Sentinel lymph node biopsy in patients with Stage I/II melanoma: Clinical experience and literature review

BACKGROUND: The sentinel lymph node (sN) represents one of the most powerful predictors of the outcome of patients with Stages I and II cutaneous melanoma, and may be relevant for the therapeutic planning of early-stage melanoma patients. Since adopting the technique of lymphatic mapping with vital blue dye (Patent Blue-V) in July 1993, we have periodically up-dated the methodology and revised our results in order to define the contribution of radio-guided surgery (RGS) to the detection of the sN as well as the role of intraoperative frozen section examination of the sN. MATERIALS AND METHODS: Between July 1993 and December 1997, 180 patients with clinically node-negative primary cutaneous melanoma (Stages I-II) underwent sN biopsy followed by "selective lymph node dissection" (SLND) whenever sN metastasis was detected. Presently, complete data are available in 165 patients who were divided into two consecutive subsets of 39 and 126 patients, based on the technique for the identification of the sN: Patent Blue-V only or Patent Blue-V associated to RGS. Moreover, in this second subset of patients intraoperative frozen section findings were compared with definitive pathologic examination. RESULTS: As regards the first subset of 39 patients (17 males and 22 females; mean age 51.3 years), the sN was identified in 35 patients (89.7%); 8 patients (22.8%) were found to have metastatic melanoma cells in their sN, and they all underwent SLND of the affected basin. As regards the second set of 126 patients (54 males and 72 females; mean age 53.5 years), the sN was detected in every case by means of the combined technique (Patent Blue-V and RGS): in 4 of 126 patients (3.2%), the sN was detected by means of RGS only whereas in no patient was the sN detected by Patent Blue-V only. Frozen section examination was performed in 123 of 126 patients who had sN detection by Patent Blue-V and RGS, and the intraoperative examination had a sensitivity of 66.6% (22 of 33), specificity of 100% (90 of 90), negative predictive value of 89.1% (90 of 101), and accuracy of 91% (112 of 123). The benefit of frozen section examination in avoiding a two-stage procedure was 17.9% (22 of 123 patients). In patients with thicker lesions (pT(3)-pT(4)), the sensitivity and the benefit of intraoperative examination were 76% (19 of 25) and 32% (19 of 59 patients), respectively. CONCLUSIONS: Sentinel node lymphadenectomy can be better accomplished when both procedures (lymphatic mapping with Patent Blue-V and RGS) are used because the two methods look quite complementary. In fact, the use of the radiocolloid mapping allows to detect a hot spot in the regional basin prior to making the skin incision in order to perform a minimal invasive access, and it may also more accurately differentiate the true sN from a secondary echelon node (non-sN). The use of frozen section examination should be restricted to patients with pT(3)-pT(4) primary melanoma, due to the higher sensitivity and benefit in terms of avoiding a two-stage operative procedure.     

Sentinel lymph node as a new marker for therapeutic planning in breast cancer patients

