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。     

早期乳腺癌前哨淋巴结活检替代腋窝清扫的临床应用

目的：探讨腋窝前哨淋巴结活检术在早期乳腺癌中替代腋窝淋巴清扫术的意义。方法：选择15例早期（T1-2N0M0）乳腺癌患者,用1%亚甲蓝溶液行腋窝前哨淋巴结活检,淋巴结阴性,不行腋窝清扫。结果：15例患者随访1～3年,术后无一例出现患侧上肢肿胀、患侧上肢感觉麻木、运动障碍等并发症。所有患者未发现有局部复发及腋窝肿大淋巴结。结论：对于早期乳腺癌患者,腋窝前哨淋巴结活检阴性可替代腋窝清扫术。     

乳腺癌前哨淋巴结活检术与彩色多普勒超声诊断的临床价值分析

目的探讨乳腺癌前哨淋巴结活检术和彩色多谱勒超声在诊断乳腺癌患者腋窝前哨淋巴结转移中的应用价值。方法选取在我院接受治疗的36例乳腺癌患者作为观察对象,术前分别应用彩色多普勒超声和乳腺癌前哨淋巴结活检术诊断患者是否发生腋窝前哨淋巴结转移,观察患者的彩色多谱勒超声表现,并与手术病理结果进行比较。结果乳腺癌前哨淋巴结活检术诊断结果与手术病理结果的符合率为97.22%,彩色多普勒超声诊断结果与手术病理结果的符合率为91.67%,两者比较存在的差异无统计学意义(P0.05)。结论乳腺癌前哨淋巴结活检术和彩色多普勒超声用于诊断乳腺癌患者腋窝前哨淋巴结转移,均具有较高的准确率。     

乳腺癌前哨淋巴结定位方法研究进展

乳腺癌患者腋窝淋巴结状态的评价对患者治疗方案的制定和预后评估都有着极大的作用,传统腋窝淋巴结清扫术(axillary lymph node dissection,ALND)起到了评价淋巴结和治疗的作用,但为患者带来的损伤和术后并发症严重地影响了患者的生活质量.前哨淋巴结活检术(sentinel lymph node biopsy,SLNB)可以以最小的代价高效地对腋窝淋巴结受累情况作出分析,一般认为乳腺癌前哨淋巴结(sentinel lymph node,SLN)活检阴性的患者不会出现腋窝淋巴结受累的情况,不必行ALND.     

淋巴显像及术中γ探测定位活检乳腺癌前哨淋巴结

目的：探讨淋巴显像及术中γ探测定位活组织检查乳腺癌前硝淋巴结的临床价值。方法：术前在乳腺肿瘤表面正中皮内注射37－74MBq ^99Tcm-大分子右旋糖酐（Dx)，用淋巴显像和术中γ探测定位乳腺癌 前硝淋巴结，术中切除前 淋巴结，而后行腑窝淋巴结清扫术，两标本连同切除的乳腺肿物同时送病理检查，分析和前哨淋巴结转移与腋窝淋巴结的关系。结果：31例均行淋巴显像和术中γ探测定位乳腺癌前哨淋巴结患者中，检出率为100％，有3例前哨淋巴结病理检查呈假阴性，假阴性率为25％，结论：术中γ探测是乳腺癌前哨淋巴结定位最可靠的手段。以乳腺 癌前哨淋巴结活组织检查取代常规腑窝淋巴结清扫术尚需进一步研究。     

~(99m)Tc-小胶体乳内淋巴闪烁显像:乳癌检查的最新报道

最近的报道证明,乳内淋巴闪烁显像对乳腺癌患者的术前评价很有用,并且根据显像结果尚可提出一种乳癌淋巴结转移的分期.此外,存活的乳内淋巴显像代表一种预后因素,其重要性如同腋窝淋巴结受到浸润一样.作者报告了七年来乳腺癌的乳内淋巴闪烁显像结果.资料提示,526例乳癌病人中乳内淋巴闪烁显像异常者占24%,其中232例腋窝淋巴结组织学     

乳腔镜下应用核素联合染料示踪法对新辅助化疗后乳腺癌患者行前哨淋巴结活检的研究(附41例报告)

