Yamashita K, Shimizu K
Department of Surgery, Division of Endocrine Surgery, Nippon Medical School, Tokyo, Japan.
Surg Endosc. 2009 Jul;23(7):1574-80. doi: 10.1007/s00464-009-0343-4. Epub 2009 Mar 5.
The preservation of the axillary node (AN) has become standard therapy for early breast cancer patients with a metastasis-positive sentinel node (SN). However, about half of the patients with metastasis in the SN have no metastasis in the other AN. Late-phase three-dimensional computed tomographic lymphography (3D-CT LG) of the breast can show the axillary lymphatic architecture from the SN into the venous angle. These nodes are classified into five groups. For the sake of aesthetics, video-assisted breast surgery (VABS) was used to sample the second and third nodes shown by 3D-CT LG.
For marking the SN on the skin, 3D-CT LG was performed the day before the surgery. Iopamiron 300 (2 ml) was injected subcutaneously. A 16-channel multidetector-row helical CT image was reconstructed to produce a 3D image of the lymph ducts and nodes. A biopsy of the SN was performed by the dye-staining method using Visiport-aided endoscopy for VABS. Stained nodes were located by following the dye in the lymph ducts on a video monitor. For SN-metastasis-positive patients, standard AN dissection was performed under video assistance.
Since July 2002, the authors have performed SN biopsy for 186 patients as well as 3D-CT LG and VABS SN biopsy for 146 patients. Five chained-node groups were shown. Even in the multiple SN case, the lymph ducts were converging into the second node. The second and third nodes beyond the SN were detected and sampled in 82 patients (56.2%) by VABS assisted with 3D-CT LG. Sentinel node metastasis (n = 40) involved SN metastasis alone in 21 cases (52.5%) and SN, second-node, and third-node metastasis in eight cases. A reviewed lymphoid path by 3D-CT LG confirmed that metastasis occurred in order of lymph flow.
The use of 3D-CT LG-guided VABS SN biopsy of the second and third nodes will predict SN metastasis alone and help to obviate the need for dissection of more nodes.
对于前哨淋巴结（SN）转移阳性的早期乳腺癌患者，保留腋窝淋巴结（AN）已成为标准治疗方法。然而，约一半SN转移患者的其他AN并无转移。乳腺晚期三维计算机断层淋巴造影（3D-CT LG）可显示从SN至静脉角的腋窝淋巴结构。这些淋巴结分为五组。为了美观，采用视频辅助乳腺手术（VABS）对3D-CT LG显示的第二和第三组淋巴结进行取样。
术前一天进行3D-CT LG以在皮肤上标记SN。皮下注射300mg碘帕醇（2ml）。重建16通道多层螺旋CT图像以生成淋巴管和淋巴结的三维图像。采用Visiport辅助内镜下染料染色法对SN进行活检以用于VABS。通过在视频监视器上追踪淋巴管中的染料来定位染色的淋巴结。对于SN转移阳性患者，在视频辅助下进行标准AN清扫术。
自2002年7月以来，作者对186例患者进行了SN活检，并对146例患者进行了3D-CT LG和VABS SN活检。显示了五个链式淋巴结组。即使在多个SN的情况下，淋巴管也汇聚到第二组淋巴结。通过3D-CT LG辅助的VABS在82例患者（56.2%）中检测并取样了SN以外的第二和第三组淋巴结。前哨淋巴结转移（n = 40）中，仅SN转移的有21例（52.5%），SN、第二组淋巴结和第三组淋巴结转移的有8例。3D-CT LG复查的淋巴路径证实转移按淋巴流动顺序发生。
使用3D-CT LG引导的VABS对第二和第三组淋巴结进行SN活检将仅预测SN转移，并有助于避免清扫更多淋巴结的必要性。
