淋巴绘图在妇科恶性肿瘤中的应用进展

淋巴绘图技术作为一种标准手术评价方法，在妇科的外阴癌和宫颈癌中已有较多研究。前哨淋巴结的检出率和阴性预测值较高，能更真实地预测其他淋巴结状况，有可能作为决定患者治疗方案依据本文综述淋巴绘图在妇科恶性肿瘤的应用进展。     

妇科恶性肿瘤术后下肢淋巴水肿的预防--附318例分析

目的比较妇科恶性肿瘤手术治疗行盆腔及腹主动脉旁淋巴结清扫术与只行盆腔淋巴结清扫术,术后下肢淋巴水肿的发生率.比较不同的引流方式对于预防下肢淋巴水肿发生的意义.方法采用经阴道或者经腹的不同的术后淋巴引流方式.结果行盆腔及腹主动脉旁淋巴结清扫术,术后行经阴道淋巴引流组淋巴水肿的发生率为26.5%;只行盆腔淋巴结清扫术,术后行经阴道淋巴引流组淋巴水肿的发生率为12.3%,两者比较差异具有显著性(P＜0.05).当术后行经腹淋巴引流方式,上述两种不同范围的淋巴清扫术组,术后淋巴水肿的发生率分别为10.5%、11.8%,并且淋巴水肿程度较轻.结论认为经腹淋巴引流是一种比较好的预防下肢淋巴水肿的引流方式.     

彩色多普勒超声在颈部淋巴结疾病诊断中的应用

目的分析彩色多普勒超声血管模式在颈部淋巴结病变检测中的应用。方法选取我院2009年1月—2013年2月收治确诊的颈部淋巴结病变患者115例临床资料,其中65例男性,年龄10～75岁,50例女性,年龄15～77岁,平均年龄（49±7．8）岁。共分析123个病变淋巴结,淋巴结依照最后的明确诊断结果共分成4组,其中有27个反应性淋巴结、15个结核性淋巴结、41个转移性淋巴结以及40个淋巴瘤。病变淋巴结的血管模式依照彩色多普勒超声的表现共分为4个类型,分别为淋巴门型、中心型、边沿型以及混和型。结果①淋巴门型,结果92．59％的反应性淋巴结与80％的淋巴瘤显示淋巴门血流,淋巴瘤中有75％显示淋巴结边沿血流;在转移性淋巴结中有60.98％出现中心血流,58．54％显示边沿血流;共有2个反应性、1个结核性显示无血供。结论淋巴结中心与边沿显示血流分布可以作为判断淋巴结恶性病变的主要特点,但不可以作为排除结核性淋巴结的手段：淋巴门显示血流分布可以作为判断良性淋巴结的主要特点,但不可以作为排除淋巴瘤的手段。     

螺旋CT间接淋巴造影及多期增强扫描在卵巢癌前哨淋巴结诊断中的评估价值

目的探讨螺旋CT间接淋巴造影及多期增强扫描在卵巢癌前哨淋巴结诊断中的评估价值。方法选取2015年12月-2016年12月在该院接受诊治的86例卵巢癌前哨淋巴结患者作为研究对象,均接受螺旋CT间接淋巴造影、多期增强扫描检查,并经手术病理确诊。观察并比较卵巢癌、前哨淋巴结检出率。结果在T0-T3时间点螺旋CT间接淋巴造影、多期增强扫描、螺旋CT间接淋巴造影联合多期增强扫描、病理活检检出卵巢癌比较,差异无统计学意义(P0.05);在T4时间点两者联合检出率明显高于螺旋CT间接淋巴造影、多期增强扫描单独检测,差异有统计学意义(P0.05);N1、N2时螺旋CT间接淋巴造影、多期增强扫描、联合检查、活检对前哨淋巴结检出率均显示高度差异(P0.05)。结论螺旋CT间接淋巴造影及多期增强扫描在卵巢癌前哨淋巴结诊断中具有一定评估价值,能为临床诊治卵巢癌前哨淋巴结提供参考依据,便于明确卵巢癌分期、淋巴结侵及情况。     

