RU2701352C1 - Method of fine-needle aspiration biopsy of parasternal lymph nodes in patients with breast cancer - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to oncology, and can be used for fine-needle aspiration biopsy of parasternal lymph nodes in breast cancer patients. US-navigation is followed by layer-by-layer infiltration anesthesia of skin, subcutaneous fat, thoracic and intercostal muscles observing the principle "end of the needle follows a novocaine stream". Anesthesia is followed by a fine-needle aspiration biopsy procedure under ultrasound guidance. For this purpose, a linear sensor is inserted in the intercostal space so that the detected altered lymph node is placed on the center of the screen. Using the color Doppler coding mode, internal thoracic vessels are visualized and the optimal plane of the needle passing around the detected vessels is selected. Puncture needle is placed directly in the center of the lateral surface of the ultrasonic sensor at angle of 30–45 degrees to the skin surface. Skin and subcutaneous fat pass slowly through the layer-by-layer way; at that, the needle tip should appear on the image screen. Further, by controlling the needle tip direction and correcting the penetration angle, the needle is directed to the detected lymph node. Having reached the edge of the lymph node, the needle is brought into the center of the lymph node, the syringe is pumped with negative pressure in the syringe and hand movements with amplitude of 2–4 mm; a morphological material is drawn into the needle lumen and the syringe cannula, after which a syringe is removed.

EFFECT: method provides effective and safe production of morphological material in patients with breast cancer ensured by biopsy control.

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Description

The invention relates to medicine, namely to oncology, a method for producing morphological material by fine-needle aspiration biopsy (puncture) of lymph nodes in order to verify the state of lymph nodes before the upcoming treatment.

In practical oncology, it is impossible to begin adequate treatment without a properly established diagnosis and stage of the disease.

Fine needle aspiration biopsy (TIAB) has important diagnostic and treatment value in modern medicine. TIAB is actively used in endocrinology, diagnosis of focal diseases of the thyroid gland, in emergency surgery, with diagnostic punctures of the abdominal and pleural cavities, in oncology, to obtain diagnostic material for diseases of the liver, pancreas, tumors of soft tissues, mammary, salivary and thyroid glands. (Khoperia V.G. Fine-needle aspiration puncture biopsy of thyroid glands: indications, technique, clinical application. Ukrainian Scientific and Practical Center for Endocrine Surgery and Transplantation of Endocrine Organs and Tissues of the Ministry of Health of Ukraine. Number: 1 (35), 2011. P. 57 -67. Fedotov Yu.N., Vorobyov SL, Chernikov RA Fine-needle aspiration biopsy in the diagnosis of thyroid diseases. Correlation between the conclusion of the cytologist and histologist, technical aspects. Clinical and experimental thyroidology. 2009. V. 5. No. 4. S. 28-32. Burdyukov MS , Nechipay AM Fine-needle puncture under the control of endoscopic ultrasonography: complications and alternatives Russian Journal of Radiological Diagnostics 2013. V. 3. No. 2. P. 26-37. Marchenko MG, Trofimov EI, Vinogradov V. B. Modern methods for the detection of metastases of cancer of the larynx and larynx and pharynx in the lymph nodes of the neck. Russian otorhinolaryngology. 2011. No. 1 (50). P. 114-117).

A methodically fine-needle aspiration biopsy is performed both under the control of radiation diagnostic methods (CT, MRI, ultrasound), and without them. Performing TIAB without using navigation is possible with palpable tumors of superficial localizations and initially large sizes of education. The use of TIAB without navigation has several disadvantages, such as: damage to underlying structures, vascular injury with subsequent development of bleeding, poor quality of diagnostic material. Using navigation, virtually eliminates the above risks. Navigation using ultrasound allows manipulation "at the patient’s bedside", which makes this technology convenient for use in resuscitation and intensive care units, in the operating room, in hospitals and in outpatient care units that do not have CT and MRI devices.

TIAB technology under the control of ultrasonic navigation has several modifications. It is possible to carry out the procedure using the “free-hand” method or use specialized nozzles on an ultrasound transducer that allows you to rigidly fix the direction and course of the needle. The “free hand” technique allows you to change the course and direction of the needle in real time, as well as to obtain material from various areas of the tumor formation, which is important for large tumor sizes.

When analyzing domestic and foreign scientific and patent literature, no description was found of a methodology for performing TIAB of the lymph nodes of the parasternal region.

