乳腺癌前哨淋巴结探查的研究进展

乳腺癌前哨淋巴结（sentinel lymph node,SLN)是乳腺癌淋巴转移通道中最先经历的第一级淋巴结。通过乳腺癌SLN预测乳腺癌区域淋巴结转移状况，为乳腺癌的准确分期和外科手术提供了重要的依据。根据示踪剂的不同，有两种方法可以探查乳腺癌SLN，其中使用放射性核素标记物作为示踪剂探查乳腺癌SLN是目前较具优势的方法，且不同于传统的淋巴显像；乳腺癌SLN探查的成功率受到诸多因素的影响，其探查技术亦需进一步的研究来提高。     

经皮超声造影在前哨淋巴结诊断中的应用研究进展

前哨淋巴结（sentinel lymph node,SLN）状态在乳腺癌、黑色素瘤等以淋巴转移途径为主的肿瘤治疗及预后中具有重要价值。经皮超声造影（percutaneous contrast-enhanced ultrasound,PCEUS）以其简便、经济、无创的优点逐渐应用于SLN的定位和定性检查中,有望成为精准施行SLN活检（SLN biopsy,SLNB）的辅助手段。本文主要综述了PCEUS在以淋巴结转移为主要途径的肿瘤中诊断SLN的应用研究进展。     

乳腺癌前哨淋巴结探查的研究进展

乳腺癌前哨淋巴结(sentinel lymph node, SLN)是乳腺癌淋巴转移通道中最先经历的第一级淋巴结。通过乳腺癌SLN预测乳腺癌区域淋巴结转移状况,为乳腺癌的准确分期和外科手术提供了重要的依据。根据示踪剂的不同,有两种方法可以探查乳腺癌SLN,其中使用放射性核素标记物作为示踪剂探查乳腺癌SLN是目前较具优势的方法,且不同于传统的淋巴显像;乳腺癌SLN探查的成功率受到诸多因素的影响,其探查技术亦需进一步的研究来提高。     

前哨淋巴结显像剂99Tcm-IT-Rituximab的制备及其定位性能

目的研究前哨淋巴结（SLN）显像剂^99Tc^m-亚氨基噻吩（IT）．美罗华（Rituximab）的标记方法及其定位效应。方法采用2-IT作为双功能连接剂，制备^99Tc^m-IT-Rituximab，确定最佳反应条件，评价标记抗体分子完整性及生物活性。观察比较^99Tc^m-IT-Rituximab及^99Tc^m-硫胶体（SC）2种示踪剂在小鼠淋巴结中的定位性能。将^99Tc^m—IT—Rituximab作为显像剂，对10例乳腺癌患者行乳腺癌SLN动态显像。结果2-IT与Rituximab连接的最佳物质的量比为10：1，4℃反应45min后，每分子抗体螯合上的游离巯基数平均为2．1个。IT—Rituximab分子保持完整、免疫活性保留完全。^99Tc^m-IT-Rituximab的标记率〉90％，其与B淋巴瘤细胞株Raji细胞的结合率为69．4％。动物显像结果显示^99Tc^m—IT—Rituximab可清晰定位小鼠SLN，注射后30min～24h SLN均可显影，2h后SLN显影清晰，至24h未见次级淋巴结显影。动物体内分布数据显示^99Tc^m-IT-Rituximab定位性能明显优于^99Tc^m-SC，24h时SLN百分注射剂量率（％ID）为4．49％，次级及第3级淋巴结基本无摄取，24h注射点滞留率为22．14％。结论该标记方法简单，标记率高；^99Tc^m—IT—Rituximab在SLN中定位性能良好，是一种潜在的新型SLN显像剂。     

