乳腺癌前哨淋巴结活检

18 94年 ,美国医生Halsted首创了乳腺癌根治术 ,使术后复发率由当时的 5 8%～ 85 %下降到 6% ,开创了肿瘤器官整块广泛切除和区域淋巴结清扫的经典肿瘤外科治疗原则。 2 0世纪 70年代 ,美国学者Fisher提出乳腺癌是一种全身性疾病 ,区域淋巴结并非癌细胞滤过的有效屏障 ,血流扩散更具重要意义的理论后 ,乳腺癌手术逐步向保乳手术迅速发展。近年来 ,不少学者对乳腺癌常规行腋淋巴结清扫 (axillarylymphnodedissection ,ALND)这一金标准的必要性提出质疑 ,引发了乳腺癌外科治疗的又一次革命[1] 。近期不断有资料显示 ,较小范围的腋淋巴结切…     

单用蓝染料示踪剂在乳腺癌前哨淋巴结活检中的价值

目的探讨单用蓝染料示踪剂在乳腺癌前哨淋巴结活检术(SLNB)中的临床价值。方法本研究共纳入308例患者,均采用联合法(蓝染料联合核素示踪剂)进行SLNB,分别记录单用蓝染料和联合法行SLNB的相关数据并进行对比分析。结果染料法与联合法行SLNB的成功率(93.5%比99.4%,P=0.000)、假阴性率(14.8%比3.3%,P=0.007)、准确性(89.6%比97.8%,P=0.006)和阴性预测值(74.0%比93.3%,P=0.012)的差异均有统计学意义。2种方法的成功率及假阴性率与患者年龄、肿瘤大小、肿瘤部位、组织学类型、肿瘤切检方式、乳房手术方式以及ER、PR和HER-2状况均无关(均P0.05)。染料法的假阴性率在临床腋淋巴结可疑肿大者中显著升高(P=0.042),并随前哨淋巴结检出数目增多而逐渐降低(P=0.000)。结论与联合法相比,染料法SLNB的成功率、准确性和阴性预测值显著降低,假阴性率显著升高,推荐临床实践中应尽量采用联合法,避免单用染料示踪剂进行SLNB。     

Sentinel Lymph Node Biopsy in Early Breast Cancer

The role of axillary surgery for the treatment of primary breast cancer is in a process of constant change. During the last decade, axillary dissection with removal of at least 10 lymph nodes (ALD) was replaced by sentinel lymph node biopsy (SLNB) as a staging procedure. Since then, the indication for SLNB rapidly expanded. Today's surgical strategies aim to minimize the rate of patients with a negative axillary status who undergo ALD. For some subgroups of patients, the indication for SLNB (e.g. multicentric disease, large tumors) or its implication for treatment planning (micrometastatic involvement, neoadjuvant chemotherapy) is being discussed. Although the indication for ALD is almost entirely restricted to patients with positive axillary lymph nodes today, the therapeutic effect of completion ALD is more and more questioned. On the other hand, the diagnostic value of ALD in node-positive patients is discussed. This article reflects today's standards in axillary surgery and discusses open issues on the diagnostic and therapeutic role of SLNB and ALD in the treatment of early breast cancer.     

Second Biopsy of Axillary Sentinel Lymph Node for Reappearing Breast Cancer After Previous Sentinel Lymph Node Biopsy

