【中文摘要】 研究背景及目的乳腺局限性病灶是女性常见疾病,其中良性者占大多数。乳腺良性病灶的传统治疗方法是外科手术切除,该手术体表留有疤痕,对部分不能触及或位置较深的病灶切除存在一定困难,所以乳腺良性病灶的微创切除治疗越来越受到临床关注。真空辅助活检系统(VABB)近年来被逐渐应用于乳腺良性病灶的微创旋切治疗。Vacora万可系统是VABB的一种,该活检系统2005年获准在我国使用。本研究旨在超声引导下使用Vacora系统对术前筛查为良性的乳腺病灶进行微创旋切治疗,评价超声检查在此方法中的应用价值及该系统在治疗乳腺良性病灶中的作用。方法本研究对2008年4月至10月在我科行乳腺超声检查发现有病灶的135例女性患者的207个乳腺病灶进行了微创旋切治疗,患者平均年龄为38±11岁。病灶筛选主要采用超声检查。二维超声重点观察病灶的位置、大小、形态、生长方向、内部回声、后方回声变化、边界、有无钙化灶及钙化灶形态,对于彩色多普勒(CDFI)模式下可观察到血流信号的病灶,联合频谱多普勒(PWD)技术对其内部和周边血流形态、分布、数量及性质、收缩期峰值流速(PSV)、阻力指数(RI)进行测量记录。根据美国放射协会...更多(ACR)推荐的乳腺影像报告数据系统(BIRADS)分级标准,超声筛选后分为以下两种情况:1)超声初步筛选为BIRADS2-3级的病灶归为本组研究治疗对象;2)超声初步筛选为BIRADS4级的病灶,经空芯针粗针活检术(CNB)诊断为良性并且患者要求进行该种治疗方法的归为本组研究治疗对象,病理诊断为非良性的不列入本研究组。对筛选后符合治疗条件的病灶在超声引导下使用Vacora旋切刀进行活检时一并切除,研究超声在术中引导的操作技巧,所有切除组织均行病理检查,将病理结果与超声筛查结果相对照,评估超声检查在术前良性病灶筛查的应用价值。半年内对术后病人进行定期随访,观察此种治疗方法的疗效及记录患者出现的并发症等相关情况。结果1、术前超声检查初步诊断为BIRADS2-3级的病灶为202个;超声检查诊断为BIRADS4级并行CNB术后病理结果为良性的病灶为5个;共对上述207个病灶进行了旋切治疗,最终病理诊断198个为良性,其余9个病灶中8个为良性病灶合并不典型增生,1个为良性病灶合并导管内癌,这9个病灶均属于术前超声检查判断为BIRADS3级的病灶。2、所有病灶治疗过程中皆采用超声引导方式,术中超声可清晰显示病灶、旋切刀位置及旋切过程中的局部出血情况。但由于旋切刀与乳腺组织的声阻抗差及反复取置旋切刀,有时会在局部看到旋切刀后方声影及气体强回声。3、135例患者中,选择一次手术切除单侧单个病灶的83例,一次手术切除单侧多个病灶的29例,一次手术切除双侧单个病灶的12例,一次手术切除一侧单个对侧多个病灶的6例,两次手术切除双侧单发或多发病灶的4例,三次手术切除双乳多发病灶的1例。其中一次入路最多切除的病灶为5个。4、所有病灶切除皆适用10G旋切刀,207个病灶依据其最大径(D)分为四组,平均每组旋切的次数及时间为:D＜1cm组(87个):平均旋切次数为5±2次,耗时为17.6±9.5min;1cm≤D＜2cm组(98个):平均旋切次数为13±7次,耗时为26.2±12.0min;2cm≤D＜3cm组(19个):平均旋切次数为36±20次,耗时为50.8±18.7min;D≥3cm组(3个):平均旋切次数为90±18次,耗时为87.7±15.7min;各组旋切次数及手术耗时差异显著(P＜0.01)。5、操作过程中患者述轻微疼痛的11例,严重者并给予追加局麻药品的3例;术中出血者4例,其中3例局部加压止血后继续手术,局部加压后择日手术者1例;术后加压包扎24-48h后复查,局部血肿形成的23例,皮肤瘀斑的5例,3-6月后复查,其皆吸收消失;局部病灶残留的3例,选择再次旋切治疗的2例,选择常规外科切除术治疗的1例。所有患者术中及术后皆未出现药物过敏、切口感染及气胸等严重并发症。结论1、术前超声对病灶的BIRADS分级,便于微创治疗适应证的选择;根据病灶位置和数量,超声可帮助选择恰当的穿刺路径;术后需对局部进行超声复检,便于对术后并发症及病灶切除治疗效果的观察;2、术前、术中、术后超声图像的对照有助于减少病灶残留的发生。由于手术方式及超声成像原理,术中会在切除局部出现旋切刀后方声影、气体强回声等声学影像;3、旋切次数及整体手术时间与病灶大小密切相关,另外有时还与术者操作熟练程度、进刀位置、切割方向及术中出现的意外情况如出血、患者疼痛等有一定关系;4、病灶性质、位置及手术入路选择是影响多病灶单次切除的重要因素;5、Vacora真空辅助活检系统体积小巧,使用电池,便于携带,使用其在超声引导下对乳腺良性病灶进行微创旋切治疗是一项简便、安全、有效的技术,具有良好的临床应用前景及优势,值得推广; 

【英文摘要】 Background and objective:Lesions of the breast are extremely common in females,most of them are benign.The general treatment for the benign breast lesions is local excision which may remain obvious scar on the skin and is difficult to resect some impalpable or deep lesions.So finding out a minimally invasive treatment becomes a focus.Vacuum-assisted breast biopsy(VABB) has been gradually applied in the minimally invasive treatment of benign breast lesions.Vacora is a kind of VABB,which was licensed to be used in 2005 in China. The objective of this research is to evaluate the application of minimally invasive Vacora vacuum assisted biopsy system in the diagnosis and treatment of benign breast lesions under ultrasound guided.Methods:135 female patients with 207 lesions underwent Vacora minimally invasive resection under the guidance of ultrasound from April to October,2008. The average age is 38±11 years.The breast lesions were mainly screened by ultrasonography and core needle biopsy(C...NB).Firstly,the location,size,shape, edge,orientation,internal echo pattern,posterior acoustic features and calcifications were observed by 2- dimensional ultrasonography.Then the lesions were further observed with color Doppler flow imaging(CDFI) and Pulse-wave Doppler(PWD).The pattern,distribution,number,character,the peak systolic velocity(PSV) and resistance index(RI) of the internal and peripheral vessels of the lesion were examined.According to breast imaging reporting and data system (BIRADS) recommended by American College of Radiology(ACR),we classified all masses into two groups:1.The lesions of BIRADS2-3 were sorted into treatment group directly.2.The lesions of BIRADS4 would firstly perform CNB with the patient's consent.If the pathologic diagnosis was benign and the patient wanted to select the Vacora minimally invasive resection,the lesions would be sorted into treatment group too,otherwise other ways would be recommended.All lesions underwent ultrasonography guided Vacora biopsy and resection.The pathologic diagnosis was made in all cases.All the