内乳淋巴结放疗研究进展

目的 对乳腺癌内乳淋巴结放疗的临床研究进展和相关毒副作用进行综述。方法 以“乳腺癌、放疗、內乳淋巴结、不良反应”为中文关键词,以“breast cancer、 irradiation、 internal mammary lymph node、 adverse effect”为英文关键词,检索PubMed、CNKI数据库2012-2022年的相关文献。纳入标准：乳腺恶性肿瘤;内乳淋巴结放疗;内乳淋巴结放疗相关毒副作用。排除标准：无关和重复文献。根据纳入和排除标准共筛选出49篇高度相关文献。结果 依据当前相关研究,对于腋窝淋巴结转移数≥4枚、1～3枚腋窝淋巴结转移且肿瘤位于内侧象限或中央区的患者强烈建议进行内乳淋巴结照射。结论 在现代放疗技术的背景下,内乳淋巴结的放疗可以使患者取得临床获益,但是仍需要谨慎选择合适的患者进行放疗。     

乳腺癌内乳淋巴结的研究进展

乳腺癌的淋巴结转移是临床分期及预后估计的重要指标，目前国内外大多数研究都集中于腋窝淋巴结。内乳淋巴结因其部位的特殊性，没有简便有效的检测方法，临床对其研究较少。本文针对内乳淋巴结的问题综述如下。     

影像学检查内乳淋巴结阴性乳腺癌患者内乳淋巴结转移风险评估与内乳淋巴引流区照射取舍

目的探讨影像学检查内乳淋巴结(IMN)阴性的乳腺癌患者IMN转移的独立危险因素和术前IMN转移风险评估方法, 以指导不同IMN转移风险分层患者的内乳淋巴引流区放疗。方法 2012年1月至2019年10月山东省肿瘤医院手术治疗的301例乳腺癌患者, 术前CT和MRI均显示无IMN转移且行内乳前哨淋巴结活检和(或)内乳淋巴结清扫, 回顾性分析其临床病理资料。通过单因素分析和多因素logistic回归分析明确IMN转移的独立危险因素, 利用IMN转移的独立危险因素对患者进行IMN转移风险分层。结果 301例患者中, 43例检出IMN转移, IMN转移率为14.3%。单因素分析显示, 脉管瘤栓、孕激素受体(PR)表达状态、T分期和N分期与IMN转移有关(均P<0.05)。多因素logistic回归分析显示, 肿瘤位于内侧象限、PR阳性、腋窝淋巴结转移是IMN转移的独立危险因素(均P<0.05)。按照患者存在独立危险因素的情况进行IMN转移风险评估:有0个危险因素为低危组, 有1个危险因素为中危组, 同时有2～3个危险因素为高危组。按照此评估标准, 将301例乳腺癌患者分为低危组(有...     

乳腺癌内乳淋巴结活检的临床研究

背景与目的:内乳淋巴结(intemal mammary node,IMN)是乳腺癌重要的转移途径之一,其状况将影响乳腺癌患者的分期、治疗、预后及疗效评价,本研究旨在探讨内乳前哨淋巴结活检(intemal mammary sentinel node biopsy,IMSNB)和经肋间IMN第Ⅰ～Ⅳ肋间活检、以及IMN微转移灶检测在临床应用的意义.方法:在行常规乳腺癌切除术中,采用核素示踪法经肋间隙行IMSNB,然后对患侧第Ⅰ～Ⅳ肋间的IMN均行活检(经肋间隙,非扩大根治术),所有IMN均行常规单一切面HE染色病理检查,阴性病例的IMN采用多层切片加免疫组化的方法检测微转移.结果:全组38例病人中发现内乳前哨淋巴结(internal mammary sentinel node,IMSN)17例,占44.7%,均成功行IMSNB,其中4例IMSN常规病理阳性,1例IMSN发现微转移,2例发现孤立的肿瘤细胞群,10例为阴性,均与对应病例经第Ⅰ～Ⅳ肋间IMN活检的病理结果一致;无发现IMSN 21例,占55.3%,经第Ⅰ～Ⅳ肋间IMN活检,常规病理阳性5例,阴性16例,未发现微转移.结论:对发现IMSN者,IMSN能够准确评价IMN状况,但对无发现IMSN者,尤其是对IMN转移可能性大者,应经肋间隙行IMN第Ⅰ～Ⅳ肋间活检,以减少假阴性的发生;多层切片加免疫组化技术有助于IMN微转移灶的检出.     