BACKGROUND AND OBJECTIVES: Literature review suggests that the sentinel lymph node (sN) represents a reliable predictor of axillary lymph node status in breast cancer patients; however, some important issues, such as the optimisation of the technique for the intraoperative identification of the sN, the role of intraoperative frozen section examination of the sN, and the clinical implications of sN metastasis as regards the surgical management of the axilla, still require further confirmation. The authors aimed (1) to assess the feasibility of sN identification with a combined approach (vital blue dye lymphatic mapping and radioguided surgery, RGS) and the specific contribution of either techniques to the detection of the sN, (2) to determine the accuracy and usefulness of intraoperative frozen section examination of the sN in order to perform a one-stage surgical procedure, and (3) to define how the sN might modulate the therapeutic planning in different stages of disease. MATERIALS AND METHODS: From October 1997 to June 2001, 334 patients with early-stage (T(1-2) N(0) M(0)) invasive mammary carcinoma underwent sN biopsy; the average age of patients was 61.5 years (range, 39-75 years). In a subset of 153 patients, both vital blue dye (Patent Blue-V) lymphatic mapping and RGS were used to identify the sN, and the relative contribution of each of the two techniques was assessed. RESULTS: In the whole group, the sN was identified in 326 of 334 patients (97.6%), and 105 of 326 patients (37.3%) had positive axillary lymph nodes (pN+). In 9 of 105 pN+ patients, the definitive histologic examination of the sN did not show metastases but these were detected in non-sN, thus giving an 8.6% false-negative rate, a negative predictive value of 94.5% (156/165), and an accuracy of 96.5% (252/261). As regards the specific contribution of the two different techniques used in the identification of the sN, the detection rate was 73.8% (113/153) with Patent Blue-V alone, 94.1% (144/153) with RGS alone, and 98.7% (151/153) with Patent Blue-V combined with RGS (P < 0.001). Noteworthy, whenever the sN was identified, the prediction of axillary lymph node status was remarkably similar (93-95% sensitivity; 100% specificity; 95-97% negative predictive value, and 97-98% accuracy) whichever of the three procedures was adopted (Patent Blue-V alone, RGS alone, or combined Patent Blue-V and RGS). Intraoperative frozen section examination was performed in 261 patients, who had at least one sN identified, out of 267 patients who underwent complete axillary dissection; 170 patients had histologically negative sN (i.o. sN-) and 91 patients histologically positive sN (i.o. sN+). All 91 i.o. sN+ were confirmed by definitive histology, whereas in 14 of 170 i.o. sN- patients (8.2%) metastases were detected at definitive histology. As regards the correlation between the size of sN metastasis, the primary tumour size, and the status of non-sN in the axilla, micrometastases were detected at final histology in 23 patients and macrometastases in 82 patients. When only micrometastases were detected, the sN was the exclusive site of nodal metastasis in 20 of 23 patients (86.9%) while in 3 patients with tumour size larger than 10 mm micrometastases were detected also in non-sN. Macrometastases were never detected in pT(1a) breast cancer patients; the sN was the exclusive site of these metastases in 30 patients (36.6%), while in 52 patients (63.4%) there were metastases both in sN and non-sN. CONCLUSIONS: Sentinel lymphadenectomy can better be accomplished when both procedures (lymphatic mapping with vital blue dye and RGS) are used, because of the significantly higher sN detection rate, although the prediction of axillary lymph node status remains remarkably similar whichever method is used. The intraoperative frozen section examination proved to be rather accurate in predicting the actual pathologic status of the sN, with a negative predictive value of 91.8%; in 35% of patients it allowed sN biopsy and axillary dissection to be performed in a one-stage surgical procedure. Finally, specific clinical and histopathologic features of the primary tumour and sN might be used to tailor the loco-regional and systemic treatment in different clinical settings, such as in ductal carcinoma in-situ (DCIS), early-stage invasive breast cancer, and patients with large breast cancer undergoing neo-adjuvant CT for breast-saving surgery as well as elderly patients with operable breast cancer.     

Sentinel lymph node mapping in early-stage breast cancer: technical issues and results with vital blue dye mapping and radioguided surgery

BACKGROUND AND OBJECTIVES: Axillary lymph node status is the most important prognostic factor in patients with operable breast cancer. Recent studies have demonstrated the possibility of identifying the sentinel lymph node (sN) as a reliable predictor of axillary lymph node status in both cutaneous melanoma and breast cancer. Sentinel lymph node identification proved feasible by either peritumoral dye injection (Patent Blue-V) or radiodetection, with identification rates of 65-97% and 92-98%, respectively. However, some important issues need further definition, namely (a) optimization of the technique for intraoperative detection of the sN, (b) predictive value of the sN with regard to axillary lymph node status, and (c) reliability of intraoperative histology of the sN. We reviewed our experience in sN detection in patients with stage I-II breast cancer to assess the feasibility and accuracy of lymphatic mapping, by vital blue dye or radioguided surgery, and sN histology as a predictor of axillary lymph node status. METHODS: Two groups of patients (55 and 48) were recruited between May 1996 and May 1997 and between October 1997 and February 1998; the patients of the first series underwent vital blue dye lymphatic mapping only, whereas those of the second series had a combined approach with both vital blue dye mapping and radioguided detection of the sN. RESULTS: In the first set of patients, the sN was identified in 36/55 patients (65.4%); sN histology predicted axillary lymph node status with a 77% sensitivity (10/13), a 100% specificity (23/23), an 88.5% negative predictive value (23/26), and an overall 91.5% accuracy (33/36). The sN was the quasi-elective site of lymph node metastases because in clinically N0 patients nodal involvement was 20-fold more likely at histology in sN than in non-sN (30% and 1.5%, respectively). In the second set of patients, 49 lymphadenectomies were performed because 1 patient had bilateral breast cancer; the sN was identified in 45/49 lymphadenectomies (92%). The sN was intraoperatively negative at frozen-section examination in 33 cases, and final histology confirmed the absence of metastases in 31/33 cases (94%), whereas in 2 cases (6%) micrometastases only were detected. Final histology of the sN predicted axillary lymph node status with an 87.5% sensitivity (14/16), a 100% specificity (29/29), a 93.5% negative predictive value (29/31), and an overall 95.5% accuracy (43/45). CONCLUSIONS: Sentinel lymphadenectomy can be better accomplished when both mapping techniques (vital blue dye and radioguided surgery) are used. In this group of patients, agreement of intraoperative histology of the sN with the final diagnosis was 94%, and sN histology accurately predicted axillary lymph node status in 43/45 lymphadenectomy specimens (95.5%) in which an sN was identified.     