目的 在乳腔镜下采用核素联合染料示踪法对新辅助化疗后的乳腺癌患者行前哨淋巴结活检(SLNB),探讨通过前哨淋巴结(SLN)对腋窝淋巴结内癌细胞转移情况进行预测的可行性.方法 选择行新辅助化疗2～4个疗程后的乳腺癌患者41例,术前15～18h在肿块或活检腔周围分4点注射~(99)Tc~m标记的硫胶体0.5～1.0mCi(1Ci=3.7×10~(10)Bq),术中在同样部化皮下注射美蓝4～6ml.使用γ探测仪在存在高放射活性的部位进行体表定位,腋窝注射溶脂剂,吸脂后,乳腔镜下行SLNB,然后行腋窝淋巴结清扫.将检出的淋巴结制成石蜡切片行常规病理检查,将结果显示有癌细胞转移的淋巴结确定为转移阳性;对病理检查显示为转移阴性的SLN进一步采用免疫组化法检测CK19的表达.计算采用SLN进行预测的准确率、敏感性、特异性、假阴性率和假阳性率.结果 41例患者中,39例患者(95.12%)检出SLN,共126枚,每例平均3.07(1～5)枚.病理检查显示,18例患者的SLN转移阳性(均为真阳性),21例SLN转移阴性(其中20例为真阴性,1例为假阴性).SLN对腋窝淋巴结内癌细胞转移情况的预测准确性为97.43%,敏感性为94.74%,特异性100%,假阴性率为5.26%,假阳性率0%.免疫组化法检测显示,1例病理检查显示转移阴性的SLN内CK19表达阳性.所有患者均对SLNB术后的美容效果较为满意.结论 乳腔镜下应用核素联合染料示踪法能提高SLN的检出率,且具有微创、美容的优点.通过SLN内癌细胞转移情况能够较为准确地预测新辅助化疗后乳腺癌患者腋窝淋巴结内癌细胞的转移情况.     

乳腺癌前哨淋巴结超声造影及活检的研究进展

在乳腺癌疾病研究中,前哨淋巴结定位及定性是研究重点。前哨淋巴结超声造影及活检在该方面的研究有所进展,能够准确判断腋窝分期,指导选择性的腋窝淋巴结清扫。本文着重以乳腺癌前哨淋巴结超声造影及活检技术的研究进展做一综述。     

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…     

乳腺癌的前哨淋巴结定位

了解患者的腋窝淋巴结情况对判断早期乳腺癌的预后非常重要，它也对制定术后的治疗计划有所帮助。我们通过对前哨淋巴结的精确定位和病灶组织学评价准确地预测其它腋窝淋巴结的转移情况，从而避免了对阴性淋巴结病人进行腋窝根治手术。放射性示踪技术在前哨淋巴结的术前和术中定位中起着很重要的作用。理想的前哨淋巴结定位是在术前和术中进行放射性淋巴闪烁显像，同时淋巴闪烁显像也可以检查出病人腋公外的淋巴引流，从而可进行更适合的治疗。常规的前哨淋巴结定位，需要了解放射性药物或其他示踪剂的动力学及所使用的探测仪器。应用前哨淋巴结技术，外科医师、核医学医师和病理科医师之间需要紧密合作。     

Alternative lymphatic pathway after previous axillary node dissection in recurrent/primary breast cancer

OBJECTIVES: The sentinel lymph node approach has almost become the standard procedure of choice in the management of patients with early breast cancer. The status of sentinel nodes, whether or not pathologically involved by cancer cells, represents those of the axillary nodes with a negative predictive value of almost 100%. If the axillary lymphatic nodal drainage is altered, alternative lymphatic pathways and accordingly sentinel node location will be changed. METHODS: In this article, 4 patients are presented, 3 with recurrent breast cancer who had already undergone lumpectomy, axillary node dissection, and radiotherapy in the past and 1 with primary breast cancer after surgical removal of a malignant melanoma on her back and had axillary node dissection on the same side as the breast cancer. These patients underwent lymphoscintigraphy followed by sentinel node localization using the gamma probe and also blue dye injection during surgery. RESULTS: All patients showed alternate lymphatic pathways, 1 had an ipsilateral internal mammary node and crossed lymphatics to a contralateral axillary node, 2 had intramammary sentinel nodes, and 1 had an internal mammary on the same side. Pathologic examination of the intramammary and contralateral sentinel nodes were negative for metastases. Internal mammary sentinel nodes were not biopsied. CONCLUSION: We feel that sentinel node lymphoscintigraphy should be done even in patients who have altered lymphatic pathways resulting from previous axillary node dissection. It allows identifying and biopsy of the sentinel node at its new unpredicted location.     

