乳腺癌前哨淋巴结活检假阴性临床研究进展

<正>乳腺癌前哨淋巴结(sentinel lymph node,SLN)指接受乳腺癌引流的第一枚(或组)淋巴结,SLN阴性的病人免除腋淋巴结清扫(axillary lymph node dissection,ALND)可以降低腋窝手术的并发症发生率,并不增加腋窝淋巴结复发的危险[1-3]。前哨淋巴结活检(sentinel lymph node biopsy,SLNB)假阴性是指SLN未发现肿瘤累及而腋窝淋巴结却有转移灶的情况。Krag等[4]在NSABP B-32试验中对5379例乳     

前哨淋巴结活检的最新进展

近年来,一系列大样本、前瞻性的乳腺癌临床研究证实前哨淋巴结活检术（sentinel lymph node biopsy,SLNB）可以安全、准确地提供腋窝淋巴结分期,且乳腺癌前哨淋巴结（sentinel lymph node,SLN）阴性患者SLNB替代腋窝淋巴结清扫术（axillary lymph node dissection, ALND）后,     

早期乳腺癌腋窝淋巴结放疗原则

早期乳腺癌病人腋窝淋巴结处理的原则是在有效控制疾病的基础上追求精准与安全。因此,以腋窝放疗替代手术成为近年来的关注焦点。在未行新辅助治疗的人群中,腋窝淋巴结初诊阴性或保乳术后前哨淋巴结（SLN）微转移的病人无须追加腋窝淋巴结清扫（ALND）或完整的腋窝照射;保乳术后SLN 1~2枚宏转移可豁免ALND并行全乳或高切线野照射,SLN转移数目＞2枚或SLN外淋巴结转移风险较高者,豁免ALND后需补充腋窝放疗;乳房切除术后SLN阳性病人中目前证据不足,如未行ALND可考虑补充腋窝放疗;在接受了新辅助全身治疗的病人中,如SLN转阴可豁免ALND并补充腋窝放疗,如SLN未转阴目前依然推荐行ALND。     

前哨淋巴结1～2个阳性乳腺癌患者腋窝非前哨淋巴结转移情况及危险因素分析

目的 探讨前哨淋巴结（sentinal lymph node,SLN）1～2个阳性乳腺癌患者腋窝非前哨淋巴结（non-sentinel lymph node metastasis,NSLN）转移情况和危险因素，为该类患者豁免腋窝淋巴结清扫（axillary lymph node dissection,ALND）的可行性提供理论依据。方法 回顾性分析铜陵市人民医院甲状腺和乳腺外科2018年1月至2023年4月期间收治的确诊为乳腺癌患者行前哨淋巴结活检（sentinel lymph node biopsy,SLNB）证实有1～2个SLN阳性且行规范化ALND的54例患者的临床病理资料，根据NSLN是否有转移分为NSLN转移组（17例）和NSLN非转移组（37例），采用卡方检验比较2组患者的基本情况和临床病理特征，采用多因素二元logistic回归模型分析筛选出腋窝NSLN发生转移的独立危险因素，并采用受试者工作特征（receiver operating characteristic,ROC）曲线评估独立危险因素联合预测腋窝NSLN转移的预测价值。结果 SLN有1～2个转移者有54例，腋窝N...     

乳腺癌前哨淋巴结活检的初步体会

目的 初步探讨乳腺癌前哨淋巴结（sentinel lymph node,SLN)检测的可行性,SLN预测腋窝淋巴结状态的可靠性。方法 对我院普外科收治的15例T1-2期、腋窝未扪及肿大淋巴结的乳腺癌病人,使用^99mTc右旋糖酐或^99mTc硫胶体为示踪剂,γ探测仪探测SLN,然后进行活检和腋窝淋巴结清扫（axillary lymph node dissection,ALND)。两处标本同时送病理检查,以此来评价SLN的病理组织学结果能否准确地反映腋窝淋巴结状态。结果 在10例病人中发现SLN,发现率为66.6%(10/15),SLN的数量为1-3枚/例,平均2.1枚/例,非前哨淋巴结（non-sentinel lymph node,NSLN)5-16枚/例,平均10.3枚/例,发现SLN的10例病人中1例（10%）SLN有癌转移,其他腋窝淋巴结未见转移;2例SLN未发现癌转移而NSLN有癌转移,假阴性率20%（2/10）,准确性80%（8/10）,结论 乳腺癌前哨淋巴结定位和活检技术以及预测腋窝淋巴结状态的可靠性方面有待进一步积累经验,提高准确性,降低假阴性率。     