Technical issues and pathologic implications of sentinel lymph node biopsy in early-stage breast cancer patients

BACKGROUND AND OBJECTIVES: Recent studies have demonstrated that the sentinel lymph node (sN) can be considered a reliable predictor of axillary lymph node status in breast cancer patients. However, some important issues, such as optimization of the technique for the intraoperative identification of the sN, and the clinical implications of sN metastasis as regards the surgical management of the axilla still require further elucidation. The objectives of this study was to assess (1) the feasibility of sN identification with a combined approach (vital blue dye lymphatic mapping and radioguided surgery, RGS) and the specific contribution of either techniques to the detection of the sN, and (2) the correlation between the size of sN metastasis (micrometastasis < or = 2 mm; macrometastasis > 2), primary tumour size, and the status of nonsentinel nodes (nsN) in the axilla. METHODS: Between October of 1997 and December of 1999, 212 patients with breast cancer (average age: 61 years; range, 40-79 years) underwent sN biopsy before performing standard axillary dissection. In a subset of 153 patients, both vital blue dye (Patent Blue-V) lymphatic mapping and RGS were used to identify the sN, and the relative contribution of each of the two techniques was assessed. RESULTS: Overall, the sN was identified in 206 of 212 patients (97.1%); at histologic examination of all dissected nodes, 77 of 206 patients had positive nodes (37.3%). The false-negative rate was 6.5% (5/77), the negative predictive value was 96.3% (129/134), and accuracy was 97.6% (201/206). Among 72 patients with positive sN, micrometastases were detected in 21 cases and macrometastases in 51. When micrometastases only were observed, the sN was the exclusive site of nodal metastasis in 17 of 21 cases (80.9%); in the remaining 4 cases (19.1%), nsN metastases were detected in 3 of 14 pT1c patients (21.5%), and 1 of 5 pT2 patients (20%). Macrometastases were detected in patients with tumors classified as pT1b or larger: the sN was the exclusive site of metastasis in 3 of 4 pT1b patients (75%), in 14 of 29 pT1c patients (48.2%), and in 3 of 18 pT2 patients (16.6%). The specific contribution of the two different techniques used in the identification of the sN was evaluated; the detection rate was 73.8% (113 of 153) with Patent Blue-V alone, 94.1% (144 of 153) with RGS alone, and 98.7% (151 of 153) with Patent Blue-V combined with RGS (P < 0.001). Noteworthy, whenever the sN was identified, the prediction of axillary lymph node status was remarkably similar (93-95% sensitivity; 100% specificity; 95-97% negative predictive value, and 97-98% accuracy) with each of the three procedures (Patent Blue-V alone, RGS alone, or combined Patent Blue-V and RGS). CONCLUSIONS: Sentinel lymphadenectomy can better be accomplished when both procedures (lymphatic mapping with vital blue dye and RGS) are used, due to the significantly higher sN detection rate, although the prediction of axillary lymph node status remains remarkably similar with each one of the methods assessed. That patients with small tumours (<1 cm) and sN micrometastasis are very unlikely to harbour metastasis in nsN should be considered when planning randomised clinical trials aimed at defining the effectiveness of sN guided-axillary dissection.     

Intraoperative examination of axillary sentinel lymph nodes in breast carcinoma patients.