美兰染色在乳腺癌前哨淋巴结清扫术中的应用

目的探讨使用国产染料美兰示踪和定位乳腺癌前哨淋巴结活检对乳腺癌腋淋巴结转移预测的准确性。方法选择我院Ⅰ～Ⅱ期乳腺癌患者112例．在乳晕下及肿瘤周围皮下注射美兰进行示踪和定位前哨淋巴结．行前哨淋巴结活检并腋窝淋巴结清扫。结果112例中成功检出前哨淋巴结109例，检出率97．34％（109／112）。109例检出SLN中，SLN阴性61例，SLN阳性48例．阳性率44．04％。112例ALN阳性49例，阳性率43．75％。SLN与ALN经病理检查完全符合者47例。2例SLN阴性而ALN阳性，1例SLN阳性而ALN阴性。灵敏度97．96％（48／49），准确性97．25％（106／109），假阴性率4．08％（2／49），假阳性率2．04％（1／49）。结论使用国产染料美兰示踪和定位乳腺癌前哨淋巴结活检，敏感性和准确性较高能茹准确撕而涮啼窑淋田结持穗的特泰     

吲哚菁绿在乳腺癌前哨淋巴结活检中的应用观察

目的 探讨吲哚菁绿(ICG)单独应用于乳腺癌前哨淋巴结(SLN)活检的临床应用前景.方法 选择2014年7-12月接受手术的72例女性乳腺癌患者,年龄33～67岁,中位年龄50岁,随机分为实验组(n=35)和对照组(n=37),分别以ICG和亚甲蓝作为示踪剂实施SLN活检.手术切除标本送快速冰冻病理检测,证实存在SLN转移者,行腋窝淋巴结清扫,SLN阴性者不行腋窝淋巴结清扫.结果 ICG法检出率为94.3％,成功检出SLN 111个,平均每例检出3.2个SLN,准确率94.3％,灵敏度100％,假阴性率0％;亚甲蓝法检出率为91.9％,成功检出SLN 78个,平均每例检出2.1个SLN,准确率89.2％,灵敏度92.9％,假阴性率为7.7％.两组平均检出个数和假阴性率差异有统计学意义(P＜0.05),检出率、准确率、灵敏度差异无统计学意义(P＞0.05).结论 采用ICG法进行SLN活检成功率高,假阴性率低,临床效果优于亚甲蓝法,有望单独应用于乳腺癌SLN活检.     

联合使用蓝染料和Tc同位素测定胃癌前哨淋巴结的临床意义

目的探讨胃癌中前哨淋巴结（sentinel lymphnode，SLN）概念的适用性，评估前哨淋巴结活检预测胃癌区域淋巴结转移状态的价值及其指导胃癌淋巴结清扫范围的临床意义。方法46例胃癌患者，术前经胃镜于病灶周围黏膜下注入锝标记的锡胶体，术中于病灶周同浆膜下分点注入亚甲蓝，待亚甲蓝显示淋巴结后，将γ探测仪检测到的放射活性最高的淋巴结视为胃癌前哨淋巴结，行术中冰冻免疫组化和常规病理检查或进一步行常规免疫组化染色，分别计算前哨淋巴结诊断胃癌淋巴结转移状态的准确性、敏感性、阴性预测值。结果胃癌前哨淋巴结的检出成功率为100％（46／46）。联合法测定SLN诊断胃癌周围淋巴结转移状态的准确性为100％．敏感性为100％，阴性预测值为100％。结论前哨淋巴结概念适合于胃癌；联合使用蓝染料和锝标锡胶体示踪检测胃癌前哨淋巴结可准确预测胃癌周围淋巴结的转移状态，并可能用于指导胃癌的淋巴结清扫范围。     

乳腺癌前哨淋巴结核素显像新进展

乳腺癌是全球女性发病率最高的恶性肿瘤, 为保证患者的生存率、减少术后并发症, 20世纪90年代用"腋窝前哨淋巴结活检术取代腋窝淋巴结清扫"的观点被提出并逐渐发展成为乳腺癌患者保乳术的常规方法。除腋窝前哨淋巴结外, 内乳前哨淋巴结的重要性同样不容忽视, 但是否将其作为前哨淋巴结活检的对象仍存在争议。面对目前形势, 核医学工作者做了大量研究, 在保证腋窝前哨淋巴结高显示率的同时尽可能提高内乳前哨淋巴结的显示率。笔者对近十年来国内外研究者在乳腺癌前哨淋巴结核素显像中的核素示踪剂、注射技术、显像仪器等方面的最新进展进行综述。     

