Life beyond Z11

The ACOSOG Z0011 (Z11) trial demonstrated the presence of a group of breast cancer patients with some residual axillary disease who did not benefit from axillary lymph node dissection (ALND) in the presence of whole breast radiotherapy and systemic therapy at short term follow-up. It is important that further long-term follow-up of this cohort continues. The outcomes of those patients fitting Z11 criteria who do not undergo ALND should be recorded on a prospective register to ensure close observation should any late divergence in overall survival develop. It is also essential that future studies are inclusive of groups excluded from Z11 rather than simply a re-hash of the trial.     

Subsequent axillary surgery after sentinel lymph node biopsy: Results from the BreastSurgANZ Quality Audit 2006–2010

ObjectivesTo use data from the BreastSurgANZ Quality Audit (BQA) to examine the patterns of completion axillary lymph node dissection (cALND) after sentinel lymph node (SLN) biopsy in women treated for early breast cancer in Australia and New Zealand and to compare it to the Australian and New Zealand guidelines in cases of both positive and negative SLN results.Materials and methodsPatients were sub grouped as having primary tumours ≤3 cm and >3 cm and further analysed according to year of surgery, SLN status and final nodal status where cALND was recorded. Multivariate analysis was performed examining tumour size, grade, presence of lymphovascular invasion (LVI), HER2 and oestrogen receptor status, patient age and number of positive sentinel nodes as predictors for subsequent axillary surgery.Results14879 patients were identified from 2006 to 2010. 79.8% of patients with a positive SLN result underwent cALND. Age >70 years and a greater number of involved SLN predicted no cALND among SLN positive patients. 10.3% of patients who had a negative SLN result underwent cALND. Younger age, higher grade, lymphovascular invasion and tumour size >3 cm predicted cALND among SLN negative patients.ConclusionsAccording to the BQA from 2006 to 2010 the Australian and New Zealand guideline recommendations for SLN positive patients to have cALND and SLN negative patients not to have cALND were adhered to in 79.8% and 89.7% of cases respectively.     

量子点技术在淋巴结显像中的应用

淋巴结显像技术是当今肿瘤学和外科学研究的新热点,该技术已经成功地应用于黑色素瘤和乳腺癌前哨淋巴结转移的诊断.但由于肿瘤自身淋巴引流的复杂性,加之色素染料和放射性示踪剂自身的缺陷和不足,使得淋巴结显像技术在大多数肿瘤的应用还存在着诸多障碍.量子点作为一种新型纳米材料,在肿瘤淋巴结显像过程中的应用越来越受到重视.     

Surgical management of the axilla: do intramammary nodes matter?

Background

The therapeutic significance of intramammary lymph nodes is uncertain. The purpose of this study was to identify the appropriate surgical management of the axilla in intramammary node-positive patients undergoing sentinel lymph node (SLN) biopsy.

Methods

A retrospective review of consecutive patients staged between September 1996 and December 2004 was performed. Intramammary node identification and pathologic findings were compared with the status of axilla.

Results

Among 7,140 patients, intramammary nodes were identified in 151 (2%). Positive intramammary nodes were identified in 36 patients (24%). Axillary disease was identified in 61% of intramammary node-positive patients. No additional axillary disease was identified when axillary lymph node dissection was performed in intramammary node-positive patients with negative axillary SLN biopsy results.

Conclusions

The results suggest that completion axillary lymph node dissection may be based on the status of axillary SLN biopsies in clinically node negative patients when intramammary lymph node metastases are identified in the breast specimens.     