Background Sentinel lymph node biopsy (SLNB) is a safe and accurate axillary staging procedure for patients with primary operable breast cancer. An increasing proportion of these patients undergo breast-conserving surgery, and 5% to 15% will develop local relapses that necessitate reoperation. Although a previous SLNB is often considered a contraindication for a subsequent SLNB, few data support this concern. Methods Between January 2000 and June 2004, 79 patients who were previously treated at our institution with breast-conserving surgery and who had a negative SLNB for early breast cancer developed, during follow-up, local recurrence that was amenable to reoperation. Eighteen of these patients were offered a second SLNB because of a clinically negative axillary status an average of 26.1 months after the primary event. Results In all 18 patients (7 with ductal carcinoma-in-situ and 11 with invasive recurrences), preoperative lymphoscintigraphy showed an axillary sentinel lymph node, with a preoperative identification rate of 100%, and 1 or more SLNs (an average of 1.3 per patient) were surgically removed. Sentinel lymph node metastases were detected in two patients with invasive recurrence, and a complete axillary dissection followed. At a median follow up of 12.7 months, no axillary recurrences have occurred in patients who did not undergo axillary dissection. Conclusions Second SLNB after previous SLNB is technically feasible and likely effective in selected breast cancer patients. A larger population and longer follow-up are necessary to confirm these preliminary data.     

Sentinel Lymph Node Biopsy in Early Breast Cancer: Magnetic Tracer as the Only Localizing Agent

World Journal of Surgery - The combined use of radioisotope and blue dye is the gold standard in sentinel lymph node (SLN) localization in early breast cancer. Superparamagnetic iron oxide (SPIO)...     

The Accuracy of Sentinel Lymph Node Biopsy in the Treatment of Multicentric Invasive Breast Cancer Using a Subareolar Injection of Tracer

BACKGROUND: The aim of this study was to evaluate the feasibility and the accuracy of sentinel lymph node biopsy in multicentric breast cancer (MBC) performed by means of a subareolar (SA) injection of both 99Tc-labeled human albumin colloid and lymphazurin. METHODS: Between January 2002 and October 2007, 34 patients with MBC with clinically negative axilla underwent sentinel lymph node biopsy (SLNB) followed by total axillary node dissection (AD). Overall successful identification rate of SLN was 100%; there were no false negatives and overall accuracy rate was 100%. RESULTS: The mean number of sentinel lymph nodes (SLNs) identified was 1.8 +/- 0.88 (range = 1-4); the mean number of axillary lymph nodes examined was 21.4 +/- 5.76 (range = 8-36). CONCLUSIONS: The authors conclude that SA injection of the tracer is feasible and efficacious in the identification of the SLN. The accuracy of SLNB in MBC is comparable to that obtained in unifocal disease.     

Biopsy Method and Excision Volume Do Not Affect Success Rate of Subsequent Sentinel Lymph Node Dissection in Breast Cancer

Introduction: Sentinel lymph node dissection (SLND) is becoming a recognized technique for accurately staging patients with breast cancer. Its success in patients with large tumors or prior excisions has been questioned. The purpose of this study was to evaluate the effect of biopsy method, excision volume, interval from biopsy to SLND, tumor size, and tumor location on SLND success rate.Methods: Consecutive patients who underwent SLND followed by completion axillary lymph node dissection from October 1991 to December 1995 were analyzed. Included were cases performed early in the series before the technique was adequately developed. Excision volume was derived from the product of three dimensions as measured by the pathologist. Two end points were analyzed: sentinel node identification rate and accuracy of SLND in predicting axillary status. Univariate analyses using x2 or Fishers exact test for categorical variables and Wilcoxon rank sums for continuous variables were performed. Multivariate analysis was performed using logistic regression.Results: There were 284 SLND procedures performed on 283 patients. Median age was 55 years. The most recent biopsy method used before SLND was stereotactic core biopsy in 41 (14%), fine-needle aspiration in 62 (22%), and excision in 181 (64%) procedures. The mean excision volume was 32 ml with a range of 0.3–169 ml. The mean time from biopsy to SLND was 17 days with a range of 0–140 days. The mean tumor size was 2.0 cm (15 Tis [5%], 184 T1 [65%], 72 T2 [25%], and 13 T3 [5%]). Tumors were located in the outer quadrants in 74%, the inner quadrants in 18%, and subareolar region in 8%. The sentinel node was identified in 81%, and 39% had metastases. There were three false-negative cases early in the series. Sensitivity was 97%, and accuracy was 99%. Negative predictive value was 98% in cases in which the sentinel node was identified. On the basis of biopsy method, excisional volume, time from biopsy to SLND, tumor size, and tumor location, there was no statistically significant difference (P..05) in sentinel node identification rate or accuracy of SLND.Conclusions: SLND has a high success rate in breast cancer patients regardless of the biopsy method or the excision volume removed before SLND. In addition, the interval from biopsy to SLND, tumor size, and tumor location have no effect on the success rate of SLND, even in this series which included patients operated on before the technique was adequately defined. Patients with breast cancers located in any quadrant and diagnosed either with a needle or excisional biopsy could be evaluated for trials of SLND.Presented at the 52nd Annual Meeting of the Society of Surgical Oncology, Oralando, Florida, March 4–7, 1999.     

