本文選題：乳腺癌 + 超聲��； 參考：《山東大學(xué)》2016年博士論文

【摘要】：目的：乳腺癌是女性常見的惡性腫瘤之一,也是女性惡性腫瘤致死的主要原因。超聲是篩查或診斷乳腺疾病常用的影像學(xué)檢查手段,其診斷技術(shù)不斷地改進(jìn)和提高。超聲引導(dǎo)的干預(yù)措施,增加了確切的腋窩淋巴結(jié)轉(zhuǎn)移的檢出率,但是,超聲診斷可能受限于醫(yī)生的主觀因素從而影響診斷效果。由于超聲檢查非常低的敏感性和特異性,不能足夠準(zhǔn)確的進(jìn)行乳腺癌患者術(shù)前的腋窩淋巴結(jié)分期。病理結(jié)果是確定腫瘤是否惡性的最準(zhǔn)確的依據(jù),病理檢查技術(shù)不斷發(fā)展,在前哨淋巴結(jié)活檢和微創(chuàng)活檢技術(shù)尚未被應(yīng)用到臨床實(shí)踐前,醫(yī)師通常都會選擇手術(shù)活檢及快速冰凍病理的方式以確診乳腺癌后行改良根治術(shù),但會帶給患者巨大身心痛苦。隨著廣大女性對生活質(zhì)量要求的提高,微創(chuàng)活檢技術(shù)應(yīng)運(yùn)而生。對于乳腺原發(fā)腫瘤,細(xì)針穿刺和空芯針穿刺是應(yīng)用最為廣泛的乳腺微創(chuàng)活檢技術(shù),其主要特點(diǎn)體現(xiàn)在準(zhǔn)確率高、速度快、傷口小、并發(fā)癥少、成本低等,因此受到臨床醫(yī)師的廣泛歡迎并迅速普及開來。隨著超聲引導(dǎo)下腋窩淋巴結(jié)活檢技術(shù)的引進(jìn),無論是細(xì)針穿刺活檢(fine-needle aspiration biopsy,FNAB)還是空芯針穿刺活檢(core-needle biopsy,CNB),均提高了腋窩淋巴結(jié)超聲檢查的敏感性。超聲引導(dǎo)下腋窩淋巴結(jié)細(xì)針穿刺活檢(FNAB)和空芯針穿刺活檢(CNB)也可提高超聲檢查在腋窩淋巴結(jié)方面的特異度。本研究擬探討超聲引導(dǎo)下初次診治的浸潤性乳腺癌患者腋窩淋巴結(jié)細(xì)針穿刺活檢(FNAB)和空芯針穿刺活檢(CNB)的診斷價(jià)值。同時(shí),分析判斷術(shù)前CNB及FNAB腋窩淋巴結(jié)標(biāo)本能否反映術(shù)后手術(shù)切除乳腺原發(fā)腫瘤組織標(biāo)本的雌激素受體(ER)、孕激素受體(PR)、人表皮生長因子受體-2(Her-2)表達(dá)狀況。材料與方法：本課題選取我院2009年09月至2015年8月符合納入標(biāo)準(zhǔn)的所有初診浸潤性乳腺癌患者參加我們的研究。最終共184例患者入組,188例腋窩進(jìn)行腋窩超聲評價(jià)(四例為雙側(cè)乳腺病變)。超聲檢查特別注意位于腋尾部的前哨淋巴結(jié)的典型位置。從最可疑的腋窩淋巴結(jié)獲取活檢樣本,并對其進(jìn)行組織病理學(xué)評價(jià)。以術(shù)后病理結(jié)果為診斷金標(biāo)準(zhǔn),比較兩種方法對腋窩淋巴結(jié)術(shù)前分期的診斷價(jià)值。收集47例CNB、FNAB及原發(fā)灶病理均有免疫組織化學(xué)(IHC)結(jié)果的病例,并進(jìn)行術(shù)前腋窩淋巴結(jié)與術(shù)后原發(fā)灶ER、PR、HER-2的IHC結(jié)果比較。結(jié)果：對188例腋窩進(jìn)行超聲檢查,共有66例(35.1%)腋窩淋巴結(jié)符合納入標(biāo)準(zhǔn)并同時(shí)進(jìn)行了FNAB和CNB。行CNB者,45例腋窩淋巴結(jié)為陽性轉(zhuǎn)移,21例為陰性或者取樣不足。而行FNAB者,37例腋窩淋巴結(jié)為陽性轉(zhuǎn)移,29例為陰性或取樣不足。其中8例腋窩淋巴結(jié)CNB正確識別陽性轉(zhuǎn)移,而FNAB顯示為陰性。無FNAB結(jié)果陽性而CNB結(jié)果陰性的病例。所有患者中,45例活檢提示陽性淋巴結(jié)轉(zhuǎn)移的直接行腋窩淋巴結(jié)清掃手術(shù)(axillary lymph node dissection,ALND)或行新輔助化療后行保乳治療,其余143例則行前哨淋巴結(jié)活檢(Sentinel lymph node biopsy, SLNB),最終另外38例仍需行腋窩淋巴結(jié)清掃手術(shù),最終結(jié)果顯示淋巴結(jié)轉(zhuǎn)移陽性患者共為83例。最終的組織病理學(xué)分析表明,83/188(44.1%)腋窩淋巴結(jié)轉(zhuǎn)移(72例宏轉(zhuǎn)移,11例微轉(zhuǎn)移)。超聲引導(dǎo)CNB確定了45/83的腋窩淋巴結(jié)轉(zhuǎn)移,FNAB確定了37/83的腋窩淋巴結(jié)轉(zhuǎn)移,前哨淋巴結(jié)活檢則確定了剩余的38例陽性轉(zhuǎn)移。CNB含有6個(gè)假陰性結(jié)果,FNAB則為14個(gè)。兩種方法之間差異顯著(P0.05)。有微轉(zhuǎn)移的腋窩中,僅有1例進(jìn)行了上述術(shù)前超聲引導(dǎo)下腋窩淋巴結(jié)活檢,結(jié)果使用兩種腋窩淋巴結(jié)活檢技術(shù)均提示腋窩淋巴結(jié)轉(zhuǎn)移陰性。如果再次統(tǒng)計(jì)分析,把微轉(zhuǎn)移解釋為轉(zhuǎn)移陰性,FNAB和CNB的敏感性會略有增加,分別為74%和90%,但方法之間的差異仍然顯著(P0.05)。對腋窩淋巴結(jié)行CNB后檢測ER、PR、Her-2與術(shù)后原發(fā)灶檢測結(jié)果比較,診斷一致率分別為93.6%、91.5%、97.9%。對腋窩淋巴結(jié)進(jìn)行FNAB后檢測ER、PR、 Her-2與術(shù)后原發(fā)灶檢測結(jié)果比較,診斷一致率分別為97.9%、95.7%、97.9%。結(jié)論：對新診斷的乳腺癌患者腋窩淋巴結(jié)行準(zhǔn)確術(shù)前分期時(shí),CNB比FNAB更敏感,提倡作為乳腺癌腋窩淋巴結(jié)一線的活檢方法,從而減少或替代不必要的前哨淋巴結(jié)活檢,指導(dǎo)進(jìn)一步治療的選擇,具有很高的臨床應(yīng)用價(jià)值。對腋窩淋巴結(jié)行CNB后檢測ER、PR、Her-2與術(shù)后原發(fā)灶檢測結(jié)果有較好的一致性(p0.05)。對腋窩淋巴結(jié)進(jìn)行FNAB后檢測ER、PR、Her-2與術(shù)后原發(fā)灶檢測結(jié)果也有較好的一致性(p0.05)。
