Cost comparison of two surgical strategies in the treatment of breast cancer: sentinel lymph node biopsy versus axillary lymph node dissection

OBJECTIVES: The feasibility and accuracy of sentinel lymph node biopsy (SLNB) in the treatment of breast cancer is widely acknowledged today. The aim of our study was to compare the hospital-related costs of this strategy with those of conventional axillary lymph node dissection (ALND). METHODS: A retrospective study was carried out to determine the total direct medical costs for each of the two medical strategies. Two patient samples (n = 43 for ALND; n = 48 for SLNB) were selected at random among breast cancer patients at the Centre Leon Bérard, a comprehensive cancer treatment center in Lyon, France. Costs related to ALND carried out after SLNB (either immediately or at a later date) were included in SLNB costs (n = 18 of 48 patients). RESULTS: Total direct medical costs were significantly different in the two groups (median 1965.86 Euro versus 1429.93 Euro, p = 0.0076, Mann-Whitney U-test). The total cost for SLNB decreased even further for patients who underwent SLNB alone (median, 1,301Euro). Despite the high cost of anatomic pathology examinations and nuclear medicine (both favorable to ALND), the difference in direct medical costs for the two strategies was primarily due to the length of hospitalization, which differs significantly depending on the technique used (9-day median for ALND versus 3 days for SLNB, p < 0.0001). CONCLUSIONS: A lower morbidity rate is favorable to the generalization of SLNB, when the patient's clinical state allows for it. From an economic point of view, SLNB also seems to be preferred, particularly because our results confirm those found in two published studies concerning the cost of SLNB.     

美兰在72例乳腺癌前哨淋巴结活检术中的临床应用分析

目的：探讨美兰染色在乳腺癌前哨淋巴结活检术中的临床应用及准确性分析。方法：选择笔者所在医院2007-2012年72例乳腺癌患者,体查均未扪及腋窝肿大淋巴结,在确诊后于乳晕周或病灶周取4个点皮下注射美兰,定位前哨淋巴结,行前哨淋巴结活检并清扫腋窝淋巴结。结果：72例患者中检出前哨淋巴结70例（检出率97.2%）,前哨淋巴结阳性31例（44.2%）,其中,其余腋窝淋巴结阳性为15例,阴性16例;前哨淋巴结阴性39例（55.7%）,其中其余腋窝淋巴结为阳性的3例,阴性的36例。结论：美兰染色在乳腺癌前哨淋巴结中的应用具有敏感性和准确性,可以预测腋窝淋巴结的转移状态。     

Omitting axilla lymphadenectomy even by positive sentinel lymph node: a change in breast cancer treatment practice

Sentinel lymph node biopsy (SLNB) has been a reliable technique to accurately predict the axilla node status in women with breast cancer with clinically negative lymph nodes. Based on predictive accuracy evidence from large-scale clinical trials, SLNB has become the current standard of care in breast cancer, preventing unnecessary axilla lymph node dissection and its related adverse events in patients who test negative with SLNB. Now a Phase III randomized trial provides evidence that avoiding axilla lymphadenectomy in patients with positive SLNB does not increase locoregional recurrence or mortality. In this article the benefits, risks and selection criteria to safely prevent axilla lymphadenectomy even by positive SLNB are discussed. Moreover, limitations of this practice-changing trial are described with emphasis on caution in patient selection.     