乳腺癌前哨淋巴结活检的研究进展

目的 报道乳腺癌前哨淋巴结活检的研究进展。方法 采用文献回顾的方法，对国外乳腺癌前哨淋巴结活检的历史、概念、活检技术以及临床应用等问题进行综述。结果 乳腺癌前哨淋巴结活检的操作方法还没有统一的标准，检出率及假阴性率变化范围广。结论 前哨淋巴结活检的临床应用还需要大量前瞻性多中心随机实验结果进一步论证。     

Sentinel Node Biopsy in Breast Cancer: ALMANAC Trial

Sentinel node biopsy of breast cancer is becoming an increasingly popular topic. The concept of the sentinel node being the first lymph node to contain metastatic cancer within a tumor's lymphatic basin was introduced by Cabanas, a South American surgeon, following his work on carcinoma of the penis. Morton and his colleagues then applied this principle to malignant melanomas, and more recently this concept has gained popularity for carcinoma of the breast. In breast cancer patients, the fact that a sentinel node can be localized and the suggestion that the sentinel node is representative of the axillary nodal status has been confirmed by a number of studies across the world. Most authors writing on this subject, however, end with a caution that the results of randomized trials are needed before this new surgical technique can be accepted as part of routine breast cancer management. The Medical Research Council of the United Kingdom has funded the audit phase of a multicenter, two phase, randomized trial called the Axillary Lymphatic Mapping Against Nodal Axillary Clearance (ALMANAC) trial, which will compare standard axillary management with sentinel node-guided axillary management. The aims and protocol of the trial are discussed in detail here.     

Sentinel Node Biopsy in Breast Cancer: An Overview

The most powerful predictor of survival in breast cancer is the presence or absence of lymph node metastases. Lymphatic mapping and sentinel node biopsy is a new technique that provides more accurate nodal staging compared to routine histology for women with breast cancer without the morbidity of a complete lymph node dissection. Sentinel lymph node biopsy is a more conservative approach to the axilla that requires close collaboration between the surgical team, nuclear medicine, and pathology. National trials are investigating the clinical relevance of the upstaging that occurs with a more intense examination of the sentinel node. Since complaints due to the axillary node dissection are a common occurrence after definitive breast cancer surgery, if the side effects of the level I and II node dissection can be avoided, particularly in the node-negative population, a major advance in treating this disease will be made.     

Cardiac Arrest after Patent Blue V Injection for Sentinel Lymph Node Biopsy in Breast Cancer

SUMMARY: BACKGROUND: Sentinel lymph node biopsy (SLNB) is a widely accepted method to determine lymph node status in for instance breast cancer, cervical cancer, or cutaneous melanomas. Although injection of blue dyes facilitates successful detection of sentinel nodes, they have also been shown to cause adverse reactions. CASE REPORT: A 62-year-old female patient was referred to the surgical department of the Atrium Medical Centre with a suspicious lesion located in the right breast, detected during population-based screening. Immediately after injection of patent blue V, the patient developed tachycardia on top of preexisting supraventricular tachycardia and showed an instant drop in blood pressure, after which cardiac arrest occurred. These clear symptoms of anaphylactic shock required prompt treatment, and the patient was treated accordingly. CONCLUSIONS: Anaphylactic shock after injection of patent blue V remains a serious adverse event and warrants awareness. Immediate action with ephedrine, antihistamines, and subsequently corticosteroids can stabilize the patient. Tc-99m, isosulphan blue, and methylene blue can alternatively be used for SLNB, although also not without side effects.     

