The role of intraoperative gamma-probe-guided sentinel lymph node biopsy in the treatment of malignant melanoma and breast cancer

In the treatment of malignant tumors regional lymphadenectomy is used for two purposes. It is used partly for staging the regional lymph nodes which is a significant and independent prognostic factor and determines the need for adjuvant oncologic treatment and partly for achieving locoregional disease control. Removal of tumor-free lymph nodes by regional lymph node clearance is unnecessary according to our current knowledge. Since the sensitivity and specificity of non-invasive clinical examinations are insufficient in predicting the nodal status the histological study of the regional lymph nodes cannot be abandoned. A new and minimally invasive surgical procedure, the mapping and removal of the first tumor draining lymph node, the sentinel node provides the possibility of pathological nodal staging without performing formal lymphadenectomy. Mapping of the sentinel node can be performed by the use of a radioisotope and intraoperative hand-held gamma-probe or a vital blue dye or a combination of these two. This latter method was used by the authors in 73 patients (25 with malignant melanoma and 48 with breast cancer). Sentinel lymph node biopsy was performed successfully in 92% of patients with melanoma and 90% of patients with breast cancer. In three breast cancer patients the sentinel node inaccurately predicted the axillary status as negative, but is was in 93% accurate in predicting the histologic nodal state. According to our preliminary experiences intraoperative gamma-probe guided sentinel lymph node biopsy is considered a feasible procedure in both malignant melanoma and breast cancer. More experiences are needed before introducing this method in the routine clinical practice.     

乳腺癌前哨淋巴结活检研究进展

乳腺癌前哨淋巴结活检（Sentinel lymph node biopsy,SLNB）是乳腺外科领域在20世纪90年代中的一个里程碑.淋巴转移是乳腺癌重要的转移方式,前哨淋巴结（sentinel lymph node,SLN）是淋巴转移必经的第一站淋巴结.以SLNB评价腋窝淋巴转移的情况为乳腺癌的手术提供了全新的思路.通过这种微创方法可以筛查出腋窝淋巴结无转移的患者,避免不必要的腋窝清扫,保证了患者的美观和上肢功能.SLNB的活检方法主要有蓝染技术、淋巴放射显影技术、蓝染与淋巴放射显影结合技术.     

Postoperative lymph node scintigraphy in patients with malignant melanoma

Completeness of regional lymph node dissection was controlled in 23 patients with melanoma malignum. For that purpose 3--6 weeks after block-dissection lymph node scintigraphy was performed, by administration of intercostal and interdigital radiopharmacutical. Blockdissection was considered as complete, when neither after intercostal, nor after interdigital administration, any lymph nodes were delineated. On the basis of investigations until now, postoperative lymph node scintigraphy proves to be suitable, held to be a non-invasive method for controlling completeness of blockdissection.     

宫颈癌前哨淋巴结活检的临床病理学意义

目的:用活性染料美兰定位进行子宫颈癌前哨淋巴结活检(Sentinel lymph node biopsy,SLNB),了解SLN的分布特点,探索SLN检测的可行性及其临床病理学意义。方法:对45例术前确诊宫颈癌、FIGO分期Ia2-Ⅱb的患者行经腹根治性子宫切除术加盆腔淋巴结清扫术加术中美兰识别SLN,将最先蓝染的淋巴结定为SLN,切除SLN送病理检查。SLN病理学评估包括连续切片中的病理诊断和广谱细胞角蛋白免疫组化检测证实。所有数据采用Stata7.0统计软件进行统计学分析,检验水准α=0.05。结果:①宫颈癌中识别和检获SLN41例占91.11(41/45),由SLN发现转移率的灵敏度为85.71(6/7);②闭孔淋巴结是宫颈癌SLN最常见部位,占检获SLN的55.04,其次髂内和髂外淋巴结分别为20.18和14.67;③癌转移SLN平均直径为(2.87±0.17)cm,显著大于无癌转移的SLN(1.57±0.05)cm;④SLN阳性检出率与宫颈癌FIGO分期、宫颈肌层浸润深度、颈管浸润呈显著正相关(均P<0.05)。结论:SLN能反映宫颈癌盆腔LN的转移情况与常见部位,并可作为确定手术范围的依据之一,有利于患者预后的评价。但染料注射时间、部位还需进一步探究与改进,以提高宫颈癌术中对SLN的判别检出率。宫颈癌根治术美兰定位检测SLN安全、可行。     

Anaphylactic shock after injection of patent blue for sentinel lymph node biopsy]

After being diagnosed with a melanoma, an 18-year-old woman developed anaphylactic shock following an intracutaneous injection of patent blue during a sentinel lymph node biopsy procedure. Intracutaneous allergy tests revealed positive reactions with patent blue (Bleu patenté V 'Guerbet') as well as with several anaesthetics and morphine. It was concluded that patent blue was the most probable causative agent for the anaphylactic reaction and that the possibility of such a reaction should be taken into consideration during sentinel node procedures. After a few days the operation was completed under epidural anaesthesia with technetium Tc 99m sulphur colloid being used to detect the sentinel node.     