RSNA2013分子影像学

RSNA2013报道的分子影像学相关研究进展主要包括以下几个方面：①靶向特异性分子探针及复合分子探针的研发及应用：如靶向特异性磁性纳米对比剂、免疫复合超声微泡对比剂及放射荧光杂交示踪剂等,应用于肿瘤血管靶向显像、肿瘤化疗疗效评价、肿瘤淋巴结转移显像等。②多模态分子显像技术的发展：采用MRI、US、SPECT及荧光反射成像（FRI）多模态监测肿瘤抗血管治疗的早期效果。③放射基因图谱的研发及能谱CT分子成像。     

临床颈淋巴转移阴性口腔鳞癌的前哨淋巴结研究

目的探讨前哨淋巴结活检术(SLNB)在口腔鳞癌治疗中的的预测价值。方法口腔鳞癌患者20例,使用亚甲蓝染色法对前哨淋巴结进行染色识别。结果SLNB成功率为70％。SLNB对颈淋巴结微转移的检测准确率为100G。前哨淋巴结(SLN)每例平均2．4枚。14例患者中有6例存在颈部淋巴转移,其中5例仅转移至SLN,1例SLN和非SLN均有转移。结论SLNB能准确预测口腔鳞癌颈淋巴结转移情况,为SLNB阴性的口腔鳞癌患者避免颈淋巴清扫术提供了诊断依据。     

Single-photon emission computed tomography/computed tomographyfor sentinel node mapping in breast cancer

Accurate lymph node staging is essential for the prognosis and treatment in patients with cancer. The sentinel lymph node is the first node to which lymphatic drainage and metastasis from the primary tumor occurs. In malignant melanoma and breast cancer, the sentinel lymph node detection and biopsy already have been implemented into clinical practice. Currently, 2 techniques are used to identify the sentinel lymph nodes: technetium-99m-labeled colloid and blue dye. After peritumoral injection, the material migrates through the lymphatics to the first lymph nodes draining the tumor. The precise anatomic localization of the sentinel lymph nodes is important for minimal invasive surgery and to avoid incomplete removal of the sentinel lymph nodes. All sentinel lymph nodes should be resected to achieve a complete nodal staging. In the inguinal or low-axillary nodal stations, planar scintigraphic images mostly are adequate for the localization of the sentinel lymph nodes. However, in the regions of the head and neck, the chest, and the pelvis, an imaging method for the more precise anatomic localization of the sentinel lymph nodes preoperatively is highly desired. Recently, integrated single-photon emission computed tomography and computed tomography (SPECT/CT) scanners have become available. Initial reports suggest that integrated SPECT/CT might have an additional value in sentinel lymph node scintigraphy in head and neck tumors and tumors draining to the pelvic lymph nodes. We evaluated the clinical use of integrated SPECT/CT in the identification of the sentinel lymph nodes in patients with operable breast cancer. In our experience, localization and identification of sentinel lymph nodes was more accurate by integrated SPECT/CT imaging in comparison with planar images and SPECT images, respectively. In this report, the experiences of sentinel lymph node imaging with SPECT/CT are summarized.     

Ultrasmall superparamagnetic iron oxide enhanced MR imaging for lymph node metastases

The presence of a lymph node metastasis is one of the most important factors influencing therapeutic planning and prognosis in patients with malignancy. For example, a single nodal metastasis approximately halves the survival rate in patients with head and neck cancer, regardless of the location or size of the primary tumor. Currently used imaging techniques such as CT or conventional MRI are unreliable in detecting involved nodes accurately. There are few new techniques that have proven to be of value in nodal staging, and one such technique is ultrasmall superparamagnetic iron oxide (USPIO) contrast agents for MRI. Administered intravenously, USPIO are phagocytosed by macrophages within lymph nodes. Homogeneous uptake of iron oxide particles in normal lymph node shortens the T2 and T2*, turning these nodes dark on post contrast images whereas malignant nodes, lacking the normal physiologic uptake, remain hyperintense on T2- and T2*-weighted images. These differences in signal intensity between normal and metastatic nodes are easily detected visually, leading to high sensitivity and specificity regardless of size or morphological features.This article will review the physiologic properties of USPIO, the technical considerations for imaging using USPIO agent, the results of various clinical trials, and other experimental agents, as well asthe future directions.     