To obtain morphological material from the lymph nodes of the parasternal collector, a number of methods were previously proposed, such as:

1. Open biopsy of parasternal lymph nodes. In 1953, McDonald proposed a biopsy of the internal thoracic lymph nodes at the stage of preoperative examination, and in the case of metastatic lesions, it was proposed to refuse radical treatment. Given the high invasiveness of the biopsy, which was accompanied by the intersection of II-III costal cartilage, the use of this technique as a preoperative diagnostic procedure for a long time was not successful with surgeons (McDonald E, Haagensen CD In: Diseases of the breast. 2nd ed. Philadelphia: WB Saunders; 1971.). It was also intended to use an urgent histological examination of the surgical material obtained from the parasternal zone, but the technique was not widely used due to the small size of the lymph nodes and the complexity of the urgent interpretation of morphological data, which led to a high percentage of incorrect results (Hovnanian A.R. A technique for the biopsy of intercostal parasternal lymph nodes // Surgery. - 1960. - Vol. 47, No. 6. - P. 891-894.).

2. Retrosternoscopy. A group of domestic scientists led by V.P. Letyagina (1996) has developed and implemented a technique for visual inspection of parasternal lymph nodes. The essence of the technique is as follows: during a radical mastectomy, intercostal muscles are dissected in the second intercostal space and the parasternal space is exposed, as a result of which the internal thoracic vessels become visible, along which the lymph nodes are located. A pediatric bronchoscope is inserted into the parasternal space, with the help of which the parasternal lymph nodes are examined. With some experience, this type of surgical intervention is extended by 10 minutes (Letyagin V.P., Laktionov K.P., Vysotskaya I.V., Kotov V.A. Breast cancer. - M., 1996. - 150 p.) .

3. Video thoracoscopic lymphatic dissection. The use of videothoracoscopy in the surgical treatment of breast cancer in Russia began with the development in 1995 of prof. E.I. Seagal et al. video thoracoscopic parasternal lymphadenectomy techniques to overcome the shortcomings of extended mastectomy according to Urban-Holdin and to preserve the radicalness of surgical treatment of breast cancer of central and medial localizations (A. Sinyakov, Video thoracoscopic parasternal lymphadenectomy in the treatment of breast cancer. 2014 International Journal of Applied and Basic Research) No. 10. . During the surgical procedure at the first stage, patients undergo a radical mastectomy or radical resection. At the second stage - videothoracoscopy of parasternal lymph nodes. Intervention is performed under endotracheal anesthesia with separate intubation of the lungs. After completion of the radical intervention on the mammary gland, the patient is turned on the healthy side in a semi-lateral position. A thoracoport with a diameter of 12 mm for the video camera is installed along the posterior axillary line in the V intercostal space. We install two similar ports for manipulators along the front axillary line in the III and V intercostal spaces. With the help of endosurgical instruments, a resection of the internal thoracic vessels on the affected side is performed with a monoblock wide excision of the surrounding tissue containing lymph collector, from I to IV intercostal space. Active drainage is established through one of the ports in the pleural cavity and suturing of the trocar holes and the surgical wound is performed. In the postoperative period, drainage from the pleural cavity is removed, as a rule, on the 1-2 day after radiologically proven lung expansion (Videothoracoscopic parasternal lymphadenectomy in assessing the lesion of the parasternal lymphatic collector in breast cancer Sinyakov A.G., Zuev V.Yu., Gribanova O.S. Medical Science and Education of the Urals. 2012. V. 13. No. 2. P. 60-64.).

The methods described above have their drawbacks: the need to use anesthesia, the invasiveness of the procedure itself, the high probability of damage to the internal chest vessels, the development of pneumotox due to wounds of the parietal pleura.

The objective of the invention is to provide a safe and effective method for obtaining diagnostic material in patients with breast cancer with suspected lesion of parasternal lymph nodes, with the aim of more accurate staging of the disease.

The problem is solved by the fact that morphological material from the lymph nodes of the parasternal collector is obtained using a fine-needle aspiration biopsy under the control of ultrasonic navigation.

The technical result of the proposed method is as follows: preoperative staging of the disease; individual, effective selection of the regimen and type of therapeutic, radiation or surgical exposure in the treatment of breast cancer; accurate prediction of long-term results of treatment; safety and low invasiveness of the method.

The inventive method is illustrated by figures 1-4.

FIG. 1. - an ultrasound picture of the lymph node is presented, before a puncture biopsy is performed. In the center of the white circle an anechogenic “black” roundish formation - the lymph node.

FIG. 2 -. during the procedure, the needle is placed directly in the center of the lateral surface of the ultrasound sensor.