前哨淋巴结活检在乳腺癌手术中的应用

目的：研究前哨淋巴结活检（SLNB）在乳腺癌手术中的应用。方法：回顾性分析本院2011年6月-2014年6月间收治的28例行乳腺癌手术患者的临床资料,于术前2~4 h在肿瘤下方或瘤床内注射0.4 mL/37MBq放射性物质99mTc_DX,术中用r探测仪定位并切除前哨淋巴结（SLN）,再行乳腺肿瘤切除及腋窝淋巴结（ALN）清扫。首先对SLN及ALN进行常规HE检测,再行免疫组织化学（1HC）检测及逆转录多聚酶链反应（RT-PCR）检测细胞角蛋白19（CKl9）mRNA的表达以检测淋巴结的微转移。结果：本次研究的检出率为100%,共检出43枚前哨淋巴结。18例患者有1枚,5例2枚、5例3枚。腋窝淋巴结共检出67枚。患者经HE染色检测后发现4例发生转移;利用印片细胞学对患者前哨淋巴结的阴阳性进行判断,经检查后发现阳性5例,阴性23例。结论：乳腺癌SLNB是可行的,SLN可以预测ALN的转移情况,它在保乳方面起到了重要作用,并且有利于判断是否为患者行腋窝淋巴结清扫,值得推广使用。     

美兰染色法在保乳术中前哨淋巴结活检定位的临床应用

目的探讨使用美兰染色法进行前哨淋巴结活检的可行性与准确性,为临床开展保乳保腋窝手术提供理论依据。方法 32例早期乳腺癌患者在切皮前10～15分钟在乳腺癌肿块周围四点法注射2%美蓝2 ml(总剂量),然后进行前哨淋巴结活检。于腋窝皱襞处沿皮纹做弧形切口,逐层切开,寻找到蓝染淋巴管后沿其追踪,直至找到蓝染淋巴结即为前哨淋巴结(Sentinel Lymph Node,SLN)。其通常位于胸大肌上端外侧缘。将所得SLN送术中冰冻及术后病理检查。然后进行常规的保乳手术及常规的腋窝淋巴结清扫(Ax-illary Lymph Node Dissection,ALND)。结果本研究成功检出SLN 31例,成功率96.8%。检出SLN个数2～4个不等,平均2.8个。术中快速冰冻病理SLN检查结果与术后ALN病理检查结果的比较,冰冻病理检查灵敏度91.7%(22/24);SLNB准确率90.3%(28/31);假阴性率8.2%(2/24);假阳性率4.1%(1/24)。术后病理,ALN检查与SLN检查结果比较,灵敏度95.8%(23/24);SLNB准确率93.5%(29/31);假阴性率4.1%(1/24);假阳性率4.1%(1/24)。比较:术中快速冰冻病理与术后病理检查SLN结果,术中快速冰冻病理SLN检查结果与术后ALN病理检查结果,术后病理ALN检查与SLN检查结果,均p>0.05,差异无统计学意义。结论本组31例患者采用美兰蓝色法定位前哨淋巴结,成功率达到96.8%。美蓝染色法能反应腋淋巴结转移状态,用于指导是否进一步腋窝淋巴结清扫有参考意义。为进一步缩小乳腺癌手术范围,开展保乳保腋窝手术提供了理论依据。     

亚甲蓝染色法检测乳腺癌前哨淋巴结临床应用研究

目的:寻找检测乳腺癌前哨淋巴结(sentinel lymph node,SLN)的方法,并研究前哨淋巴结活检(sentinel lymph node biopsy,SLNB)预测腋窝淋巴结状况的准确性。方法:对81例乳腺癌患者进行亚甲蓝染色法检测SLN,并与腋窝淋巴结切除术(axillary lymphnode dissection,ALND)后的淋巴结转移状况进行对比分析。全部病例均经病理证实。结果:81例患者中成功检测出SLN79例,成功率为97%。共检出SLN166个,平均每例检出2.1个。共出现3例假阴性结果,未有假阳性,假阴性率为3%。79例患者中有30例SLN阳性,阳性率为38.0%;共检测出SLN66个,其中54个为转移癌,转移率为81.8%(54/66)。结论:亚甲蓝染色法检测乳腺癌SLN经济实用,可以较准确地预测腋窝淋巴结的转移状况。     

超声诊断在乳腺癌前哨淋巴结检查中的应用进展

乳腺癌疾病是当前发病率比较高的一种疾病,发病的人群也趋于年轻化.前哨淋巴结是原发肿瘤发生淋巴结转移所必经的第一批淋巴结,其可以作为阻止肿瘤细胞从淋巴道扩散的屏障,临床意义受到人们重视,腋窝淋巴结状态是衡量乳腺癌患者恢复情况的重要指标.随着当前乳腺癌手术方式的多样化,在处理乳腺癌患者腋窝淋巴结的相关问题过程中也有了新的认...     

