乳腺癌前哨淋巴结活检术的发展历史及研究进展

乳腺癌前哨淋巴结活检术（sentinel lymph node biopsy,SLNB）是一项兼具诊断及治疗目的的外科技术，是近年来乳腺外科领域具有里程碑意义的重大进展之一。作为一种腋窝微创外科术式，在乳腺癌综合治疗效果不断提高的背景下，SLNB在近40年的发展呈现出降阶梯趋势，也从侧面反映出乳腺癌作为一种全身性疾病的生物学本质。首先，米兰SLNB185、NSABP-B32等一系列前瞻性随机对照临床试验证实，SLNB可以作为临床腋窝淋巴结阴性早期乳腺癌准确的腋窝分期手段。ACOSOG Z0011、IBCSG 23-01等临床试验结果则进一步丰富了腋窝外科手术降阶梯的概念，前哨淋巴结（sentinel lymph node,SLN）阳性的患者手术范围缩小，即SLN低肿瘤负荷患者中，SLNB可以安全替代腋窝淋巴结清扫（axillary lymph node dissection,ALND）。随后，SLNB以及由此衍生而来的标记淋巴结活检将腋窝微创手术的可行性人群范围进一步扩展到了新辅助治疗的患者。近年来，以EUBREAST-061为代表的回顾性研究及有限的前瞻性研究数据初步证实了腋窝降阶梯...     

早期子宫内膜癌前哨淋巴结活检和淋巴结微转移的研究进展

子宫内膜癌（endometrial cancer,EC）是妇科常见恶性肿瘤之一,近年来很多研究指出前哨淋巴结活检（sentinel lymph node biopsy,SLNB）和前哨淋巴结（sentinel lymph node,SLN）病理超分期可以明确转移淋巴结位置和判定淋巴结转移与否,并被广泛应用于妇科肿瘤。早期子宫内膜癌淋巴结转移率低,然而淋巴结转移情况是指导术后辅助治疗和预测复发的独立危险因素。SLNB与病理超分期等检测手段结合可发现更多的淋巴结转移类型,尤其对淋巴结微转移具有较好检出效果,为早期子宫内膜癌诊疗提供更多依据。本文将对近年来有关早期子宫内膜癌SLNB技术、影响SLNB准确性相关问题、淋巴结微转移问题三方面进行简述,为促进早期子宫内膜癌精准手术治疗,减少术中风险和术后并发症提供可行性方案。     

前哨淋巴结活检术在早期乳腺癌保乳术中的应用

目的探讨前哨淋巴结活检术（sentinellymph node biopsy,SLNB）在早期乳腺癌保乳术中的应用效果。方法回顾性分析56例pT1.2N0M0期乳腺癌行保乳术＋前哨淋巴结活检术的临床资料。56例SLN阴性,未行腋窝淋巴结清扫术（axillary lymph node dissection,ALND）。术后辅以化疗、放疗,激素受体阳性患者行内分泌治疗。结果56例成功施行保乳手术,保乳术后双乳对称。SLNB替代ALND者各项术后并发症少。中位随访时间36个月（1～72个月）,1例发现局部复发,行乳腺癌改良根治术时发现腋窝淋巴结转移;1例发现腋窝淋巴结复发转移。结论SLNB可以缩小手术范围,减少术后并发症,保留腋窝形态,提高保乳质量。     

前哨淋巴结时代乳腺癌的精准区域处理：演进与展望

区域淋巴结状况是乳腺癌重要的预后指标之一,可以指导分期和辅助治疗策略的制定。近30年来乳腺癌前哨淋巴结活检术（sentinel lymph node biopsy,SLNB）研究发展迅速,循证医学Ⅰ类证据支持其为临床腋窝淋巴结阴性早期乳腺癌患者安全、有效的腋窝分期技术,前哨淋巴结阴性及低肿瘤负荷患者SLNB替代腋窝淋巴结清扫术后腋窝复发风险和并发症极低。乳腺癌局部区域控制新理念——应该综合考虑远处转移风险、全身治疗效果与不良反应以及局部区域治疗（手术/放疗）效果与不良反应——推动了SLNB适应人群不断扩展,新辅助治疗与SLNB、内乳SLNB将进一步促进区域淋巴结处理降阶梯,豁免腋窝手术临床研究值得期待。SLNB标志着乳腺癌区域淋巴结迈入微创化精准诊疗时代。本文就前哨淋巴结时代乳腺癌的精准区域处理的演进过程和最新进展进行总结,以期为广大临床工作者提供参考。     