Axillary and Extra-axillary Lymph Node Recurrences after a Tumor-Negative Sentinel Node Biopsy for Breast Cancer Using Intralesional Tracer Administration

Background At our institution, tracer fluids are administered in the primary breast cancer and, in addition to the ones in the axilla, sentinel nodes outside the axilla are rigorously pursued. The objective of the present study of sentinel node-negative breast cancer patients was to determine the lymph node recurrence rates in the axilla and elsewhere, the false-negative rates, and the survival. Methods Between January 1999 and November 2005, 1,019 breast cancer patients underwent a sentinel node biopsy. In 748 of them, 755 sentinel node biopsies did not reveal a tumor-positive sentinel node and they did not undergo axillary node dissection. Metastases were revealed in 284 sentinel node biopsies performed in the remaining 271 patients: 247 in the axilla, 20 outside the axilla, and 17 both in the axilla and elsewhere. The median follow-up duration was 46 months. Results Two of the 748 sentinel node-negative patients developed an axillary lymph node recurrence (0.25%) and two others developed a supraclavicular lymph node recurrence (0.25%). The overall lymph node recurrence rate was 0.5%. The false-negative rates were 1.4% overall, 0.8% for the axilla, and 5.1% for the extra-axillary nodes. After five years, 95.9% of all sentinel node-negative patients were alive and 89.7% were alive without evidence of disease. Conclusion The low recurrence and false-negative rates and promising survival figures show that our lymphatic mapping method with intralesional tracer administration is accurate for the axilla. Outside the axilla, 5.1% of involved sentinel nodes were missed.     

Radioguided Sentinel Node Biopsy to Avoid Axillary Dissection in Breast Cancer

Background: Sentinel node (SN) biopsy may predict axillary status in breast cancer. We retrospectively analyzed more than 500 SN cases, to suggest more precise indications for the technique.Methods^99mTc-labeled colloid was injected close to the tumor; lymphoscintigraphy was then performed to reveal the SN. The next day, during surgery, the SN was removed by using a gamma probe. Complete axillary dissection followed, except in later cases recruited to a randomized trial. The SN was examined intraoperatively by conventional frozen section, in later cases by sampling the entire node and using immunocytochemistry.Results: In the first series, the SN was identified in 98.7% of cases; in 6.7%, the SN was negative but other axillary nodes were positive; in 32.1%, the SN was negative by intraoperative frozen section but metastatic by definitive histology, prompting introduction of the exhaustive method. In the randomized trial, the SN was identified in all cases so far, the false-negative rate is approximately 6.5%, and in 15 cases, internal mammary chain nodes were biopsied.Conclusions: SN biopsy can reliably assess axillary status in selected patients. The problems are the SN detection rate, false negatives, and the intraoperative examination, which can miss 30% of SN metastases. Our exhaustive method overcomes the latter problem, but it is time consuming.Presented at the 52nd Annual Meeting of Society of Surgical Oncology, Orlando, Florida, March 4–7, 1999.     

Sentinel Lymph Node Biopsy for Breast Cancer: Current Controversies

Abstract:   Sentinel lymph node biopsy (SLNB) has replaced the routine level I and II axillary lymph node dissection (ALND) for women with clinically node-negative T1 and T2 breast cancer. Studies have shown that SLNB is highly predictive of axillary nodal status with a false-negative of rate less than 10%. Our purpose was to address some of the ongoing controversies about this procedure, including technical issues, use of preoperative lymphoscintigraphy, internal mammary lymph node biopsy, criteria for patient selection (in intraductal carcinoma?), its staging accuracy, and the clinical approach when a SLNB was found to be negative or positive on pathologic examination. After the revision of the American Joint Committee on Cancer (AJCC) staging system for breast cancer in 2002, the evaluation of internal mammary lymph nodes and determination of micrometastases by hematoxylin-eosin or by immunohistochemistry have become increasingly important in staging of patients. Recent guideline recommendations developed by the American Society of Clinical Oncology (ASCO) Expert Panel in 2005 are also discussed. Long-term follow-up results of ongoing studies will provide more accurate assessment of the prognostic significance of SLNB and its value in the prevention of breast cancer-related morbidity in axillary staging compared to ALND.      