Impact of internal mammary sentinel node imaging in breast cancer

A 28-year-old woman underwent mammary lymphoscintigraphy for evaluation of the sentinel node status of a small infiltrating ductal carcinoma in the central, lower, and outer quadrant of the left breast confirmed by biopsy. The patient was scheduled for lumpectomy and sentinel node biopsy. Lymphoscintigraphy showed increased uptake at two sites of the peritumorally injected tracer (60 MBq; 1.6 mCi rhenium sulfur nanocolloid) in internal mammary nodes, two of which were located most proximal to the tumor and related to the tumor by two distinct lymphatic ducts. An axillary lymph node was also detected. At surgery, the gamma probe confirmed the location of all the hot spots, and four nodes were harvested: one axillary, two first internal mammary nodes in the third intercostal space, and one internal mammary node in the second intercostal space. Histologic analysis revealed that the axillary sentinel node was free of disease, but the two first intramuscular sentinel nodes were metastatic. The second-echelon internal mammary node above the sentinel nodes (second intercostal space) was free of disease. This case shows the benefit of imaging all the drainage pathways of a breast tumor and retrieving nonaxillary lymph nodes, which may be the only positive nodes. As a result of the findings, the patient's prognosis may be altered and the subsequent therapeutic approach may be modified. Although exclusive involvement of the internal mammary chain is well established and relatively rare (occurring in approximately 5% of cases), it is important to remember that the axillary status of a breast tumor is not the only major prognostic factor.     

Breast cancer with metastatic invasion of the sentinel lymph node in an internal mammary chain and with axillary chains free of tumor lesionS

The lymphoscintigraphy is a widely accepted procedure to detect the sentinel node in breast cancer. This is a case report of a 45 year old woman diagnosed of breast cancer who was referred to the nuclear medicine facility to perform the sentinel node detection procedure. The lymphoscintigraphy prior to surgery shows a double pathway in the tracer migration: one going to the axillary area and the second to the internal mammary chain and shows hot spots that represent the sentinel nodes. After surgical removal of those nodes, the pathological analysis report indicated tumor infiltration in the internal mammary chain sentinel node with all axillary nodes free of malignant cells. The aim of this report is to emphasize the importance of performing a pathological analysis of all the sentinel nodes detected in lymphoscintigraphy.     

Sentinel node detection in pre-operative axillary staging

The concept of sentinel lymph node biopsy in breast cancer surgery is based on the fact that the tumour drains in a logical way via the lymphatic system, from the first to upper levels. Since axillary node dissection does not improve the prognosis of patients with breast cancer, sentinel lymph node biopsy might replace complete axillary dissection for staging of the axilla in clinically N0 patients. Sentinel lymph node biopsy would represent a significant advantage as a minimally invasive procedure, considering that about 70% of patients are found to be free from metastatic disease, yet axillary node dissection can lead to significant morbidity. Subdermal or peritumoural injection of small aliquots (and very low activity) of radiotracer is preferred to intratumoural administration, and (99m)Tc-labelled colloids with most of the particles in the 100-200 nm size range would be ideal for radioguided sentinel node biopsy in breast cancer. The success rate of radioguidance in localising the sentinel lymph node in breast cancer surgery is about 97% in institutions where a high number of procedures are performed, and the success rate of lymphoscintigraphy in sentinel node detection is about 100%. The sentinel lymph node should be processed for intraoperative frozen section examination in its entirety, based on conventional histopathology and, when necessary, immune staining with anti-cytokeratin antibody. Nowadays, lymphoscintigraphy is a useful procedure in patients with different clinical evidence of breast cancer.     

Biopsy of sentinel lymph nodes guided by lymphoscintigraphic mapping in patients with breast cancer

OBJECTIVE. The purpose of this study was to determine the technical success rate of sentinel node biopsy with lymphoscintigraphy in women with breast cancer and the frequency with which sentinel node biopsy obviated axillary dissection. Factors affecting the success rate of sentinel node biopsy and lymphoscintigraphy were also evaluated. MATERIALS AND METHODS. Retrospective review revealed 119 women with breast cancer who underwent lymphoscintigraphy and sentinel node biopsy at our institution during the study period. A planned axillary dissection was performed in 13 of the first 16 patients; otherwise, axillary dissection was only performed if tumor was present in sentinel nodes or if the sentinel node biopsy was unsuccessful. RESULTS. Sentinel node biopsy was successful in 96% of patients, and sentinel node metastases were found in 20%. In 78% of patients, a negative sentinel node biopsy obviated axillary dissection. Prior excisional biopsy was not associated with a failed sentinel node biopsy (p = 0.750) but was associated with failed lymphoscintigraphy (p = 0.01). Successful lymphoscintigraphy was associated with successful sentinel node biopsy (p < 0.0001). No association was found between the histology or size of the tumor and a failed sentinel node biopsy (p = 0.46 and p = 0.1, respectively) or failed lymphoscintigraphy (p = 0.36 and p = 0.47, respectively). CONCLUSION. Sentinel node biopsy guided by lymphoscintigraphy, intraoperative gamma probe, and isosulfan blue dye is an effective alternative to axillary dissection in patients with breast cancer. Lymphoscintigraphy improved the success rate of sentinel node biopsy. Large tumor size or prior excisional biopsy should not prevent patients from having sentinel node biopsy.     

