肢端黑色素瘤前哨淋巴结活检临床结果分析

目的 探讨肢端黑色素瘤前哨淋巴结活检的临床规律及临床意义.方法 对2012年3月至2019年8月北京积水潭医院骨肿瘤科收治的肢端黑色素瘤患者中符合前哨淋巴结活检指征的110例行前哨淋巴结活检,前哨淋巴结活检结果 阳性的患者再行淋巴结清扫术.术后常规行病理检查,统计非前哨淋巴结阳性结果.结果110例黑色素瘤患者中,发病于...     

前哨淋巴结活检在皮肤恶性黑色素瘤中的应用现状及进展

前哨淋巴结活检（sentinel lymph node biopsy,SLNB）是皮肤恶性黑色素瘤诊治过程中不可或缺的手段,在进行准确分期、预后判断以及治疗指导等方面都发挥着重要的作用。SLNB的操作方法已基本成熟,但在适应症的选择方面还存在一定的争议,仍无足够的证据表明前哨淋巴结活检联合区域淋巴结清扫（complete lymph node biopsy,CLND）能够延长转移患者的生存。此外,由于国内恶性黑色素瘤的发病率较低,SLNB尚未得到广泛开展,相关的操作方法也较为落后。近年来,随着恶性黑色素瘤发病率增高,其外科治疗也受到越来越多的关注。本文通过总结分析近年来的相关文献,对SLNB在皮肤恶性黑色素瘤中的应用现状和进展进行综述。      

前哨淋巴结活检在中国皮肤和肢端恶性黑色素瘤患者诊治中的临床意义

背景与目的：恶性黑色素瘤近年来在中国发病率呈上升趋势。前哨淋巴结活检（sentinel lymph node biopsy,SLNB）在欧美是皮肤恶性黑色素瘤外科诊治规范的重要环节,但在中国却未广泛开展。中国黑色素瘤具有多肢端亚型、浸润深度厚、溃疡率高和预后差等特点。但中国黑色素瘤外科治疗后的预后仍未明确。该研究旨在分析中国黑色素瘤患者的临床数据,评价SLNB的可行性及其对预后的影响。方法：回顾性分析2009—2017年在复旦大学附属肿瘤医院治疗的无临床淋巴转移和远处转移征象的黑色素瘤患者。每例患者在接受原发病灶扩大切除的同时,进行相应区域淋巴结的SLNB。前哨淋巴结（sentinel lymph node,SLN）的定位通过美兰染色和同位素示踪完成。所有患者术后均进行随访。结果：本研究共纳入452例黑色素瘤患者。平均Breslow浸润深度为3.29 mm,66.4%为肢端病灶,溃疡率达59.7%。SLN阳性率为26.8%,假阴性率为4%,淋巴结总转移率为30.8%。本组患者5年总生存率（overall survival,OS）和无病生存率（disease-free survival,DFS）分别为66.6%和55.8%。SLN状态是显著影响患者预后的独立危险因素,而Breslow浸润深度是预测SLN转移状态的独立危险因素。结论：对于无临床大体转移的中国黑色素瘤患者,应常规开展SLNB。SLN状态是影响复发和总体生存的重要因素,SLNB能提高淋巴结微转移患者的生存,提供准确的临床分期。     

肢端黑色素瘤前哨淋巴结活检临床结果分析

目的探讨肢端黑色素瘤前哨淋巴结活检的临床规律及临床意义。方法对2012年3月至2019年8月北京积水潭医院骨肿瘤科收治的肢端黑色素瘤患者中符合前哨淋巴结活检指征的110例行前哨淋巴结活检,前哨淋巴结活检结果阳性的患者再行淋巴结清扫术。术后常规行病理检查,统计非前哨淋巴结阳性结果。结果110例黑色素瘤患者中,发病于手部20例,其余90例发病于足部。所有病例均检出前哨淋巴结,检出率为100％。前哨淋巴结阳性24例,阳性率为22％。24例患者均行淋巴结清扫术,术后病理分析发现,非前哨淋巴结阳性患者9例,占38％。结论前哨淋巴结活检在肢端黑色素瘤的分期诊断、临床治疗中具有重要的临床意义。     