Update on detection of sentinel lymph nodes in patients with breast cancer

Sentinel lymph node biopsy is now the practice of choice for the management of many patients with breast cancer. This was not true in the early 1990s, when the first such procedures were performed and protocols for such were refined often. This was also not true in the first years of the 21st century, when a decade of collective experience and information acquired from numerous clinical investigations dictated additional subtle and not-so-subtle refinements of the procedures. However, it is true today; reports of the latest round of clinical investigations indicate that there are several breast cancer sentinel node procedures that result in successful identification of potential sentinel nodes in nearly all patients who are eligible for such procedures. A significant component of many of these successful sentinel node procedures is a detection and localization protocol that involves radiotracer methodologies, including radiopharmaceutical administration, preoperative nuclear medicine imaging, and intraoperative gamma counting. The present state and roles of nuclear medicine protocols used in breast cancer sentinel lymph node biopsy procedures is reviewed with emphasis on discussion of recent results, unresolved issues, and future considerations. Included are brief reviews of present radiotracer and blue-dye techniques for node localization, including remarks about injection strategies, counting probe technology, and radiation safety. Included also are discussions of on-going investigations of the implications of the presence of micrometastases; of the management value of detection, localization, and excision of extra-axillary nodes such as internal mammary nodes; and of the broad range of recurrence rates presently being reported. Remarks on the present and possible near- and long-term roles for nuclear medicine in the staging of breast cancer patients including comments on positron emission tomography and intraoperative imaging conclude the article.     

A preliminary study on sentinel lymph node biopsy: feasibility and predictive ability in oral cavity cancer

The main factor that affects the prognosis of patients with head and neck cancer (HNC) is regional lymph node metastases. For this reason, the accurate evaluation of neck metastases is required for neck management. This study investigates the sentinel lymph node identification and the accuracy of the histopathology of the sentinel lymph node in patients with HNC. Eleven patients with histologically proven oral squamous cell carcinoma accessible to radiocolloid injection were enrolled in this study. Using both lymphoscintigraphy and a handheld gamma probe, the sentinel lymph node could be identified in all 11 patients. Subsequently, the sentinel lymph nodes and the neck dissection specimen were examined for lymph node involvement due to tumor. The histopathology of sentinel lymph nodes was consistent with the pathological N classification in all 11 patients. Furthermore, the histopathology of sentinel lymph nodes was superior to physical examination, computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) scan. The results of this study indicate that sentinel lymph node identification is technically feasible and predicts cervical metastases in patients with oral cavity cancer. This may be a useful diagnostic technique for identifying lymph node disease in staging lymph node dissection.     

Scintigraphic visualization of an epigastric sentinel node in recurrent breast cancer after lumpectomy and postoperative radiation therapy

Sentinel node imaging and biopsy have become standard procedures for staging early breast cancer. Positive sentinel lymph node (SLN) biopsy necessitates the need for axillary lymph node dissection (ALND). Failure to visualize a sentinel lymph node in recurrent breast cancer after treatment by surgery, chemotherapy, and high-dose postoperative radiation therapy is almost the case in every patient. The reason for failure to visualize the sentinel node is the fibrosis that follows high-dose radiotherapy and blocks the lymphatics preventing spread of the tumor cells to the lymph nodes. Alternative pathways for the drainage of lymph from the breast are developed in these patients. We have previously reported on the alternative pathways of lymphatics to the contralateral axilla, supraclavicular area, and also reported on the development of intramammary lymph nodes. In this report, we are presenting another alternative pathway of lymphatics to the region of the epigastrium below the lower end of the sternum.     

The role of sentinel node detection techniques in vulvar and cervical cancer

The sentinel node is the first lymph node that receives the lymph drainage from the primary tumour. The pathological status of the sentinel node should reflect the histopathology of the entire regional lymph drainage area--both vulvar and cervical cancer spread through the lymphatic system. In gynaecological oncology recent studies have confirmed the utility of the sentinel node concept in vulvar and cervical cancer. Three techniques for sentinel node localisation are available. The preoperative lymphoscintigraphy and intraoperative hand-held gamma probe detection require the administration of the technetium-99m-labelled colloid around the tumour. The other method is based on the injection of the patent blue dye--during the surgery of the sentinel node because of the dye uptake becomes visible. Following detection, the sentinel lymph node can be removed separately and assessed with ultrastaging and immunohistochemical staining. In the early stages of vulvar and cervical cancer the lymph nodes metastases rate is relatively low--in most cases lymphadenectomy is not necessary. The determination of the regional lymph nodes' pathological status may limit the extent of the surgical treatment. The sentinel node detection rate is relatively high and depends on the applied technique. This technique may play an important role in the treatment of vulvar and cervical cancer. This paper describes the details of sentinel node identification and reviews the literature.     

