早期子宫颈癌前哨淋巴结检测的临床意义

目的　评价前哨淋巴结 (SLN)对早期宫颈癌盆腔淋巴结转移状况的预测价值 ,探讨检测SLN在指导早期宫颈癌盆腔淋巴清扫术中的意义。方法　对 2 0 0 2年 11月～ 2 0 0 3年 8月在山东省肿瘤医院手术治疗的 2 3例早期宫颈癌患者行SLN检测 ,分别利用亚甲蓝和99mTc 硫胶体定位并原位切除SLN送快速冰冻病理检查 ,然后行经腹广泛全子宫切除 盆腔淋巴清扫术 ,比较SLN快速冰冻切片、SLN及其他盆腔淋巴结石蜡切片和抗角蛋白免疫组化染色结果。结果　 2 3例患者中 19例成功检测到SLN ,共检出SLN 5 9枚 ,平均每例 3枚 ,SLN检出率为 83% (19/2 3)。SLN活检术灵敏性为 83% ,特异性为 10 0 % ,与病理检查结果符合率为 95 %。结论　SLN检测能较为准确地预测早期宫颈癌盆腔淋巴结的转移状况 ,但以SLN活检术替代传统的手术方式的可行性和安全性还需要更大样本量的前瞻性病例研究来进一步评价     

纳米炭在腹腔镜下早期宫颈癌前哨淋巴结示踪的临床研究

目的:探讨腹腔镜下应用纳米炭混悬液检测前哨淋巴结(SLN)在早期宫颈癌患者中的识别价值。方法:选取2014年1月至2016年1月在广西医科大学附属肿瘤医院行手术治疗的ⅠA2~ⅡA期宫颈癌患者40例。术前从宫颈3、9点注射纳米炭混悬注射液,腹腔镜直视下识别最先黑染淋巴结作为SLN并切取,单独行病理检查及免疫组化检查。切取SLN后,患者均行腹腔镜下盆腔淋巴结切除术+根治性子宫切除(±腹主动脉旁淋巴结取样术)。结果:40例患者中,38例成功检出至少1枚SLN,检出率为95%(38/40),共检出173枚SLN,平均每例每侧3.9枚SLN。8例(20%)患者共检出29枚阳性淋巴结,其中包括6例患者的阳性SLN,共25枚(86.20%)。前哨淋巴结定位于闭孔37.52%,髂外29.52%,髂内13.94%,宫旁5.09%,髂总12.13%。SLN检测的灵敏度为75%(6/8),准确性为100.0%(38/38),阴性预测值为100.0%(29/29)。结论:早期宫颈癌SLN的转移状态同盆腔淋巴结真实转移状态一致性较高,闭孔淋巴结为SLN检出频次最高的淋巴结,腹腔镜下纳米炭示踪早期宫颈癌SLN具有可行性。     

子宫颈癌根治术中的淋巴显影和前哨淋巴结识别

目的 探索子宫颈癌根治术中淋巴显影和前哨淋巴结识别的方法及其可行性,评价前哨淋巴结预测盆腔淋巴结有无肿瘤转移的准确性。方法 应用染料法对20例宫颈癌患者(临床分期为Ib期3例、Ⅱa期12例、Ⅱb期5例)在根治术中于宫颈肿瘤周围的正常组织中分4点(3、6、9、12点处)注入美蓝或专利蓝溶液4ml,识别和定位蓝染的淋巴结(即前哨淋巴结),然后再按常规行盆腔淋巴清扫术,所有淋巴结一起送病理检查。结果 20例宫颈癌患者中淋巴管有蓝色染料摄取者18例,共有蓝染淋巴结33枚,其中左侧15枚,右侧18枚,前哨淋巴结识别成功14例,识别率为78％(14／18)。共有6例有淋巴结转移,淋巴结转移率为33％(6／18)。成功识别前哨淋巴结的14例中,淋巴结转移5例,其中前哨淋巴结和盆腔淋巴结均转移者2例,仅有前哨淋巴结转移者3例,准确性为100％,假阴性率为0。结论 宫颈癌根治术中淋巴显影和前哨淋巴结识别技术是可行的,但识别率尚有待提高。     