乳腺癌前哨淋巴结检测的临床研究

目的通过前哨淋巴结(sentinel lymph node,SLN)活检,了解前哨淋巴结是否能反映乳腺癌腋窝淋巴结转移情况,从而决定是否行腋窝淋巴结清扫(axillary lymph node dissection,ALND). 方法 47例T1、T2、T3临床检查腋窝淋巴结无肿大的乳腺癌患者,术前30 min于乳腺肿块周围腺体注射蓝色染料,术中取蓝染的SLN病理检查,术后将病理检查结果与腋窝淋巴结转移情况进行比较分析. 结果 47例中5例未见淋巴结及淋巴管蓝染,其余42例找到腋窝淋巴结608个,阳性18例168个,阴性24例440个;SLN共78个,阳性16例29个,阴性26例49个.SLN的检出率89.4%,准确性95.2% ,特异性100%,敏感性88.9%,假阴性率11.1%,假阳性率0. 结论 SLN活检反应腋窝淋巴结的肿瘤转移状况,可以用于术中确定是否行ALND.     

乳腺癌前哨淋巴结活检进展

前哨淋巴结(sentinel lymph node,SLN)是指区域淋巴引流最先到达的淋巴结。据其定义,肿瘤学阴性的SLN意味着该区域淋巴结无肿瘤转移。这样就可对一个SLN阴性的乳腺癌病人免行腋下淋巴结清扫(axillary lymph node dissection,ALND),从而避免ALND带来的不良后果,如患侧上肢麻木、疼痛、水肿、腋下积液和感染,还可缩短住院天数．节省医疗费用,为是否采用辅助治疗提供更准确的指导．     

前哨淋巴结活检在乳腺癌中的临床应用

目的 探讨术中前哨淋巴结（sentinel lymph node,SLN）定位和活检（SLNB）对预测乳腺癌腋窝淋巴结（axillary lymph node,ALN）转移的准确性.方法 对48例乳腺癌患者术前10min用亚甲蓝注射液4ml注射到肿瘤周围或活检腔的正常乳腺组织,进行SLN定位和活检,然后行乳腺癌改良根治术.结果 SLNB的检出成功率为95.8%,准确率为97.8%,假阴性率3.0%,假阳性率为0.结论 用亚甲蓝作SLN定位进行SLNB能准确预测乳腺癌ALN转移状态.     

乳晕下亚甲蓝法乳腺癌前哨淋巴结活检术169例应用报告

目的探讨乳晕下注射亚甲蓝示踪法进行前哨淋巴结活检术(sentinel lymph node biopsy,SLNB)在乳腺癌治疗中的意义。方法 2005年1月～2010年3月,对169例(年龄33～70岁,中位年龄45岁)临床腋窝淋巴结阴性的乳腺癌术中乳晕下注射亚甲蓝2 ml行SLNB。SLN病理为阴性的患者,SLNB替代腋窝淋巴结清扫术。结果 163例(96.4%)成功实施SLNB,6例(3.6%)术中未能发现SLN,立即改行腋窝淋巴结清扫术(axillary lymph node dissection,ALND)。行SLNB的163例中,23例术中冰冻报告SLN癌转移,即行ALND;140例冰冻切片检查SLN未见癌转移。6例术后HE染色检查发现SLN存在1枚微转移淋巴结,5例接受ALND,1例拒绝行腋窝淋巴结清扫。135例SLNB代替ALND者中位随访时间16个月(3～62个月),均未发现腋窝淋巴结转移。结论亚甲蓝法SLNB安全、有效、简便易行,SLNB阴性的患者,可以替代ALND。     

乳腺癌前哨淋巴结活检的实践与体会

目的评价乳腺癌前哨淋巴结活检(sentinel lymph node biopsy,SLNB)的可行性,并分析影响该技术成功率的相关因素。方法术前于肿瘤周围皮内分别注射放射性胶体和蓝色染料两种前哨淋巴结示踪剂,术前先行淋巴闪烁扫描,术中应用γ计数探测仪检测,并结合淋巴结蓝染情况定位SLN,切除SLN后再行腋窝淋巴结清扫(axillary lymph node dissection,ALND),两标本均行组织学检查。结果全组116例乳腺癌SLNB的检出率98.3%,该技术的灵敏度93.6%,准确性97.4%,假阴性6.4%。结论乳腺癌SLNB是一种简便、安全的检测技术,可用于了解腋窝淋巴结的状况,有望在早期乳腺癌中取代常规的ALND。     