纳米炭在乳腺癌腋窝前哨淋巴结活检中的临床应用

目的 探讨纳米炭对乳腺癌腋窝前哨淋巴结示踪的临床效果.方法 对57例乳腺癌患者,术前30 min于乳晕周围分4点及肿瘤表面皮肤皮下均匀注入纳米炭混悬注射液,找到腋窝黑染的第1枚淋巴结确定为前哨淋巴结,然后行改良乳腺癌根治术,观察纳米炭的应用价值.结果 成功检出前哨淋巴结56例,检出率为98.2％（56/57）,准确率为98.2％（55/56）,灵敏度为95.2％（20/21）,假阴性率为4.8％（1/21）,假阳性率为0.结论 纳米炭混悬注射液作为示踪剂能准确反映腋窝淋巴结转移状态,具有操作简便、定位准确、特异性强、染色时间长的优点,值得临床推广.     

A decade of sentinel lymph node biopsy for breast cancer: time for adaptations

A decade of sentinel lymph node biopsy for breast cancer has taught us that old assumptions on contraindications (prior surgery, clinical positive axilla, multicentricity/multifocality, and neoadjuvant chemotherapy) should be discarded. Many clinical evaluation studies have shown that a new sentinel lymph node procedure after previous surgery of the breast and the axilla is feasible. It allows specialists to determine more precisely the biological activity of local recurrences and to re-conserve the axilla. In order to save as many axillas as possible, clinically suspect axillary lymph nodes should only be considered tumour positive if this is proven by biopsy. Also, in cases of multicentricity or multifocality a sentinel lymph node procedure should be performed. With the objective of conserving the axilla in as many patients as possible, a sentinel lymph node biopsy should be performed after neoadjuvant chemotherapy.     

乳腺癌前哨淋巴结活检现状及研究进展

目的分析、探讨乳腺癌前哨淋巴结活检(Sentinel lymph node biopsy,SLNB)技术的现状及研究进展。方法复习近年来国内、外关于乳腺癌SLNB的相关文献,对SLNB的发展、乳腺癌SLNB临床价值、应用现状、方法、适应症、禁忌症、存在的问题及前景的展望等进行分析与综述。结果乳腺SLNB是一项比较稳定、准确的技术,能够准确定位、检取SLN。随着SLNB研究的不断改进和深入,SLNB的适应症范围正在不断扩大,越来越多的相对禁忌症都将变为适应症。且该技术创伤小,并发症少,能准确判断腋窝淋巴结分期,指导选择性的腋窝淋巴结清扫(axillary lymph node dissection,ALND),提高患者生活质量。结论乳腺癌SLNB代表目前乳腺癌外科治疗的最高发展水平,成为乳腺癌外科治疗的主要手段,随着该项研究的不断进展及相关检验、检测设备和水平的不断提高,假阴性、微小转移等问题都将迎刃而解,乳腺癌SLNB这项乳腺癌外科治疗史上的革命性的技术必将有更加广泛和深入的应用前景。     

乳腔镜下前哨淋巴结活检和腋窝淋巴结清扫术的临床研究(附36例报告)

目的探讨乳腔镜下乳腺癌前哨淋巴结活检和腋窝淋巴结清扫术的可行性及可靠性。方法采用亚甲蓝染色法在乳腔镜下切除36例乳腺癌患者的前哨淋巴结(SLN)和腋窝淋巴结(ALN),随后行患侧全乳腺切除术。结果36例患者SLN检出率为97.22%(35/36),灵敏度为92.86%(13/14),准确率为97.14%(34/35),假阴性率为7.14%(1/14)。ALN每例切除数目12~21枚。结论乳腔镜下前哨淋巴结活检和腋窝淋巴结清扫术准确可靠,并发症少,易于临床开展。     