Indocyanine Green Fluorescence Imaging with Lymphoscintigraphy for Sentinel Node Biopsy in Melanoma: Increasing the Sentinel Lymph Node-Positive Rate

Annals of Surgical Oncology - The goal of this study was to analyze patients who underwent a sentinel lymph node biopsy (SLNB) in melanoma with the combination of radioisotope lymphoscintigraphy...     

乳腺癌前哨淋巴结活检的研究进展

目的总结乳腺癌前哨淋巴结活检（SLNB）的研究现状和进展。方法复习近年来国内外的相关文献,对乳腺癌SLNB的概念、适应证、活检技术、提高检出准确率的方法、病理学检查方法、转移灶类型、临床应用等进行综述。结果 SLNB的适应证在不断扩大。示踪剂、影像学检查和病理学检查技术的发展有助于对乳腺癌前哨淋巴结（SLN）状态的评估。乳腺癌SLNB的操作方法还没有统一的标准,对其能否指导选择性的腋窝淋巴结清扫的争议较大,且SLNB的SLN检出率及假阴性率变化范围较大。结论 SLNB已成为乳腺癌外科治疗的重要辅助手段,但其操作尚需进一步规范,其临床应用范围还需要大量前瞻性、多中心的随机试验进一步论证。     

Unfiltered Sulfur Colloid and Sentinel Node Biopsy for Breast Cancer: Technical and Kinetic Considerations

Background: There are few clinical data on technical limitations and radiocolloid kinetics related to sentinel lymph node (SLN) biopsy for breast cancer.Methods: In 70 clinical node-negative patients, unfiltered^99mTc sulfur-colloid was injected peritumorally and cutaneous hot spots were mapped with a gamma probe. SLN biopsy was performed followed by axillary lymph node dissection. Missed radioactive nodes (nodes not under hot spots) were removed from axillary lymph node dissection specimens and submitted separately.Results: At least one hot spot was mapped in 69 patients (98%) and SLNs were retrieved in 62 (89%). No radiolabeled nodes were found in five (7%) and only nodes not under hot spots were retrieved in three patients (4%). Residual nodes not under hot spots were retrieved in 17 patients (24%) in whom at least one SLN specimen had been found. Diffuse radioactivity around the radiocolloid injection site impeded identification of all radiolabeled nodes during SLN biopsy, and was responsible for one of two false negatives (20 node-positive patients; false-negative rate 10%). Hot spot radioactivity, number of radiolabeled nodes, and nodal radioactivity did not change with time interval from radiocolloid injection to surgery (0.75–6.25 hours).Conclusions: Although SLN localization rate is high, intraparenchymal injection may predispose to failure of radiocolloid migration, failure to identify SLNs because of high radiation background, and false-negative outcomes. Alternative routes of radiocolloid administration should be explored.     

Effect of Intraoperative Radiocolloid Injection on Sentinel Lymph Node Biopsy in Patients with Breast Cancer