彩色多普勒超声在颈部淋巴结病变诊断中的应用价值

淋巴结为体内周围淋巴器官之一,属于网状内皮系统,有滤过淋巴的作用。颈部淋巴结肿大在临床上很常见,其病因也相当复杂,一般可分为炎症性淋巴结肿大和肿瘤性淋巴结肿大。全身各个部位的恶性肿瘤若发生淋巴道扩散时．均有机会转移至颈部而导致其淋巴结肿大,全身性和局部性感染、结核、淋巴瘤和转移癌等都可表现为淋巴结肿大,肿大淋巴结的定性诊断,对确定治疗方案、疗效的评估和肿瘤进展的监控均有一定的临床意义。     

乳腺癌术后腋窝淋巴结放射治疗研究进展

腋窝淋巴结是乳腺淋巴引流最主要的区域,Vanderent等进行的一项大样本淋巴显像研究显示,淋巴引流至腋淋巴结占95%,至内乳淋巴结占25%。     

妇科肿瘤前哨淋巴结研究现状

前哨淋巴结 (SLN)是指最先接受肿瘤引流的第一站区域淋巴结。这组淋巴结多靠近肿瘤原发部位 ,且位于淋巴直接引流通道上 ,因此常常是最有可能发生转移的淋巴结。 1 974年Cabanas在阴茎癌的研究中提出了 SLN概念 ,之后逐渐引起了肿瘤外科界的重视。目前 ,SL N的研究几乎涉及到了所有实体肿瘤。在某些肿瘤 ,特别是乳腺癌的研究方面取得了突出的成果 ,已经认识到 SLN能够准确地反映乳腺癌区域淋巴结状况 ,对于 SLN阴性的病例可以采用较为局限的前哨淋巴结活检(SLNB)取代传统的区域淋巴结清扫术。在妇科领域 ,Leven-back于 1 984年最早…     

四大信号警示淋巴瘤

在我们身体内部,淋巴和血管、神经一起围绕连接着各个重要器官,淋巴系统起着过滤以及防御功能,它是由淋巴管道、淋巴组织和淋巴器官所组成的。淋巴瘤是一组起源于淋巴结或其他淋巴组织的恶性疾病,常发生于淋巴结和／或结外淋巴组织。相对于肺癌、肝癌、胃癌等各种常见的恶性肿瘤,淋巴瘤显得更抽象、知晓率更低。     

乳腺癌前哨淋巴结活检研究进展

乳腺癌前哨淋巴结活检（Sentinel lymph node biopsy,SLNB）是乳腺外科领域在20世纪90年代中的一个里程碑.淋巴转移是乳腺癌重要的转移方式,前哨淋巴结（sentinel lymph node,SLN）是淋巴转移必经的第一站淋巴结.以SLNB评价腋窝淋巴转移的情况为乳腺癌的手术提供了全新的思路.通过这种微创方法可以筛查出腋窝淋巴结无转移的患者,避免不必要的腋窝清扫,保证了患者的美观和上肢功能.SLNB的活检方法主要有蓝染技术、淋巴放射显影技术、蓝染与淋巴放射显影结合技术.     

乳腺癌前哨淋巴结活检可减少无谓手术

乳腺癌前哨淋巴结(sentinel lymph node,SLN)是最早接受肿瘤区内淋巴引流和发生肿瘤转移的第一站淋巴结。若该淋巴结无转移,则其他淋巴结出现转移几率小,估计仅为5%以下或更低。通过SLN活检预测腋窝淋巴结是否转移,可避免无转移腋窝淋巴     

Lymphatic mapping and sentinel lymph node biopsy for malignant melanoma in Japanese

