【作者】 赵军；

【导师】 贾国丛；

【作者基本信息】 郑州大学 ， 外科学（专业学位）， 2014， 硕士

【摘要】 乳腺癌（breast cancer）是目前女性恶性肿瘤中最常见的疾病，随着近几年来，女性乳腺癌的患病率逐年来在不断地增加发展，乳腺癌发病率的逐步增高也引起了全球范围内重视，据统计在我国许多城市乳腺癌的患病率也有显著的上升，现已占据女性恶性肿瘤的第一位，对女性的身心健康及生活带来了严重的影响。从乳腺癌患者目前来看是最常见的癌症。在相关死亡原因的恶性肿瘤中20～59岁女性乳腺癌的年龄是最常见的。根据统计美国癌症协会，2010年美国新的乳腺癌病例人数超过20万，乳腺癌和超过40000人死亡，死亡率占总死亡率的14．1％[1]。我国资料统计，从1982至2001年北京乳腺癌的发病率增长了91％，平均每年增长4．6％[2]。由杨玲[3]等在2006年研究资料中显示：从2000年到2005年中国女性乳腺癌患者5年之间的发展趋势来看，不管是发病率还是死亡率都是增加的。通过中国癌症死因回顾调查数据表明，年轻女性乳腺癌死亡率有增长的趋势，是近十几年来乳腺癌死亡主要原因。此外，我国人口老龄化加剧的持续增长，也是乳腺癌死亡率增高的重要原因。20世纪中叶，乳腺癌生物学特性理论的出现逐步取代了以解剖学原理为主导的原则，这期间是一个新的转折点。从经典Halsted根治手术的创立，逐步到改良根治手术、保乳手术和微创手术的发展,都应在保证病灶完整切除的前提下,预防和减少术后所产生的并发症以提高患者术后生活质量,尽力保护患侧上肢功能,以达到最完美的治疗效果。乳癌改良根治术（Auchincloss术）仍是我国目前乳腺癌外科治疗的主要术式。乳腺癌改良根治术一般只保留胸长神经（Longthoracic nerve）和胸背神经（thoracodorsal nerve）来预防术后背阔肌的萎缩,而肋间臂神经(intercostobrachial nerve, ICBN)和胸前神经（anterior thoracicnerve,ATN）在清除腋淋巴结过程中随之一并切除。但术后易出现胸壁及上臂内侧感觉麻木、疼痛、肌肉萎缩、患肢水肿功能障碍等并发症，恢复时间长甚至不能恢复[4]。总之，除了传统的保留胸长神经，胸背神经外，也要同时保留胸前神经和肋间臂神经，评估术后对胸肌功能、皮瓣成活情况、患侧上臂感觉功能障碍的影响。并对术中保留胸前神经和肋间臂神经的必要性及临床效果做出总结，尽量减少并发症,患者的生活质量可得以改善,临床意义重大。目的腋窝淋巴结清扫在乳腺癌研究中除了常规的保留胸长神经和胸背神经，同时也要保留肋间臂神经、胸前神经,。术中操作过程中重视ICBN和ATN的保留可明显改善上述并发症，术后可以获得满意的临床效果,值得推广。同时，总结乳腺癌腋窝淋巴结清扫的必要性和胸前神经、肋间神经的保留在临床中的疗效。评估患者的生活质量改善情况及临床意义。材料和方法统计和选取2012年12月至2013年12月在郑州大学第三附属医院乳腺科行乳腺癌改良根治术病例资料100例的临床资料，临床分期为Ⅰ期--Ⅲ期，给予统计分组。病例资料分成术中保留胸前神经和肋间臂神经的保留组（50例）和对照组（50例）为术中不保留胸前神经和肋间臂神经。观察二组术后对胸大小肌功能、患侧上臂感觉功能障碍、疼痛的差异回顾性研究。采用SPSS17.0统计软件进行统计分析，并采用x2检验对统计学数据进行检验。以α=0.05为检验水准，测出P＜0.05为差异具有统计学意义。结果本组乳腺癌患者共100例均为女性，年龄22-78岁，手术方式均行乳腺癌改良根治术。分为保留组保留胸前神经和肋间臂神经（50例）和对照组（50例）不保留胸前神经和肋间臂神经进行综合比较。分成术中保留胸前神经和肋间臂神经的保留组（50例）和对照组（50例）为术中不保留胸前神经和肋间臂神经进行综合比较。保留组与对照组术后分别观察3、6、12个月。1．在胸肌萎缩及外形改变两组的比较胸肌萎缩：保留组2例为重度，9例均为轻度萎缩。对照组24例为重度萎缩，17例为轻度萎缩。两组进行比较差异均有统计学意（x2=21.75，P＜0.05）。胸壁外形改变：保留组3例胸壁皮肤凹陷，无胸廓改变。对照组18例，其中胸壁皮肤凹陷12例，胸廓改变8例。两组进行比较差异均有统计学意义（x2=23.98，P＜0.05）。2．在患侧腋窝皮肤感觉功能障碍两组上臂的比较：保留组3例，包括只影响上臂皮肤麻木1例，上臂腋窝皮肤麻木2例。对照组17例出现患侧上臂及腋窝区皮肤麻木感。两组进行比较差异均有统计学意义（x2=19.97，P＜0.05）。3．两组在患侧上臂及腋窝区疼痛的比较:保留组2例腋窝区出现，疼痛，感觉较轻均能耐受。对照组8例腋窝区出现明显疼痛。两组进行比较差异均有统计学意义（x2=17.62，P＜0.05）。4．两组在肿瘤复发及腋窝转移的比较:在观察期间保留组无复发及腋窝转移情况。对照组有1例在术后12个月时出现锁骨上淋巴结转移。1例在术后6个月左右出现患侧胸壁复发。两组比较无显著差异无统计学意义（x2=4.63，P>0.05）。5．两组在患侧上肢负重的比较:保留组：患侧上肢术后均可正常负重，日常生活不受限。对照组：有14例术后负重受限，出现上肢肌力减退。日常农活或重体力劳动受限。其中术后3个月出现8例、术后6个月出现4例、术后12个月出现2例。两组进行比较差异均有统计学意义（x2=26.73，P＜0.05）。结论1.腋窝淋巴结清扫术中保留组与对照组术后观察3、6、12个月。保留组胸廓外观正常,胸肌无明显萎缩表现,上肢负重能力满意，与不保留组存在差异。2．保留组与对照组术后观察3、6、12个月。保留组患侧上臂内侧及腋窝区无明显皮肤感觉障碍及疼痛现象,与不保留组存在差异。3.保留组与对照组术后观察3、6、12个月。肿瘤复发及腋窝转移两组无显著差异。更多还原

【Abstract】 Breast cancer is the most common malignant tumor in women’s diseases. Inrecent years, female breast cancer prevalence increased in constant development, theincidence of breast cancer increased gradually has attracted worldwide attention,According to the statistics in our country a lot of city of breast cancer incidence wassignificantly increased, has become the first female malignancy, serious impact onwomen’s physical and mental health and quality of life. Judging from the currentsituation of breast cancer is a most common malignant tumor in women.20-relateddeath in malignant tumor at the age of59female breast cancer is the most common. Accordingto the American Cancer Society estimates, number of new cases of breast cancer in2010America will exceed200000, the death toll of more than40000of total cancerdeaths, mortality rate14.1%. Statistical data in China, from1982to2001, theincidence of breast cancer in Beijing area of the rate of growth of91%, averageannual growth of4.6%. Display by Yang