乳腺癌前哨淋巴结规范化处理

前哨淋巴结活检术（sentinel lymph node biopsy, SLNB）标志着乳腺癌淋巴结手术进入微创时代,循证医学I类证据支持SLNB是临床腋窝淋巴结阴性早期乳腺癌患者安全、有效的腋窝诊断技术,前哨淋巴结阴性及低肿瘤负荷患者行SLNB替代腋窝淋巴结清扫术后,腋窝淋巴结复发风险和并发症极低。作为乳腺癌区域淋巴结微创诊断技术,SLNB安全有效替代腋窝淋巴结清扫术应建立在规范化操作前提下。目前SLNB在我国早期乳腺癌患者中逐渐趋于规范化和普及化,本文将对临床实践中SLNB的适应证、示踪剂应用、学习曲线掌握、手术规范操作和组织标本处理等问题进行综述。      

乳腺癌前哨淋巴结活检术中分子诊断的研究进展

乳腺癌前哨淋巴结（sentinel lymph node,SLN）能准确反映腋窝淋巴结的状况。前哨淋巴结活检术（sentinel lymph node biopsy,SLNB）已成为临床腋窝淋巴结阴性早期乳腺癌患者的标准腋窝处理模式。准确、快速、客观的SLN术中诊断可以使SLN阳性患者通过一次手术完成腋窝淋巴结清除,避免二次手术带来的风险及并发症,为患者和术者节约了时间,降低了手术风险,并减少了二次手术带来的费用负担。近年来,术中分子诊断已成为乳腺癌SLN研究的热点之一。     

早期乳腺癌前哨淋巴结活检的新思路

摘 要：前哨淋巴结活检（sentinel lymph node biopsy，SLNB）是乳腺外科较为成熟的一种诊疗手段，但仍存在许多不足。随着研究的推进，针对SLNB也涌现出一些新的思路，如超声造影引导下SLNB、次级前哨淋巴结及相关概念的提出等。全文将对早期乳腺癌前哨淋巴结活检中现存的两大争议问题及新思路进行综述。     

乳腺癌前哨淋巴结活检研究进展

近年来，乳腺癌前哨淋巴结（sentinel lymph node，SLN）研究发展迅速。一系列大样本、前瞻性临床试验证实了前哨淋巴结活检（sentinel lymph node biopsy，SLNB）的安全性。SLNB可以提供准确的腋窝淋巴结分期、SLN阴性患者SLNB替代腋清扫术腋窝复发率和并发症很低，为其提供了循证医学Ⅰ、Ⅱ级的证据。此外，目前的研究也证实SLNB中应用的放射性同位素对患者和医务人员是安全的。SLNB的适应证也在不断扩大。     

前哨淋巴结活检指导乳腺癌腋窝淋巴结清扫的研究进展

腋窝淋巴结清扫（axillary lymph node dissection,ALND）对降低乳腺癌患者的复发转移率、延长乳腺癌患者生存期具有重要意义,临床上绝大部分前哨淋巴结活检（sentinel lymph node biopsy,SLNB）结果阳性的乳腺癌患者均接受ALND。但现有研究显示,部分前哨淋巴结阳性的乳腺癌患者并没有因ALND而取得生存获益,这就引发了对于SLNB阳性的乳腺癌患者是否必须行ALND问题的思考。本文就近年来SLNB指导乳腺癌患者ALND相关研究的新进展进行综述。     

前哨淋巴结活检术在乳腺癌新辅助化疗中的应用进展

前哨淋巴结活检术（sentinel lymph node biopsy,SLNB）主要用于腋窝淋巴结阴性的早期乳腺癌患者,前哨淋巴结阴性者可免除腋窝淋巴结清扫术。但SLNB在非早期乳腺癌患者新辅助化疗过程中的应用是否具有同样的价值,以及如何保证准确率及假阴性率,目前尚无统一共识。本文就SLNB在乳腺癌患者新辅助化疗应用中的研究进展进行综述。     

Sentinel lymph node biopsy in breast cancer patients: the medical oncology perspective