Failure of sentinel lymph node mapping in breast cancer patients qualified for treatment sparing axillary lymph nodes—Clinical importance and management strategy—One‐center analysis

Sentinel lymph node biopsy (SLNB) is a standard in diagnostic and therapeutic management of patients with nonadvanced invasive breast cancer. The aim of this paper was to evaluate the clinical importance of the failure of sentinel lymph node (SLN) identification during SLNB performed to spare axillary lymph nodes. A total of 5396 patients with invasive breast cancer qualified for SLNB, treated in a period from Jan 2004 to June 2018. All cases of the failure of SLN identification and reasons underlying this situation were analyzed retrospectively. In 196 (3.6%) patients, SLN was not identified (group I), and this resulted in a simultaneous axillary lymph node dissection. 48.5% patients from this group were diagnosed with cancer metastases to lymph nodes (vs 23.6% patients with SLN removed—group II, P < .00001)—stage pN1 in 44.2% of the cases, stage pN2 in 22.1% of the cases, and pN3 in 33.7% (in group II—73.4%, 19.5% and 7.1%, respectively), with a presence of extracapsular infiltration in 68.4% patients (vs 41.7% in group II) and with a significantly higher percentage of micrometastatic nature in group II (17.0%, vs 3.2% in group I). The failure of intraoperative sentinel lymph node mapping indicates a significantly increased risk of breast cancer metastases to the axillary lymph system. At the same time, it can also indicate higher cancer stage and its increased aggressiveness. For this reason, in such situation performance of axillary lymph node dissection still appears to be the approach most advantageous for patients.     

胃癌单个淋巴结转移规律及临床意义

目的分析胃癌淋巴结转移的规律以指导临床规范化治疗。方法对天津医科大学附属肿瘤医院1999年7月至2004年6月间经手术治疗、清扫淋巴结数大于或等于10枚、术后病理证实仅有1枚淋巴结转移的胃癌患者临床资料进行回顾性分析．并对淋巴结跳跃与非跳跃转移、横向与非横向转移患者的资料进行对比。结果全组65例患者共检出淋巴结1415枚．平均21．8枚／例;单个淋巴结转移率的分布从多到少依次为N0．3（30．8％）、No．4（21．5％）、No．6（15．4％）、No．7和No．8（均为6．2％）、No．1和No．2及N0．5（均为4．6％）、No．12（3．1％）和No．14及No．16（均为1．5％）;其中跳跃转移20．0％（13／65）,横向转移42．2％（19／45）。单因素分析显示．淋巴结跳跃性转移仅与肿瘤大小有关（X2=4．447,P=0．035）：淋巴结横向转移与各临床病理因素均无关。但淋巴结跳跃与非跳跃转移、横向与非横向转移间患者的生存曲线差异有统计学意义（P=0．000．P=0．000）。结论胃癌淋巴结转移规律总体遵循由远及近的转移顺序．但跳跃转移和横向转移方式也占有一定比例．对于胃癌淋巴结跳跃转移和横向转移的高危患者．术中应加强相应区域淋巴结清扫以提高患者生存率。     

102例前哨淋巴结阳性乳腺癌患者腋窝非前哨淋巴结转移相关因素分析

目的:回顾性研究我中心前哨淋巴结(sentinel lymph node,SLN)阳性并续行腋窝淋巴结清扫术(axillary lymph node dissection,ALND)早期乳腺癌患者的临床病理资料,分析腋窝非前哨淋巴结(non-sentinel lymph node,NSLN)转移的相关危险因素,为建立符合本地区的预测模型提供依据。方法:收集温州市人民医院2009年1月—2016年12月102例前哨淋巴结活检阳性并进一步接受腋窝淋巴结清扫术的早期乳腺癌患者临床及病理资料,采用单因素分析及多因素Logistic回归分析方法研究这些临床病理因素与NSLN转移的关系。结果:本研究中共有102例SLN阳性乳腺癌患者进一步接受了ALND,其中36例NSLN发现有转移,NSLN转移检出率是35.3%(36/102)。根据单因素分析结果显示:组织学分级(χ~2=8.8214,P=0.0030)、SLN转移率≥0.5(χ~2=5.2377,P=0.0221)、SLN转移灶最大径 2 mm (χ~2=4.3290,P=0.0370)是NSLN转移的危险因素。多因素Logistic回归分析结果显示:SLN转移率≥0.5(OR=1.63,95%CI:1.29-2.10,P=0.001)、SLN转移灶最大径 2 mm(OR=1.34,95%CI:1.02-2.12,P=0.032)是NSLN转移的独立预测因素。结论:SLN转移率≥0.5、SLN转移灶最大径 2 mm是预测乳腺癌NSLN转移的危险因素,可以作为预测因素,进一步用来构建符合本地区的预测模型。     