Ling in2006China study: women with breast cancerfrom2000to2005, the incidence and mortality of5years showed an upward trend, theincidence increased by38.5%, the death toll rose37.1%. According to the two nationalmortality retrospective survey data shows, the upward trend in young women withbreast cancer mortality, is nearly15years leading causes of mortality rate of breastcancer in China continued to rise. Moreover, China’s population growth and aging, but also improve the important cause of breast cancer mortality.The middle of the twentieth Century, the theory of biological characteristics ofbreast cancer appears gradually replaced by anatomical concept as the guideline, thisperiod of surgical treatment of breast cancer appears new turning point. From theclassic Halsted radical operation to the development of modified radical operation ofbreast conserving operation, and minimally invasive operation, in order to ensure theeradication of tumor, improve the quality of life of patients with breast cancer afteroperation, as far as possible to retain the function of upper limbs, become the finalgoal in the surgical treatment of breast cancer. At present, breast modified radicalmastectomy surgery mainly classical Chinese style is still. Modified radicalmastectomy for breast cancer in general only keep long thoracic nerve andthoracodorsal nerve to prevent postoperative posterior latissimus muscle atrophy, andintercostobrachial nerve and anterior thoracic nerve in the removal of axillary lymphnode in the process is removed. But easy to postoperative chest wall and medial armnumbness, pain, muscle atrophy, limb edema and dysfunction and othercomplications, long recovery time can’t even return.In short, breast cancer axillary lymphadenectomy in addition to conventionalretention long thoracic and dorsal thoracic nerve, while preserving anterior thoracicnerve and intercostobrachial nerve, observe the postoperative chest size musclefunction, the survival rate of the flap, the ipsilateral arm sensory dysfunction.Summed up the breast cancer axillary lymph node cleaning necessity and clinicaleffect of preserving anterior thoracic nerve and intercostobrachial nerve duringoperation, to reduce postoperative complications, improve the quality of life ofpatients, clinical significance.ObjectiveStudy of breast cancer axillary lymphadenectomy in addition to conventionalretention long thoracic and dorsal thoracic nerve, while preserving anterior Thoracicnerve andintercostobrachial nerve during operation, intraoperative attention to retainICBN and ATN can significantly improve the complications. Clinical effect of postoperative satisfaction, worthy of application. Summed up the breast canceraxillary lymph node cleaning necessity and clinical effect of anterior thoracic nerveand Intercostobrachial nerves. To reduce the postoperative complications, improve thequality of life of patients.Materials and methodsFrom2012December to2013statistical and clinical data of December in theThird Affiliated Hospital of Zhengzhou University Department of breast modifiedradical mastectomy was done in100cases data, clinical stage Ⅰ-Ⅲ period, givestatistical grouping. Case information into preservation group preserving anteriorthoracic nerve and intercostobrachial nerve during operation (50cases) and controlgroup (50cases) were not preserve the anterior thoracic nerve and intercostobrachialnerve. Two groups were observed after the chest size muscle function, with