黑色素瘤前哨淋巴结活检的意义

黑色素瘤可发生于皮肤和黏膜,是目前发病率增长较快、易早期淋巴结转移的恶性肿瘤。淋巴结状态的评估对于黑色素瘤的分期和治疗具有重要意义,前哨淋巴结活检（sentinel lymph node biopsy,SLNB）扮演着重要角色。目前,SLNB技术发展较快,但是SLNB阳性患者行淋巴结清扫（complete lymph node dissection,CLND）是否显著延长总生存期（overall survival,OS）仍然存在争议。全球多中心临床试验结果对前哨淋巴结阳性病例行CLND仍存争议,未得到黑色素瘤特异性生存率（melanoma specific survival,MSS）获益,但是可以确定SLNB能显著提高患者局部控制率,是现阶段循证医学证据下评估和分期的可靠方法。本文就黑色素瘤SLNB的研究进展和意义进行述评。      

99Tcm-IT-Rituximab示踪的前哨淋巴结活检在四肢皮肤恶性黑色素瘤中的应用

  目的  研究99Tcm-IT-Rituximab示踪的前哨淋巴结活检(sentinel lymph node biopsy, SLNB)的准确性及可行性; 探讨其在四肢皮肤恶性黑色素瘤(malignant melanoma, MM)诊治中的应用价值。  方法  2008年3月至2012年3月期间, 北京肿瘤医院骨与软组织肿瘤科收治的67例四肢皮肤MM患者接受99Tcm-IT-Rituximab示踪的SLNB。统计SLNB的检出率和阳性率, 分析SLB状态与T分期、溃疡、年龄、性别、部位等临床特征的关系, 分析其对总生存时间(overall survival, OS)和无病生存时间(disease free survival, DFS)的影响。  结果  67例患者均通过γ探测仪检测到SLN, 检出率为100%;SLN阳性15例, 阳性率为22.4%。χ2检验提示SLN转移与患者年龄、原发灶T分期及是否溃疡有关(P < 0.05)。63例患者获得随访, 随访时间24~69个月, 中位随访时间43个月; Kaplan-Meier生存分析显示, SLN阴性组的3年OS和DFS均优于SLN阳性组(OS:93.9% vs.57.1%, P < 0.01;DFS:79.6% vs.28.6%, P < 0.01);Cox多因素回归分析提示SLN状态和T分期是影响黑色素瘤DFS的独立因素。  结论  99Tcm-IT-Rituximab标记的SLNB能很好地反映恶性黑色素瘤的淋巴结转移状态, 对判断预后、准确分期和指导治疗有重要的意义; 其操作简单, 准确性良好, 是一种方便可行的SLNB手段。      

前哨淋巴结活检对黑色素瘤预后的预测价值

目的探讨前哨淋巴结活检(SLNB)对黑色素瘤预后的预测价值。方法回顾性分析2012年3月至2019年6月北京积水潭医院诊治的118例黑色素瘤患者的临床病理资料。患者术前行体格检查和影像学检查排除区域淋巴结转移,采用99Tcm-右旋糖酐行术前示踪显像,术中γ射线探测仪精准定位,切取前哨淋巴结(SLN)行病理活检;原发灶局部行扩大切除重建术;SLN病理阳性患者行区域淋巴结清扫。采用Cox回归模型分析患者的预后及其影响因素。结果118例患者的病史为2~360个月,平均病史为53.6个月。原发灶位于手足84例,甲下27例,皮肤7例。平均Breslow厚度为3.6 mm,合并溃疡72例(61.0%,72/118)。全组患者平均切取SLN 2.8枚,SLN阳性29例(24.6%,29/118),假阴性率为2.5%(3/118)。淋巴结显性转移和远处转移24例(20.3%,24/118),其中远处转移合并淋巴结转移7例(5.9%,7/118),单纯淋巴结显性转移8例(6.8%,8/118),远处脏器转移9例(7.6%,9/118)。全组患者病理分期为Ⅰ期33例,Ⅱ期56例,Ⅲ期29例,5年生存率为69.5%。Breslow厚度为SLN阳性的独立危险因素,Breslow厚度、SLN状态、SLN阳性数目和远处转移是影响患者总生存的独立影响因素(均P<0.05)。结论对于临床及影像学检查无区域淋巴结转移的患者,SLNB能够提供准确的病理分期并预测患者的预后,临床应常规开展。     

完全性淋巴结清扫对前哨淋巴结阳性黑色素瘤患者的预后价值Meta分析

目的 探讨完全性淋巴结清扫对前哨淋巴结活检阳性黑色素瘤患者的预后价值。方法 计算机检索数据库PubMed、Embase、Cochrane Library、中国知网和万方,并联合参考文献追查,采用Meta分析分析患者生存状态。结果 纳入10篇符合标准的文献,Meta分析结果显示：完全性淋巴结清扫组与淋巴结观察组的肿瘤特异性生存（HR: 0.99, 95%CI: 0.86~1.14, P=0.89）、无复发生存（HR: 0.89, 95%CI: 0.72~1.08, P=0.24）和无远处转移生存（HR: 1.03, 95%CI: 0.89~1.20, P=0.71）差异无统计学意义。结论 完全性淋巴结清扫不能为前哨淋巴结活检阳性黑色素瘤患者带来生存获益。     