BACKGROUND: Routine histologic examination of axillary sentinel lymph nodes predicts axillary lymph node status and may spare patients with breast carcinoma axillary lymph node dissection. To avoid the need for two separate surgical sessions, the results of sentinel lymph node examination should be available intraoperatively. However, routine frozen-section examination of sentinel lymph nodes is liable to yield false-negative results. This study was conducted to ascertain whether extensive intraoperative examination of sentinel lymph nodes by frozen section examination would attain a sensitivity comparable to that obtained by routine histologic examination without intraoperative frozen section examination. METHODS: In a consecutive series of 155 clinically lymph node negative breast carcinoma patients, the axillary sentinel lymph nodes were examined intraoperatively, before complete axillary lymph node dissection. The frozen sentinel lymph nodes were sectioned subserially at 50-microm intervals. For each level, one section was stained with hematoxylin and eosin and the other section immunostained for cytokeratins using a rapid immunocytochemical assay. RESULTS: Sentinel lymph node metastases were detected in 70 of the 155 patients (45%). In 37 cases the sentinel lymph nodes were the only axillary lymph nodes with metastases. Immunocytochemistry did not increase the sensitivity of the examination. Five patients had metastases in the nonsentinel axillary lymph nodes despite having negative sentinel lymph nodes. The general concordance between sentinel and axillary lymph node status was 96.7%; the negative predictive value of intraoperative sentinel lymph node examination was 94.1%. CONCLUSIONS: The intraoperative examination of axillary sentinel lymph nodes is effective in predicting the axillary lymph node status of breast carcinoma patients and may be instrumental in deciding whether to spare patients axillary lymph node dissection.     

Sentinel lymph node biopsy in melanoma patients: the medical oncologist's perspective

With the advent of sentinel node (sN) biopsy in melanoma patients, elective lymph node dissection (ELND) can be considered an exceeded procedure. Regardless of the possible therapeutic benefits, sN biopsy efficiently predicts prognosis avoiding the morbidity rate of ELND. The importance of the sN is underlined by multivariate analyses, which show that the sN status represents the most important prognostic factor influencing disease-free and distant disease-free survival in patients with stage I and II melanoma. Moreover, sN biopsy provides a minimally invasive method for identifying those patients with subclinical nodal metastasis who actually have stage III disease, with a very high risk of occult distant metastases and who may benefit by adjuvant therapy.     

New fields of application of the sentinel lymph node biopsy in the pathologic staging of solid neoplasms: review of literature and surgical perspectives

Sentinel lymph node (sN) biopsy has gained special attention among surgical and medical oncologists as it represents an accepted technique for detecting occult nodal disease in regional lymph nodes of patients with melanoma and breast cancer. The histopathologic examination of the sN may well predict regional lymph node status in order to define the most suitable loco-regional and systemic treatment. Recently, this technique has also been applied to other solid tumor types such as gynecologic and urologic malignancies, squamous head and neck cancer, thyroid cancer, non-small-cell lung cancer, Merkel cell carcinoma, and gastric cancer. The aim of this literature review is to define the rationale of sN biopsy in these tumor sites, the most effective procedure for sN detection, and the accuracy of the sN in predicting regional nodal status, as well as the surgical perspectives of sN biopsy application.     

Sentinel lymph node biopsy in melanoma patients with clinically negative regional lymph nodes--one institution's experience

The purpose of this prospective study of sentinel lymph node (SLN) biopsy in a large series of melanoma patients with clinically negative regional lymph nodes from one cancer centre was to analyse the reliability of the procedure, the pattern of failures during follow-up and the factors affecting the clinical outcome of patients. Between April 1995 and November 2001, 726 consecutive patients with primary cutaneous malignant melanoma underwent SLN biopsy with preoperative lymphoscintigraphy. The vital blue dye technique was used in 170 patients, and the blue dye technique combined with intraoperative lymphoscintigraphy in 556 patients. The primary melanoma sites were head and neck in nine patients, the extremities in 419 patients, and the trunk in 298 patients. The median Breslow thickness was 3.0 mm. All patients were followed closely, the median follow-up time being 34 months. The sentinel node(s) were successfully identified in 96% of patients. Intraoperative lymphoscintigraphy combined with the blue dye technique improved the SLN identification rate (technical success in 97.3% of cases) compared with the blue dye technique alone (technical success in 91.6%). The rate of failed SLN procedures was significantly (P = 0.007) lower in inguinal basins (3.1%) compared with axillary basins (7.9%). SLN metastases were detected in 147 patients (20.2%). The presence of SLN metastases correlated significantly with primary tumour thickness and ulceration (P < 0.001). The false-negative SLN biopsy rate was 4.66% (27 out of 579 SLN-negative patients). All but two node-positive patients underwent complete lymphadenectomy. Lymph nodes other than SLNs were found to contain metastases in 26.9% of patients (39 out of 145). The 5 year overall survival (OS) rate was 84% for SLN-negative patients and 40% for SLN-positive patients. Five variables showed a strong, statistically significant negative independent prognostic association with OS: positive SLN status (P = 0.000001), primary melanoma thickness > 4 mm (P = 0.0009), male gender (P = 0.001), more than one lymph node involvement (P = 0.02) and lymph node extracapsular extension (P = 0.03). SLN biopsy is currently a valuable and effective diagnostic procedure for the precise staging of patients with clinically N0 cutaneous melanoma. So far SLN biopsy seems to be the only accessible method for consciously oriented detection of nodal micrometastases in melanoma that would otherwise go undetected. SLN status is the most important factor proven to distinguish high and low risk melanoma patients.     