patients would have been followed up in half a year;the therapeutic effect and complication were observed.Results:1.202 BIRADS2-3 and 5 BIRADS4 lesions were diagnosed by ultrasonography before the operation,the latter were done CNB and the pathologic diagnosis was benign.All of the 207 lesions underwent ultrasonography guided Vacora biopsy and resection.198 lesions were pathologically diagnosed as benign,8 lesions were as benign combining atypical hyperplasia,and another one was benign combining intraductal carcinoma.2.The whole operation was performed under the guidance of ultrasound.The ultrasonography had many advantages in preoperative localization and the display of the lesion,the biopsy needle and the hemorrhage during the operation.At times some acoustical artifact,such as posterior acoustic shadow of the needle,gas echo, can be seen during the operation.3.Among the 135 patients,83 patients underwent the resection of single lesion at one side by an operation.29 patients underwent the resection of multi-lesions at one side by an operation.12 patients underwent the resection of single lesion at every side by an operation.6 patients underwent the resection of single lesion at one side and multi-lesions at the other side by an operation.4 patients underwent the resection of single lesion or multi-lesions at every side single lesion by two times operation.1 patient underwent the resection of multi-lesions at every side by three times operation.5 lesions were resected through one tunnel.4.All lesions were biopsied and resected by 10-gauge probe.Depend on the maximal diameter(D) of the lesions;they were divided into four groups.The mean number of times and operation time:group 1(D≤1cm,n=83) took 5±2 times and 17.6±9.5min,group 2(1cm≤D＜2cm,n=98) took 13±7 times and 26.2±12.0 min,group 3(2cm≤D＜3cm,n=19) took 36±20 times and 50.8±18.7 min,group 4(D≥3cm,n=3) took 90±18 times and 87.7±15.7 min,the above indexes had the significant difference among the groups(P＜0.01).5.Pain during operation was reported in 11 cases,3 patients had severe pain and were appended anesthetic again.Hemorrhage was reported in 4 cases,3 of which were sequentially underwent the operation after pressor haemostasis,the other one chose another day to complete the treatment.All the patients were rechecked after 24-48h pressor binding,Local hematoma were found in 23 cases and skin ecchymosis were found in 5 cases,all of them disappeared after 3-6 months follow-up.3 patients was found residual lesion at the original location.2 of them underwent the second operation;the other one chose the local excision.There wasn't any severe complication in the cases,such as drug allergy;infection, pneumothorax.Conclusions:1.BIRADS level judged by ultrasonography is convenient to select suitable lesions.The well operation guide line can be selected by ultrasonography according to the location and number of lesions.The postoperative recheck of ultrasonography needs to be done,which is important to observe complication and therapeutic effect.2.The ultrasonography comparison during the operation is help to reduce residual lesion.Because of the operation way and the principle of the ultrasonography,some special sonogram,such as posterior acoustic shadow of the needle,gas echo,can be seen during the operation.3.The number of resection and the time of operation are closely correlated with the size of lesion,sometimes:they also are influenced by the operator's skill, the location of needle,the direction of resection,the patient's pain and the hemorrhage during the operation.4.The property and location of lesions and the selection of the operation tunnel are the important influenced factor of multi-lesions resection.5.Vacora vacuum assisted biopsy system has the advantage of small volume, internal battery,and convenient to carry.The ultrasonography guided Vacora minimally invasive biopsy and resection is an ideal method for the treatment of benign breast lesions. 

【中文关键词】 超声检查; 乳腺良性病灶; Vacora活检系统; 治疗
【英文关键词】 Ultrasonography; Benign breast lesion; Vacora vacuum assisted biopsy system; Treatment