乳腺癌内乳区淋巴结转移研究进展

 内乳区淋巴结的转移状况是乳腺癌的独立预后指标,也是乳腺癌分期的重要依据之一。内乳区淋巴结转移的患者预后较差。内乳区淋巴结的总体转移率为18 %～33 %,仅有内乳区淋巴结转移而无腋窝淋巴结转移的发生率为2 %～11 %,其转移受腋窝淋巴结状况、患者年龄、原发肿瘤的位置和特点等多因素影响。随着前哨淋巴结活检技术的不断发展,内乳区前哨淋巴结活检术可能以最小的风险评估内乳区淋巴结状况,并进一步完善乳腺癌的淋巴结分期,有助于为患者制定更为准确的个体化治疗方案。     

乳腺癌内乳区淋巴结照射研究进展

乳腺癌内乳区淋巴结照射能够降低局部和远处复发并改善患者的生存,NCCN指南也在内乳区淋巴结照射方面进行了相应的更新,但由于内乳区淋巴结照射造成的心肺损伤不容忽视,因此需要提供更为准确的个体化内乳区放疗指征。内乳区前哨淋巴结活检能够以微创的方法评估内乳区淋巴结的转移情况,为内乳区淋巴结照射提供准确的放疗指征,使乳腺癌患者获得更大的生存获益。本文主要从内乳区放疗获益、不良反应控制及内乳区前哨淋巴结活检指导放疗的探讨等方面进行了综述。     

乳腺癌内乳区淋巴结治疗现状

乳腺癌内乳区淋巴结(IMN)是否需要治疗仍存争议,多数学者认为,对淋巴结造影证明有初始IMN引流的早期乳腺癌及原发灶位于乳腺内侧或中央区伴腋淋巴结阳性和因局部晚期伴淋巴结转移行乳腺切除术后的病人给予IMN照射是必要的.     

乳腺癌内乳区淋巴结治疗现状

乳腺癌内乳区淋巴结（IMN）是否需要治疗存争议,多数学者认为,对淋巴结造影证明有初始IMN引流的早期乳腺癌及原发灶位于乳腺内侧或中央区伴腋淋巴结阳性和因局部晚期伴淋巴结转移行乳腺切除术后的病人给予IMN照射是必要的。     

乳腺癌术后内乳淋巴结放射治疗研究进展

近年来发表的几个有关乳腺切除术后放射治疗的随机分组研究发现，放射治疗可以增加有高危因素患者的生存率，引起了人们对乳腺癌术后局部或区域放射治疗的更大关注。目前认为，对于早期患者，内乳淋巴结照射的价值并不明确。而对内象限和中央区病变、腋窝淋巴结阳性的患者，内乳淋巴结的术后放疗仍有争议。减少内乳区的照射范围，改进照射技术，可以减少心血管等系统的放射并发症。     

乳腺癌内乳区淋巴结诊疗的研究进展

内乳区淋巴结（internal mammary lymph node,IMLN）引流整个乳腺约25%的淋巴液,其转移状况为乳腺癌预后指标之一,也是确定分期和制定治疗方案的重要依据。内乳区前哨淋巴结活检术（internal mammary-sentinel lymph node biopsy,IM-SLNB）作为微创诊断技术实现对IMLN的评估,有助于为患者制定更为准确的个体化治疗方案。在乳晕周围腺体内增加注射部位和注射剂量的新型注射技术显著提高内乳区前哨淋巴结（internal mammary sentinel lymph node,IMSLN）检出率,使得常规开展IM-SLNB成为可能。随着内乳区淋巴引流规律的深入研究,新型注射技术引导下的IM-SLNB的准确性目前已得到初步验证。本文将对乳腺癌内乳区淋巴结诊疗的研究进展进行综述。      