The effect of delay time between primary melanoma biopsy and sentinel lymph node dissection on sentinel node status, recurrence, and survival

For primary melanoma, there is a delay between the initial skin biopsy and sentinel lymph node dissection, which may cause anxiety for the patient. The consequences of this delay on disease progression are unknown. The goal of this study was to determine whether delay time for sentinel node dissection from the initial cutaneous melanoma biopsy affects patient outcomes. A retrospective analysis of 492 patients with melanoma who underwent a sentinel node dissection between 1993 and 1999 was carried out. The endpoints assessed were sentinel node tumor status, recurrence, and mortality. Time to sentinel node dissection was compared between patients with positive and negative sentinel nodes. Long-term survival and recurrence were evaluated in relation to the time between the cutaneous biopsy and the sentinel node dissection (delay time), comparing less than 40 days with at least 40 days. In total, 15.9% of patients had positive sentinel nodes. The median follow-up was 11.7 years. Positive sentinel node patients had a median delay of 35 days between the primary melanoma biopsy and the sentinel node dissection compared with 41 days for negative sentinel node patients (P=0.5). Kaplan-Meier survival curves showed that a delay time of less than 40 days versus at least 40 days was not related to recurrence of melanoma (log-rank P=0.13) or overall survival (log-rank P=0.14). On multivariate analysis of age, thickness, ulceration, and sentinel node status, there was no difference in disease-free survival (P=0.58) or overall survival (P=0.53) between the less than 40 days and the at least 40 days groups. A modest delay in sentinel node dissection from the initial melanoma biopsy does not adversely affect sentinel node status, recurrence, nor survival.     

Intraoperative Frozen Biopsy of Central Lymph Node in the Management of Papillary Thyroid Microcarcinoma

The purpose of this study was to evaluate the usefulness and accuracy of intraoperative frozen section examination in the diagnosis of metastatic central lymph nodes in comparison to the final histopathological findings. A retrospective review was performed to evaluate patients with a preoperative diagnosis of papillary thyroid microcarcinoma (PTMC) and a plan to perform thyroid lobectomy at our Hospital from September 2011 to September 2013. Sixteen patients were identified. Intraoperative frozen section examination diagnosed ten patients as negative malignant cells of the central lymph node and the remaining six patients as metastatic central lymph node. The final histopathological results corresponded with intraoperative frozen section examination. Intraoperative frozen section examination had a sensitivity, specificity and accuracy of 100 % for diagnosing metastatic central lymph nodes of PTMC. Intraoperative frozen section examination of central lymph nodes is a useful and accurate adjunct for determining the operation method in PTMC.     

完全性淋巴结清扫对前哨淋巴结阳性黑色素瘤患者的预后价值Meta分析

目的 探讨完全性淋巴结清扫对前哨淋巴结活检阳性黑色素瘤患者的预后价值。方法 计算机检索数据库PubMed、Embase、Cochrane Library、中国知网和万方,并联合参考文献追查,采用Meta分析分析患者生存状态。结果 纳入10篇符合标准的文献,Meta分析结果显示：完全性淋巴结清扫组与淋巴结观察组的肿瘤特异性生存（HR: 0.99, 95%CI: 0.86~1.14, P=0.89）、无复发生存（HR: 0.89, 95%CI: 0.72~1.08, P=0.24）和无远处转移生存（HR: 1.03, 95%CI: 0.89~1.20, P=0.71）差异无统计学意义。结论 完全性淋巴结清扫不能为前哨淋巴结活检阳性黑色素瘤患者带来生存获益。     

Lymph node status and survival in cutaneous malignant melanoma--sentinel lymph node biopsy impact.

