前哨淋巴结定位和检测的现状

本文就近年来前哨淋巴结在外科治疗临床应用方面的国外文献作一综述。对前哨淋巴结的定义、历史发展过程、现状和争议 ,并着重对胃肠癌方面的应用意义进行了概述。     

前哨淋巴结定位和检测的现状

本文就近年来前哨淋巴结在外科治疗临床应用方面的国外文献作一综述。对前哨淋巴结的定义、历史发展过程、现状和争议，并着重对胃肠癌方面的应用意义进行了概述。     

前哨淋巴结定位在结直肠癌外科中的应用

研究表明，结直肠癌前哨淋巴结定位是一种切实可行的技术，前哨淋巴结的状态可以准确预测区域淋巴结群的肿瘤转移情况；细致地分析前哨淋巴结有助于发现传统病理学检查漏诊的微转移灶，从而使部分患者肿瘤分期上调。目前的研究结果已展现前哨淋巴结检测对结直肠癌准确分期的潜在价值，但离临床常规应用还有距离，还有待进一步的研究。     

腹腔镜下胃癌前哨淋巴结标示的临床应用及意义

目的：探讨腹腔镜下胃癌前哨淋巴结（SLN）检测的可行性及SLN活检预测胃周淋巴结转移状况的准确性,评价SLN活检在指导胃癌手术治疗中的应用价值。方法：2010年3—11月诊断明确的126例胃癌,在腹腔镜胃癌切除术中向肿瘤边缘正常胃壁浆膜下肌层、黏膜下层注射亚甲蓝标示SLN,腔镜下识别和切取蓝染淋巴结活检。以术后所有切除的胃周淋巴结常规病理检查结果为诊断金标准,观察SLN活检对预测胃周淋巴结有无肿瘤转移的准确性。结果：116例成功检测出SLN,检出率92．1％（116／126）。62例有淋巴结转移,其中前哨淋巴结与非前哨淋巴结（nSLN）均有转移47例,仅前哨淋巴结有转移10例,仅非前哨淋巴结有转移5例。前哨淋巴结预测胃周淋巴结转移的敏感性为91．9％（57／62）,准确率为94．0％（109／116）,假阴性率为8．1％（5／62）。结论：腹腔镜下胃癌SLN检测可行。通过SLN,术中能准确预测胃癌淋巴结转移状况,淋巴结转移阴性的胃癌患者,有望免除常规淋巴清扫。     

胃肠间质瘤的超声影像学特点分析

目的分析胃肠间质瘤的彩色多普勒超声影像学特点。方法对我院2008年7月至2015年1月期间收治且经手术病理证实的胃肠间质瘤(51例)与胃肠癌(59例)患者的超声图像进行对比分析。结果胃间质瘤好发于胃底和胃体部(17例),肠间质瘤好发于小肠(24例)。胃癌好发于胃窦部(18例),肠癌好发于结、直肠(结肠癌20例,直肠癌12例)。与胃肠癌比较,胃肠间质瘤多以肿瘤不包绕肠腔为主、边界清晰、形态多较规整、内部回声多不均匀及周边淋巴结无转移(P0.05),肿瘤大小和血流丰富程度比较差异无统计学意义(P0.05),而单独将肠间质瘤的血流丰富程度与肠癌进行比较的结果发现二者的差异有统计学意义(P0.05)。结论从本研究的初步研究结果来看,超声作为一种简便、快捷的检查方法,对于胃肠间质瘤与胃肠癌的鉴别具有一定的诊断价值。     

胃癌前哨淋巴结活检技术及其微转移检测应用研究

目的 探讨前哨淋巴结活检技术在胃癌中应用及流式细胞术对胃癌前哨淋巴结微转移检测的可行性。方法 南通大学附属医院普外科2006年6月至2007年6月对60例胃癌病人术中应用亚甲蓝定位活检前哨淋巴结（SLN）,术后行HE染色及流式细胞术检测。结果 60例中56例找到SLN,检出率为93.3%,SLN组织学状态能比较准确预测胃癌区域淋巴结转移状况, 在T1、T2期中更为明显。HE发现49枚/24例SLN转移,流式细胞术发现71枚/37例SLN转移,即22枚/13例SLN存在微转移。结论 亚甲蓝行前哨淋巴结活检（SLNB）在胃癌中是可行的,特别在T1、T2期中更具有重要意义,流式细胞术结合SLNB检测胃癌的淋巴结微转移具有较高的检出率, 具有临床可行性。     

