术中切除活检对亚甲蓝行乳腺癌前哨淋巴结活检术检出率的影响

目的 探讨肿物切除活检术后对亚甲蓝染色行乳腺癌前哨淋巴结活检的检出率有无影响.方法 回顾性分析2009年7月-2014年7月南方医科大学附属南海医院接受前哨淋巴结活检的T1-2N0M0期乳腺癌患者共76例,其中直接行前哨淋巴结活检者37例,将乳腺肿物局部切除后再行前哨淋巴结活检者39例.比较两组患者前哨淋巴结的检出率差异有无统计学意义.结果 76例患者共有70例成功检出前哨淋巴结,检出率为92.1％.其中切除活检组成功活检34例,检出率为87.2％,穿刺活检组成功活检36例,检出率为97.3％,但两组结果经统计其差异并无统计学意义(P＞0.05).结论 术中切除活检对亚甲蓝行乳腺癌前哨淋巴结活检术的检出率似乎并无显著影响.     

Stage migration with sentinel node biopsy in breast cancer

Background

Axillary staging provides the single most important piece of prognostic information in breast cancer patients. This retrospective study was performed to document the phenomenon of stage migration.

Methods

Of 392 patients, 5 (1%) failed identification of sentinel lymph nodes (SLNs) and therefore underwent axillary lymph node dissection (ALND). Four patients (80%) had metastatic lymph nodes, 302 (77%) patients had negative SLNs, 47 (15%) underwent ALND, 85 (22%) had positive SLNs, 11 (13%) received adjuvant radiation treatment to the axilla, and 74 (87%) underwent completion ALND.

Results

The median (quartiles) follow-up period was 29 months (19-46 mo). Twenty of 392 (5%) patients had disease relapse; 2 of which were local (.5%) and the rest were systemic. Earlier relapse was related significantly to lymph node status, tumor grade, and tumor size. SLN-negative patients who did not receive ALND had a relapse rate of 2.3% (6 of 256) compared with 0% in those who were truly negative based on confirmatory ALND. SLN-positive patients who did not receive ALND had a 9% (1 of 11) relapse rate.

Discussion

The stage-matched pattern of relapse between SLN biopsy and ALND patients revealed lower relapse rates in SLN biopsy-staged patients, documenting the stage migration phenomenon.     

Reoperative sentinel lymph node biopsy in patients with locally recurrent breast cancer

BACKGROUND: Sentinel lymph node biopsy (SLNB) is considered a standard of care in the staging of breast cancer. The objective was to examine our experience with reoperative SLNB. METHODS: We identified 19 patients in our breast cancer database who had a SLNB in the reoperative setting. All 19 patients had undergone previous breast-conserving surgery with either an axillary lymph node dissection or an SLNB. The reoperative sentinel lymph node (SLN) was identified using blue dye, radioisotope, or both. RESULTS: The SLN was identified in 84% of the reoperative cases. Of these successful cases, both blue dye and radioisotope were used in five cases, and radioisotope alone was used in 11 cases. Radioisotope identified the SLN in the 100% of successful SLNB cases (P = .0003). There were 3 unsuccessful cases in which blue dye and radioisotope failed to identify the sentinel node. CONCLUSIONS: Reoperative SLNB after previous axillary surgery is technically feasible.     

Use of reoperative sentinel lymph node biopsy in breast cancer patients

BACKGROUND: Ipsilateral breast recurrence or second primary breast cancer can develop in patients who have undergone breast conservation and sentinel lymph node biopsy (SLNB). This brings into question the necessity of complete axillary lymph node dissection (CALND) versus a second SLNB (remapping). Our objective is to determine the feasibility of a reoperative SLNB. STUDY DESIGN: A review of patients receiving a reoperative SLNB between April 1994 and December 2006 was conducted with IRB approval. Fifty-six patients underwent a second SLNB on the ipsilateral side an average of 42.5 months after their first SLNB. RESULTS: Sentinel lymph nodes were successfully remapped in 45 of 56 (80.4%) patients. Of 45 patients successfully remapped, 36 (80%) were node negative and were spared CALND. There was only 1 patient (2.2%) in whom a sentinel lymph node was identified outside of the ipsilateral axilla. At 26 months mean followup for the second SLNB, there have been no axillary recurrences and 1 death. CONCLUSIONS: Our findings demonstrate that remapping sentinel nodes in patients with ipsilateral recurrence or new primary breast cancer after SLNB achieved success in 80.4% of patients. Overall, 80.0% (36 of 45) of the successfully remapped patients were spared a CALND.     