肢端恶性黑色素瘤前哨淋巴结活检35例报告

目的：探索99Tcm 标记的右旋糖苷结合γ射线探测仪在淋巴结显像中的用药规律和前哨淋巴结活检的准确性;探讨前哨淋巴结活检在恶性黑色素瘤早期转移诊治中的临床意义。方法2012年3月至2013年5月,我科收治35例肢端恶性黑色素瘤患者,其中手部8例、足部27例。所有病灶Breslow厚度均＞1 mm,且无临床及影像学淋巴结转移的证据。除外淋巴结已有转移的患者。术前4～6 h 在病灶周围注射1～2 mCi的99Tcm标记的右旋糖苷,注射后30 min、2、4 h行核素显像,获得前哨淋巴结的显像图。然后在麻醉下切取前哨淋巴结,术中用γ射线探测仪帮助定位和切取前哨淋巴结。术后淋巴结行3 mm一层的切片,行HE 染色和 HMB-45,S-100,Melan-A 免疫组化染色。前哨淋巴结活检结果阳性的行局部淋巴结清扫。结果核素注射后4 h前哨淋巴结显像稳定。27例足部黑色素瘤患者前哨淋巴结中有7例窝及腹股沟均显像,其余20例仅腹股沟淋巴结显像;8例手部黑色瘤患者中有2例滑车上及腋窝淋巴结均显像,其余6例仅腋窝淋巴结显像。35例均检出前哨淋巴结,前哨淋巴结检出率为100%。前哨淋巴结的个数为1～3个。5例患者的前哨淋巴结病理检查发现有转移,阳性率为14.3%。此5例均行淋巴结清扫术。结论用99Tcm标记的右旋糖苷作为显像剂、术中应用γ射线探测仪的前哨淋巴结活检技术在肢端黑色素瘤中是一种可靠的技术。     

前哨淋巴结活检在外阴恶性黑色素瘤治疗中的初步研究

目的:初步探讨前哨淋巴结(SLN)在外阴恶性黑色素瘤治疗中的临床应用可行性.方法:3例外阴恶性黑色素瘤患者接受根治性外阴切除术+双腹股沟淋巴结清扫术,术前在肿瘤周围皮下粘膜注射1%亚甲蓝溶液1.5ml.术中先行SLN活检术(SLNB),根据染料指示在腹股沟术野内对淋巴结组织进行精细解剖,分离出蓝染的淋巴结为SLN.SLN与清扫术中的非前哨淋巴结(NSLN)分别送检,通过HE染色常规病理检查时病理结果进行比较.结果:3例患者均有SLN检出,分别为1、5、3枚.清扫手术切除NSLN分别为19、32、16枚.3例中1例出现淋巴结转移,为1枚SLN转移;其余2例无淋巴结转移发生.没有假阴性情况出现,无与本研究相关的损伤及副反应发生.结论:SLNB应用于外阴恶性黑色素瘤具有可行性.     

Diagnostic biopsy of cutaneous melanoma,sentinel lymph node biopsy and indications for lymphadenectomy

The incidence of cutaneous melanoma appears to be increasing worldwide and this is attributed to solar radiation exposure. Early diagnosis is a challenging task. Any clinically suspected lesion must be assessed by complete diagnostic excision biopsy (margins 1-2 mm); however, there are other biopsy techniques that are less commonly used. Melanomas are characterized by Breslow thickness as thin (< 1 mm), intermediate (1-4 mm) and thick (> 4 mm). This thickness determines their biological behavior, therapy, prognosis and survival. If the biopsy is positive, a wide local excision (margins 1-2 cm) is finally performed. However, metastasis to regional lymph nodes is the most accurate prognostic determinant. Therefore, sentinel lymph node biopsy (SLNB) for diagnosed melanoma plays a pivotal role in the management strategy. Complete lymph node clearance has undoubted advantages and is recommended in all cases of positive SLN biopsy. A PET-CT (positron emission tomography-computed tomography) scan is necessary for staging and follow-up after treatment. Novel targeted therapies and immunotherapies have shown improved outcomes in advanced cases.     

Desmoplastic melanoma: A 12-year experience with sentinel lymph node biopsy

Aims

Given the paucity of data regarding nodal involvement in desmoplastic melanoma (DM), we decided to review the incidence of nodal metastasis in our patients with DM to better define guidelines regarding the performance of sentinel lymph node biopsy (SLNB) in this specific melanoma subtype.