人胃肠癌裸鼠模型研究现状

人胃肠恶性肿瘤裸鼠模型是体外整体研究人胃肠癌的重要途径,尤其是近年来原位移植(orthotopic implantation)技术的应用,使人胃肠癌裸鼠模型不但具有移植成功率高,而且保存人肿瘤原有的结构、功能的一致及转移特性。本文就人胃肠恶性肿瘤裸鼠模型建立及在肿瘤基础和临床应用方面的研究状况予以综述。     

前哨淋巴结活检在食管癌手术中的应用

前哨淋巴结（SLN）是原发肿瘤发生淋巴结转移时首先累及到的淋巴结,SLN导航手术在黑色素瘤和乳腺癌中的应用得到了广泛证实.近年来,在胃肠道肿瘤手术中的应用也得到越来越高的重视.然而,与其他肿瘤相比,由于食管癌特殊的解剖学部位和淋巴引流途径,SLN在食管癌手术中应用的有效性和可行性存在较大争议.淋巴结微转移是影响无淋巴结转移食管癌患者预后的重要因素,SLN微转移的检测对食管癌治疗方案的制定具有重要意义.本文简要论述近年来SLN活检在食管癌手术中的应用,并阐述其临床意义.     

胃癌前哨淋巴结术中定位和病理学检查

目的探讨肿瘤前哨淋巴结(SLN)活检技术在胃癌诊疗中应用的可行性。方法将38例胃癌患者,按肿瘤浸润深度分组,用术中注射美蓝的方法定位前哨淋巴结,用细胞角蛋白(CK-19)免疫组织化学染色判断淋巴结转移情况。结果38例患者全部检出SLN(100%)。出现淋巴结转移的有18例,其中SLN出现转移的有15例。SLN预测淋巴结癌转移的敏感性、假阴性率和准确率分别为83.3%、16.7%和92.1%;胃癌T1组无SLN假阴性者,准确率100%;T2组有1例假阴性者,准确率94.1%;T3组假阴性2例,准确率6/8例。结论采用肿瘤周围注射亚甲蓝的方法术中定位淋巴结为可行的SLN术中定位方法。     

前哨淋巴结活检在新辅助化疗乳腺癌患者中的临床研究进展

前哨淋巴结活检作为早期乳腺癌患者腋窝淋巴结分期的手段已被肿瘤学界普遍接受,而且对前哨淋巴结阴性患者可以避免腋窝淋巴结清扫术带来的不良后果。随着前哨淋巴结活检技术的发展,其适应证不断扩大,但该方法在新辅助化疗乳腺癌患者中的应用目前尚有争议。本文对新辅助化疗乳腺癌患者前哨淋巴结活检的可行生及时机选择进行综述。     

可切除胃癌的前哨淋巴结示踪研究

目的 探讨前哨淋巴结活检在胃癌中的临床价值.方法 回顾性分析2003年1月至2006年6月46例行D2根治术的胃癌患者进行亚甲蓝前哨淋巴结活检的临床资料.结果 38例成功识别前哨淋巴结.前哨淋巴结敏感性、假阴性、准确性、特异性、阴性预测值及阳性预测值分别为69%(18/26)、31%(8/26)、79%(30/38)、100%(12/12)、60%(12/20)、100%(12/12).pT1期、TNM Ⅰ期和肿瘤直径<4 cm的患者,敏感性、准确性和阴性预测值均高达100%.肿瘤部位和淋巴结转移程度影响活检成功率,而肿瘤浸润深度、临床分期、淋巴结转移程度影响活检的敏感性、准确性和阴性预测值.结论 亚甲蓝前哨淋巴结活检在胃癌中的应用是可行的,早期患者的敏感性、准确性和可靠性高.     