纳米炭标记前哨淋巴结在早期宫颈癌中的临床应用

淋巴结转移与否是判断早期宫颈癌患者预后的独立危险因素和术后是否需要辅助治疗的依据。早期宫颈癌淋巴结转移率较低,大多数患者因无盆腔淋巴结转移而不能从全盆腔淋巴结清扫术中受益。若通过前哨淋巴结(sentinel lymph node,SLN)检测来准确评估早期宫颈癌盆腔淋巴结转移状态,则可以用SLN活检技术替代系统淋巴结清扫术减少手术并发症。虽然目前由于各种原因该项技术未能被临床广泛应用,但纳米炭(carbon nanoparticle,CNP)的出现为其提供了新的契机。CNP具有淋巴系统趋向性和吸附抗癌药物等特点,能在淋巴管、淋巴结高密度且长时间聚集,有利于指导恶性肿瘤的淋巴结清除及淋巴化疗。综述运用CNP混悬液在术前标记早期宫颈癌SLN的可行性,使SLN活检技术替代系统淋巴结清扫术成为可能。     

前哨淋巴结活检技术在早期子宫颈癌腹腔镜手术中的应用

目的探讨前哨淋巴结(SLN)活检技术在早期子宫颈癌腹腔镜手术中的应用。方法本研究是一项前瞻性、单臂、单中心的临床研究, 入组时间为2015年7月, 截止时间为2018年12月, 共入组了在河北医科大学第四医院诊治的78例初治的早期子宫颈癌患者, 其年龄为(50.2±9.3)岁。所有患者均于麻醉后在无瘤块的子宫颈组织处采用浅注射(2～3 mm)、深注射(1～2 cm)法注射示踪剂(亚甲蓝或纳米炭), 随后在腹腔镜下先行蓝染或黑染的SLN切除, 再行子宫广泛性切除+系统性盆腔淋巴结切除±腹主动脉旁淋巴结切除术, 术后对常规病理检查(HE染色)阴性的SLN行连续切片联合免疫组化法细胞角蛋白检测进行病理超分期检查。分析SLN的检出率、SLN的分布、SLN与非SLN的病理检查结果, 评价SLN活检诊断淋巴结转移的效能。结果 (1)SLN的检出率:78例子宫颈癌患者中, 77例检出SLN, SLN总检出率为99%(77/78), 其中SLN双侧检出率为87%(68/78)、单侧检出率为12%(9/78)。(2)SLN的分布:78例子宫颈癌患者共切除盆腔淋巴结1 930枚, 平均每例患者每侧切除盆腔...     

同位素标记白蛋白和异硫蓝染料联合注射用于术中识别早期宫颈癌前哨淋巴结

广泛性子宫切除及盆腔淋巴结清扫术是治疗早期宫颈癌的标准术式,但发生盆腔淋巴结转移的患者约10%～15%,说明盆腔淋巴结清扫不仅对大部分患者无益,反而有并发淋巴囊肿、淋巴水肿等风险。前哨淋巴结是指最早接受肿瘤淋巴引流的淋巴结,也是最早发生转移的淋巴结,前哨淋巴结组织学检查阴性预示其他淋巴结无转移。因此检测前哨淋巴结的转移状况可避免对患者实施过度治疗。为研究联合应用异硫蓝和放射性同位素标记法识别宫颈癌前哨淋巴结的可行性。对24例I期宫颈癌患者和1例IIa期患者术前1d在宫颈4个象限肿瘤周围分别注射99m锝标记的白蛋白,然…     

磁共振间接淋巴造影诊断宫颈癌淋巴结转移的价值

目的评估磁共振(MR)间接淋巴系统造影诊断宫颈癌前哨淋巴结及盆腔淋巴结转移的价值。方法选取2006年1月至2009年3月南京鼓楼医院收治的Ⅰa2～Ⅱa期的宫颈癌患者21例,检查前未行盆腔手术或放疗,在双足趾蹼间或外阴大小阴唇皮内或宫颈间质注射欧乃影造影剂,行MR间接淋巴造影,观察前哨淋巴结、盆腔淋巴管引流情况及淋巴结转移情况。患者均行广泛全子宫切除+盆腔淋巴清扫术。结果 21例成功行MR间接淋巴造影的宫颈癌患者中,能清晰观察到淋巴结形态及淋巴管走行。淋巴造影阳性患者4例,术后病理淋巴结为阳性,1例造影示右腹股沟深淋巴结转移,术后病理为右髂内淋巴结转移;阴性17例,16例术后病理淋巴结检查结果阴性,1例假阴性的病理示左闭孔淋巴结有1/1转移。结论对宫颈癌患者行MR间接淋巴造影可有效显示盆腔引流区域淋巴管、淋巴结的解剖形态,评价前哨淋巴结状态及诊断宫颈癌淋巴是否转移是可行的。     