前哨淋巴结活检在结直肠癌根治术中的应用研究

目的探讨前哨淋巴结活检（SLNB）在结直肠癌根治术中临床应用的可行性及其价值。方法应用美蓝对67例结直肠癌患者行前哨淋巴结（SLN）定位活检,分体内、体外组,采用HE染色病理检查法、CK-20免疫组化染色（SP法）检测SLN中转移癌。结果共检出淋巴结660枚,其中SLN130枚,检出率19．7％。腹腔镜结直肠癌根治术和开腹结直肠癌根治术对SLN的检出差异无统计学意义（P=0．742）;体内、体外两种SLN的标记方法差异无统计学意义（P=0．564）;SP法检测SLN癌转移的敏感性明显高于HE染色,而假阴性率明显低于后者;肿瘤细胞在SLN的转移率明显高于区域淋巴结的转移率（P〈0．01）。结论结直肠癌根治术中体内、体外SLN定位方法均可以获得成功,均具有切实的可行性,与手术方式无关,并能够预测区域淋巴结的转移状况;通过SP法检查有助于明确结直肠癌的病理分期,有利于判断预后和个体化治疗方案的制定。     

肺鳞癌、腺癌纵隔淋巴结转移的特点

目的 研究原发肺鳞癌及腺癌纵隔淋巴结转移特点,探讨临床意义.方法 对353例原发肺癌施行同侧纵隔淋巴结廓清术,病理检测淋巴结转移频度.结果 清除淋巴结2380组,平均每例6.74组.N2 淋巴结转移率16.2%.T1、T2、T3间淋巴结转移率差异有统计学意义(P<0.01).N2转移率在鳞癌、腺癌分别为30.1%、44.1%.64.2% 鳞癌N2转移为某一组淋巴结,腺癌3组以上转移者46.2%.上叶肺癌跨区域N2转移占15.1%,下叶(包括中叶)肺癌跨区域转移占53.1%.跳跃式转移占N2转移的53.7%.结论 肺鳞癌及腺癌纵隔淋巴结转移具有多发性、跳跃性及跨区域性特点.     

Modified radical inguinal lymphadenectomy for carcinoma of the penis: technique and results

PURPOSE: Modified radical inguinal lymphadenectomy for carcinoma of the penis is presented that satisfies the requirement for complete groin dissection, while significantly decreasing postoperative complications. MATERIALS AND METHODS: Eight patients with squamous cell carcinoma and 2 with leiomyosarcoma of the penis underwent bilateral modified inguinal lymphadenectomy, including removal of the superficial and deep inguinal lymph nodes. To avoid damage to the vessels of the groin region that run parallel to the inguinal ligament and lie in the fat of the superficial layer of the superficial fascia dissection is done beneath this layer. The proper cleavage plane is just above the membranous layer of the superficial fascia, beneath which the superficial inguinal lymph nodes are located. The saphenous vein is preserved and the sartorius muscle is left in situ, so as not to disturb collateral lymphatic drainage. RESULTS: At a followup of 6 to 104 months no skin necrosis, infection or deep venous thrombosis occurred. In 2 patients early moderate lymphedema of the lower extremities resolved with time, 2 had scrotal edema and 3 had a transient lymphocele. CONCLUSIONS: As described, modified radical inguinal lymphadenectomy decreases the morbidity associated with groin dissection, while removing superficial and deep inguinal lymph nodes.     

