核医学在乳腺癌前哨淋巴结活检术中的方法学研究现状

乳腺癌是女性最常见的恶性肿瘤之一,腋窝淋巴结清扫术一直被认为是乳腺癌外科治疗中最基本的手术方法。近年来发展起来的前哨淋巴结活检术因既能避免腋窝淋巴结清扫术引起的并发症,又能对乳腺癌进行准确地分期,具有操作简单、安全、准确率高、创伤小等优点,从而逐渐被国内外认可,已代替腋窝淋巴结清扫术成为治疗腋下淋巴结阴性患者的主要方法。在前哨淋巴结活检术中,核医学检查起了至关重要的作用,其中,放射性显像剂、注射技术、探测技术以及探测标准对乳腺癌腋下淋巴结和内乳淋巴结检测的准确率和假阴性率有着重要的影响,该文对近年来国内外关于核医学在乳腺癌前哨淋巴结活检术中的方法学研究现状进行综述。     

乳腺癌前哨淋巴结探查的研究进展

乳腺癌前哨淋巴结(sentinel lymph node, SLN)是乳腺癌淋巴转移通道中最先经历的第一级淋巴结。通过乳腺癌SLN预测乳腺癌区域淋巴结转移状况,为乳腺癌的准确分期和外科手术提供了重要的依据。根据示踪剂的不同,有两种方法可以探查乳腺癌SLN,其中使用放射性核素标记物作为示踪剂探查乳腺癌SLN是目前较具优势的方法,且不同于传统的淋巴显像;乳腺癌SLN探查的成功率受到诸多因素的影响,其探查技术亦需进一步的研究来提高。     

探测乳腺癌前哨淋巴结的初步应用

目的 评价核素淋巴显像和γ探针定位确定乳腺癌前哨淋巴结（SLN）的价值。方法 28例妇性乳腺癌患者,体检腋窝未扪及肿块。^99Tc^m－右旋糖酐（Dx）37MBq皮下注射,行淋巴显像后用γ探针皮肤定位,并与手术、病理检查结果对照。结果 28例患者中活检的SLN26例,灵敏度为85.7%(6/7例）,特异性100％（19／19例）。结论 核素淋巴显像和γ探针定位是一种简便、安全、易被患者接受的检测SLN的方法,对预测腋窝淋巴结转移有很大帮助。     

乳腺癌前哨淋巴结显像研究

目的　探讨乳腺癌前哨淋巴结 (SLN)显像的方法及其临床意义。方法　对 117例早期乳腺肿瘤患者进行乳腺SLN显像 ,6例进行双侧比较和SPECT CT图像融合。其中 13例在瘤体表面皮下注射99Tcm DTPA 人血清白蛋白 [HSA ,5 5 5MBq(0 5ml) ];5 0例在瘤周乳腺组织内注射未过滤99Tcm 硫胶体 [SC ,92 5MBq(4ml) ,分 4点 ];5 4例在瘤体上部乳腺组织内一点注射相同体积SC。结果　 3种方法均能快速显示SLN ,但最佳显示时间和淋巴结显示量因人而异 ,与注射深度和体积有关 ,第 3种方法能显示较多的锁骨区和内乳淋巴结。HSA、SC显像成功率分别为 6 9 2 % (30min时 )和 >84 % (2h内 )。断层图像融合有助于识别SLN和引流变异。结论　乳腺SLN显像对于正确定位SLN、识别淋巴引流变异和制定辅助治疗方案是必需的。     

头颈部肿瘤前哨淋巴结放射性核素探测研究进展

头颈部肿瘤前峭淋巴结是指肿瘤淋巴引流区域中的第一级淋巴结。探测头颈部肿瘤前哨淋巴结转移状况为肿瘤的准确分期和手术方案的制定提供了重要依据。放射性核素探讨可对前哨淋巴结进行显示和准确定位,检出率达90%以上,有着良好的应用前景。     

