| The pathologic status of internal mammary lymph nodes of breast cancer, next to axillary lymph node, is an another important independent prognostic factor. Internal mammary lymph nodes and axillary lymph nodes both belong to the first station to which the breast lymph fluid return. Internal mammary lymph node metastasis has similar prognostic importance as axillary nodal involvement. The prognosis of patients without lymph node metastasis is better than any single regional lymph node-positive patients, but patients with both internal mammary and axillary lymph nodes metastasis have the worst prognosis. Studies have shown that the residual tumor cells in the internal mammary lymph nodes after removal of the primary tumor in the breast may become a future source of recurrence and metastasis. Making the pathological status of internal mammary lymph nodes clear has significant clinical value in staging of breast cancer, individualized comprehensive treatment,prognosis, and outcome evaluation for breast cancer patients. Extended radical mastectomy (ERM) for breast cancer can help to understand the internal mammary lymph node metastasis status. With the development of the theory of breast cancer biology, systemic therapy and radiation therapy, breast cancer surgical approach is gradually shrinking, for example, ERM has been abandoned. Therefore, the problem of lack of a simple and safe surgical method obtaining internal mammary lymph nodes emerged. In the late 1990s, a new technology, clinical endoscopic technology came into being. And this endoscopic technology has been used in excision of internal mammary lymph node, which is an innovation in technology. But the methods of detecting internal mammary lymph nodes reported are different, and there has been controversial in the existence of internal mammary sentinel lymph node and clinical value of its biopsy. With these questions we performed this preliminary study to try to get answers. Methods & ResultsPart I. study on comparing endoscopic surgery with open surgery in internal mammary lymph chain of breast cancerMethods: This study was reviewed and approved by The Southwest Hospital, Third Military Medical University Ethics Committee. Ninety-seven breast cancer patients with high risk of internal mammary lymph node metastases were collected in the Breast Disease Center of Southwest Hospital from June 2004 to November 2010.Among them,50 patients underwent modified radical mastectomy plus endoscopic resection of internal mammary lymph chain (the endoscopic surgery group),and 47 patients underwent extended or modified radical mastectomy (the open surgery group).The operative duration,the volume of intraoperative blood loss,the number of internal mammary lymph nodes resected,the postoperative drainage time,the postoperative recovery time,the postoperative pain score and the postoperative complications were recorded and compared between the two groups, with an attempt of finding out a more suitable surgical method for breast cancer patients with high risk of internal mammary lymph node metastasis.Results: Operations were completed successfully in all the 97 patients,and no organ damage,postoperative bleeding or other serious complications were found.The 72-hour pain scores after surgery in the endoscopic surgery group were lower than in the open surgery group (Z=2.26,P=0.02).There were no statistically significant differences in the average operation duration,the mean blood loss,the average number of internal mammary lymph nodes resected,the postoperative drainage time,the postoperative recovery time,and the postoperative 24-hour pain score between the two groups (P>0.05).The follow-up of 6-15 months (mean 12 months) showed no recurrence,distant metastasis or death in both groups.Part II. Study on comparing lymphoscintigraphy plus carbon nanoparticles with lymphoscintigraphy plus methylene blue in detecting internal mammary sentinel lymph chain of breast cancerMethods: This study was reviewed and approved by The Southwest Hospital, Third Military Medical University Ethics Committee. Fifty-one patient of breast cancer patients with high risk of internal mammary lymph node metastases were collected in the Breast Disease Center of Southwest Hospital from December 2008 to May 2010.Patients were randomly divided into two groups, a lymphoscintigraphy+carbon nanoparticles group (n=25 patients), and a lymphoscintigraphy + methylene blue group (n=26 patients). Preoperative radionuclide imaging examination, intraoperativeγprobe detection were performd to determine the initial location of internal mammary sentinel lymph node. The carbon nanoparticles and the methylene blue were taken as intraoperative tracers. Modified radical mastectomy plus endoscopic resection of internal mammary lymph chain or extended mastectomy or modified extended mastectomy were performed. The two methods of internal mammary sentinel lymph node detection of breast cancer were compared and anslyed in order to find a more effective method of detecting internal mammary lymph nodes of breast cancer. Postoperative pathological results were statistically analyzed to explore whether internal mammary sentinel lymph nodes exist in breast cancer and the clinical value of internal mammary sentinel lymph node biopsy.Results: The positive rate of internal mammary sentinel lymph nodes of breast cancer was 80.0% (20/25) in the lymphoscintigraphy plus carbon nanoparticles group, and 73.1% (19/26) in the lymphoscintigraphy plus methylene blue group. There was no statistically significant difference between the two groups (P>0.05). However, the staining effect was better in the lymphoscintigraphy plus carbon nanoparticles group than in lymphoscintigraphy plus methylene blue group. The total detection rate of internal mammary sentinel lymph node of breast cancer in all patients was 76.5% (39/51). Among them, the internal mammary sentinel lymph node metastasis was found in 20 patients, accounting for 39.2% (20/51). Among 20 patients with internal mammary sentinel lymph node metastasis, 12 had sentinel lymph node metastasis and negative non-sentinel lymph node, occupying 23.5% (12/51), and 8 had metastatic sentinel lymph nodes and non-sentinel lymph nodes, occupying 15.7% (8/51). Thirty-nine patients were detected with positive internal mammary sentinel lymph node by the combined methods. Among the patients with internal mammary sentinel lymph nodes detected by combined methods, 19 patients had negative internal mammary sentinel lymph nodes and non-sentinel lymph nodes, occupying 37.3% (19/51). Twelve patients were detected with negative internal mammary sentinel lymph nodes by the combined methods, accounting for 23.5% (12/51). Among them, 9 patients were confirmed with internal mammary lymph nodes by pathological examination, but without metastasis, accounting for 17.6% (9/51). No internal mammary lymph nodes in intercostals were found after internal mammary lymph node dissection in 3 patients, accounting for 5.9% (3/51). No patients with internal mammary sentinel lymph node negative and non-sentinel lymph nodes metastasis were found.Conclusions1. Endoscopic resection of internal mammary lymph chain after modified radical mastectomy is safe and feasible,with less invasion and similar therapeutic effect with open surgery.2. Lymphoscintigraphy plus carbon nanoparticles in detecting internal mammary sentinel lymph nodes is reliable, and the use of intraoperativeγ-probe is an effective complement to the preoperative examination, also provides assistance for the surgery to reduce difficulties of surgery.3. Internal mammary lymph pathway exists sentinel lymph nodes in breast cancer. Internal mammary sentinel lymph nodes can accurately reflect the pathological status of the internal mammary lymph node chain in breast cancer. Internal mammary sentinel lymph node biopsy can be used as the basis for judging whether internal mammary lymphatic chain dissection is needed. |
PDF Full Text Request