【作者】 李敏；

【导师】 田兴松；

【作者基本信息】 山东大学 ， 外科学（普外科）（专业学位）， 2024， 硕士

【摘要】 目的:分析乳腺癌前哨淋巴结(sentinel lymph node,SLN)及非前哨淋巴结(non-sentinel lymph node,NSLN)的转移情况、相关危险因素及预后。方法:回顾性分析2013年1月至2022年12月于山东省立医院乳腺甲状腺外科行前哨淋巴结活检术(sentinel lymph node biopsy,SLNB)的乳腺癌患者1169例,根据SLN状态分为SLN阴性(SLN-)组862例及SLN阳性(SLN+)组307例,根据NSLN状态分为NSLN阴性(NSLN-)组168例及NSLN阳性(NSLN+)组107例。比较各组患者的临床病理特点和SLN阳性患者预后。所有数据均使用SPSS27.0进行分析,P<0.05表示差异有统计学意义。结果:1.本研究纳入患者1169例,SLN阳性307例(26.3%),行腋窝淋巴结清扫术(axillary lymph node dissection,ALND)275 例(89.6%),32 例(10.4%)未行 ALND 患者中 5例为 SLN 宏转移;NSLN 阳性 107 例(38.9%),NSLN 阴性 168 例(61.1%)。2.SLN阳性影响因素:年龄、月经状态、病理类型、肿瘤大小、脉管侵犯(lymphovascular invasion,LVI)、ER、PR、Her-2表达及分子分型、中性粒细胞计数/淋巴细胞计数(neutrophils-lymphocyte ratio,NLR)及血小板计数/淋巴细胞计数(platelet-lymphocyte ratio,PLR)与SLN阳性相关。其中浸润性导管癌、肿瘤>2cm、LVI、ER及Her-2阳性为SLN阳性的独立危险因素。3.NSLN阳性影响因素:年龄、肿瘤多灶、肿瘤大小、LVI及SLN转移类型、数目、比例及NLR、PLR与NSLN阳性相关。其中肿瘤多灶及SLN转移比例>50%为NSLN阳性的独立危险因素,所得预测NSLN转移的曲线下面积(areaunderthe curve,AUC)为 0.750>0.7。4.预后情况:NSLN-和NSLN+组患者的5年无病生存期(disease free survival,DFS)分别为 87.3%、63.3%;5 年总生存期(overall survival,OS)分别为 93.4%、77.6%。5.肿瘤>2cm、LVI、Ki-67>14%、淋巴结转移总数≥4枚是SLN阳性患者复发转移的独立危险因素;肿瘤>2cm、LVI、淋巴结转移总数≥4枚是SLN 阳性患者死亡的独立危险因素。结论:1.本研究纳入的乳腺癌患者SLN 阳性率为26.3%,但超半数(61.1%)的SLN阳性患者NSLN为阴性。2.浸润性导管癌、肿瘤>2cm、LVI、ER及Her-2阳性为SLN阳性的独立危险因素,此类患者应积极采取腋窝处理。3.肿瘤多灶及SLN转移比例>50%为NSLN阳性的独立危险因素,所得预测NSLN转移的AUC为0.750>0.7,可以较好地预测乳腺癌NSLN转移的危险性。4.NSLN阳性与乳腺癌较差的预后相关;肿瘤>2cm、LVI、Ki-67>14%、淋巴结转移总数≥4枚是SLN阳性患者预后不良的独立危险因素。5.在进行腋窝手术前,我们应充分评估乳腺癌患者的相关临床病理因素及炎症指标,谨慎选择手术方式,且针对NSLN转移的患者术后应积极、规范治疗,给患者带来最大收益。更多还原

【Abstract】 Objective:To analyze the clinicopathological characteristics,prognosis and associated risk factors of breast cancer with positive sentinel lymph node(SLN)or non-sentinel lymph node(NSLN).Methods:1169 patients with breast cancer who underwent Sentinel Lymph Node Biopsy(SLNB)in Shandong Provincial Hospital from January 2013 to December 2022 were divided into SLN negative(SLN-)group and SLN positive(SLN+)group according to SLN status,and NSLN negative(NSLN-)group and NSLN positive(NSLN+)group according to NSLN status.The clinicopathological characteristics in each group and the prognosis of patients with positive SLN were compared.After data analysing by SPSS27.0,if P<0.05,the difference was statistically significant.Results:1.This study included 1169 patients,and 307(26.2%)were positive for SLN,among which 275(89.6%)were performed Axillary Lymph Node Dissection(ALND),32(10.4%)were not performed ALND,and 5(15.6%)of them were macrometastasis of SLN.There were 107(38.9%)NSLN positive patients and 168(61.1%)NSLN negative patients.2.Factors of SLN metastasis:Age,Menstrual status,Pathological type,Tumor size,Lymphovacular invasion(LVI),ER,PR,Her-2 status and Molecular types,Neutrophils-lymphocyte ratio(NLR)and Platelet-lymphocyte ratio(PLR)were risk factors of SLN metastasis.Invasive ductal carcinoma,Tumor size>2cm,LVI,Positive Her-2 and ER were independent risk factors of SLN metastasis.3.Factors of NSLN metastasis:Age,Tumor size,LVI,Type of SLN metastasis,Number of SLN metastasis,Proportion of SLN metastasis,NLR and PLR were risk factors of NSLN metastasis.Multiple tumors and Proportion of SLN metastasis>50%were independent risk factors of NSLN metastasis.Combined them,area under the curve(AUC)of NSLN metastasis was 0.750>0.7.4.Prognosis:Disease free survival(DFS)of patients in NSLN-and NSLN+groups were 87.3%and 63.3%,and Overall survival(OS)were 93.4%and 77.6%,respectively.5.COX proportional hazard model showed that Tumor size>2cm,LVI,Ki-67>14%and Number of metastatic lymph nodes≥4 were independent risk factors for recurrence and metastasis in SLN+patients,while Tumor size>2cm,LVI and Number of metastatic lymph nodes≥4 were independent risk factors for death in SLN+patients.Conclusion:1.The positive rate of SLN in breast cancer patients was 26.3%,but more than half(61.1%)of SLN positive patients with negative NSLN.2.Invasive ductal carcinoma,Tumor size>2cm,LVI,ER and Her-2 positive are independent risk factors for SLN positive,and axillary treatment should be actively adopted in such patients.3.Multiple tumors and SLN metastasis ratio>50%are independent risk factors of NSLN positive patients,and AUC for predicting NSLN metastasis is 0.750>0.7,which can better predict the risk of NSLN metastasis.4.Positive NSLN is related with poor prognosis of breast cancer;Tumor size>2cm,LVI,Ki-67>14%and Number of metastatic lymph nodes≥4 were independent risk factors for poor prognosis in SLN positive patients.5.Before axillary surgery,we should fully evaluate the relevant clinicopathological factors and inflammatory indicators of breast cancer patients,carefully select the surgeries,and actively and standardized postoperative treatment should be provided for patients with NSLN metastasis to bring maximum benefits to them.更多还原