Recent data indicates that the sentinel lymph node biopsy (SLNB) is a possible alternative to axillary lymph node dissection (ALND) in early breast cancer patients, with minimal risk of complications. From the medical oncologist's point of view, the impact of SLNB on the management of patients should consider if SLNB is useful to choose adjuvant treatment, if it is adequate to provide local control, and what is the significance of lymph node micrometastases on treatment and staging. Lymph node involvement has always been recognised as the most important prognostic factor in early-stage breast cancer, even if many other parameters have been evaluated in recent years. However, the lack of knowledge of nodal status in patients with false-negative SLNB seems to result in an undertreatment in a very low percentage of patients. Adjuvant chemotherapy and hormonal therapy with tamoxifen are associated with an absolute reduction of the risk of recurrence and death both in node-positive and in node-negative patients, then if patients are treated with modern adjuvant systemic therapy, any effect associated with false negative SLN should be minimised. The impact of axillary treatment on survival is still controversial, but in recent times axillary lymph node positivity is considered as an indicator for high risk of systemic diffusion of the disease rather than a possible origin of systemic metastases. The significance of occult sentinel lymph node metastases detected by immunohistochemistry (IHC) or molecular biology on prognosis is still uncertain. The new version of the staging system of breast cancer has recognised the need for a standard diagnostic approach and of a nomenclature system which also takes SLNB into account.     

乳腺癌前哨淋巴结的研究热点与评价

前哨淋巴结活检已成为早期乳腺癌区域淋巴结评估的标准术式。随着乳腺癌精准诊疗和预后判断的需要,临床上仍有一些问题值得深入探讨,包括新型示踪剂的临床应用、内乳前哨淋巴结活检在乳腺癌预后判断中的价值、淋巴结阳性患者新辅助治疗后豁免腋窝淋巴结清扫的安全性等。从以上几方面的问题出发,引用近期国内外相关研究结果,就这些乳腺癌前哨淋巴结的研究热点进行分析并展开讨论,以推动早期乳腺癌外科诊疗的规范化。     

前哨淋巴结活检对乳腺癌外科导航的临床分析

目的 探讨前哨淋巴结活检(SLNB)对乳腺癌手术导航的临床价值及可靠性。方法 用染料法(1％亚甲蓝)对30例乳腺癌病人进行腋窝前哨淋巴结(SLN)染色切除。术中冰冻切片，术后石蜡切片，并常规行腋窝淋巴结清除术(ALND)。结果 SLN染色成功率96．7％(29／30)，失败1例。SLN阳性10例，后站淋巴结有癌转移6例(60％)，无癌转移4例（40％)。SLN阴性19例，其中假阴性1例，后站淋巴结均无癌转移。SLNB评价：检出率96．7％、准确率93．3％、敏感度90．9％、假阴性率9．1％、假阳性率0。结论 只要提高技术水平，SLN染料着色和检出率都相对较高，对外科术式选择有实际指导意义。相信SLNB取代传统的ALND已为时不远。     

前哨淋巴结活检在早期乳腺癌患者腋窝管理中的研究进展

传统的观点认为腋窝淋巴结清扫(axillary lymph node dissection,ALND)是前哨淋巴结(sentinellymph node,SLN)阳性乳腺癌患者的标准治疗方法,而ALND容易引起上肢水肿、功能障碍等术后并发症,影响患者生活质量.近几年研究显示,对于SLN阳性的早期乳腺癌,并非所有患者都需...     

早期乳腺癌腋窝亚LevelⅡ淋巴结清扫的初步研究

目的:探索基层医院早期乳腺癌腋窝淋巴结外科处理的适宜方法。方法:对9例符合研究条件的病例先美兰染色(meythylene blue staining)实施前哨淋巴结活检(sentinel lymph node biopsy,SLNB),再补充实施腋窝淋巴结清扫术(axillary lymph node dissection,ALND);ALND术中显露腋静脉,以腋静脉下2cm为界缝线标记,术后将标本从缝线处分离,对淋巴结进行分组取材,将前哨淋巴结、腋静脉下2cm内淋巴结(亚levelⅡ淋巴结)、腋窝其余淋巴结(其余淋巴结)分组送病理检查,观察各组淋巴结数量及肿瘤细胞腋淋巴结转移规律。结果:找到前哨淋巴结6例;5例前哨淋巴结、亚levelⅡ淋巴结、其余淋巴结均为阴性;1例前哨淋巴结、亚levelⅡ淋巴结、其余淋巴结均为阳性;另有1例患者前哨淋巴结未找到,而亚levelⅡ淋巴结检出阳性。结论:基层医院对于早期乳腺癌腋窝淋巴结清扫,可以用美兰染色行前哨淋巴结活检,若前哨淋巴结阳性或未找到前哨淋巴结,行ALND;若前哨淋巴结阴性,行亚levelⅡ淋巴结清扫。     