乳腺癌前哨淋巴结探查的研究进展

乳腺癌前哨淋巴结（sentinel lymph node,SLN)是乳腺癌淋巴转移通道中最先经历的第一级淋巴结。通过乳腺癌SLN预测乳腺癌区域淋巴结转移状况，为乳腺癌的准确分期和外科手术提供了重要的依据。根据示踪剂的不同，有两种方法可以探查乳腺癌SLN，其中使用放射性核素标记物作为示踪剂探查乳腺癌SLN是目前较具优势的方法，且不同于传统的淋巴显像；乳腺癌SLN探查的成功率受到诸多因素的影响，其探查技术亦需进一步的研究来提高。     

核医学在乳腺癌前哨淋巴结检测中的应用

随着乳腺癌发病率的上升 ,对淋巴结体检阴性的乳腺癌患者其前哨淋巴结(ＳＬＮ)的研究更加重视。尽管腋窝淋巴结清扫术可防止肿瘤进一步扩散 ,但可导致上肢疼痛 ,麻木 ,水肿等一系列术后并发症 ,直接影响乳腺癌患者术后的生活质量。ＳＬＮ活检不仅可用于乳腺癌准确分期 ,而且可避免腋窝淋巴结的盲目清扫 ,这使乳腺癌的治疗向前迈出了一步[1 3 ] 。一、ＳＬＮ及其定位1 关于ＳＬＮ。ＳＬＮ是肿瘤淋巴引流的第一站淋巴结 ,也是最先出现转移的淋巴结。目前研究乳腺癌的ＳＬＮ多是腋窝淋巴结。 1993年Ａｌｅｘ等[4 ] 用99Ｔｃｍ 标记硫胶体进行乳…     

前哨淋巴结显像研究

前哨淋巴结系指原发肿瘤淋巴引流的第一级淋巴结，淋巴显像可准确定位前哨淋巴结及其数目，检出率达80%-100%，常用的前哨淋巴结显像剂有^99Tc^m-硫胶体，^99Tc^m-人血清白蛋白，^99Tc^m-右旋糖酐等，该法简便安全，实用性强，已先后应用于黑色素瘤，乳腺癌，妇科肿瘤等疾病的术前常规定位诊断，取得了很好的结果。     

前哨淋巴结显像研究

前哨淋巴结系指原发肿瘤淋巴引流的第一级淋巴结,淋巴显像可准确定位前哨淋巴结及其数目,检出率达80%~100%。常用的前哨淋巴结显像剂有99Tcm-硫胶体、99Tcm-人血清白蛋白、99Tcm-右旋糖酐等。该法简便安全、实用性强,已先后应用于黑色素瘤、乳腺癌、妇科肿瘤等疾病的术前常规定位诊断,取得了很好的结果。     

乳腺癌前哨淋巴结的临床研究

目的　评价乳腺癌前哨淋巴结活检(sentinellymphnodebiopsy ,SLNB)的必要性、可行性、准确性及临床应用价值。方法　利用脂质体 亚甲蓝混合物对本院 2 0 0 1年 6月～ 2 0 0 2年 12月收治的 32例T1～ 2 N0 M0 乳腺癌患者进行SLNB。随后常规行腋窝淋巴结清扫(axillarylymphnodedisescetion,ALND)。将切除的前哨淋巴结 (SLN)和腋窝淋巴结 (ALN)同时送病理检查 ,了解其符合率 ,并评价SLNB在早期乳腺癌中的可行性及临床应用价值。结果　成功确定患者SLN 31例 ,共 5 7枚 ,成功率为 96 .9% (31/ 32 ) ;SLN阳性 9例(2 9.0 % ) ,SLN阴性 2 2例 (70 % ) ;ALN阳性 10例 (31.3% ) ,ALN阴性 2 2例(6 8.8% ) ;SLNB的灵敏度为 90 .0 % ,准确性为 93.8% ,假阴性率为 10 .0 % ,假阳性率为 0。结论　SLNB可以准确地预测乳腺癌患者ALN的组织学特征 ;利用脂质体 亚甲蓝混合物作为显示剂可以提高SLNB的成功率     