differentside arm sensory dysfunction, pain, retrospective study. Statistical analysis wasperformed using SPSS17.0statistical software, and x2test was used to test thestatistical data. Two independent sample compared with T-test, correlation analysisusing linear correlation, P <0.05with significant difference.ResultsThis group of breast cancer patients with a total of100patients were female, age22-78years old, operation underwent modified radical mastectomy of breast cancer.Divided into preservation group preserving anterior thoracic nerve andintercostobrachial nerve during operation (50cases) and control group (50cases)were not preserve the anterior thoracic nerve and intercostobrachial nerve werecomprehensively compared. And the control group were observed postoperatively3,6,12months retention group.1. the comparison between the two groups in the change of muscle atrophy andmuscle atrophy: shape retention group2cases, were mild atrophy.16cases of thecontrol group, the two groups were compared the differences were statisticallysignificant (x2=21.75, P <0.05). Changing the shape of the chest wall: keep the group 0cases, control group18cases, the thoracic skin collapse in12cases, thoracic in6cases. The two groups were compared the differences were statistically significant(x2=23.98, P <0.05).2.Comparison of2two groups of upper arm on the affected side and axillaryskin sensory dysfunction: keep the group of3cases, including1cases of onlyaffected arm numbness of skin,2cases of upper arm and armpit skin numbness. Acontrol group of17cases appeared ipsilateral upper arm and axillary skin numbness.The two groups were compared the differences were statistically significant(x2=19.97, P <0.05).3. two groups of pain in the affected side upper arm and axillary region,preserving group:2patients with axillary pain, feeling lighter tolerated. A controlgroup of8cases of axillary fossa pain. The two groups were compared thedifferences were statistically significant (x2=17.62, P <0.05).4. group two metastasis in tumor recurrence and axillary comparison: preservinggroup without recurrence and axillary metastasis in the observation period. In1casesof the control group after1years when the metastasis of supraclavicular axillary.Comparing the two groups had no significant difference was not statisticallysignificant (x2=4.62, P>0.05).5. The two group in upper limb weight-bearing comparison: preserving group:upper limb after operation can be normal weight, daily life is not limited. Controlgroup:14cases of postoperative weight-bearing restriction, upper extremity weakness.Limited daily farm work or heavy manual labour.3months after operation in8cases,6months after operation in4cases,12months after operation in2cases. The twogroups were compared the differences were statistically significant.(x2=26.73, P <0.05).Conclusions1. axillary lymphadenectomy retention group and control group were observedafter3,6,12months. Preserving group pectoral muscle in good shape, no obviousatrophy, limb weight-bearing activities function is good, and the not preserving group differences.2. retention group and control group were observed after3,6,12months.Preserving group ipsilateral medial arm and axilla without obvious skin sensorydisturbance and pain, and the not preserving group differences.3. retention group and control group were observed after3,6,12months. Tumorrecurrence and metastasis has no significant difference between the two groups.更多还原