AIM: The survival benefit of sentinel lymph node biopsy (SLB) with lymphadenectomy for microscopic melanoma metastases to regional lymph nodes (SLND) is uncertain. The aim of the study was to analyse the factors influencing clinical outcome (overall survival (OS) and disease free survival (DFS)) of patients undergone lymph node dissection (LND) as result of positive sentinel lymph node disease (SLND) or as consequence of clinically detected metastases (CLND). PATIENTS AND METHODS: This was a single-institution retrospective analysis of survival data of 350 consecutive, prospectively collected, melanoma patients who underwent radical LND in 1995-2001. One hundred and forty-five patients underwent SLND and 205 underwent CLND. RESULTS: The median OS and DFS times of the entire group of melanoma patients, computed from the date of primary lesion excision, were 46.3 months and 26.5 months (5-year OS ratio 41.8% and 5-year DFS ratio 31.5%). The factors which correlated with poor OS by multivariate analysis were: primary tumour Breslow thickness >4 mm (p=0.001), extracapsular extension of lymph node metastases (p=0.004), male sex (p=0.001) and metastases to more than one regional lymph node (p=0.04). The negative factors for DFS were: nodal extracapsular invasion (p=0.00002) and primary tumour Breslow thickness >4 mm (p=0.004). There were no significant differences in OS and DFS between SLND and CLND groups, when calculated from the date of primary tumour excision. However, if OS and DFS were estimated from the date of LND, the SLND group demonstrated significantly better survival in comparison with CLND. CONCLUSION: The study demonstrates no survival benefit from SLB with subsequent radical regional LND in malignant melanoma patients with lymph node metastases.     

The sentinel lymph node status is an important factor for predicting clinical outcome in patients with Stage I or II cutaneous melanoma.

BACKGROUND: In a cohort of patients, the authors investigated whether and to what extent the sentinel lymph node (SLN) status contributes to predicting the probability of remaining disease free for at least 3 years. In addition, several traditional prognostic factors were analyzed: Breslow thickness, Clark invasion level, ulceration, lymphatic invasion, location, type of the melanoma, and age and gender of the patient. METHODS: In 263 consecutive patients with proven American Joint Committee on Cancer Stages I and II cutaneous melanoma, the triple technique SLN procedure was used, i.e., preoperative visualization of the lymph channels from the initial site of the melanoma toward the SLN by (dynamic) lymphoscintigraphy, intraoperative visualization of those particular lymph channels and lymph nodes with blue dye, and a gamma probe to measure accumulated radioactivity in radiolabeled lymph nodes. Median follow-up time was 48 months (range, 36-84 months). Multivariate logistic regression analysis was performed to examine the influence of the SLN status and several other prognostic factors on a minimum 3-year disease free survival. RESULTS: In 20% of patients, the SLN proved to be tumor positive. For SLN negative patients, the 5-year disease free survival rate was 91% (+/- 2.4%), and for SLN positive patients it was 49% (+/- 9%). Five variables showed a strong and statistically significant independent prognostic association with outcome, i.e., SLN status (P = 0.0007), thickness of primary melanoma (1.01-2.0 mm; P = 0.04), ulceration (P = 0.05), and lymphatic invasion (P = 0.01) of primary melanoma, and age (40-50 years; P = 0.01). CONCLUSIONS: The SLN status-along with Breslow thickness, ulceration, lymphatic invasion, and age--seems to have strong additional value in predicting a minimum 3-year disease free period after the SLN procedure. Patients with a positive SLN have a poorer prognosis than those with a negative SLN.     

甲状腺乳头状癌颈部淋巴结转移的处理态度和诊疗现状

甲状腺乳头状癌(Papillary thyroid carcinoma,PTC)虽以惰性居多,但颈部淋巴结转移的患者并不少见,而颈淋巴结转移的发生也意味着死亡率增加和复发风险的提高,甲状腺手术前应使用彩超充分评估颈部淋巴结的状态,对直径较大的淋巴结行超声引导下淋巴结细针抽吸(Echo-guided fine needle aspiration of the lymph node,LN-FNA)或联合测定洗脱液的甲状腺球蛋白水平,在怀疑远处转移或肿瘤浸润性生长时可联合CT、PET-CT或磁共振检查。建议临床医生在有技术保证的前提下对术中冰冻为阴性的cN0患者行单侧的预防性中央区淋巴结清扫术(Prophylactic central neck dissection,pCND),对术中冰冻为阳性的cN0患者行双侧的中央区淋巴结清扫术,在降低患者复发率的同时减少术后并发症的发生,应严格按照指南评估患者术后是否需行放射性碘治疗,以减少不必要的放射性治疗,更好地服务于患者,提升患者的生存质量。     

Multi-institutional melanoma lymphatic mapping experience: the prognostic value of sentinel lymph node status in 612 stage I or II melanoma patients.