Methods

Using a prospectively maintained database, we reviewed all patients who underwent treatment for melanoma at the Yale Melanoma Unit in a twelve-year period (1998–2010), during which 3531 cases were treated. We identified 24 patients (0.7%) diagnosed with DM. These patients' records were studied for clinical and histologic parameters and clinical outcomes.

Results

Twenty-two patients from the DM group had SLNB, of which four (18%) were diagnosed with micro-metastasis. These four patients were all treated with completion lymphadenectomy and none had additional positive nodes in the remainder of the nodes. Patients were followed after surgery for a median of 25 months (range 2–60 months). Two patients (9%) developed local recurrence, two (9%) in-transit recurrence, and six (27%) showed distant metastases (three patients were pure DM and three patients showed mixed morphology). Patients with mixed DM had a higher rate of nodal metastasis (25%) vs those with pure DM (14%).

Conclusions

Other authors have reported that patients diagnosed with pure DM were less likely to have a positive SLN (0–2%) than those patients with the mixed DM subtype (12–16%). Our findings of higher incidence rates of regional lymph node metastases in both the pure and mixed DM subtypes (14% and 25%) compel us to continue to still recommend that SLNB be considered in patients with both subcategories, pure and mixed DM.

Level of evidence

Level IV.     

Sentinel node biopsy versus elective lymph node dissection in patients with cutaneous melanoma in a Japanese population

Background In Japan, elective lymph node dissection (ELND) has been the standard treatment for patients with possible nodal melanoma. Sentinel node biopsy (SNB) has now replaced ELND, not only in Japan but also worldwide. The objective of this study was to compare the interim outcomes of SNB and ELND. Methods A retrospective study was conducted among patients with clinically node-negative disease treated at our institute with either SNB (n = 30) or ELND (n = 72). Results The background was similar in the two groups. Nodal metastases were found in 40.0% of patients in the SNB group, but in only 26.4% in the ELND group (P = 0.173). The median follow-up was 31.5 months for the SNB group and 82 months for the ELND group. The incidence of locoregional recurrence and distant metastasis in the SNB group was 10.0% and 16.7%, respectively, and for the ELND group the incidence was 5.6% and 31.9%, respectively. The 3-year disease-free survival rate was similar in the two groups (P = 0.280), and the 3-year disease-free survival rates for node-positive patients were also similar in the two groups (P = 0.90), as were the 3-year disease-free survival rates for node-negative patients (P = 0.193). Conclusion This interim result in a Japanese melanoma population with clinically node-negative disease demonstrated that SNB identified more nodal micrometastases than ELND. This increase in accurate staging likely resulted from the reliable identification of the lymph node field by lymphoscintigraphy, as well as the more detailed pathologic examination of the nodes removed in SNB. It is quite reasonable to perform SNB instead of ELND in this population.     

前哨淋巴结活检指导保留乳房手术患者行选择性腋窝淋巴结清除术的研究

目的研究通过前哨淋巴通道（SLC）行前哨淋巴结活检（SLNB）以指导保留乳房手术（breast—conservingtherapy,BCT）患者行选择性腋窝淋巴结清除术（ALND）的可行性。方法采用非随机对照研究,在BCT患者中采用联合示踪法通过SLC行SLNB。对术中检出的前哨淋巴结（SLN）行细胞印片和冰冻切片检查,根据SLN的术中病理结果行选择性ALND,其中SI。N阳性、行ALND者为A组,SI。N阴性仅行SLNB者为B组。定性资料的比较选用Y。检验,两组均数的比较采用t检验。结果2009年1月至2009年12月采用联合示踪法行SLNB的BCT患者共43例,检出42例,A组28例,B组14例。两组患者的SLC均被显影。每例患者被检出SLN1～3枚,平均1．4枚,共被检出59枚。SLNB检出率为97．7％（42／43）。术后病理检查共检出阳性SI,N29例,其中术中细胞印片、冰冻切片及二者联合病理检测分别检出阳性淋巴结27、27、28例。A组ALND相关并发症发生率明显高于B组（P=0．003）。结论通过SLC行SLNB有助于准确定位SLN,能够指导BCT患者行选择性ALND,降低术后并发症。     