Usefulness of sentinel lymph node detection in early stages of cervical cancer

Purpose Sentinel lymph node (SLN) mapping in combination with surgical biopsy is an emerging technique for use in the early stages of cervical cancer. The purpose of this study was to evaluate the technique in a series of 40 consecutive women with early stage cervical cancer.Methods Forty patients with early stage cervical cancer [FIGO stage IA2 (2), IB1 (34), IB2 (1) or IIA (3)] were referred for radical hysterectomy with pelvic lymphadenectomy. Patients were submitted to preoperative lymphoscintigraphy (four ^99mTc-nanocolloid injections around the tumour) and intraoperative SLN detection. Hand-held or laparoscopic gamma probes were used to locate SLNs during surgery.Results The mean number of SLNs was 2.5 per patient (interiliac 49%, external iliac 19%). Of the total of 99 SLNs, six, in four women, showed metastases (all 68 non-SLNs removed were negative). In the other 36 patients, all the removed lymph nodes (sentinel and non-sentinel) were negative (0% false negative rate). During the follow-up (median 25 months), only two patients presented distant metastases: one died 6 months after surgery (two of three SLNs positive, both hot and blue), while the second patient is alive 4 years after surgery (lung metastasis, no isotope drainage, negative blue SLN). The survival rate was 95% and disease-free survival, 97%.Conclusion SLN surgical biopsy based on lymphoscintigraphy and blue dye is a feasible and useful technique to avoid lymph node dissection in the early stages of cervical cancer. It has a high negative predictive value, can be incorporated into clinical routine (laparoscopy or open surgery) and is close to achieving validation in this setting.     

Lymphatic mapping and retrieval of the sentinel lymph node in treatment of early breast cancer

Lymphatic mapping and sentinel lymph node biopsy is an important step to surgical individualization of breast cancer therapy. With lymphatic mapping and minimally invasive biopsy of one or two detected lymph nodes the method provides an exact evaluation of the nodal status. Using sentinel lymph node biopsy (SLNB), costs and morbidity of an axillary lymph node dissection (ALND) can be avoided in nodal negative patients, whereas nodal positive patients are chosen for ALND very selectively according to the detection of an increased percentage of micrometastases. While experienced centers are introducing this method into clinical practice for the benefit of patients with early-stage breast cancer in Europe, further research should focus on quality control, definition of standards considering the individual needs of the individual patient, and the evaluation of the impact of micrometastases. This article gives an overview of the current knowledge of SLNB and discusses critically current indications and methods as well as application techniques.     

结肠癌前哨淋巴结微转移的检测

目的:探讨监测结肠癌淋巴结转移的简便而准确的方法.方法:对56例结肠癌患者应用术中染料定位的方法对其前哨淋巴结(sentinel lymph node, SLN)进行了定位,绿染的第一个淋巴结为SLN,术后从根治性切除的标本中寻找SLN.常规HE染色检查从标本中找到的SLN;对常规检查为阴性的SLN进行抗CEA免疫组化染色(SP法),寻找阳性染色的淋巴结.结果:共检出SLN130枚,每例患者的SLN为1～4枚,平均2.5枚.HE染色共发现有转移者15例,24枚,患者淋巴结转移率为27%(15/56);淋巴结阳性率为18%(24/130).免疫组化法在41例HE染色阴性的患者中又发现有30例存在微转移,微转移的发生率为73%(30/41);在HE染色阴性的106枚SLN中共有80枚免疫组化阳性,SLN微转移发生率为75.5%(80/106).结果显示免疫组化检测SLN的转移率明显高于常规HE染色(P＜0.01).结论:通过对结肠癌SLN进行术中定位,术后深入细致的病理学检测,可以在不增加病理科医生工作量的情况下明显提高对结肠癌淋巴结转移的检出率.     