BACKGROUND: Clinical records of 24 Japanese patients suffering from a primary malignant skin tumor were summarized, and the efficacy of lymphatic mapping (LM) and sentinel lymph node biopsy (SLNB) in cases with possible lymphatic metastasis was investigated, and compared with previous reports. METHODS: There were 17 cases of malignant melanoma (MM), 4 of squamous cell carcinoma (SCC), 2 of extramammary Paget's disease, and 1 of eccrine porocarcinoma. LM and SLNB were performed as additional treatment during extended surgery. RESULTS: Blue-stained lymph ducts and nodes were observed in 21 of 24 cases (87.5% identification rate). In these 21 cases, 3 sentinel lymph nodes (SLNs) were identified in 1 patient (4.8%), 2 SLNs in 5 patients (23.8%), and one SLN in 15 patients (71.4%). In MM, distant metastasis was seen in 3 of 10 cases (30%) with negative SLN. In these 3 cases, Breslow's thickness of the tumor ranged from 2.0 to 3.9 mm (average 2.6 mm). Except for MM, no distant metastases were observed in 7 cases with negative SLN. CONCLUSION: The incidence of MM in Japanese is about 0.001%, and the accumulation of reliable data is slow. Although MM is rare, SCC is more common. Therefore we investigated the clinical data of non-MM patients at risk of metastasis. SLN biopsy in non-MM patients was shown to be linked with their prognosis. In conclusion, the SLN biopsy technique is useful in the early stages of MM, and for non-MM patients at risk of lymphatic metastasis.     

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.     

The historical perspective of the sentinel lymph node concept

The sentinel lymph node procedure is currently standard care in the treatment of breast cancer. The introduction of this procedure in 1992 would not have been possible without the pioneering discoveries regarding lymph nodes and cancer. The Italian surgeon Gaspar Asellius (1581-1626) visualized the lymphatic vessels of a dog after it had been fed and shortly before dissection. At the end of the 17th century, the French anatomists Lauth and Sappey visualized the lymphatics by injecting deceased criminals with mercury. In 1858, the German pathologist Virchow (1821-1902) launched the theory that lymph nodes act as defensive barriers. He also made the first microscopical illustration ofa sentinel lymph node. Gould et al. and Caba?s independently launched the precursors of the current modern sentinel lymph node concept in 1959 and 1977 respectively. Gould et al. were the first people to use the term "sentinel node'. Caba?as used lymphangiography for the visualisation of the sentinel lymph node. Controversies about the barrier function of the lymph nodes, the fear of skip metastasis and the difficulties of performing the Caba?as procedure, prevented a breakthrough of this concept. In 1992 Morton et al. rediscovered the valuable sentinel node biopsy concept and introduced blue dye for the investigation of patients with melanoma. The combination of lymphoscintigraphy, intra-operative gamma probe guidance and patent blue further increased the reliability of the sentinel lymph node biopsy procedure. Unnecessary lymph gland dissection procedures with considerable morbidity can be prevented by this procedure.     

Sentinel node metastasis in the case of colorectal cancer. No role for sentinel node biopsy at present

With sufficient experience, sentinel node biopsy has a high identification rate for several techniques in the case of colorectal cancer. However, the sensitivity of the procedure seems to be too low to justify the replacement of routine pathological examination of the whole mesentery by sentinel node biopsy. Unexpected lymphatic drainage patterns can be found in about 5% of the patients. Therefore, the role of sentinel node biopsy in determining the extension of the resection is minimal in the case of colorectal cancer. In contrast, sentinel node biopsy is helpful in identifying the lymph nodes with the highest risk of harbouring metastases and it facilitates the scrutinising of the lymph node by the pathologist. This will lead to more micrometastases being detected. The prognostic significance of micrometastases and the impact on survival of adjuvant systemic therapy in such patients should be investigated in randomised controlled trials. At present, sentinel node biopsy in colorectal cancer should be restricted to a research setting.     

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识。超声是当前临床上比较常见的用于检查乳腺癌前哨淋巴结的方法,本文针对其实际应用和研究情况进行综述,旨在为临床实践提供参考。     

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.     