早期子宫颈癌宫旁淋巴结的识别及其临床意义

目的探讨早期子宫颈癌患者宫旁淋巴结(PLN)存在与否及其分布、转移规律,进而评估以生物染料法(亚甲蓝染色)结合标本的局部解剖识别 PLN 的临床价值。方法选择接受广泛性子宫切除+盆腔淋巴清扫术治疗的早期子宫颈癌(临床分期Ⅰb～Ⅱa期)患者60例,术前在肿瘤周围的宫颈组织内注射1%亚甲蓝4 ml,术中检查有蓝染的淋巴结为前哨淋巴结(SLN)。术后立刻对切除的子宫标本进行局部解剖,从宫旁软组织中分离出 PLN 送病理检查。结果 60例患者中,38例(63%)患者存在 PLN,共检出 PLN 95枚,PLN 的平均直径为(0.46±0.24)cm。其中,57枚(60%)PLN 位于阔韧带内,沿子宫动脉走向分布;另38枚(40%)分布于主韧带、骶韧带及膀胱宫颈韧带内。95枚 PLN 中,69枚(73%)因被亚甲蓝染色而易于识别,并被认定为宫旁组织内的 SLN。60例患者中,12例(20%)患者共17枚 PLN 有转移,其中2例(3%)PLN 是惟一的转移部位。对于78枚无转移的 PLN 中的36枚进行连续切片及免疫组化染色检查发现,3枚有微小转移灶。结论 PLN 存在于大部分宫颈癌患者的宫旁组织内,且为肿瘤转移的好发部位,但极易被忽视。采用生物染料法结合细致的局部解剖可识别 PLN。     

子宫颈癌前哨淋巴结检测技术研究进展

经腹广泛全子宫切除加盆腔淋巴清扫术是目前公认的早期宫颈癌的首选术式，但相当一部分没有淋巴结转移的病人也接受了不必要的、损伤大的盆腔淋巴清扫术。前哨淋巴结(sentinel lymph node，SLN)活检术(sentinel lymph node biopsy，SLNB)这种新兴技术的开展，可以预测早期宫颈癌病人盆腔淋巴结受侵状态，依此决定手术方式，避免非必须的淋巴清扫，缩短手术时间，减少手术并发症，提高病人的生存质量。     

卵巢癌前哨淋巴结的研究意义及进展

前哨淋巴结是指接受原发肿瘤淋巴引流的第一站淋巴结,其病理学性质可代表整个区域淋巴结的状态。早期卵巢癌前哨淋巴结(SLN)的检测有助于判断区域淋巴结有无转移,指导卵巢癌临床分期及行个体化淋巴结清扫术,降低手术并发症。高效、准确的SLN检测是其应用于卵巢癌临床的关键。本文就SLN的概念、示踪方法、分布、临床意义、存在问题及前景进行综述。     

Sentinel lymph node detection in patients with cervical cancer

PURPOSE: We investigated the validity of sentinel lymph node (SLN) detection after radioactive isotope and/or blue dye injection in patients with cervical cancer. PATIENTS AND METHODS: Between December 1998 and May 2000, 50 patients (mean age 44 years) with cervical cancer FIGO stage I (n = 32), stage II (n = 16), or stage IV (n = 2) underwent SLN detection during primary operation (radical laparoscopic-vaginal or abdominal hysterectomy, exenteration). The day before surgery 1 ml of Albu-Res labeled with 50 MBq Technetium 99m was applied into the cervix at 3(00), 6(00), 9(00), and 12(00). Blue dye injection (Patentblue) occurred intraoperatively into the cervix at the same locations. RESULTS: The detection rate of SLN was 78%. Ten patients (20.0%) were diagnosed with lymph node metastases. No SLN was detected in 10 patients, of which 4 patients had positive lymph nodes. Sensitivity and negative predictive value were 83.3 and 97.1%, respectively. The false-negative rate was 16.6% (1 of 6 patients). After the combined injection, the detection rate, sensitivity, and negative predictive values were 100%. A mean of 2.7 pelvic and 2.6 para-aortic SLNs were detected. Para-aortic SLNs were located in the paracaval region in 66.6%, whereas pelvic SLNs were detected in 25.7% at the origin of the uterine artery and in 24.7% at the division of the common iliac artery. CONCLUSION: A combination of radioactively labeled albumin with blue dye allows successful detection of SLN in patients with cervical cancer. The clinical validity of this technique must be evaluated prospectively.     