结直肠癌前哨淋巴结体外亚甲蓝染色的临床研究

目的探讨用体外亚甲蓝作为染色剂寻找前哨淋巴结(sentinel lymph node,SLN)的方法在结直肠癌SLN定位中的临床价值。方法将根治性切除大肠癌标本,在肿块四周浆膜下注射亚甲蓝后常规固定送病理检查。蓝染的淋巴结视为SLN。结果67例患者中找到SLN的有63例(91.3%),SLN镜下转移14例(22.22%)。结肠的SLN转移阳性的诊断价值与非SLN相比差异有统计学意义(P=0.0005),但在直肠癌中SLN转移阳性的诊断价值与非SLN相比差异无统计学意义(P=0.60),且SLN转移阳性在结肠癌病例中假阴性率为11.11%,而在直肠癌病例中则高达42.86%。结论体外亚甲蓝染色寻找SLN的方法在结肠癌中的应用是有效、可靠的,但在直肠癌中的应用其可靠性值得进一步的研究。     

Subpleural injection of tracer improves detection of mediastinal sentinel lymph nodes in non-small cell lung cancer.

BACKGROUND: The advantages and disadvantages of various tracer injection protocols for sentinel lymph node (SLN) mapping have been extensively discussed in relation to breast and gastric cancer. But no such discussion has taken place in relation to SLN mapping in non-small cell lung cancer. We therefore studied the effect of two tracer injection protocols on SLN mapping in patients with non-small cell lung cancer; of particular interest was the relationship between subpleural tracer injection and identification of mediastinal SLNs. METHODS: A quadrant injection group (n=49) received 1.6 ml of ferucarbotran by peritumoral quadrant injection after thoracotomy. In the subpleural injection group, the same amount of ferucarbotran was injected into the peritumoral quadrants plus the subpleural region (n=27). SLNs were then detected intraoperatively by measuring the magnetic force within lymph nodes using a hand-held magnetometer. After completing the SLN mapping, lobectomy and hilar and mediastinal lymph node dissection was performed. RESULTS: The incidence of mediastinal SLNs was significantly higher in the subpleural injection group (45.4%) than in the quadrant injection group (14.6%) (p=0.007). Moreover, nominal logistic regression analysis revealed subpleural injection to be a significant independent factor contributing to detection of mediastinal SLNs (p=0.024, odds ratio 5.26). In the quadrant injection group, mediastinal lymph node metastasis was detected in two patients thought to have nonmetastatic parenchymal SLNs. By contrast, there were no false-negative cases in the subpleural injection group. CONCLUSION: Subpleural tracer injection significantly improves detection of mediastinal SLNs in non-small cell lung cancer.     

专利蓝和放射物联合示踪检测胃癌前哨淋巴结及其临床意义

目的 探讨胃癌中前哨淋巴结(SLN)概念的适用性,评估前哨淋巴结活检预测胃癌区域淋巴结转移状态的价值及其指导胃癌淋巴结清扫范围的临床意义。方法26例胃癌患者,术前经胃镜于病灶周围黏膜下注入^99mTc标记的硫胶体,术中于病灶周围浆膜下直接注入专利蓝,将γ探测仪检测放射活性高出背景组织10倍以上或(和)蓝染的淋巴结视为胃癌前哨淋巴结,行常规病理检查和细胞角蛋白免疫组化染色,分别计算前哨淋巴结诊断胃癌淋巴结转移状态的准确性、敏感性、阴性预测值和假阴性率,并根据前哨淋巴结活检结果决定胃癌的手术方式。结果胃癌前哨淋巴结的检出成功率为96％(25／26),每例检出1～6个,平均3．2个／例。胃癌前哨淋巴结仅限于N1分布的占50％(13／26),仅限于N2或N3分布的占12％(3／26)。SLN诊断胃癌周围淋巴结转移状态的准确性为96％,敏感性为94％,阴性预测值为7／8,假阴性率为6％。对前哨淋巴结的彻底病理检查使2／7胃癌病例的淋巴结病理分期得到上调。结论前哨淋巴结概念适合于胃癌;联合示踪法胃癌前哨淋巴结活检可准确预测胃癌周围淋巴结的转移状态,并可能用于指导胃癌的淋巴结清扫范围。     

Intraoperative imprint cytology for evaluation of sentinel lymph nodes from visceral malignancies