[Abstract]:Objective: breast cancer is one of the common malignant tumors in women and the main cause of death in female malignant tumors. Ultrasound is a common imaging method for screening or diagnosis of breast diseases. Its diagnostic techniques are constantly improved and improved. Ultrasound guided interventions increase the detection rate of axillary lymph node metastases, but, super Acoustic diagnosis may be limited to the subjective factors of the doctor and affect the diagnosis. Due to the very low sensitivity and specificity of ultrasound examination, the preoperative axillary lymph node staging is not accurate enough for breast cancer patients. The pathological results are the most accurate basis for determining the malignancy of the tumor, and the pathological examination technology is developing continuously and in the outpost. Before the application of knot biopsy and minimally invasive biopsy to clinical practice, physicians usually choose surgical biopsy and rapid frozen pathology to make modified radical mastectomy for the diagnosis of breast cancer, but it will bring great physical and mental pain to the patients. With the improvement of the quality of life for women, minimally invasive biopsy technique arises at the historic moment. Adenocarcinoma, fine needle puncture and hollow needle puncture are the most widely used minimally invasive biopsy techniques. The main features are high accuracy, fast speed, small wound, less complications and low cost. Therefore, it is widely welcomed by clinicians and is popularized rapidly. With the introduction of axillary lymph node biopsy technique under ultrasound guidance, Both fine needle biopsy (fine-needle aspiration biopsy, FNAB) or hollow needle aspiration biopsy (core-needle biopsy, CNB) enhanced the sensitivity of axillary lymph node ultrasonography. Ultrasound guided fine needle aspiration biopsy of axillary lymph nodes (FNAB) and hollow needle puncture biopsy (CNB) can also improve the axillary lymph nodes. The purpose of this study is to explore the diagnostic value of axillary lymph node biopsy (FNAB) and hollow needle aspiration biopsy (CNB) for the first diagnosis of invasive breast cancer under ultrasound guidance. At the same time, the analysis of CNB and FNAB axillary lymph nodes before operation can reflect the estrogen of the primary breast tumor tissue specimen after operation. The expression of receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor -2 (Her-2). Materials and methods: this subject selected all of the first diagnosed invasive breast cancer patients in our hospital from 09 months to August 2015 2009 to participate in our study. A total of 184 patients were enrolled in the group, and 188 axillary fossa were evaluated by axillary ultrasound (four cases). Ultrasound examination paid special attention to the typical position of the sentinel lymph nodes located at the tail of the axillary. Biopsy samples were obtained from the most suspected axillary lymph nodes, and the histopathological evaluation was made. The diagnostic value of the two methods for the preoperative staging of axillary lymph node was compared with the postoperative pathological results. 