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??Express and interpretation on American society of clinical oncology guideline update for Sentinel lymph node biopsy in early-stage breast cancer WU Ke-jin.
Department of General Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
Abstract 2014 April, American Society of Clinical Oncology (ASCO) issued new clinical practice guideline on sentinel lymph node biopsy for patients with early-stage breast cancer in Journal of Clinical Oncology (JCO). This guideline update reflects some changes since the 2005 guideline. Based on randomized clinical trials (RCTs), there are three recommendations: (1) Women without sentinel lymph node (SLN) metastases should not accept axillary lymph node dissection (ALND). (2) In most cases, Women with 1-2 metastatic SLNs going to undergo breast-conserving surgery (BCS) with whole-breast radiotherapy should not adopt ALND. (3) Women with SLN metastases planning to receive mastectomy should be provided ALND. Based on cohort studies and/or informal consensus, there are two prime recommendations. (1) Sentinel node biopsy (SNB) may be offered to those women with operable breast cancer and multicentric tumors, with ductal carcinoma in situ (DCIS) planning to undergo mastectomy, who previously got breast and/or axillary surgery or who accepted preoperative/neoadjuvant systemic therapy. (2) SNB should not be offered to those women with large or locally advanced invasive breast cancer (tumor size T3/T4), inflammatory breast cancer, or DCIS will undergo BCS, or are pregnant.     

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??Problems and treatment options of sentinel lymph node in breast cancer WU Di, FAN Zhi-min. Department of Breast Surgery??the First Hospital of Jilin University??Changchun 130021??China
Corresponding author: FAN Zhi-min, E-mail:fanzhimn@163.com
Abstract Sentinel lymph node biopsy (SLNB) has been the primary care in clinically node negative breast cancer. Controversy still surrounds the SLNB of the internal mammary nodes. Because different kinds of tracer have respective feature, surgeons should choose the suitable tracer. All blue lymph nodes and any lymph nodes at the end of a blue lymphatic channel should be removed and designated as SLNs.Clinicians should not recommend ALND for women with early-stage breast cancer who have one or two SLN metastases and will receive breast-conserving surgery with conventionally fractionated whole-breast radiotherapy.Clinicians may offer ALND for women with early-stage breast cancer with nodal metastases found on SNB who will receive mastectomy. For patients who recieved neoadjuvant chemotherapy, SLNB after neoadjuvant chemotherapy is optimal.     

乳腺癌前哨淋巴结活检的若干问题和处理方案

前哨淋巴结活检（SLNB）已成为腋窝淋巴结临床阴性早期乳腺癌的首选腋窝手术方式,但其适应证范围已有所扩大。内乳淋巴结是否需要SLNB,尚存争议。不同示踪剂有各自的特点,应用时需要根据各临床中心的实际情况予以选择。寻找前哨淋巴结（SLN）时,原则上要循着色淋巴管解剖至腋窝寻找SLN。对于符合美国外科医师协会肿瘤学组（ACOSOG）Z0011试验入组标准的存在1～2枚SLN转移的病例不需腋窝淋巴结清扫（ALND）。仅行全乳切除的病例,如果SLN阳性,则需要进行腋窝淋巴结清扫。对于接受新辅助治疗病人接受SLNB的时机,目前认为在新辅助治疗后进行为好。     

Sentinel Node Biopsy is Important in Mastectomy for Ductal Carcinoma In Situ

Background There is uncertainty about the utility of sentinel node biopsy (SNB) for ductal carcinoma in situ (DCIS) and its potential to avoid axillary lymph node dissection (ALND) in patients undergoing mastectomy for DCIS. Methods A review was conducted of 179 patients who underwent mastectomy with sentinel node biopsy for DCIS without invasion or microinvasion on premastectomy pathology review. Results The sentinel node identification rate was 98.9% (177/179). Twenty (11.3%) of 177 mastectomies for DCIS had a positive SNB: two micrometastasis (pN1mi) and 18 isolated tumor cells [pN0(i+)]. Unsuspected invasive cancer was found in 20 (11.2%) of 179 mastectomies, eight T1mic, five T1a, three T1b, and four T1c tumors. Sentinel nodes were identified in 19 of 20 patients with invasive cancer and four were positive: one pN1mi and three pN0(i+). Eighteen of 19 patients with unsuspected invasive cancer were able to avoid axillary dissection on the basis of SNB results. Of the 159 patients whose final pathology revealed DCIS without invasion, a sentinel node was identified in 158 (99.4%). The SNB was positive in 16 patients (10.1%): one pN1mi and 15 pN0(i+). Three patients underwent ALND on the basis of positive SNBs and in each the SNB was the only positive node. Conclusions 11% of patients undergoing mastectomy for DCIS were found to have invasive cancer on final pathology. The use of SNB during mastectomy for DCIS allowed nearly all such patients to avoid axillary dissection. These results support routine use of SNB during mastectomy for DCIS.     