胃窦癌前哨淋巴结及淋巴结转移规律的临床研究

目的研究胃窦癌前哨淋巴结分布规律并探讨其在早期胃窦癌手术治疗中的临床应用价值。方法在对病人行胃癌手术前先进行前哨淋巴结活检(即开腹后在原发灶周围注射亚甲蓝,切除在5min之内被染色的所有淋巴结),然后行胃切除手术和扩大淋巴结切除术。结果本组病人30例有29例均找到SLN(成功率为99%),均为幽门下淋巴结(第六组淋巴结),并对淋巴结转移规律进行研究,为胃窦癌手术淋巴结清扫范围提供参考依据。结论对于SLN阴性及早期胃窦癌施行D1或D1+切除可获得A级根治度,并通过亚甲蓝术中间接淋巴染色,可提高胃癌根治术中淋巴结和阳性淋巴结清除的绝对数,避免不必要的标准手术,减少并发症。     

胃窦癌前哨淋巴结及淋巴结转移规律的临床研究

目的研究胃窦癌前哨淋巴结分布规律并探讨其在早期胃窦癌手术治疗中的临床应用价值。方法在对病人行胃癌手术前先进行前哨淋巴结活检（即开腹后在原发灶周围注射亚甲蓝，切除在5min之内被染色的所有淋巴结），然后行胃切除手术和扩大淋巴结切除术。结果本组病人30例有29例均找到SLN（成功率为99％），均为幽门下淋巴结（第六组淋巴结），并对淋巴结转移规律进行研究，为胃窦癌手术淋巴结清扫范围提供参考依据。结论对于SLN阴性及早期胃窦癌施行D1或D1＊切除可获得A级根治度，并通过亚甲蓝术中间接淋巴染色，可提高胃癌根治术中淋巴结和阳性淋巴结清除的绝对数，避免不必要的标准手术，减少并发症。     

Cost comparison of two surgical strategies in the treatment of breast cancer: sentinel lymph node biopsy versus axillary lymph node dissection

OBJECTIVES: The feasibility and accuracy of sentinel lymph node biopsy (SLNB) in the treatment of breast cancer is widely acknowledged today. The aim of our study was to compare the hospital-related costs of this strategy with those of conventional axillary lymph node dissection (ALND). METHODS: A retrospective study was carried out to determine the total direct medical costs for each of the two medical strategies. Two patient samples (n = 43 for ALND; n = 48 for SLNB) were selected at random among breast cancer patients at the Centre Leon Bérard, a comprehensive cancer treatment center in Lyon, France. Costs related to ALND carried out after SLNB (either immediately or at a later date) were included in SLNB costs (n = 18 of 48 patients). RESULTS: Total direct medical costs were significantly different in the two groups (median 1965.86 Euro versus 1429.93 Euro, p = 0.0076, Mann-Whitney U-test). The total cost for SLNB decreased even further for patients who underwent SLNB alone (median, 1,301Euro). Despite the high cost of anatomic pathology examinations and nuclear medicine (both favorable to ALND), the difference in direct medical costs for the two strategies was primarily due to the length of hospitalization, which differs significantly depending on the technique used (9-day median for ALND versus 3 days for SLNB, p < 0.0001). CONCLUSIONS: A lower morbidity rate is favorable to the generalization of SLNB, when the patient's clinical state allows for it. From an economic point of view, SLNB also seems to be preferred, particularly because our results confirm those found in two published studies concerning the cost of SLNB.     

中华墨汁在宫颈癌前哨淋巴结活检示踪中的应用

目的探讨中华墨汁在宫颈癌前哨淋巴结（scentinel lymph node，SLN）识别中的作用。方法术前在官颈癌周围正常黏膜3，6，9，12点处注射消毒的10％中华墨汁1ml，共计4ml。待中华墨汁进入腹腔后，打开阔韧带及后腹膜，观察宫颈旁、闭孔区、髂血管区的淋巴脂肪组织。结果注射中华墨汁至观察到淋巴组织染色的平均时间为150min。18例宫颈癌患者中，可识别SLN为16例，成功率为89％。这16例可识别SLN为79枚，平均每侧可识别为2．4枚。每例可识别SLN为1～8枚，2处以上可识别SLN为14例；单侧可识别者为3例，双侧可识别为13例。其中2例淋巴结转移，预测准确性为100％，假阴性率为0。未能识别SLN的2例，为术前行放疗所致。18例患者示踪后无明显不良反应。结论中华墨汁作为淋巴系统示踪剂，效果可靠、染色持久、经济方便，是宫颈癌SLN检测的理想示踪剂。