Background  Preoperative injection of radiocolloid before a sentinel lymph node (SLN) biopsy is painful for patients with breast cancer. Injection after anesthesia eliminates this discomfort but allows less time for radiocolloid migration. Our goal was to validate the efficacy of intraoperative injection. Methods  In this retrospective study of prospectively collected data, patients underwent periareolar dermal injection of technetium sulfur colloid. Patients in the preoperative injection (PO) group were injected by radiologists in the breast imaging center. Patients in the intraoperative injection (IO) group were injected by surgeons after induction of anesthesia. Consecutive cases were evaluated for radioactive “hotspots,” time elapsed before incision, number of SLNs removed, number of positive SLNs, and percentage of positive biopsies. Results  Two hundred fourteen breasts were evaluated (PO = 102; IO = 112). The mean time from injection to incision was significantly shorter by 107 minutes for the IO group. There were no differences in the percentage of positive biopsies (PO: 20.6%; IO: 19.6%; P = 0.863), the number of SLNs removed (PO: 3.3; IO: 3.0; P = 0.091), or the number of positive SLNs (PO: 1.4; IO: 1.4; P = 0.657). Conclusions  There are no significant differences in the principal results of SLN biopsy between PO and IO injection methods. Dermal radiocolloid injection after induction of anesthesia seems to be an oncologically sound procedure and may be a preferable technique.     

Patterns of Recurrence After Sentinel Lymph Node Biopsy for Breast Cancer

Background: Sentinel lymph node biopsy (SLNB) is gaining acceptance as an alternative to axillary lymph node dissection. The purpose of this study was to determine the frequency and pattern of disease recurrence after SLNB.Methods: Two-hundred twenty-two consecutive patients undergoing SLNB from April 6, 1998, to October 27, 1999, and who were 24 months out from their procedure were identified from a prospectively maintained database. Retrospective chart review and data analysis were performed to identify variables predictive of recurrence.Results: The median patient follow-up was 32 months (range, 24–43 months). A total of 159 patients (72%) were sentinel lymph node (SLN) negative and had no further axillary treatment. Five of these patients (3.1%) developed a recurrence (one local and four distant), with no isolated regional (axillary) recurrences. Sixty-three patients (28%) were SLN positive and underwent a subsequent axillary lymph node dissection. Six of these patients (9.5%) developed a recurrence (three local, one regional, and two distant). Pathologic tumor size (P < .001), lymphovascular invasion (P = .018), and a positive SLN (P = .048) were all statistically significantly associated with disease recurrence.Conclusions:With a minimum follow-up of 24 months, patients with a negative SLN and no subsequent axillary treatment demonstrate a low frequency of disease recurrence. This supports the use of SLNB as the sole axillary staging procedure in SLN-negative patients.     

Sentinel Lymph Node Biopsy in Pregnant Women with Breast Cancer

Background

Sentinel lymph node biopsy (SNB) in pregnant women with breast cancer is uncommonly pursued given concern for fetal harm. This study evaluated efficacy and safety outcomes in pregnant breast cancer patients undergoing SNB.

Methods

Patients who underwent SNB while pregnant were identified from a retrospective parent cohort of women diagnosed with breast cancer during pregnancy. Chart review was performed to tabulate patient/tumor characteristics, method/outcome of SNB, and short-term maternal/fetal outcomes.

Results

Within a cohort of 81, 47 clinically node-negative patients had surgery while pregnant: 25 (53.2 %) SNB, 20 (42.6 %) upfront axillary lymph node dissection, and 2 (4.3 %) no lymph node surgery. Of SNB patients, 8, 9, and 8 had SNB in the first, second, and third trimesters, respectively. 99 m-Technetium (99-Tc) alone was used in 16 patients, methylene blue dye alone in 7 patients, and 2 patients had unknown mapping method. Mapping was successful in all patients. There were no SNB-associated complications. At a median of 2.5 years from diagnosis, there was one locoregional recurrence, one new primary contralateral tumor, three distant recurrences, and one breast cancer death. Among patients who underwent SNB, there were 25 liveborn infants, of whom 24 were healthy, and 1 had cleft palate (in the setting of other maternal risk factors).

Conclusions

SNB in pregnant breast cancer patients appears to be safe and accurate using either methylene blue or 99-Tc. This is one of the largest reported experiences of SNB during pregnancy; however, numbers remain limited. SNB rates in this cohort were lower than in non-pregnant breast cancer patients.