2019年 · 第34卷第06期

The axillary lymph node metastasis of breast cancer is an important index to judge the prognosis of breast cancer and decide the follow-up treatment plan. axillary node dissection (ALND) has always been the standard method for axillary staging diagnosis and surgical treatment of lymph node metastasis. However, with the continuous rooting of the concept of precision medicine, how to obtain the same or even better therapeutic effect with minimal damage has become our continuous pursuit goal. This concept also needs to be implemented in the assessment and management of axillary lymph nodes. We will comb and summarize axillary lymph node assessment and management methods combining the existing evidence-based evidence and our own clinical practice experience.

The patient was a 39-year-old female who was not pregnant. A week ago, the patient found a mass at 7 and 10 o'clock in his right breast by ultrasound, and the mass was removed under local anesthesia. Postoperative pathology: low-grade papillary ductal carcinoma in situ of the right breast, size 1 cm ×1 cm and 0.8 cm ×0.6 cm (T₁N₀M₀)； The tumor cells are papillary , ER 50%, PR 50%, HER2 (−), Ki-67 5%. The patient was admitted to the hospital in February 2017 for further treatment. Axillary ultrasound: No enlarged lymph nodes were found, and no abnormalities were found in lung CT, liver B-ultrasound and bone scan. The patient asked to preserve the shape of the breast, but the tumor was multifocal and the breast volume was small, which was not suitable for breast-conserving surgery. Intraoperative sentinel lymph node biopsy was negative; "Right breast subcutaneous glandectomy with preservation of nipple areola + sentinel lymph node biopsy + free dermal fat flap reconstruction of lower abdominal wall" was performed. Surgical procedure: Removal of the right gland (preserving the nipple and areola): The scalpel carefully frees the flap, reaching the parasternum medially, reaching the right subclavicle, reaching the anterior sheath of the rectus abdominis muscle, and reaching the anterior edge of the latissimus dorsi muscle externally, and completely removing the right gland and pectoralis major fascia. Excision of glands 8 cm ×7 cm ×2.5 cm. The margin of tissue at the base of areola was removed and frozen section was sent. The dilated catheter was seen, but no cancerous tissue was seen. According to the area of the resected breast gland, a fusiform incision was made under the umbilicus of the abdominal wall with a length of about 10 cm. The epidermis was removed with scissors, and a 10 cm ×9 cm dermal fat flap was removed to reach the deep fascia of the abdominal wall. After trimming the flap, it was inverted to the receptor area, the dermis was attached to the pectoralis major muscle, and the upper, lower, medial and lateral edges were sutured and fixed to the margin tissue of the pectoralis major muscle respectively (Figure 1)。 Drainage tubes were placed in the axilla, medial breast incision and lower abdominal defect respectively, and the breast incision and lower abdominal wall incision were sutured to reduce tension. The postoperative breast incision was mildly compressed, the lower abdominal belt was compressed, the incision was changed routinely, and the drainage volume was less than 10 ml on the 5th postoperative day. Thirteen months after surgery, the patient's breast appearance was good, no obvious change, 10% retraction compared with that before surgery, but the volume was still 10% larger than that of the healthy side, the thickness changed not obviously, and the texture was slightly hard. The patient was satisfied with the postoperative breast appearance (Figure 2)。

A 25-year-old female was admitted to the hospital for "1 week of abdominal mass found on physical examination". Physical examination showed no abnormalities. Laboratory test: Serum CA19-9 154.85 U/ml, serum CA125, AFP and CEA were not abnormal. Abdominal enhanced CT showed that there was a round mass about 8.5 cm in diameter between the tail of the pancreas, stomach and spleen, with a large number of cystic changes in it. the solid components were delayed and unevenly enhanced, and the boundary with the tail of the pancreas was not clear. Consider the possibility of solid pseudopapillary tumor of the pancreas (SPTP) (Figure 1)。 Ultrasonic gastroscopy showed that the tail of the pancreas was thickened, the echoes of the parenchyma were uneven, solid and anechoic cystic changes were seen, and the internal echoes were uneven. There was no obvious dilatation of the pancreatic duct, and the relationship between the lesion and the pancreatic duct was unclear. Consider the possibility of SPTP. Exploratory laparotomy showed that the tumor originated from the mesangium of the splenic region of the colon, was tough in texture, the capsule was intact, and the adhesion to the tail of the pancreas was obvious (Figure 2)。 Partial resection of body and tail of pancreas + spleen + colon was performed. Postoperative pathological report: mesenteric fibromatosis (MF), the lesions accumulated in colonic muscle propria and pancreatic parenchyma, no obvious change in spleen, chronic inflammation of colonic mucosa, reactive hyperplasia of 3 lymph nodes around splenic hilum (Figure 3)。 Immunohistochemical staining: β-catenin (nuclear +) (Figure 4), CD34 (−), CD117 (−), DOG-1 (−), Actin (−), Desmin (−), S-100 (individual +), CK (−), EMA (−), Ki-67 (index about 1%). After 1 year follow-up, the patient was generally in good condition without recurrence.