PURPOSE: To compare the effect of pathologic sentinel lymph node (SLN) status with that of other known prognostic factors on recurrence and survival in patients with stage I or II cutaneous melanoma. PATIENTS AND METHODS: We reviewed the records of 612 patients with primary cutaneous melanoma who underwent lymphatic mapping and SLN biopsy between January 1991 and May 1995 to determine the effects of tumor thickness, ulceration, Clark level, location, sex, and SLN pathologic status on disease-free and disease-specific survival. RESULTS: In the 580 patients in whom lymphatic mapping and SLN biopsy were successful, the SLN was positive by conventional histology in 85 patients (15%) but negative in 495 patients (85%). SLN status was the most significant prognostic factor with respect to disease-free and disease-specific survival by univariate and multiple covariate analyses. Although tumor thickness and ulceration influenced survival in SLN-negative patients, they provided no additional prognostic information in SLN-positive patients. CONCLUSION: Lymphatic mapping and SLN biopsy is highly accurate in staging nodal basins at risk for regional metastases in primary melanoma patients and identifies those who may benefit from earlier lymphadenectomy. Furthermore, pathologic status of the SLN in these patients with clinically negative nodes is the most important prognostic factor for recurrence. The information from SLN biopsy is particularly helpful in establishing stratification criteria for future adjuvant trials.     

Intraoperative examination of sentinel lymph nodes by ultrarapid immunohistochemistry in breast cancer

BACKGROUND: The ultrarapid immunohistochemistry (IHC) technique was applied to the intraoperative examination of sentinel lymph nodes (SLNs) because routine SLN frozen section examinations sometimes produce false-negative results. The present study was undertaken to develop a reliable protocol for the ultrarapid IHC of SLNs. METHODS: SLNs from 79 breast cancer patients with clinically negative axillary node were examined intraoperatively by frozen hematoxylin-eosin (H&E) stain and by ultrarapid cytokeratin IHC assay. On the basis of the result of serially sectioned permanent study, the sensitivity and accuracy of each intraoperative technique were compared. RESULTS: The total number of dissected SLNs was 178 with a mean of 2.3 (1-5) per patient. The mean turnaround time for ultrarapid IHC was 20 min. The sensitivity rates of frozen H&E staining and ultrarapid IHC were 70.0 and 85.0%, respectively (P = 0.083). Each method had a specificity of 100%. The accuracy rates for frozen H&E staining and rapid IHC were 92.4 and 96.2%, respectively (P = 0.083). Ultrarapid IHC detected one additional patient with sentinel node micrometastasis and two additional patients with isolated tumor cells (ITCs). In those patients, two underwent completion axillary dissection simultaneously and could avoid a second operation. CONCLUSIONS: Ultrarapid cytokeratin IHC enhanced the intraoperative detection of sentinel node micrometastasis and ITCs in breast cancer without consuming much time. In patients who need completion axillary dissection after sentinel node biopsy, this technique could be helpful in avoiding a second operation.     

The role of axillary lymph node dissection in breast cancer patients with sentinel lymph node micrometastases.

AIM: To identify by means of clinical and histopathological features a subset of breast cancer patients with sentinel lymph-node (sN) micrometastases and metastatic disease confined only to the sN in order to spare them an unnecessary axillary lymph node dissection (ALND). MATERIALS AND METHODS: From January 1998 to December 2004, 116 patients with sN micrometastases underwent standard ALND for early-stage (T1-2 N0 M0) invasive breast cancer; clinical and histopathologic parameters were prospectively collected and evaluated by means of univariate and logistic regression analysis in order to identify which patients with sN micrometastases were free of metastasis in axillary non-sN. RESULTS: Sixteen of 116 patients with sN micrometastases had tumour involvement of non-sN, with six and 10 patients having non-sN micrometastases and macrometastases, respectively. None of 19 patients with primary tumour measuring 相似文献   

Radical surgery for gallbladder cancer: a worthwhile operation?

AIMS: Extended operations are the only chance of a cure for patients with advanced gallbladder carcinoma, but there is no consensus about which subset of patients can benefit. The aim of this retrospective study is to evaluate the results of surgical resection with special reference to the prognostic factors and to long-term survival. METHODS: A retrospective review of 70 patients with a diagnosis of gallbladder cancer treated from 1985-1998 was performed: 33 patients had a curative resection and were included in this study. For stage I disease, simple cholecystectomy was considered curative; in most of the other cases, cholecystectomy was associated with lymph node dissection and liver resection. RESULTS: Hospital mortality and morbidity were 6% and 33%, respectively. Curative resection was associated with an actuarial 5-year survival of 27.4%. Survival of pT1-2 patients was significantly better than that of pT3 (P=0.04) or pT4 patients (P=0.002). Patients with lymph node spread had a poorer prognosis (P=0.06) but four were alive and disease-free with a median survival of 22 months. CONCLUSIONS: Depth of the tumour and lymph node metastases are important prognostic factors. Patients with pT3-4 tumours or regional lymph node spread should be considered for curative resection because long-term survival is possible.     