Less operations required due to perioperative frozen section examination of sentinel nodes in 275 breast cancer patients]

OBJECTIVE: To determine the reliability of a peroperative frozen section examinations of sentinel lymph nodes in mammary carcinoma. DESIGN: Retrospective. METHOD: In the Reinier de Graaf Hospital and Diagnostic Centre SSDZ Delft, the Netherlands, the results of frozen section from sentinel lymph node investigations of mammary carcinomas from 1997-2000 were compared with the final pathological results. If axillary dissection had been performed on these patients, the histopathological findings of the dissected lymph nodes were also studied. RESULTS: Frozen sections were made of 287 sentinel lymph nodes from 275 patients. A tumour was found in the sentinel lymph nodes of 64 patients and these patients immediately underwent a complete axillary lymph node dissection. For 31 of these patients a tumour was also found in the other lymph nodes. In 29 of these 31 patients, histological examination had shown extranodal extension. The frozen sections from the sentinel nodes of the remaining 211 patients were considered negative. However, in 13 of these patients, the paraffin sections of the sentinel node nevertheless showed a tumour and the remaining axillary lymph nodes were removed in a second operation. In the last 89 patients studied, the sentinel lymph nodes were cut at four levels and stained immunohistochemically at one level for cytokeratins. Accordingly micrometastases were found in the sentinel lymph nodes of 4 of the 13 patients with (false-)negative frozen sections. False-positive results did not occur. CONCLUSION: The major advantage of the sentinel node method in breast cancer is that for women without metastasis present in the sentinel node, axillary dissection is avoided. By means of a peroperative examination of frozen sections, 83% of the patients with a metastasis in the sentinel lymph node (or about one quarter of all patients) were spared from having a second operation for axillary dissection at a later stage.     

纳米炭在乳腺癌腋窝前哨淋巴结活检中的临床应用

目的 探讨纳米炭对乳腺癌腋窝前哨淋巴结示踪的临床效果.方法 对57例乳腺癌患者,术前30 min于乳晕周围分4点及肿瘤表面皮肤皮下均匀注入纳米炭混悬注射液,找到腋窝黑染的第1枚淋巴结确定为前哨淋巴结,然后行改良乳腺癌根治术,观察纳米炭的应用价值.结果 成功检出前哨淋巴结56例,检出率为98.2％（56/57）,准确率为98.2％（55/56）,灵敏度为95.2％（20/21）,假阴性率为4.8％（1/21）,假阳性率为0.结论 纳米炭混悬注射液作为示踪剂能准确反映腋窝淋巴结转移状态,具有操作简便、定位准确、特异性强、染色时间长的优点,值得临床推广.     

Very slight chance of other metastases in axillary nodes of breast cancer patients with a small sentinel node metastasis without extranodal tumor growth

OBJECTIVE: To determine in patients with mammary carcinoma and a sentinel node metastasis whether pathological parameters of the sentinel node metastasis and the primary tumour might have predictive value with respect to the presence of metastases in other axillary nodes. DESIGN: Prospective. METHOD: The study group consisted of the first 100 consecutive patients with a sentinel node metastasis, who subsequently underwent a complete axillary dissection. The patients with metastases in the non-sentinel nodes were compared to those without such metastases regarding the size of the largest sentinel node metastasis and the presence of extranodal tissue invasion near any such node, and size, and type of the primary tumour. RESULTS: The median size of the metastases in the sentinel lymph node in the two groups was 3 mm versus 13 mm respectively (p < 0.001) and the frequency of extranodal tissue invasion 3% versus 74% respectively (p < 0.001); the combination of these factors strongly predicted the presence of non-sentinel lymph node metastases in the axilla (94% area under the receiver operating characteristics curve). None of the 30 patients with a micrometastasis < or = 2.0 mm in the sentinel lymph node had metastases in the non-sentinel axillary lymph nodes. Metastases were present in the non-sentinel axillary lymph nodes in 29 of the 31 patients with extranodal tissue invasion near the sentinel node. CONCLUSION: In breast cancer patients with a sentinel lymph node metastasis < or = 2.0 mm and without extranodal tumour growth a complete axillary lymph node dissection might be unnecessary as the risk of additional metastases was very small.     

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.