分化型甲状腺癌区域淋巴结清扫策略及争议

甲状腺乳头状癌颈部淋巴结转移出现早,但预后好。甲状腺切除手术和彻底合理的淋巴结清扫是公认治疗甲状腺癌的最佳选择。cN1 病人需要行颈淋巴结清扫术,但cN0 病人是否需要进行预防性中央区或颈侧区淋巴结清扫术仍有很多的争议。     

残胃复发癌治疗策略

残胃复发癌的治疗策略取决于癌的浸润深度。内镜下黏膜切除术（EMR）、内镜黏膜下剥离术（ESD）适应证以外的早期残胃癌原则上应行全胃切除术;黏膜内癌应行D1或D1+淋巴结清扫术; 黏膜下层癌应行D1+或D2淋巴结清扫术;缝合部位或吻合口癌应行D2淋巴结清扫术。进展期残胃癌应行全胃切除术和D2淋巴结清扫术。对于能治愈性切除的进展期T3或T4残胃癌,按淋巴流向及淋巴结转移规律行D2+、16a2b1淋巴结清扫术,必要时合并脏器切除。     

乳腺癌分子分型与腋窝淋巴结外科处理

目的探讨乳腺癌分子分型是否影响腋窝淋巴结的术式选择。方法检索有关乳腺癌分子分型与腋窝淋巴结转移情况的文献并进行综述。结果三阴型乳腺癌患者的前哨淋巴结与非前哨淋巴结阳性率均较低,luminalB型和HER-2过表达型患者的腋窝淋巴结转移率较高,尤其是luminalB型乳腺癌患者,其前哨淋巴结阳性率、非前哨淋巴结阳性率均较其他分子分型高,对于行保乳手术的老年患者,当仅有1～2枚前哨淋巴结转移时,可免行腋窝淋巴结清扫;对于肿瘤体积较大的年轻患者,即使前哨淋巴结阴性,非前哨淋巴结阳性的可能性仍然较大,行腋窝淋巴结清扫可能会使这部分患者受益。结论对于腋窝淋巴结的术式选择,乳腺癌分子分型也是需要考虑的因素之一。     

胃癌前哨淋巴结研究进展

前哨淋巴结是从原发肿瘤淋巴引流途中首先可能发生转移的部位。Cabana在阴茎癌中提出前哨淋巴结的概念后,前哨淋巴结活检技术不断在多种肿瘤中广泛应用。目前,该技术已成功用于黑色素瘤、乳腺癌等手术。但在胃癌中,由于胃淋巴引流复杂、存在跳跃转移以及假阴性率较高,前哨淋巴结活检技术应用于临床还为时过早,其可行性和适用性尚无定论。因此,前哨淋巴结活检技术应用于胃癌,还有许多问题需要回答。     

A protocol for performing extended lymph node dissection using primary tumor pathological features for patients treated with radical nephrectomy for clear cell renal cell carcinoma

PURPOSE: We determined the primary pathological features of clear cell renal cell carcinoma that are predictive of positive regional lymph nodes at radical nephrectomy (RN) and developed a protocol for the selective use of extended lymph node dissection. MATERIALS AND METHODS: We studied 1,652 patients who underwent RN for unilateral pM0 sporadic clear cell renal cell carcinoma between 1970 and 2000. A multivariate logistic regression model was used to determine the pathological features of the primary tumor that were associated with positive regional lymph nodes at RN. RESULTS: There were 887 (54%) patients with no positive nodes (pN0), 57 (3%) with 1 positive node (pN1), 11 (1%) with 2 or more positive nodes (pN2) and 697 (42%) who did not have any lymph nodes dissected (pNx). Nuclear grade 3 or 4 (p <0.001), presence of a sarcomatoid component (p <0.001), tumor size 10 cm or greater (p = 0.005), tumor stage pT3 or pT4 (p = 0.017) and histological tumor necrosis (p = 0.051) were significantly associated with positive regional lymph nodes in a multivariate setting. These features can be used to identify candidates for extended lymph node dissection at the time of RN. For example, only 6 (0.6%) of the 1,031 patients with 0 or 1 of these features had positive lymph nodes at RN compared with 62 (10%) of the 621 patients with at least 2 of these features. CONCLUSIONS: The primary tumor pathological features of nuclear grade, sarcomatoid component, tumor size, stage and presence of tumor necrosis can be used to predict patients at the greatest risk for regional lymph node involvement at RN.