Although originally described for breast cancer and melanoma, sentinel lymph node (SLN) mapping techniques are being investigated in the treatment of visceral malignancies. There is no literature evaluating intraoperative analysis of SLNs from visceral sites. We evaluated the utility of touch preparation intraoperative imprint cytology (IIC) in evaluating SLNs harvested in the setting of visceral malignancy. SLN mapping procedures involving 50 cases of visceral malignancy (37 colon, 12 gastric, and 1 small bowel), from February 1999 through August 2001, were studied. In each case, subserosal injections of isosulfan blue were used to identify the SLN. The SLNs were then sent fresh to the pathology laboratory for evaluation by IIC. A standard lymphadenectomy was performed in all cases. Postoperatively, the SLNs were evaluated by means of using hematoxylin and eosin staining. If these stains were normal, immunohistochemical analyses using carcinoembryonic antigen and cytokeratin were subsequently performed. SLNs were successfully identified in 46 cases (92%), and a total of 95 SLNs were harvested. The average number of SLNs was 1.9 with a range of one to six. More SLNs were found with gastric than with colonic lesions (2.8 vs. 1.8; P = .017). Evaluable IIC in 41 cases revealed metastatic disease in 10 SLNs, representing seven patients. Of the 34 patients with normal IIC, five were found to have positive SLNs on hematoxylin and eosin staining. An additional three patients were found to have positive SLNs only on immunohistochemical analysis. The overall sensitivity and specificity of IIC was 64% and 100%, respectively. This resulted in a positive predictive value of 100% and a negative predictive value of 86%. The use of IIC to evaluate SLNs from visceral malignancies is clearly feasible. When the IIC of the SLN is positive, the surgeon may feel confident that disease is actually present in the SLN. If there is a negative result, the technique may miss disease that is present on subsequent permanent sections. We do not recommend routine use of IIC; however, it may be of use in clinical trials. Presented at the Society of Surgical Oncology meeting, Denver, Colorado, March 15–17, 2002. Supported in part by a grant from the Comprehensive Cancer Center of Wake Forest University.     

Do cytokeratin-positive-only sentinel lymph nodes warrant complete axillary lymph node dissection in patients with invasive breast cancer?

The small number of nodes harvested with lymphatic mapping and sentinel lymph node (SLN) biopsy has allowed a more detailed pathologic examination of those nodes. Immunohistochemical stains for cytokeratin (CK-IHC) have been used in an attempt to minimize the false negative rate for SLN mapping. This study examines the value of CK-IHC positivity in predicting further lymph node involvement in the axillary basin. From April 1998 through May 1999, 519 lymphatic mappings and SLN biopsies were performed for invasive breast cancer. SLNs were examined by imprint cytology, hematoxylin and eosin (H&E), and CK-IHC. Patients with evidence of metastatic disease by any of the above techniques were eligible for complete axillary node dissection (CAND). The frequency with which these modalities predicted further lymph node involvement in the axillary basin was compared. Of the 519 lymphatic mappings, 39 patients (7.5%) had a CK-IHC-positive-only SLN. Five (12.8%) of these 39 patients had at least 2 SLNs positive by CK-IHC. Twenty-six of the CK-IHC-positive-only patients underwent CAND. Three of these 26 patients (11.5%) had additional metastases identified after CAND. The sensitivity levels with which each modality detected further axillary lymph node involvement were as follows: CK-IHC, 98 per cent; H&E, 94 per cent; and imprint cytology, 87 per cent. A logistic regression to compare the prognostic value of the three modalities was performed. All were significant, with odds ratios of 19.1 for CK-IHC (P = 0.015), 5.3 for H&E (P = 0.033), and 3.86 for imprint cytology (P = 0.0059). These data validate the enhanced detection of CK-IHC for the evaluation of SLNs. Detection of CK-IHC-positive SLNs appears to warrant CAND in patients with invasive breast cancer. However, the therapeutic value of CAND or adjuvant therapies based on CK-IHC-positive SLNs would be best answered by prospective randomized trials.     