Comparison of American Joint Committee on Cancer pathologic stage T3a versus T3b urothelial carcinoma: Analysis of patient outcomes

BACKGROUND:

The radical cystectomy experience at Vanderbilt University Medical Center was scrutinized to determine whether there was a difference in survival between patients with lymph node‐negative pathologic T3a versus pathologic T3b urothelial carcinoma of the bladder.

METHODS:

Pathologic and clinical data were reviewed on patients who underwent radical cystectomy for urothelial carcinoma between 1995 and 2005. We excluded patients with nontransitional cell cancer, lymph node disease, or with unknown lymph node status. Of the 790 reviewed patients, 75 patients (9.4%) were diagnosed with pathologic T3 urothelial cancer of the bladder. The impact of pathologic substaging (pT3a vs pT3b) was examined to determine the effect on overall, disease‐specific, and recurrence‐free survival.

RESULTS:

The mean age was 68.6 years (36 years to 83 years). Median overall follow‐up was 25.3 months (1.13 months to 130.17 months). Median follow‐up for patients alive at last follow‐up was 55.9 months (25.3 months to 130.2 months). Actuarial overall survival at 5 years was 29.5% for pT3a and 29.3% for pT3b (P = .79). Actuarial disease‐specific survival at 5 years was 54.1% for pT3a and 42.4% for pT3b (P = .21). Actuarial recurrence‐free survival at 5 years was 68.1% for pT3a and 71.9% for pT3b (P = .53).

CONCLUSIONS:

There were no significant differences in overall, disease‐specific, or recurrence‐free survival when comparing lymph node‐negative pT3a versus pT3b urothelial cancer of the bladder following radical cystectomy. Simplification of pathologic staging for urothelial carcinoma of the bladder should be considered at future revisions of the American Joint Committee on Cancer staging system. Cancer 2009. © 2009 American Cancer Society.     

Prognostic value of sentinel lymph node biopsy in the pathologic staging of colorectal cancer patients

BACKGROUND AND OBJECTIVES: Over the last decade, lymphatic mapping and sentinel lymph node (sN) biopsy have greatly increased the possibility of identifying nodal metastasis in clinically node-negative patients with melanoma and breast cancer, thus improving the accuracy of pathologic staging. Recently, sN biopsy has been applied also in colorectal cancer. This prospective study aimed to assess its feasibility and accuracy in predicting regional lymph nodes metastases in colorectal cancer patients as well as the impact on treatment decision-making. MATERIALS AND METHODS: Lymphatic mapping was accomplished by means of blue dye, which was intraoperatively injected into the subserosa overlying the tumor site in 26 patients undergoing colorectal cancer surgery. Following bowel resection, the operative specimen was inspected to identify each blue-stained node, the sN, which was sent separately to the pathologist. One half of each sN was examined by multiple 200 microm sections, while the second half was examined by standard bi-valving technique with hematoxylin-eosin (H and E) staining; all the other regional non-sentinel nodes were routinely examined by standard bi-valving technique and H and E staining. RESULTS: At least one sN was detected in 24 of 26 patients (92.3%); two patients with rectal cancer had no sN identified. Overall, 70 sN were retrieved into the operative specimens, with a mean of 2.9 sNs/patient, and 19 sNs were tumor-positive. An agreement between sN and regional lymph-node status was observed in 20 of 24 patients (83.4%). The sN was histologically negative in two of nine patients with positive regional nodes (sensitivity = 77.8%; false-negative rate of 22.2%); in two of seven patients with tumor-positive sN (28.6%), the sN was the exclusive site of regional nodal metastasis. The negative predictive value was 88.2% (15 of 17 patients), and the overall accuracy was 91.7% (22 of 24 patients). As regards the contribution to the detection of nodal metastasis according to the pathologic technique, standard H and E bi-valving technique detected 16 of 19 tumor-positive sNs (84.2%) while, by means of serial sectioning, metastases were detected in the remaining 3 of 19 sNs (15.8%). CONCLUSIONS: The sN biopsy proved feasible, with a rather short learning curve. The focused analysis of the sN by means of serial sectioning improved the detection rate of nodal metastasis compared to standard bi-valving examination, so that a more accurate nodal staging should be expected; finally, an elective localization of metastasis within the sN was observed in almost one third of regional node-positive patients.