乳腺癌患者乳腺肿块及腋窝淋巴结的超声声像图特征与腋窝淋巴结转移的关系

目的:探究乳腺癌患者的乳腺肿块及腋窝淋巴结的超声声像图特征和腋窝淋巴结转移的关系.方法:选择2018年6月~2019年3月来本院进行治疗的乳腺癌患者84例作为调查对象,术前对所有患者落实高频二维超声以及多普勒彩色超声的检验,检查患者的乳腺肿块情况,并对患者腋窝淋巴结进行检验,对超声声像图表现加以记录.对所有患者术中进行淋巴结清扫,并对超声检验结果和淋巴结清扫结果进行比较.结果:本文84例患者经病理检验均明确得到确诊,经淋巴结清扫得出45例患者存在淋巴结转移,39例患者没有淋巴结转移,P>0.05;淋巴结转移患者图像的毛刺相对于无淋巴结转移患者而言更加的突出,P<0.05;淋巴结转移患者血流分级比无淋巴结转移更高,P<0.05;经超声判断可疑淋巴结转移患者高于非转移者,P<0.05.结论:通过超声手段检验乳腺癌患者的乳腺肿块和腋窝淋巴结,肿块,毛刺真和血流分级等都提示患者可能存在腋窝淋巴结的转移,能够为乳腺癌腋窝淋巴结转移术前预测提供科学的参考价值.     

Quality-of-Life Impact of Sentinel Lymph Node Biopsy Versus Axillary Lymph Node Dissection in Breast Cancer Patients

ObjectivesControversy about quality-of-life (QOL) benefits of sentinel lymph node biopsy (SLNB) versus axillary lymph node dissection (ALND) in patients with breast cancer remains. Our aim was to compare the impact of SLNB and ALND on QOL and arm symptoms of patients with early breast cancer, using generic (short form 36 health survey) and tumor site–specific (FACT-B+4) instruments.MethodsThis was a prospective longitudinal observational study of 93 patients (64 SLNB, 29 ALND). Patients were evaluated presurgery and 1, 6, and 12 months postsurgery. Generalized estimation equation models were constructed to assess the effect of treatment on QOL. The relative risks of edema, dysesthesia, and heaviness were calculated comparing ALND to SLND.ResultsMost patients presented T1 (67.7%) and underwent breast-conserving surgery (92.5%). At 12 months, the SLNB group presented deterioration on the FACT-B+4 Arm Scale (beta coefficient estimated a change of −1.6 score points; P < 0.01) while, compared with SLNB, the deterioration in the ALND group was almost 2 additional score points higher (P = 0.009). FACT-B+4 global summary and short form 36 health survey did not show statistically significant differences between groups. Relative risk of dysesthesia and subjective edema was higher for the ALND group than for the SLNB group (1.97 and 2.11 at month 12; P < 0.01).ConclusionThese results confirm the benefit of SLNB due to its lower arm morbidity impact on QOL, compared with ALND. There are clinically relevant between-treatment differences in the Arm Scale of FACT-B+4, while there were no relevant differences in general well-being, measured with the disease-specific FACT-B+4 and the generic short form 36 health survey.     