47 cases of CNB, F were collected. NAB and primary pathology have immunohistochemical (IHC) results, and the preoperative axillary lymph node and the primary focus of ER, PR, HER-2 IHC results. Results: 188 cases of axillary ultrasound examination, a total of 66 cases (35.1%) of axillary lymph nodes conformed to the inclusion criteria and simultaneous FNAB and CNB. CNB, 45 cases of axillary lymph nodes For positive metastasis, 21 cases were negative or lack of sampling. In FNAB, 37 cases of axillary lymph nodes were positive, 29 cases were negative or lack of sampling. Among them, 8 cases of axillary lymph nodes were correctly identified with positive metastasis, and FNAB showed negative. No FNAB positive but negative CNB results. 45 cases with positive lymph node biopsy suggested positive lymph nodes. The metastatic direct axillary lymph node dissection (axillary lymph node dissection, ALND) or new adjuvant chemotherapy was performed after breast conserving treatment. The remaining 143 cases underwent sentinel lymph node biopsy (Sentinel lymph node biopsy, SLNB), and the other 38 cases still needed axillary lymph node dissection. The final result showed positive lymph node metastases. A total of 83 cases. The final histopathological analysis showed that 83/188 (44.1%) axillary lymph node metastases (72 cases of macrometastasis, 11 micrometastases). Ultrasound guided CNB to determine the axillary lymph node metastasis of 45/83, FNAB determined the axillary lymph node metastasis of 37/83, and the sentinel lymph node biopsy confirmed the remaining 38 positive metastatic.CNB containing 6 false negative nodes. Fruit, FNAB was 14. The difference between the two methods was significant (P0.05). Only 1 cases of axillary lymph node biopsy under the ultrasound-guided axillary lymph node with micrometastases were performed, and the axillary lymph node metastasis was negative with two axillary lymph node biopsy techniques. If again, the micrometastasis was interpreted as negative transfer, FNAB and The sensitivity of CNB increased slightly, 74% and 90%, respectively, but the difference between the methods was still significant (P0.05). The detection of ER, PR and Her-2 after CNB for axillary lymph nodes was 93.6%, 91.5%, respectively, and 97.9%. was used to detect ER in axillary lymph nodes after FNAB, and PR, Her-2 and postoperative primary detection results were compared. The diagnostic consistency was 97.9%, 95.7%, 97.9%., respectively. Conclusion: CNB is more sensitive than FNAB for the accurate preoperative staging of axillary lymph nodes in newly diagnosed breast cancer patients. It is advocated as a biopsy of the breast cancer axillary lymph nodes, thereby reducing or replacing unnecessary sentinel lymph node biopsy, guiding the choice of further treatment. High clinical value. The detection of ER, PR, Her-2 after CNB for axillary lymph node was better conconformance (P0.05). After FNAB in axillary lymph nodes, ER, PR, Her-2 were also found to be in good agreement with the results of post operation detection (P0.05).
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R737.9

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