Sentinel lymph node detection in early stage cervical cancer: a prospective study comparing preoperative lymphoscintigraphy, intraoperative gamma probe, and blue dye

OBJECTIVE: The objective of this prospective study was to determine the feasibility of sentinel lymph node (SLN) detection in patients with cervical cancer using lymphoscintigraphy (LS), gamma probe, and blue dye. METHODS: A total of 32 patients with early stage cervical cancer (FIGO IA2-IIA) who were treated with total abdominal hysterectomy and bilateral pelvic and paraortic lymphadenectomy underwent SLN biopsy. LS was performed on all the patients following the injection of 74 MBq technetium-99m-nanocolloid pericervically. The first appearing persistent focal accumulation on either dynamic or static images of LS was considered to be an SLN. Blue dye was injected just prior to surgical incision in 16 patients (50%) at the same locations as the radioactive isotope injection. During the operation, blue-stained node(s) were excised as SLNs. For gamma probe, a lymph node was accepted as an SLN, if its ex vivo radioactive counts were at least 10-fold above background radioactivity. SLNs, which were negative by routine hematoxylin and eosin (H&E) examination, were histopathologically reevaluated for the presence of micrometastases by step sectioning and immunohistochemical staining with pancytokeratin. RESULTS: At least one SLN was identified for each patient by gamma probe. Intraoperative gamma probe was the most sensitive method with a technical success rate of SLN detection of 100% (32/32), followed by LS 87.5% (28/32) and blue dye 68.8% (11/16), respectively. The average number of SLNs per patient detected by gamma probe was 2.09 (range 1-5). The localizations of the SLNs were external iliac 47.8%, obturatory 32.8%, common iliac 9%, paraaortic 4.4%, and paracervical 6%. Micrometastases, not detected by routine H&E were found by immunohistochemistry in one patient. On the basis of the histopathological analysis, the negative predictive value for predicting metastases was 100%, and there were no false-negative results. CONCLUSIONS: Preoperative LS with radiocolloids, intraoperative lymphatic mapping with blue dye and gamma probe are all feasible methods comparable with each other for SLN detection in early stage cervical cancer patients, but gamma probe is the most useful method in terms of technical success.     

乳腺癌前哨淋巴结核素显像新进展

乳腺癌是全球女性发病率最高的恶性肿瘤, 为保证患者的生存率、减少术后并发症, 20世纪90年代用"腋窝前哨淋巴结活检术取代腋窝淋巴结清扫"的观点被提出并逐渐发展成为乳腺癌患者保乳术的常规方法。除腋窝前哨淋巴结外, 内乳前哨淋巴结的重要性同样不容忽视, 但是否将其作为前哨淋巴结活检的对象仍存在争议。面对目前形势, 核医学工作者做了大量研究, 在保证腋窝前哨淋巴结高显示率的同时尽可能提高内乳前哨淋巴结的显示率。笔者对近十年来国内外研究者在乳腺癌前哨淋巴结核素显像中的核素示踪剂、注射技术、显像仪器等方面的最新进展进行综述。     

乳腺癌前哨淋巴结活检技术的临床应用

目的:探讨前哨淋巴结活检(Sentinel lymph node biopsy,SLNB)在乳腺癌外科中的应用,并评价其准确性及可行性.方法:对2002-01～2004-01我院收治的161例Ⅰ、Ⅱ期乳腺癌病例,在常规行乳腺癌手术前均进行SLNB,即肿瘤局部皮内联合注射99mTc-DX及美蓝,根据核素示踪及美蓝染色结果寻找SLN并摘除,行冰冻病理检查.将SLNB结果与术后腋窝淋巴结病理结果进行分析.结果:161例中149例发现SLN,检出率为92.5%(149/161);共检出SLN273个,平均1.83个/例.比较SLNB与术后病理结果,SLNB检出灵敏度为96.1%(49/51),准确性98.7%(147/149),假阴性率3.9%(2/51),假阳性率0。结论:SLN可比较准确地反映腋窝淋巴结状况,SLNB是乳腺癌治疗中的实用技术.     