乳腺癌前哨淋巴结活检的研究进展

腋窝淋巴结清扫（axillary lymph nodes dissection，ALND）一直是乳腺癌外科治疗中不可缺少的组成部分，对乳腺癌临床分期、判断预后、指导治疗和防止局部复发具有重要的临床价值。但随着腋窝淋巴结阴性的早期乳腺癌发病比例逐年增高，ALND的治疗意义也逐渐下降，还可导致术后许多并发症，影响了患者的肢体功能和生活质量。因此，越来越多的学者对乳腺癌常规行ALND的必要性提出质疑。随着对前哨淋巴结活检（sentinel lymph node biopsy，SLNB）技术研究的不断深入，已有越来越多的医生和医疗机构接受了这一全新的概念和技术。     

Axillary management after sentinel lymph node biopsy in breast cancer patients

According to the available data, sentinel lymph node (SLN) biopsy is proving to be an accurate staging technique with less post-surgical morbidity than standard axillary lymph node dissection (ALND). Survival benefits associated with SLN biopsy and, as well as the significance of IHC detected micrometastases have yet to be determined. The long term results of several multicenter trials are pending, yet preliminary results are in favor of abandoning ALND in favor of the less invasive alternative. Despite this, ALND remains the standard of care in breast cancer patients with clinically palpable axillary lymph nodes that are suspicious for metastatic disease. Although controversial, many clinicians believe that axillary metastases will precede systemic spread of disease. Therefore, axillary clearance of clinically palpable nodes could potentially quell the progression of metastases. Regardless of whether or not this theory is true, not many would argue against debulking suspicious nodal disease.     

乳腺癌内乳区前哨淋巴结活检术研究进展

内乳区淋巴结的转移状况是乳腺癌的独立预后指标,也：是乳腺癌淋巴分期的重要依据之一。内乳区淋巴结转移的患者预后较差。随着前哨淋巴结活检技术的不断发展和新型注射技术的出现,内乳区前哨淋巴结活检的显像率显著提高,经肋间行内乳区前哨淋巴结活检术可以最小的风险评估内乳区淋巴结状况,并进一步完善乳腺癌的淋巴结分期．有助于为患者制定更为准确的个体化治疗方案。     

Evidence-based medicine applied to sentinel lymph node biopsy in patients with breast cancer

Sentinel lymph node biopsy (SLNB) has not been examined using the principles of evidence-based medicine (EBM). Specifically, likelihood ratios have not been used to assess the validity of SLNB.The Surveillance, Epidemiology, and End Results (SEER) public database of the National Cancer Institute was used to establish the baseline or pretest probability of finding a positive lymph axillary node for each stage of breast cancer. Rates of false negative results of SLNB for all breast cancer stages were determined from the surgical literature. Positive and negative likelihood ratios (LR) were calculated. For each stage of breast cancer, the Bayesian nomogram was used to find the post-test probability of missing a metastatic axillary node when the SLN was negative. The SEER database of 213,292 female patients with breast cancer yielded the following rates of positivity of axillary lymph nodes for each breast tumor size: T1a, 7.8 per cent; T1b, 13.3 per cent; T1c, 28.5 per cent; T2, 50.2 per cent; T3, 70.1 per cent. The combined data from 13 published studies of SLNB (6444 successful SLNBs) demonstrated a false negative rate of 8.5 per cent. The LR of a negative test is 0.086. According to the nomogram, the chances of missing a positive node for stage of cancer are as follows: T1a, 0.7 per cent; T1b, 1.5 per cent; T1c, 3.0 per cent; T2, 7 per cent; T3, 18 per cent. The risk of missing a positive axillary node can accurately be estimated for each stage of breast cancer using the LR, which is much more useful than the simple false negative rate. Surgeons should use this information when deciding whether to perform SLNB and in their informed consent discussions.     