Sentinel lymph node biopsy improves staging in early cervical cancer

OBJECTIVES: The main study objective was to describe the distribution of sentinel lymph nodes (SLNs) and the prevalence of SLN micrometastases in patients with early cervical cancer. The secondary objective was to confirm the SLN detection rate and negative predictive value found in our preliminary study. PATIENTS AND METHODS: We prospectively included 25 patients with early cervical cancer, each of whom received an injection of 120 MBq of technetium-99m for preoperative lymphoscintigraphy and intraoperative node detection using an endoscopic gamma probe. Patent blue dye was injected intraoperatively. SLNs were sought in the pelvic and para-aortic drainage areas. Radical iliac dissection was performed routinely at the end of the procedure. SLNs were examined after hematoxylin-eosin-saffron staining; negative specimens were assessed using immunohistochemistry. RESULTS: Most (85%) of the SLNs were in the inter-iliac territory. Para-aortic or parametrial SLNs were found respectively in 2 patients and common iliac SLNs in 5 patients. Thus 9/25 patients had additional information due to SLN detection. One metastasis and one micrometastasis were detected in SLNs. No patients had positive non-sentinel nodes with negative SLNs. CONCLUSION: SLN detection ensures the identification of SLNs in unusual locations in 36% of patients. SLN disease was found in 8% of our patients. Thus, SLN biopsy improves staging in patients with early cervical cancer. Studies in larger patient populations are needed to evaluate the clinical impact of SLN biopsy.     

Sentinel node detection in cervical cancer with (99m)Tc-phytate

OBJECTIVES: The aim of this study was to investigate the feasibility of sentinel lymph node (SLN) identification using radioisotopic lymphatic mapping with technetium-99 m-labeled phytate in patients undergoing radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer. METHODS: Between July 2001 and February 2003, 56 patients with cervical cancer FIGO stage I (n = 53) or stage II (n = 3) underwent sentinel lymph node detection with preoperative lymphoscintigraphy ((99m)Tc-labeled phytate injected into the uterine cervix, at 3, 6, 9, and 12 o'clock, at a dose of 55-74 MBq in a volume of 0.8 ml) and intraoperative lymphatic mapping with a handheld gamma probe. Radical hysterectomy was aborted in three cases because parametrial invasion was found intraoperatively and we performed only sentinel node resection. The remaining 53 patients underwent radical hysterectomy with complete pelvic lymphadenectomy. Sentinel nodes were detected using a handheld gamma-probe and removed for pathological assessment during the abdominal radical hysterectomy and pelvic lymphadenectomy. RESULTS: One or more sentinel nodes were detected in 52 out of 56 eligible patients (92.8%). A total of 120 SLNs were detected by lymphoscintigraphy (mean 2.27 nodes per patient) and intraoperatively by gamma probe. Forty-four percent of SLNs were found in the external iliac area, 39% in the obturator region, 8.3% in interiliac region, and 6.7% in the common iliac area. Unilateral sentinel nodes were found in thirty-one patients (59%). The remaining 21 patients (41%) had bilateral sentinel nodes. Microscopic nodal metastases were confirmed in 17 (32%) cases. In 10 of these patients, only SLNs had metastases. The 98 sentinel nodes that were negative on hematoxylin and eosin were submitted to cytokeratin immunohistochemical analysis. Five (5.1%) micrometastases were identified with this technique. The sensitivity of the sentinel node was 82.3% (CI 95% = 56.6-96.2) and the negative predictive value was 92.1% (CI 95% = 78.6-98.3). The accuracy of sentinel node in predicting the lymph node status was 94.2%. CONCLUSION: Preoperative lymphoscintigraphy and intraoperative lymphatic mapping with (99m)Tc-labeled phytate are effective in identifying sentinel nodes in patients undergoing radical hysterectomy and to select women in whom lymph node dissection can be avoided.     