The hidden sentinel node and SPECT/CT in breast cancer patients

Purpose  In a minority of breast cancer patients, lymphoscintigraphy shows no lymphatic drainage and ‘hidden’ sentinel nodes may remain undiscovered. The purpose of this study was to explore the additional value of the recently introduced hybrid SPECT/CT in breast cancer patients with axillary non-visualisation on planar images. The role of blue dye and careful palpation of the axilla was evaluated in patients in whom axillary sentinel nodes remained hidden after SPECT/CT. Methods  Fifteen breast cancer patients with non-visualisation on planar lymphoscintigraphy and 13 women with only extra-axillary sentinel nodes underwent SPECT/CT following late planar imaging without re-injection of the radiopharmaceutical. Results  SPECT/CT visualised lymphatic drainage in eight of the 15 patients (53%) with non-visualisation on planar imaging, depicted nine of the 14 harvested sentinel nodes (64%) and three of five tumour-positive sentinel nodes. In two of the 13 patients (15%) with only extra-axillary sentinel nodes on their planar lymphoscintigram, SPECT/CT showed an axillary sentinel node that appeared to be uninvolved. Careful exploration of the axilla with the combined use of blue dye, a gamma probe and intra-operative palpation revealed an axillary sentinel node in the remaining 18 patients. SPECT/CT showed the exact anatomical location of all visualised sentinel nodes. Conclusion  SPECT/CT discovered ‘hidden’ sentinel nodes in the majority of patients with non-visualisation, but was less valuable in patients with only extra-axillary lymphatic drainage on the planar images. Exploration of the axilla in patients with persistent non-visualisation improved the identification of axillary (involved) sentinel nodes.     

乳腺癌前哨淋巴结CT淋巴管造影的可行性分析

目的 初步评价CT淋巴管造影(LG)显示早期乳腺癌前哨淋巴结(SLN)的可行性.方法 选取25例穿刺证实且腋窝触诊为阴性的乳腺癌患者行CT-LG检查.自注射部位指向腋窝方向的引流淋巴管上最先显像的1个或数个淋巴结为SLN,与前哨淋巴结活检(SLNB)结果相对照,数目相等者为符合,多于和少于分别为高估和低估.显像质量根据容积重组后有无淋巴管显像分为Ⅰ和Ⅱ级;并以体质量指数(BMI)≥25时为肥胖.对所得结果行Fisher精确检验.结果 (1)25例患者中,5例有局部切除手术史;BMI＜25者20例,≥25者5例.(2)25例患者CT-LG均见SLN显像,其中84.0%(21例)患者图像质量为Ⅰ级,16.0%(4例)为Ⅱ级.肥胖患者CT-LG显像质量较差,两者差异有统计学意义(P＜0.05).(3)25例患者共显示56枚SLN和45条淋巴管.与SLNB对照,36.0%(9例)患者两种结果符合,而高估和低估者分别为28.0%(7例)和36.0%(9例).造成两种结果不一致的原因主要与肥胖因素和局部切除手术有关,两者差异均有统计学意义(P＜0.05).(4)SLNB证实18例(52枚)阴性SLN,7例(15枚)阳性SLN,对应CT-LG共56枚SLN显像,其中阴性43枚,阳性13枚.形状为圆形在阴性和阳性SLN的比例分别为32.6%(14/43)和76.9%(10/13),二者差异有统计学意义(P＜0.05).中央区出现充盈缺损在阴性和阳性SLN中的比例分别为9.3%(4/43)和23.1%(3/13),但边缘区表现为不规则充盈缺损只在30.8%(4/13)的阳性SLN中出现.3枚(2例)SLN周围伴有多发小淋巴结,组织学显示有癌细胞浸润.结论 CT-LG可有效显示乳腺癌的SLN,但其准确性易受患者肥胖因素及患侧乳房手术的影响.SLN为圆形,边缘出现虫蚀样充盈缺损,以及伴有多发小淋巴结者均可提示痛细胞浸润.     

99Tcm-硫胶体及其联合染色法对早期乳腺癌前哨淋巴结探测的比较

目的 评价单用99Tcm-硫胶体和99Tcm-硫胶体与亚甲蓝联合应用探测早期乳腺癌前哨淋巴结(SLN)的效能.方法 76例早期乳腺癌患者分为单用99Tcm-硫胶体组(25例)和99Tcm-硫胶体与亚甲蓝联合组(51例),分别在术前进行乳腺癌SLN探测,以腋窝淋巴结病理检查结果作为评价标准.结果 76例患者中成功探测到S...