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.     

Single institution's initial experience with sentinel lymph node biopsy in breast cancer patients

Background: The sentinel lymph node is the first draining node from a cancer‐bearing area and is therefore the first to manifest metastasis. In breast cancer it has been shown to predict the axillary status. Axillary dissection provides information determining prognosis and need for adjuvant therapy but carries a certain morbidity. Our aim was to determine the feasibility of detecting the sentinel node in a teaching hospital and whether the sentinel node accurately predicts the axillary status. Methods: All patients with stage I and II breast cancer and non‐palpable axillary nodes were eligible, including those with previous excision biopsy. We excluded pregnant women, those with previous axillary surgery and women with advanced breast cancer with enlarged axillary nodes. The sentinel node was detected with technetium‐99m‐labelled tin colloid and vital blue dye and removed, and axillary clearance was performed. Results: A total of 312 patients were examined from August 1996 to December 1998. The mean age was 53 years (range 28?83) and mean tumour size 2.6 cm (range 0.2?9.0). The detection rate of the sentinel node was 86%. The sentinel lymph node predicted the axillary status with a sensitivity of 83% and specificity of 100%. The false‐negative rate was 16.7%. Conclusions: Detection of the sentinel lymph node is feasible and it can accurately predict the nodal status of the axilla. ­However, the high false‐negative rate precludes as yet the use of sentinel lymph node biopsy in replacing axillary clearance as the standard of care for breast cancer.     

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。     

Internal mammary sentinel node biopsy for breast cancer

Background

The purpose of this study was to determine the value of lymphoscintigraphy (LS) for internal mammary sentinel node (IMSN) identification, the metastatic rate, and the change in staging and treatment.

Methods

Between 2001 and 2007 a prospective database was obtained of all patients undergoing IMSN biopsies using an open or thoracoscopic approach. Radiotracer injection was peritumoral.

Results

Thirty-four patients were included. There was one man. Three had ductal carcinoma in situ. LS showed IMSN in 47.1%. The IMSN biopsy success rate was 91.2%. Seven of the 28 successfully biopsied invasive cancer patients had metastatic IMSNs (25%). Positive IMSNs were associated with positive axillary nodes in 71.4% (P = .036). All patients with positive IMSNs were upstaged and received radiation to the internal mammary chain. In 4 of 28 patients (14%) the chemotherapy plans were probably altered. In univariate and multivariate analyses tumor size, location, nuclear grade, estrogen receptors, progesterone receptors, Her-2, and histology were not significant predictors of positivity.

Conclusions

IMSNs were positive in 25% of the invasive cancer patients. All had treatment changes. LS identified less than 50% of IMSNs. There are no good tumor-related predictors of IMSN positivity.     

The value of sentinel lymph node biopsy in elderly breast cancer patients

BACKGROUND: Although sentinel lymph node biopsy has been accepted as a useful procedure for certain breast cancer patients, the value of this procedure in the elderly remains unknown. We undertook this study to evaluate changes in adjuvant treatment attributable to sentinel lymph node biopsy. METHODS: A total of 104 patients > or =65 years underwent sentinel lymph node biopsy plus lumpectomy or mastectomy for the treatment of clinically node-negative invasive breast cancer. Demographic, pathologic, and treatment data were evaluated using an SAS software package (SAS, Cary, North Carolina). RESULTS: Twenty-nine of 104 patients (28%) had metastatic disease in > or =1 sentinel lymph node. Nonsurgical treatment was modified in 38% of patients because of sentinel lymph node biopsy results. Changes included adjuvant chemotherapy and/or hormonal therapy, adjuvant axillary radiotherapy, and decisions against adjuvant therapy. CONCLUSIONS: These data suggest that sentinel lymph node biopsy in elderly breast cancer patients is beneficial.