Validation of sentinel node mapping in patients with colon cancer

Background Sentinel lymph node (SLN) mapping techniques have been validated in breast cancer and melanoma. This study summarizes our experience with SLN mapping for colon cancer. Methods Fifty-five patients with colon cancer underwent intraoperative SLN mapping. One mL of 1% isosulfan blue was injected subserosally around the tumor. The first nodes highlighted with blue were identified as the SLNs. SLNs underwent multiple sectioning and immunohistochemical staining for cytokeratin. The overall learning curve was calculated. Results Lymphatic mapping adequately identified at least 1 SLN in 45 patients (82%). SLNs adequately predicted regional status in 44 of 45 (98%) cases. In 9 of 45 cases (20%), the SLNs were the only sites of metastases. Among the 14 cases that were SLN positive, 6 of 55 patients (11%) were positive only by immunohistochemistry. Of the 31 cases with negative SLNs, 1 case had a 3.5-mm pericolonic tumor-replaced non-SLN (3% false-negative rate). The overall learning curve stabilized after five cases. Conclusions Intraoperative SLN mapping is a feasible technique, with a quick learning curve, and had a reasonable SLN identification rate. Negative SLNs accurately predict the status of non-SLNs 97% of the time. Eleven percent of patients were upstaged by demonstration of micrometastases and may benefit from adjuvant chemotherapy.     

Lymphatic mapping for gastric adenocarcinoma

The role of lymphadenectomy for gastric carcinoma has been debated for decades. Lymphatic mapping has revolutionized the treatment of melanoma and breast cancer. However, its potential utility in guiding lymphadenectomy for gastric carcinoma is unknown. Therefore we initiated a trial to investigate lymphatic mapping for gastric carcinoma at Wake Forest University Baptist Medical Center. Lymphatic mapping for gastric carcinoma was attempted in 14 cases of gastric carcinoma. Mapping was performed by perilesional injection of isosulfan blue and the first node in the draining basin was harvested and sent fresh to pathology. Sentinel lymph nodes (SLNs) were evaluated by hematoxylin and eosin (H&E) staining. Immunohistochemical analysis was performed on all SLNs that were found to be negative on initial histologic studies. Radical gastrectomy with celiac node dissection was performed in all cases. SLNs were identified in 14 cases. In one case the technique was abandoned because of bulk nodal disease. The average number of SLNs found in each case was 2.8 with a range of one to five. Eight of 14 patients were found to have SLNs positive for metastatic carcinoma. In seven of these patients pathologic analysis of the final resection specimen confirmed the presence of nodal disease. In one case carcinoma was found in a SLN on touch preparation and no nodal disease was noted in the resection specimen. Immunohistochemical studies performed on SLNs found to be negative on initial H&E histologic analysis failed to reveal the presence of carcinoma. The overall sensitivity and specificity were found to be 72.7 and 75 per cent, respectively. Lymphatic mapping is technically possible in the setting of gastric carcinoma and SLNs can be successfully identified in the majority of cases. Upstaging occurred in one case which may have ramifications for adjuvant therapy. SLN positivity accurately predicts the presence of additional nodal disease beyond the SLN in the final resection specimen (positive predictive value 89%). However, SLN negativity does not definitively prove that the remaining nodal basin is free of disease (negative predictive value 50%). Lymphatic mapping for gastric carcinoma is a promising technique worthy of further investigation.     

结直肠癌前哨淋巴结体外标记的研究

目的探讨结直肠癌前哨淋巴结（SEN）体外亚甲蓝定位活检方法的可行性，研究前哨淋巴结组织学状况能否用于预测区域淋巴结转移情况。方法将32例手术切除的结直肠癌标本纵行剪开，在癌肿四周注射亚甲蓝，2—5min后沿着蓝染的淋巴管追踪寻找首先蓝染的前哨淋巴结。将其切下后单独进行病理切片，检测有无癌转移，并与系膜淋巴结病理结果予以比较。结果有30例标本成功显示57枚SLN，平均每例标本显示1．9枚SLN。在SLN阳性的13例患者中。5例非SLN呈阳性，8例非SLN呈阴性；在17例SLN为阴性的标本中，15例非SLN呈阴性，仅2例非SLN呈阳性。统计本组患者SLN标记成功率为93．8％（30／32），准确率为93．3％（28／30），假阴性率为11．8％（2／17），特异性为100％（13／13）。结论结直肠癌标本前哨淋巴结体外亚甲蓝标记法可行，其组织学状况可较准确反映区域淋巴结群的癌转移情况。