早期乳腺癌腋窝处理研究热点

前哨淋巴结活检（SLNB）替代腋窝淋巴结清扫（ALND）已成为临床腋窝淋巴结阴性早期乳腺癌病人的标准处理方式。有限腋窝淋巴结转移的病人,接受保乳治疗满足美国外科医师协会肿瘤学组（ACOSOG）Z0011、IBCSG 23-01入组条件,可豁免ALND;或参考AMAROS,考虑腋窝放疗替代ALND;接受乳房完全切除无放疗的病人,推荐ALND。区域淋巴结放疗能够降低乳腺癌局部区域复发,在早期乳腺癌病人的腋窝处理中应权衡临床病理指标进行个体化治疗。新辅助治疗初始临床腋窝淋巴结阴性的病人可在新辅助治疗后行SLNB。新辅助治疗前可疑腋窝淋巴结优选超声引导下穿刺明确状态并标记转移淋巴结。选择适宜病人,采用双示踪、活检超过2枚以上前哨淋巴结、评估标记的新辅助治疗前转移淋巴结,并考虑将淋巴结分期N0（i＋）纳为进行ALND的标准,满足上述条件,则初始腋窝淋巴结有转移新辅助治疗后临床完全缓解的病人可谨慎考虑接受SLNB。实践中,除外参与相关临床试验,ALND仍是这部分病人的治疗推荐。     

Value of sentinel lymph node biopsy in breast ductal carcinoma in situ upstaged to invasive carcinoma

Abstract:  The role of sentinel lymph node (SLN) biopsy in patients with initial diagnosis of ductal carcinoma in situ (DCIS) is still a dilemma. Different studies are trying to define predicting factors of invasive cancer in DCIS. The aim of this study was to confirm the value of SLN biopsy in DCIS because of the invasive upstaging risk on final histology. Patients with initial diagnosis of DCIS and with axillary SLN biopsy were selected. All diagnoses were confirmed by biopsy of mammographic lesions. Surgical treatment was lumpectomy or mastectomy associated with SLN biopsy. Imprint stains were performed, and then serial sections were stained with hematoxylin and eosin (H&E) and with immunohistochemistry (IHC). A complete axillary lymph node dissection (ALND) was performed during the same surgery when a node metastasis was found. Eighty patients were enrolled in the study. Of the 61 patients who were initially diagnosed with DCIS, 12 (20%) were upstaged to microinvasive or invasive carcinoma and 9 (15%) had a metastatic SLN. Patients upstaged to invasive carcinoma had macrometastatic SLN immediately fed by a complete ALND. SLN micrometastases and isolated cells were detected by IHC and secondary complete ALND found an additional metastatic lymph node in one patient. Tumor size larger than 30 mm and mastectomy were the only significative predicting factors of upstaged disease (p < 0.0001) in our study. In patients with initial diagnosis of large DCIS programmed for mastectomy, SLN biopsy should be discussed in order to detect underlying invasive disease and to spare patients a second operating time.     

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??Research hotspots in axillary treatment for early-stage breast cancer WANG Mao-li,WU Ke-jin. Department of Breast Surgery, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200011, China
Corresponding author: WU Ke-jin, E-mail: kejinwu@163.com
Abstract Sentinel lymph node biopsy(SLNB) has replaced axillary lymph node dissection(ALND) to stage clinically node-negative breast cancer patients. In the patients with low-volume nodal metastasis, ALND could be safely avoided when treated with breast-conserving therapy eligible for Z0011 or IBCSG 23-01, or radiation considered referring to AMAROS. ALND is still recommended for patients with involved axillary nodes received mastectomy and not planned for radiation. Addition of regional nodal irradiation in subgroups of patients reduces locoregional recurrence significantly and should be recommended taken all clinical and pathologic factors considered for individual patients. For patients with clinically node-negative disease, SLNB following neoadjuvant therapy is considered an acceptable approach.Ultrasound-guided biopsy and localization of suspicious axillary lymph nodes before neoadjuvant therapy are preferred. SLNB may be an option after neoadjuvant therapy in patients with proven positive axillary nodes who achieved clinical complete response, given that usage double tracers, biopsy more than 2 sentinel lymph nodes, evaluation the labelled lymph node before neoadjuvant therapy, and stage N0 (i+) may be regarded as the criteria for ALND. ALND remains the standard-of-care for the subset of patients in clinical practice, unless enrolled on some clinical trials. Staying the current of axillary treatments in early-stage breast cancer helps to make wiser clinical decision and organize further in-depth research, so that safe, effective and moderate axillary treatments can be performed.     