FIG. 3. - the needle is located at an angle of 30-45 degrees to the surface of the skin. In the figure, the border of the skin is conditionally marked with a black line.

FIG. 4. - ultrasound picture of the lymph node during the procedure of puncture biopsy. The arrow indicates a bright hyperechoic signal from the tip of the needle.

The inventive method is as follows.

The procedure is carried out in the conditions of a control room by an ultrasound diagnostic doctor together with a surgeon doctor, using an ultrasound diagnostic apparatus equipped with a linear sensor.

At the first stage, the processing of the surgical field and the ultrasound probe with an antiseptic solution is performed. A sterile plastic bag is put on the ultrasound transducer. As a conductive medium between the skin and the sensor, you can use an antiseptic solution, for example, the Katedzhel drug. Then, under ultrasound navigation, layer-by-layer infiltration anesthesia of the skin, subcutaneous fat, pectoral and intercostal muscles is performed. In this case, the principle “the end of the needle follows the stream of novocaine” must be observed. With the right technique, the patient feels only the first injection, when passing through the skin. Anesthesia under ultrasound control, in addition to the task of anesthesia, also allows you to outline the course of the needle, for direct thin needle biopsy. Ultrasonic monitoring of the course of the needle is carried out with the simultaneous longitudinal arrangement of the ultrasonic sensor and the needle.

After anesthesia, a fine-needle aspiration biopsy is performed. For the procedure, a linear sensor is used, which is installed in the intercostal space, so that the detected altered lymph node is placed on the center of the screen (Fig. 1). Using the color Doppler coding mode, the internal thoracic vessels are visualized and the optimal plane of the needle passing around the detected vessels is selected. A fine-needle aspiration biopsy is performed with a 20 ml syringe with a G20-22 needle (0.7-0.9 mm). The puncture needle is placed directly in the center of the lateral surface of the ultrasound probe, at an angle of 30-45 degrees to the skin surface (Fig. 2, 3). The skin and subcutaneous fat pass through layers in slow motion, while the tip of the needle should appear on the image screen. Further, by controlling the direction of the end of the needle and adjusting the angle of penetration, they direct the needle to the revealed lymph node. When they reach the edge of the lymph node, they carefully draw the needle into the center of the lymph node (Fig. 4), create negative pressure with the syringe piston and, with gentle movements of the hands with an amplitude of 2-4 mm, collect morphological material into the lumen of the needle and the cannula of the syringe. After taking the material, the syringe with the needle is removed, the resulting material is applied to a glass slide and the material is sent for cytological examination.

After the procedure, it is necessary to evaluate the puncture site for the presence of hematomas and possible pleural damage and the development of pneumothorax.

Clinical examples

1. Patient M., 57 years old. Upon receipt of a complaint: does not actively present.

Anamnesis of the disease: Considers herself a patient since August 2018, when a routine mammogram of the mammary gland revealed a nodule in the left mammary gland. Tumor biopsy performed. Cancer detected. Sent to the Federal State Budgetary Institution Scientific Research Center for Oncology named after N.N. Blokhina »of the Ministry of Health of Russia for further examination and further treatment. According to MMG data from 09.2018: in the lower-inner quadrant, hyperdensation of irregular shape with a fuzzy contour is determined. The size of the formation is 1.7 × 1.2 × 1.3 cm. There are no malignant calcifications. Ultrasound of the mammary glands, regional zones: in the lower inner quadrant is determined hypoechoic formation, irregular in shape, with fuzzy contours of 1.5 × 1.0 cm. In the axillary, sub- and supraclavicular regions, pathologically altered lymph nodes were not detected. Parasternal lymph nodes on the right are not visualized, on the left they are visualized. In the parasternal region on the left, in the 2nd intercostal space, a hypoechoic lymph node 1.5 × 1.0 × 1.9 cm in size with an even, clear contour is visualized, the structure is not preserved, round, the cortical layer does not differentiate. With elastography - hard. In the 3rd intercostal space, a hypoechoic lymph node 1.5 × 1.5 × 0.9 cm in size with an even, clear contour is visualized, the structure is not preserved, rounded, the cortical layer does not differentiate. With elastography - hard.

Histologically: invasive cancer of the HCT G3 with severe lymphoid infiltration. The tumor is negative in all respects, according to Ki67 80%. Triple negative cancer.

The patient underwent TIAB parasternal lymph nodes under ultrasound control by the present method.

Conclusion: In the material received, the changes found correspond to the code: 8010/6 Cancer, metastatic.