Technical aspects of sentinel node lymphoscintigraphy for breast cancer.

OBJECTIVE: A significant morbidity risk is associated with axillary nodal dissections for breast cancer. Many treatment decisions are based on axillary nodal status. Lymphatic mapping and sentinel node biopsy have been investigated to determine if the histology of the sentinel node reflects the remaining lymph node basin. We describe the technical aspects of sentinel node lymphoscintigraphy for breast cancer. METHODS: Ninety-three patients had lymphoscintigraphy for breast cancer. Patients with palpable lesions had 4 concentric injections around the site and lesions requiring localization had injections made through tubing connected to the localizing wire introducer needle. Immediate static images were acquired and the sentinel node was marked for surgery. Marks were reverified using a handheld gamma probe. RESULTS: Lymph nodes were visualized by lymphoscintigraphy in 87% of cases. Time to visualization of lymph nodes ranged from 1-120 min with a mean of 28 min. An average of 1.5 nodes were visualized. The overall success rate for identifying the sentinel node at time of surgery was 85%. CONCLUSION: We conclude that lymphoscintigraphy for breast cancer is a detailed procedure that requires coordination with radiology and surgery teams to ensure proper identification of sentinel lymph nodes.     

Evaluation of early versus delayed lymphoscintigraphic imaging in detecting internal mammary sentinel lymph nodes in breast cancer: a multicenter study to establish an optimal lymphatic mapping protocol

OBJECTIVE: Metastases in the internal mammary lymph nodes have an important prognostic value in breast cancer. Lymphatic mapping and sentinel node biopsy of internal mammary nodes improves staging and permits specific therapeutic strategies, thereby possibly improving final outcome. Therefore, optimal lymphoscintigraphic results are needed. Visualization of internal mammary lymph drainage, however, is influenced by several factors. We evaluated the effect of different time intervals between radioactive tracer injection and lymphoscintigraphy on visualization of internal mammary sentinel lymph nodes. METHODS: From February 1997 to August 2001 a total of 682 eligible breast cancer patients underwent sentinel lymph node mapping. The technique involved the injection of 370 MBq (10 mCi) (99m)Tc-nanocolloid peritumorally. In 470 patients (group A) the time interval between injection of the radiocolloid and lymphoscintigraphy was 16 h, compared to 2.5 h in 212 patients (group B). RESULTS: Patient characteristics showed no statistically significant difference between both groups for age and location of the tumour. Axillary hotspots were visualized in 97% in group A and 96% in group B. Lymphoscintigraphy showed internal mammary hotspots in 21% in group A, compared to 27% in group B. The mean number of internal mammary hotspots per patient was 1.9 in group A and 1.8 in group B. CONCLUSIONS: We found no significant differences between early and delayed lymphoscintigraphic imaging in visualizing internal mammary sentinel lymph nodes.     

Intramammary sentinel lymph node preoperative identification with SPECT/CT in a patient with breast cancer. Clinical meaning and relevance

We present the case of a patient with breast cancer who underwent selective sentinel lymph node biopsy. An intramammary sentinel lymph node was identified with SPECT/CT in the preoperative lymphoscintigraphy. We describe our diagnostic and therapeutic procedure regarding this finding and the literature review to evaluate the clinical significance of their identification and metastases, especially in regards to more appropriate axillary management. Further studies with more statistical significance are necessary to elucidate the most suitable attitude when an intramammary sentinel lymph node is identified with the lymphoscintigraphy.     

Clinically node-negative breast cancer, internal mammary lymph nodes, and sentinel lymph node biopsy

We report 2 cases demonstrating that localization of internal mammary (IM) sentinel lymph nodes with lymphoscintigraphy using peritumoral injection of Tc-99m antimony sulfide colloid, followed by resection using minimal access surgery, can reveal nodal metastatic disease in patients with clinically node-negative breast cancer when axillary sentinel nodes are not affected by metastatic disease. When this is found, it changes staging and can affect prognosis and treatment. These cases confirm that the technique used is sampling true sentinel IM nodes, that is nodes that receive direct lymph flow from the breast cancer, and confirm the importance of sampling IM sentinel lymph nodes. Unless techniques are used that are specifically designed to identify IM node drainage from the breast cancer site itself, with subsequent directed surgical removal of sentinel IM nodes, some patients with breast cancer will not be staged correctly.