皮肤恶性黑素瘤的前哨淋巴结活检技术

目的:评估前哨淋巴结活检(sentinel lymph node biopsy,SLNB)应用于皮肤恶性黑素瘤诊断和治疗中的临床价值。方法:对18例临床评估无区域淋巴结转移的皮肤恶性黑素瘤患者,应用淋巴核素显像以及术中核素扫描等方法定位前哨淋巴结(sentinel lymph node,SLN);切除SLN后进行快速冰冻和常规石蜡切片病理检查,若SLN为阳性,则加行相应区域淋巴结清扫。结果:18例患者中共检出SLN34枚,其中阳性7枚(20.6%)。5例SLN阳性患者加行区域淋巴结清扫,包括3例腹股沟清扫、1例腋窝清扫和1例颈部清扫;除SLN以外,共清扫淋巴结84枚,其中阳性39枚(46.4%)。结论:SLNB有助于诊断皮肤恶性黑素瘤的淋巴转移,为实施区域淋巴清扫提供重要的临床依据。     

Recurrence after sentinel lymph node biopsy with or without axillary lymph node dissection in patients with breast cancer

BACKGROUND: A regional nodal recurrence is a major concern after a sentinel lymph node biopsy (SLNB) alone in patients with breast cancer. In this study we investigated patterns and risk factors of regional nodal recurrence after SLNB alone. PATIENTS AND METHODS: Between January 1999 and March 2005, a series of 1,704 consecutive breast cancer cases in 1,670 patients (34 bilateral breast cancer cases) with clinically negative nodes or suspicious nodes for metastasis who underwent SLNB at a single institute (Saitama Cancer Center) were studied. All 1,704 cases were classified based upon presence or absence of a metastatic lymph node, treated with or without axillary lymph node dissection (ALND). The site of first recurrence was classified as local, regional node, or distant. The regional node recurrences were subclassified as axillary, interpectoral, infraclavicular, supraclavicular, or parasternal. RESULTS: After a median follow-up period of 34 months (range, 2-83 months), first recurrence occurred in local sites in 32 (1.9%) cases, regional nodes in 26 (1.5%) cases, and distant sites in 61 (3.6%) cases. In 1,062 cases with negative nodes treated without ALND and 459 cases with positive nodes treated with ALND, 11 (1.0%) and 15 (3.3%) recurred in regional nodes, respectively, and 4 (0.4%) and 2 (0.6%) recurred in axillary nodes, respectively. Of 822 cases of invasive breast cancer with negative nodes treated with SLNB alone, 10 (1.4%) recurred in regional nodes, and 4 (0.5%) recurred in axillary nodes. In the 10 patients with regional nodal failure, all of the tumors were negative for estrogen receptor (ER) and/or progesterone receptor (PR) and were nuclear grade (NG) 3. CONCLUSIONS: The axillary recurrence rate was low in patients treated with SLNB alone. Omitting ALND is concluded to be safe after adequate SLNB. Risk factors for regional nodal failure after SLNB alone are negative hormone receptor status and high NG.     

Early (sentinel lymph node biopsy‐guided) versus delayed lymphadenectomy in melanoma patients with lymph node metastases

BACKGROUND:

It is debated whether patients with melanoma who undergo lymphadenectomy after a positive sentinel lymph node (SN) biopsy (SNB) have a better prognosis compared with patients who are treated for clinically evident disease.

METHODS:

The records of 190 patients with cutaneous melanoma who underwent radical lymph node dissection after a positive SNB (completion lymph node dissection [CLND]; n = 100) or who had clinically evident lymph node metastasis (therapeutic lymph node dissection [TLND]; n = 90) were analyzed. Moreover, the MEDLINE, EMBASE, and Cochrane databases were searched for studies that investigated the survival impact of SNB‐guided CLND compared with TLND for clinically evident disease. Standard meta‐analysis methods were used to calculate the overall treatment effect across eligible studies.

RESULTS:

In the authors' series, tumor characteristics did not differ significantly between patients who underwent CLND and those who underwent TLND. After a median follow‐up of 52.6 months, the 5‐year overall survival rate did not differ significantly between CLND patients and TLND patients (68.9% vs 50.4%, respectively; log‐rank test; P = .17). In contrast, a meta‐analysis of 6 studies (n = 2633) that addressed this issue (including the authors' own series) indicated that there was a significantly higher risk of death for patients who underwent TLND compared with that for patients who underwent CLND (hazard ratio, 1.60; 95% confidence interval, 1.28‐2.00; P < .0001).

CONCLUSIONS:

Although no significant survival difference was observed in either series, the pooling of summary data from all the studies that dealt with this issue suggested that SNB‐guided CLND is associated with a significantly better outcome compared with TLND for clinically evident lymph node disease. Cancer 2010. © 2010 American Cancer Society.