After conducting TIAB according to the claimed method, complications are not registered.

Given the defeat of parasternal lymph nodes, the stage of the disease with Ia increased to stage IIIa, which, according to the recommendations of the NCCN, suggests a course of chemotherapy at the first stage of treatment.

2. Patient O. 57 years old.

Upon receipt of a complaint: does not actively present.

Medical history: In 2010, the patient was diagnosed with cancer of the right breast. 12/15/2010, a radical resection of the right breast was performed. Histological examination No. 41783: infiltrative lobular cancer of the 2nd degree of malignancy with small foci of lobular cancer in situ. IHC study: RE - 6b, RP - 3b, Her-2 / neu - 0, Ki - 25%. In the mid-term period, 4 courses of PCT were performed according to the AS regimen; DLT was performed on the right mammary gland ROD = 2 Gy, SOD = 50 Gy and "boost" on the bed of the removed tumor 16 Gy. Until 2016, she took Tamoxifen 20 mg / day. In February 2018, she independently discovered the formation in the area of the scar scar. Appealed to the Federal State Budgetary Institution Scientific Research Center for Oncology named after N.N. Blokhin »Ministry of Health of Russia. MMG + ultrasound from 02.22.2018: the right mammary gland is deformed due to surgery. In the area of the postoperative scar, a nodular formation with fuzzy contours of 2.3 × 1.6 cm. TAB formations were performed, cytological conclusion No. 2018/3900: cancer. On March 13, 2018, an operative measure was performed in the department of radiosurgery in the scope of sectoral resection of the right breast. Histological conclusion No. 9609/2018: infiltrative lobular cancer. IHC - RE 7, RP 3, Her-2 / neu 3+, Ki67 = 46%. In the postoperative period, drug treatment was performed on the 1st block: 4 courses of AS (adriablastin 60 mg / m2 + endoxan 600 mg / m2) iv with a preliminary premedication with an interval of three weeks. Then the 2nd block: 4 courses - paclitaxel 80 mg / m2 iv weekly 12 administrations + Herceptin first administration of 8 mg / kg, subsequent 6 mg / kg once every three weeks up to a year.

After chemotherapy was completed, a PET CT scan was performed, which revealed the progression of the disease in the form of a relapse of the process in the mammary gland, metastases to parasternal l / u.

Performed TIAB parasternal lymph nodes according to the claimed method.

Conclusion: in the material obtained, the detected cells correspond to the code: 8010/6 Cancer, metastatic (parasternal lymph nodes). The patient was discussed with chemotherapists, taking into account the early progression after chemotherapy and against the background of herceptin, conditionally radical treatment followed by radiation therapy was recommended.

In the period 2017-2018, we performed 42 fine-needle aspiration biopsies of parasternal lymph nodes. The immediate and long-term complications after the procedure are not recorded.

Thus, the claimed method is minimally invasive, eliminates the use of anesthesia and the risks of postoperative complications, reduces the risks of traumatic damage to the pleural cavity and internal chest vessels, allows to obtain morphological material in the shortest possible time, at the preoperative level and to more accurately establish the stage of the disease, which increases the efficiency of treatment of patients with a diagnosis of breast cancer.

Claims (1)

The method of fine-needle aspiration biopsy of parasternal lymph nodes under ultrasound control in patients with breast cancer, characterized in that at the first stage, ultrasound navigation is used to perform layer-by-layer infiltration anesthesia of the skin, subcutaneous fat, pectoral and intercostal muscles in compliance with the principle “the end of the needle follows a stream of novocaine "; after anesthesia, a fine-needle aspiration biopsy procedure is performed, under ultrasound guidance: a linear sensor is installed in the intercostal space, so that the detected changed lymph node is placed on the center of the screen, using the color Doppler coding mode, visualize the internal chest vessels and select the optimal needle passage plane bypassing the identified vessels; a puncture needle is placed directly in the center of the lateral surface of the ultrasound sensor, at an angle of 30-45 degrees to the skin surface; skin and subcutaneous fat pass through layers in a slow motion, while the tip of the needle should appear on the image screen; further, controlling the direction of the end of the needle and adjusting the angle of penetration, direct the needle to the detected lymph node; When they reach the edge of the lymph node, they draw a needle into the center of the lymph node, create a negative pressure in the syringe using the piston of the syringe and move the arm with an amplitude of 2-4 mm, morphological material is collected into the lumen of the needle and the cannula of the syringe, after which the syringe is removed.

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