Sentinel lymph node detection in early cervical cancer with combination 99mTc phytate and patent blue

OBJECTIVE: The purpose of this study was to examine sentinel lymph node (SLN) detection in patients with early stage cervical cancer using (99m)Tc phytate and patent blue dye and to compare our method with published findings utilizing other radioisotopic tracers. PATIENTS AND METHODS: A total of 20 consecutive patients with cervical cancer scheduled for radical hysterectomy and total pelvic lymphadenectomy at our hospital underwent SLN detection study. The day before surgery, lymphoscintigraphy was performed with injection of 99m-technetium ((99m)Tc)-labeled phytate into the uterine cervix. At surgery, patients underwent lymphatic mapping with a gamma-detecting probe and patent blue injected into the same points as the phytate solution. RESULTS: At least one positive node was detected in 18 patients (90%). A total of 46 sentinel nodes were detected (mean, 2.3; range, 1-5). Most sentinel nodes were in one of the following sites: external iliac (21 nodes), obturator (15 nodes), and parametrial (7 nodes). Eleven (24%) sentinel nodes were detected only through radioactivity and two (4%) were detected only with blue dye. The sensitivity, specificity, and negative predictive value for SLN detection were all 100%. Nine published studies involving 295 patients had a summarized detection rate of 85%. Summarized sensitivity, specificity, and negative predictive value were 93%, 100%, and 99%, respectively. CONCLUSION: Combination of (99m)Tc phytate and patent blue is effective in SLN detection in early stage cervical cancer.     

Tracer injection sites and combinations for sentinel lymph node detection in patients with endometrial cancer

Objective

The aim of the present study was to clarify the most effective combination of injected tracer types and injection sites in order to detect sentinel lymph nodes (SLNs) in early endometrial cancer.

Patients and methods

The study included 100 consecutive patients with endometrial cancer treated at Tohoku University Hospital between June 2001 and December 2012. The procedure for SLN identification entailed either radioisotope (RI) injection into the endometrium during hysteroscopy (55 cases) or direct RI injection into the uterine cervix (45 cases). A combination of blue dye injected into the uterine cervix or uterine body intraoperatively in addition to preoperative RI injection occurred in 69 of 100 cases. All detected SLNs were recorded according to the individual tracer and the resultant staging from this method was compared to the final pathology of lymph node metastases including para-aortic nodes.

Results

SLN detection rate was highest (96%) by cervical RI injection; however, no SLNs were detected in para-aortic area. Para-aortic SLNs were detected only by hysteroscopic RI injection (56%). All cases with pelvic lymph node metastases were detected by pelvic SLN biopsy. Isolated positive para-aortic lymph nodes were detected in 3 patients. Bilateral SLN detection rate was high (96%; 26 of 27 cases) by cervical RI injection combined with dye.

Conclusion

RI injection into the uterine cervix is highly sensitive in detection of SLN metastasis in early stage endometrial cancer. It is a useful and safe modality when combined with blue dye injection into the uterine body.     

Lymph node mapping and sentinel node detection in patients with cervical carcinoma: a 2-year experience

OBJECTIVE: To describe our experience with the sentinel lymph node biopsy in cervical cancer patients, using a laparotomic approach and blue dye technique. METHODS: Between January 2003 and January 2005, patients with histologically proven FIGO stage IA2 to IIA carcinoma of the uterine cervix were submitted to SLN procedure if they were scheduled to have radical abdominal hysterectomy and pelvic lymphadenectomy. The SLN mapping was done after intracervical methylene blue (4 ml) injection. Final pathologic evaluation of SLNs included serial step sections and wide spectrum cytokeratin immunohistochemical analysis. RESULTS: Fifty patients were accrued to this prospective observational double-center study. A total of 86 SLNs (mean 1.9) were identified in the 45 patients with fruitful quest for SLN detection. The SLN detection rate per patient was 90%, and for the side of dissection, 72%. Bilateral SLNs were detected in 60% of cases. SLNs were identified in the external iliac and obturator areas in 55% and 38%, respectively; 5 isolated SLNs were discovered in the common iliac region. Ten patients (20%) had lymph node metastases; one of these had false-negative SLN. The false-negative rate and the negative predictive value, calculated by patient and by side of dissection, were 10% and 97.2%, and 8.3% and 98.4%, respectively. CONCLUSIONS: SLN detection with blue dye is a feasible procedure, particularly useful as a surgical staging procedure in young patients with small tumors. The true morbidity-sparing role of this technique in cervical cancer treatment is yet to be found.     