The potential role of SPECT/CT in the preoperative detection of sentinel lymph nodes in breast cancer

Regional lymph node status is the most important prognostic factor in breast cancer. Sentinel lymph node biopsy is the standard method of axillary staging in early breast cancer patients with clinically negative nodes. Preoperative lymphoscintigraphy might support refining biopsy findings by determining the number and location of sentinel lymph nodes. In aged or overweight patients, in the presence of atypical or extra-axillary lymphatic drainage, non-visualized lymph nodes, or sentinel lymph nodes close to the isotope injection site, detection could be aided by a new, hybrid imaging tool: the single-photon emission computed tomography combined with computed tomography (3D SPECT/CT). For the first time in Hungarian language, authors overview the literature: all 14 English-language articles on the implementation of 3D SPECT/CT in sentinel lymph node detection in breast cancer are included. It is concluded that 3D SPECT/CT increases the success rate and quality of preoperative sentinel node identification, and is capable of providing a more accurate staging of breast cancer patients in routine clinical practice.     

Kai1在乳腺癌中的表达

目的探讨Kail的表达与乳腺癌淋巴结转移的关系。方法用免疫组化方法（SABC）检测18例淋巴结转移的乳腺癌和28例无淋巴结转移的乳腺癌组织中Kail的表达.利用计算机图像分析系统采集、分析图像,并对数据进行统计学处理。结果Kail蛋白在无淋巴结转移的乳腺癌中呈阳性或弱阳性表达,淋巴结转移的乳腺癌中呈弱阳性或阴性表达,Kail蛋白在无淋巴结转移的乳腺癌中表达显著高于伴淋巴结转移的乳腺癌（P〈0．01）。结论Kail的低表达可能在乳腺癌淋巴结转移的过程中发挥重要作用。     

Estimates of the Lifetime Direct Costs of Treatment for Metastatic Breast Cancer

OBJECTIVE: Breast cancer remains the highest incident cancer among females in the United States and previous research suggests that a considerable portion of patients will eventually progress to the metastatic phase of the disease. This paper provides the first estimate of the lifetime direct costs of treating metastatic disease for one annual diagnostic cohort of breast cancer patients. METHODS: Incidence rates were combined with US population counts to estimate the number of breast cancer cases diagnosed in 1994. Estimates of progression to metastatic disease (from Canadian provincial cancer registry data), costs of care (derived from patients' claims histories), survival (from SEER data), and national mortality rates (from US Census Bureau) were integrated, using Statistics Canada's Population Health Model (POHEM) to calculate lifetime costs. RESULTS: This study estimates that more than 40% of the women diagnosed with breast cancer will progress to metastatic disease. On average, women with metastatic disease are expected to live 3 years and to incur direct treatment costs of approximately dollar 60,000 per case, resulting in a total lifetime cost for the cohort of almost dollar 4.2 billion. CONCLUSIONS: The high rate of recurrence of breast cancer argues for the development of interventions that can prevent or delay the onset of metastatic disease. These estimates of lifetime costs and the methodology on which they are based can be used to evaluate the cost-effectiveness of such secondary prevention strategies. These estimates also can serve as a benchmark against which the lifetime costs of treating other diseases can be assessed.     

99mTc-硫胶体淋巴结显像联合亚甲蓝在乳腺癌前哨淋巴结活检中的临床研究

目的 探讨99mTc-硫胶体(99mTc-SC)淋巴结显像联合亚甲蓝行乳腺癌前哨淋巴结活检(SLNB),对前哨淋巴结(SLN)阴性者避免行腋窝淋巴结清扫(ALND)的可行性及其临床应用价值.方法 187例乳腺癌患者术前行99mTc-SC淋巴结显像,并进行体表定位,术中加用亚甲蓝示踪SLN,切除后快速冰冻切片.其中51例SLN转移患者行改良根治术,将136例SLN阴性患者分为两组,A组[为腋窝淋巴结阳性患者,58例为术中检测阳性,2例为SLNB术后淋巴结常规病理检查阳性,再次行ALND,共60例]行乳腺切除或象限切除加ALND,B组(术中检测阴性78例,除去术后检测阳性2例,共76例)行SLNB,未行ALND.结果 A组术后上肢麻木、上肢水肿、上肢功能障碍分别为36、8、45例,B组分别为2、0、0例,两组比较差异有统计学意义(P<0.05).A组1、3、5年局部复发分别为0、0、2例,腋窝及锁骨上淋巴结转移分别为1、5、8例,远处转移分别为2、8、12例,无瘤生存分别为60、57、49例;B组1、3、5年局部复发分别为0、0、6例,腋窝及锁骨上淋巴结转移分别为3、8、12例,远处转移分别为4、8、16例,无瘤生存分别为76、70、61例,两组比较差异无统计学意义(P>0.05).结论 99mTc-SC淋巴结显像联合亚甲蓝行SLNB方法 简便,准确率高,疗效确实可靠.