200 Sentinel lymph node biopsies without axillary lymph node dissection -- no axillary recurrences after a 3-year follow-up

The aim of this study is to evaluate the rate of axillary recurrences in sentinel lymph node (SLN)-negative breast cancer patients after sentinel lymph node biopsy (SLNB) alone without further axillary lymph node dissection (ALND). Between May 1999 and February 2002, 333 consecutive patients with primary invasive breast cancer up to 4 cm and clinically negative axillae were entered into this prospective study. Sentinel lymph nodes were identified using the combined method with blue dye (Patent blue V) and technetium 99m-labelled albumin (Nanocoll). Sentinel lymph nodes were examined by frozen sections, standard haematoxylin and eosin staining and immunohistochemistry staining. In SLN-positive patients, ALND was performed. Sentinel lymph node-negative patients had no further ALND. The SLN identification rate was 98.5% (328 out of 333). In all, 128 out of 328 (39.0%) patients had positive SLNs and complete ALND. A total of 200 out of 328 (61.0%) patients were SLN negative and had no further ALND. The mean tumour size of SLN-negative patients was 16.5 mm. The mean number of SLNs removed was 2.1 per patient. There were no local or axillary recurrences at a median follow-up of 36 months. The absence of axillary recurrences after SLNB without ALND in SLN-negative breast cancer patients supports the hypothesis that SLNB is accurate and safe while providing less surgical morbidity than ALND. Short-term results are very promising that SLNB without ALND in SLN-negative patients is an excellent procedure for axillary staging in a cohort of breast cancer patients with small tumours.     

The sentinel node biopsy after previous breast surgery: preliminary results on 543 patients treated at the European Institute of Oncology

Background. Sentinel lymph node biopsy (SLNB) is an accurate alternative to complete axillary lymph node dissection (ALND) in clinically node-negative breast cancer patients. A previous breast biopsy has been considered a relative contraindication to SLNB. We examined the accuracy of SLNB by following the axillary relapses after the procedure in patients who had undergone a breast biopsy before SLNB.Patients and Methods. Up to December 2003, 4351 patients with the diagnosis of invasive breast cancer underwent SLNB at the European Institute of Oncology. Already, 543 of these patients had undergone a breast biopsy; from June 1997 to January 2004, these patients received SLNB by lymphoscintigraphy performed on the biopsy area. We followed these patients with a clinical assessment every 6 months and instrumental examinations every year, particularly focusing on the research of axillary relapse of disease.Results. In 70.4% of cases, the sentinel node was negative, and only three cases underwent further axillary dissection. The sentinel node was identified in 99% of cases and this was the only positive node in 61.5% of cases with positive axillary nodes. The median follow-up was 2 years; 4 nodal recurrences were observed: 3 axillary lymph node relapses and 1 loco-regional.Conclusions. SLNB accuracy after a previous breast biopsy is comparable with the results obtained in validation studies. SLNB after a previous breast biopsy can be considered a standard procedure. Lymphoscintigraphy identifies the sentinel node in 99% of patients.     

术前淋巴结显像在乳腺癌前哨淋巴结活检中的应用价值

[目的]探讨术前淋巴显像在乳腺癌前哨淋巴结活检中的应用价值。[方法]回顾性分析2010年7月至2013年8月在河南省肿瘤医院行前哨淋巴结活检术的乳腺癌患者1041例,其中483例患者术前行淋巴结显像,558例患者未行淋巴显像而术中直接行前哨淋巴结活检术。[结果]在淋巴显像组中,84.3％（407／483）的患者显像成功,该组SLNB的成功率为98．9％（478／483）。而在未行淋巴显像组中SLNB的成功率为98．7％（551／558）。两组SLNB检出成功率差异无统计学意义（P=0．78）。即使术前淋巴显像失败,其SLNB的检出成功率仍达到98．7％。[结论]术前淋巴显像并不能提高SLNB的成功率。因此,临床工作中行前哨淋巴结活检前,淋巴显像不是必备条件。