Laparoscopic sentinel lymph node mapping for cervix cancer--a detailed evaluation and time analysis

OBJECTIVE: To provide data from a US center on laparoscopic (LSC) approach to sentinel lymph node (SLN) detection in cervix cancer with detailed time analysis. METHODS: This prospective trial enrolled patients with stage IA2-IIA cervix cancer undergoing primary radical surgery. Tc-99 radiocolloid was injected the morning of surgery, followed by hybrid SPECT/CT lymphoscintigraphy. Blue dye injection occurred just prior to incision. After bilateral LSC SLN detection, all patients received complete LSC pelvic lymphadenectomy. Institutional SLN protocol was followed for frozen section, hematoxylin and eosin, and cytokeratin staining. RESULTS: Between December 2003 and February 2006, 20 enrolled patients received 9 LSC-assisted radical vaginal hysterectomies, 7 radical abdominal hysterectomies, 2 LSC-assisted radical vaginal trachelectomies, and 2 LSC lymphadenectomies alone (secondary to positive lymph nodes). Mean tumor size was 2.5 cm. Nineteen percent of the 64 SLNs were found in unusual sites, including common iliac (11%), presacral (5%) and para-aortic (3%). The negative predictive value was 100%. The combined technique detected SLNs bilaterally in all patients. If blue dye alone was used, this rate would have dropped to 67.5% and was negatively correlated with elapsed surgical time (-0.7; p=0.002). The ability to visualize blue SLNs remained steady for 30 min and was completely gone by 50 min. CONCLUSIONS: Laparoscopic SLN mapping can be newly introduced into gynecologic oncology centers with high detection rates and negative predictive values. The visualization of blue dye in SLNs is transient, and this negative time correlation may explain the previously reported inferior detection rates with this technique. CLINICAL TRIAL REGISTRATION.: ClinicalTrials.gov, http://www.clinicaltrials.gov, NCT 00205010.     

Change in clinical management of sentinel lymph node location in early stage cervical cancer: the role of SPECT/CT

Objective

The aim of this study was to investigate the feasibility of the sentinel lymph node (SLN) identification with SPECT/CT lymphoscintigraphy imaging in the early stage invasive cervical cancer in patients undergoing radical hysterectomy and pelvic lymphadenectomy.

Methods

Between March 2007 and June 2009, a prospective consecutive study was designed for SLN mapping. Twenty-two patients with cervical cancer FIGO stage IB1 (n = 20) or stage IIA1 (n = 2) underwent SLN identification with preoperative SPECT/CT and planar images (technetium-99 m colloid albumin injection around the tumor) and posterior intraoperative detection with both blue dye and a handheld or laparoscopic gamma probe. Complete pelvic lymphadenectomy was performed in all cases by open (n = 2) or laparoscopic (n = 20) surgery.

Results

In the present series, a total of 35 SLN were detected with planar images and 40 SLN were identified and well located by SPECT/CT lymphoscintigraphy (median 2.0 nodes per patient). In 5/22 patients (22.7%) SPECT/CT procedure improves the number of localized SLN. Intraoperatively, 57 SLNs were identified, with a median of 3 SLNs per patient by gamma probe (a total of 53 hot nodes) and a median of 2 nodes per patient after blue dye injection (a total of 42 blue nodes). Microscopic nodal metastases (eight nodes, corresponding to four patients) were confirmed in 18.18% of cases; all these lymph nodes were previously detected as SLN. The remaining 450 nodes, including SLNs, following complete pelvic lymphadenectomy, were histologically negative.

Conclusions

Sentinel lymph node detection is improved by SPECT/CT imaging because of the increased number of SLN detected and the better tridimensional anatomic location, allowing easier intra-operative detection with gamma probe and showing, in this series, a 100% negative predictive value.