Abstract：

Objective To evaluate the clinical significance of the axillary conservative surgery by sentinel lymph node biopsy (SLNB) using preoperative lymphoscintigraph technique with 99mTc-SC and methylene blue in early-stage breast cancer patients. Methods The sentinel lymph node (SLN) of 187 patients were located with preoperative lymphoscintigraph technique with 99mTc-SC and labeled with methylene blue during the operations. The metastasis of SLN was detected using frozen section technique. There were 51 patients whose SLN were positive having been carried with modified radical mastectomy of breast cancer and axillary lymph node dissection (ALND), 136 patients' SLN were negative,58 patients of those were carried with mammectomy or partial mastcctomy and ALND (group A),while 78 patients were carried out with mammectomy or partial mastectomy only (group B). The sentinel lymph nodes were detected with HE stain after surgery. All the patients were treated with chemotherapy,and the patients with partial mastcctomy must be treated with radiotherapy. There were 2 patients with micrometastasis in group B being treated with mammectomy or partial mastcctomy only,and carried out with ALND again. Results The number of cases with upper limb numbness, edema, dysfunction in group A were 36,8 and 45 cases, in group B were 2,0,0 case respectively. Group A compared with group B was increased significantly (P< 0.05). The number of local recurrence within 1, 3 and 5 years were 0,0,2 cases;lymphatic metastasis were 1,5,8 cases; the distant metastasis were 2,8,12 cases; the disease-free survival were 60,57,49 cases. In group B, the number of local recurrence within 1, 3 and 5 years were 0,0,6 cases, lymphatic metastasis were 3,8,12cases,the distant metastasis were 4,8,16 cases,the disease-free survival were 76,70,61 cases. There were not significant differences between the two groups(P> 0.05). Conclusion It is simple and accurate to carry out SLNB using preoperative lymphoscintigraph technique with 99mTc-SC combined with methylene blue,and the effect is reliable.     

乳腺癌中金属硫蛋白的表达及与其与配对淋巴结转移的关系

目的探讨金属硫蛋白在乳腺浸润性导管癌中的表达及与淋巴结转移的关系。方法用免疫组化s—P法检测乳腺癌及人正常乳腺组织中金属硫蛋白的表达。结果金属硫蛋白在正常乳腺组织几乎不表达,在乳腺癌中的阳性表达阳性率为73.0%;金属硫蛋白在有淋巴结转移组和无淋巴结转移组的阳性率分别为55.2%和13.2%(P<0.05),有统计学意义。结论金属硫蛋白在乳腺癌中表达增高,且同乳腺癌淋巴结转移相关,提示有促进乳腺癌发生、发展的可能。     

探讨B超诊断乳腺癌腋窝淋巴结转移的价值

目的 分析探讨B超诊断乳腺癌腋窝淋巴结转移的价值.方法 对来我院诊治的336例乳腺癌患者进行术前腋窝淋巴结超声检测,及术后常规病理检查,对术前术后结果进行对比验证.结果 经病理证实,临床触诊的灵敏度和诊断符合率相对较低,而B超检查的灵敏度和诊断符合率相对比较高,两者具有较为显著差异,P＜0.05,具有统计学意义;在多年组B超医生与低年组B超医生的诊断结果的灵敏性和差异性均有较为显著的差异.结论 对于判断乳腺癌腋窝淋巴结转移情况,B超诊断明显优于临床触诊,而B超医生经验也对诊断结果有影响,总体而言可作为该病常规检查项目.     

