection, ALND) or new adjuvant chemotherapy was performed after breast conserving treatment. The remaining 143 cases underwent sentinel lymph node biopsy (Sentinel lymph node biopsy, SLNB), and the other 38 cases still needed axillary lymph node dissection. The final result showed positive lymph node metastases. A total of 83 cases. The final histopathological analysis showed that 83/188 (44.1%) axillary lymph node metastases (72 cases of macrometastasis, 11 micrometastases). Ultrasound guided CNB to determine the axillary lymph node metastasis of 45/83, FNAB determined the axillary lymph node metastasis of 37/83, and the sentinel lymph node biopsy confirmed the remaining 38 positive metastatic.CNB containing 6 false negative nodes. Fruit, FNAB was 14. The difference between the two methods was significant (P0.05). Only 1 cases of axillary lymph node biopsy under the ultrasound-guided axillary lymph node with micrometastases were performed, and the axillary lymph node metastasis was negative with two axillary lymph node biopsy techniques. If again, the micrometastasis was interpreted as negative transfer, FNAB and The sensitivity of CNB increased slightly, 74% and 90%, respectively, but the difference between the methods was still significant (P0.05). The detection of ER, PR and Her-2 after CNB for axillary lymph nodes was 93.6%, 91.5%, respectively, and 97.9%. was used to detect ER in axillary lymph nodes after FNAB, and PR, Her-2 and postoperative primary detection results were compared. The diagnostic consistency was 97.9%, 95.7%, 97.9%., respectively. Conclusion: CNB is more sensitive than FNAB for the accurate preoperative staging of axillary lymph nodes in newly diagnosed breast cancer patients. It is advocated as a biopsy of the breast cancer axillary lymph nodes, thereby reducing or replacing unnecessary sentinel lymph node biopsy, guiding the choice of further treatment. High clinical value. The detection of ER, PR, Her-2 after CNB for axillary lymph node was better conconformance (P0.05). After FNAB in axillary lymph nodes, ER, PR, Her-2 were also found to be in good agreement with the results of post operation detection (P0.05).
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R737.9

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