Sentinel node biopsy in breast cancer

Background: Sentinel lymph node biopsy (SNB) in breast cancer may be used in place of axillary lymph node dissection (ALND) if SNB accurately stages the axilla. This study assessed the success and accuracy of axillary SNB with isosulfan blue (ISB) and technetium-99 sulfur colloid (TSC) compared to ALND. Methods: Forty-two women with T1 or T2 breast cancer underwent SNB and ALND. Sixty to 90 minutes before anesthetic induction, a mixture of 3 mL ISB and 1 mCi TSC was injected around the primary cancer or prior biopsy site. Intraoperatively, the SLN was identified using a gamma detector (Neoprobe 1000) or by visualization of the blue-stained lymph node and afferent lymphatics. The SLN was excised separately, and a level I/II ALND was completed. The histologic findings of the axillary contents and SLN were compared. Results: An axillary SLN was found in 38 of 42 (90%) cases. SLN localization rate and predictive value were the same for women who had and those who had not undergone excisional biopsy before the date of SNB. Fifteen of 42 (36%) patients had lymph node metastases. The SLN was positive in all women with axillary metastases (negative predictive value, 100%). Conclusions: If confirmed by larger series, a negative SNB may eliminate the need for ALND for select women with breast cancer. Presented at the 50th Annual Cancer Symposium of The Society of Surgical Oncology, Chicago, Illinois, March 20–23, 1997.     

What is the value of axillary dissection or sentinel node biopsy in patients with ductal carcinoma in situ?

BACKGROUND: Some surgeons have advocated sentinel node biopsy (SNB) for ductal carcinoma in situ (DCIS). The value of the information obtained is not clear. METHODS: From 1972 to 2005, 564 selected patients with pure DCIS had axillary staging with either SNB or axillary lymph node dissection (ALND). Data were collected in a prospective database. RESULTS: Only 2 of 564 patients had positive nodes by hematoxylin and eosin, and they were both in the ALND group. Both patients had mastectomies, were upstaged, received chemotherapy, and survived for more than 10 years without local or distant recurrence. Among 171 patients who had SNB, 10 had isolated tumor cells found by immunohistochemistry. Two patients who underwent SNB had local recurrence, neither developed distant or regional recurrence. Six of 564 patients in the ALND group developed local invasive recurrence and died of metastatic breast cancer, but none of them had positive nodes. CONCLUSIONS: Information from lymph node examination in DCIS patients failed to predict poor outcome. SNB is useful for DCIS in mastectomy, especially with immediate reconstruction. It may be indicated for DCIS at high risk for upgrading to invasive cancer on final excision, but reliable criteria for identifying these tumors are not yet available.     

Sentinel Node and Recurrent Breast Cancer (SNARB): Results of a Nationwide Registration Study

Background

Knowledge of regional lymph node involvement is important in patients with recurrent breast cancer for obtaining better locoregional control and predicting prognosis. To determine technical feasibility, validity, aberrant drainage rates, and clinical consequences of performing repeat sentinel node biopsy (SNB) in patients with locally recurrent breast cancer we conducted the “Sentinel Node and Recurrent Breast Cancer (SNARB)” study.

Methods

A total of 150 patients with locally recurrent breast cancer underwent lymphatic mapping and SNB. In case of an intact axillary lymph node basin, ipsilateral axillary lymph node dissection (ALND) was performed subsequently.

Results

A total of 41 patients previously underwent breast conserving therapy (BCT) with SNB, 82 patients BCT with ALND, and 21 patients a mastectomy, of which 9 with SNB and 12 with ALND. In 95 patients (63.3 %) a sentinel node was identified and in 78 patients (52 %) the sentinel node was successfully removed. In 18 patients (22.8 %) a (micro)metastasis was found on pathologic examination. Confirmation ALND in 18 patients showed no axillary lymph node metastases. Aberrant drainage pathways were visualized in 58.9 % of the patients, significantly more frequently after a previous ALND (79.3 %) than after a previous SNB (25.0 %) (P < .0001). Overall, the result of this repeat SNB led to a change in the adjuvant treatment plan in 16.5 % of the patients with a successful repeat SNB.

Conclusions

Repeat SNB is technically feasible and provides reliable results in patients with locally recurrent breast cancer, leading to change in management in 1 of 6 patients.