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随着社会的进步,广大妇女对乳腺疾病的重视程度越来越高,早期乳腺癌发现率随之增高,手术作为乳腺癌治疗的重要手段之一,有着不可替代的作用。如何最大程度切除肿瘤,同时把手术后的并发症降低到最小程度,改善病人的生活质量,一直是乳腺外科界孜孜追求的目标。文献显示常规乳腺癌改良根治术行腋窝淋巴结清扫(ALND)后,2年内同侧上臂水肿的发生率最高达40%~60%[1],随着前哨淋巴结活检术的开展,使得一部分病人避免了ALND,同侧上臂淋巴水肿的发生率也随之下降,但是最高也能达到7%[2]。上臂水肿不仅影响美观,严重者甚至影响到日常生活,给病人精神和肉体带来不可弥补的创伤。如何找到有效的方法来进一步减少甚至杜绝此类并发症的发生。我们的团队在这方面已经做了很多工作,自2009年至今,术中开展腋窝反向淋巴作图(ARM)达500余例,在严格控制适应证的情况下,作图成功并保留ARM淋巴结的病人,2年随访出现严重的上肢水肿的发生率为0[3]。然而,目前对上臂淋巴回流与腋窝淋巴结之间关系的应用解剖基础研究甚少,为了给临床ARM提供解剖学上的理论依据,本实验对20具(40侧)经甲醛溶液固定的成年女性尸体标本的腋窝及上臂区域进行解剖,观察上臂淋巴回流与腋窝淋巴结之间的解剖学关系,为临床医生在手术时保护上臂淋巴回流网,有效减少ALND及前哨淋巴结活检(SLNB)术后上臂水肿提供解剖学依据。
上臂淋巴回流与腋窝淋巴结的应用解剖关系及意义
Applied anatomical relation between upper arm lymphatic drainage and axillary lymph node, and its significance
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摘要:
目的为乳腺癌病人行前哨淋巴结活检(SLNB)及腋窝淋巴结清扫术(ALND)中,保留上臂淋巴回流,减轻上臂淋巴水肿提供解剖学依据。 方法对20具成人女性尸体的40侧腋区及近侧上臂区进行解剖,观察腋区各组淋巴结的数量、位置及近侧上臂浅表淋巴回流与腋区淋巴结、腋静脉三者的关系。 结果外侧群淋巴结数目为(3±1.3)个,肩胛下群淋巴结数目为(4±1.8)个,胸肌群淋巴结数目为(4±1.1)个,中央群淋巴结数目为(5±1.3)个,尖群淋巴结数目为(2±1.3)个,上臂浅层淋巴管有分支汇入贵要静脉12例(30.0%),至腋窝主要汇入外侧群淋巴结25例(62.5%),中央群淋巴结13例(32.5%);并有分支直接汇入液静脉20例(50.0%)。 结论ALND和SLNB术中保留反向淋巴作图淋巴管及淋巴结可有效保障上臂淋巴回流。 Abstract:ObjectiveTo provide the anatomical basis in preserving the upper limb lymphatic drainage to alleviate upper limb lymphedema during the sentinel lymph node biopsy (SLNB) and axillary lymph node (ALN) dissection (ALND) in breast cancer patients. MethodsThe axillary region and proximal upper arm region of 40 sides in female adult cadavers were dissected, and the number and location of lymph node in each axillary region were observed.The relationships among the superficial lymphatic reflux of proximal upper arm, axillary lymph node and axillary vein were analyzed. ResultsThe average number of lateral ALN, subscapularis ALN, pectoral ALN, central ALN and apical ALN was (3±1.3) (4±1.8) (4±1.1) (5±1.3) and (2±1.3), respectively.The superficial lymphatic drainage of upper limb draining into basilic vein in 12 cases (30.0%), lateral ALN in 25 cases (62.5%), central ALN in 13 cases (32.5%) and axillary vein in 20 cases (50.0%) were identified. ConclusionsPreservating the axillary reverse mapping lymphatic drainage and lymph nodes during ALND and SLNB can effectively protect the upper limb lymphatic drainage. -
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