高频彩色超声在乳腺癌淋巴结转移诊断中的价值

目的 分析乳腺癌原发灶及腋窝淋巴结转移的高频彩色超声声像图以及相关因素.方法 回顾性分析132例乳腺癌患者的超声、手术及病理资料,利用ROC曲线评价诊断指标.结果 132例乳腺癌腋窝淋巴结转移阳性率42.4%(56/132).超声诊断符合率92.9%(52/56);淋巴结转移阴性率57.6%(76/132),超声诊断符合率85.5%(65/76).结论 综合考虑乳腺癌原发灶与腋窝淋巴结,有助于提高超声诊断腋窝淋巴结转移的正确率,判断淋巴结状态,为临床分期及制定手术方案提供有价值的信息.     

The role of intraoperative gamma-probe-guided sentinel lymph node biopsy in the treatment of malignant melanoma and breast cancer

In the treatment of malignant tumors regional lymphadenectomy is used for two purposes. It is used partly for staging the regional lymph nodes which is a significant and independent prognostic factor and determines the need for adjuvant oncologic treatment and partly for achieving locoregional disease control. Removal of tumor-free lymph nodes by regional lymph node clearance is unnecessary according to our current knowledge. Since the sensitivity and specificity of non-invasive clinical examinations are insufficient in predicting the nodal status the histological study of the regional lymph nodes cannot be abandoned. A new and minimally invasive surgical procedure, the mapping and removal of the first tumor draining lymph node, the sentinel node provides the possibility of pathological nodal staging without performing formal lymphadenectomy. Mapping of the sentinel node can be performed by the use of a radioisotope and intraoperative hand-held gamma-probe or a vital blue dye or a combination of these two. This latter method was used by the authors in 73 patients (25 with malignant melanoma and 48 with breast cancer). Sentinel lymph node biopsy was performed successfully in 92% of patients with melanoma and 90% of patients with breast cancer. In three breast cancer patients the sentinel node inaccurately predicted the axillary status as negative, but is was in 93% accurate in predicting the histologic nodal state. According to our preliminary experiences intraoperative gamma-probe guided sentinel lymph node biopsy is considered a feasible procedure in both malignant melanoma and breast cancer. More experiences are needed before introducing this method in the routine clinical practice.     

三阴乳腺癌的动态增强磁共振特点分析

目的：探讨三阴乳腺癌的动态增强MRI特点.方法：分析有完整资料的三阴乳腺癌41例,所有病例均在MRI检查结束后经组织病理学证实.应用GE AW4.3图像工作站观察病灶的MRI特点,包括动态增强病灶的形态、边缘、病灶数目、内部强化特点、TIC类型、ADC值及腋窝淋巴结转移情况,并进行统计学分析.结果：41例三阴乳腺癌均为肿块型病变,有46％出现腋窝淋巴结转移.病灶单发的占85％（35/41）,动态增强扫描病灶环形强化占51％（21/41）,TIC类型为Ⅲ型的占80％（33/41）.边缘光滑的三阴乳腺癌占51％（21/41）,边缘不光滑的占49％（20/41）,边缘光滑的病灶形态多为圆形,边缘不光滑的病灶形态多为不规则形,2组间差别有统计学意义.患者年龄、病灶平均大小、病灶数目、动态增强扫描内部强化特点、TIC类型、ADC值的组间差异均无统计学意义.结论：三阴乳腺癌的动态增强MRI多表现为单发肿块,边缘光滑,环形强化,较低的ADC值和Ⅲ型曲线;边缘光滑的三阴乳腺癌多表现为圆形,边缘不光滑的多表现为不规则形;腋窝淋巴结转移率高.