Cervical lymph nodes

The lymph node staging is a very important prognostic parameter for patients with presenting with head neck cancer and is influencing the selection of the different therapeutic strategies including surgery, chemotherapy, radiotherapy or a combination of them. The accuracy of imaging techniques, such as US, MR imaging, and CT, depends on the appropriateness of radiological criteria used for diagnosing lymph node metastases. Size of nodes and evidence of necrosis are still the most important radiological criteria. However, the size shows great variability. A spherical lymph node larger than 10mm is an indicator for a malignant node, whereas an oval shape and/or a fatty hilus are more benign signs. But there are many limitations and different cut offs published in the literature, indicating that the size of a lymph node is not a reliable criteria for the assessment of lymph nodes in the head and neck region. Today new high-resolution MRI sequences and the development of specific contrast agents are offering new possibilities in the diagnostic work-up of head and neck lymph nodes. Ultrasmall superparamagnetic iron oxide particles (USPIO's) are resulting after intravenous application in a reduction of the T2 relaxation time. This is causing a signal decrease on T2-weighted MR images in benign lymph nodes after administration of USPIO's, whereas malignant lymph nodes do not show a significant signal decrease. Some clinical studies presented already very promising results. Based on the fact, that the size evaluation of lymph nodes in the head and neck has not changed during the last decade, this paper will mainly focus on MRI with new contrast agents and new techniques as diffusion weighted imaging (DWI).     

Imaging axillary lymph nodes in patients with newly diagnosed breast cancer

The presence of axillary lymph node metastasis in patients newly diagnosed with breast cancer carries significant prognostic and management implications. As a result, there is increasing interest to stage accurately the axilla with preoperative imaging to facilitate treatment planning. Currently, the most widespread imaging techniques for the evaluation of the axilla include ultrasound and magnetic resonance imaging. In many settings, the ability to detect axillary lymph nodes containing metastases with imaging and image-guided biopsy can allow surgeons to bypass sentinel lymph node dissection and proceed with full axillary lymph node dissection. However, no imaging modality currently has sufficient negative-predictive value to obviate surgical staging of the axilla if no abnormal lymph nodes are detected. Promising advanced imaging technologies, such as diffusion-weighted imaging and magnetic resonance lymphangiography, hold the potential to improve the accuracy of axillary staging and thereby transform management of the axilla in patients newly diagnosed with breast cancer.     

Internal mammary lymph node metastases in breast cancer: what should radiologists know?

The internal mammary lymph node (IMLN) chain is a pathway through which breast lymphatic drainage flows. The internal mammary lymphatic vessel runs around the internal mammary artery and veins with IMLN in the parasternal intercostal spaces. IMLN metastasis, which forms a part of clinical TNM staging, may negatively affect the prognosis of primary breast cancer patients. IMLN metastasis is clinically detected using ultrasound, computed tomography, magnetic resonance imaging, and ¹⁸F-deoxyglucose positron emission tomography computed tomography. The uptake of radioactive tracers in IMLN with clinically negative axillary lymph nodes is often identified using sentinel lymph node mapping (SLNM) in primary breast cancer patients. The indication for IMLN biopsy or resection that is clinically detected or visualized using SLNM is controversial. The clinically suspicious IMLN may be considered for ultrasound-guided fine-needle aspiration. First IMLN recurrence needs to be biopsied. Irradiation of the breast, chest wall, and/or regional nodal irradiation, including IMLN, following lumpectomy or postmastectomy is recommended. Although radiation therapy for IMLN recurrence may improve clinical outcomes, it is also associated with pulmonary and cardiac toxicities. This review covers the local anatomy of IMLN, lymph drainage and image findings of IMLN with a discussion.