Radiotherapy of MRI-detected involved internal mammary lymph nodes in breast cancer

Background

The internal mammary (IM) lymph node chain, along with the axillary nodal basin, is a first-echelon breast lymphatic draining site. A growing body of evidence supports irradiation of this region in node-positive breast cancer. This study evaluated the effectiveness of radiotherapy in treating magnetic resonance imaging (MRI)-detected abnormal IM lymph nodes in newly-diagnosed non-metastatic breast cancer.

Methods

A structured query was performed on an electronic institutional database to identify women with radiographic evidence of abnormal IM node(s) on breast MRI from 2005 to 2013. Manual review narrowed inclusion to patients with a primary diagnosis of non-metastatic breast cancer with abnormal IM node(s) based on pathologic size criteria and/or abnormal enhancement.

Results

Of the 7070 women who underwent pre-treatment MRI, 19 (0.3%) were identified on imaging to have a total of 25 abnormal pre-treatment IM lymph nodes, of which 96% were located in the first two intercostal spaces and 4% in the third space. A majority of the primary tumors were high-grade (94.7%) and hormone-receptor negative (73.7%), while 47.4% overexpressed HER-2/neu receptor. Axillary nodal disease was present in 89.5% of patients, while one patient had supraclavicular involvement. At a median follow-up of 38 months, 31.6% of patients had developed metastatic disease and 21.1% had died from their disease. Of the patients who received IM coverage, none had progressive disease within the IM lymph node chain.

Conclusions

Radiologic evidence of pre-treatment abnormal IM chain lymph nodes was associated with advanced stage, high grade, and negative estrogen receptor status. The majority of positive lymph nodes were located within the first two intercostal spaces, while none were below the third. Radiation of the IM chain in combination with modern systemic therapy was effective in achieving locoregional control without surgical resection in this cohort of patients.

     

Motion-specific internal target volumes for FDG-avid mediastinal and hilar lymph nodes

Background and purpose

To quantify the benefit of motion-specific internal target volumes for FDG-avid mediastinal and hilar lymph nodes generated using 4D-PET, vs. conventional internal target volumes generated using non-respiratory gated PET and 4D-CT scans.

Materials and methods

Five patients with FDG-avid tumors metastatic to 11 hilar or mediastinal lymph nodes were imaged with respiratory-correlated FDG-PET (4D-PET) and 4D-CT. FDG-avid nodes were contoured by a radiation oncologist in two ways. Standard-of-care volumes were contoured using conventional un-gated PET, 4D-CT, and breath-hold CT. A second, motion-specific, set of volumes were contoured using 4D-PET.Contours based on 4D-PET corresponded directly to an internal target volume (ITV_4D), whereas contours based on un-gated PET were expanded by a series of exploratory isotropic margins (from 5 to 13 mm) based on literature recommendations on lymph node motion to form internal target volumes (ITV_3D).

Results

A 13 mm expansion of the un-gated PET nodal volume was needed to cover the ITV_4D for 10 of 11 nodes studied. The ITV_3D based on a 13 mm expansion included on average 45 cm³ of tissue that was not included in the ITV_4D.

Conclusions

Motion-specific lymph-node internal target volumes generated from 4D-PET imaging could be used to improve accuracy and/or reduce normal-tissue irradiation compared to the standard-of-care un-gated PET based internal target volumes.     

Factors influencing the outcome of breast cancer patients with 10 or more metastasized axillary lymph nodes

Background  

The purpose of this study was to investigate prognostic factors in breast cancer patients with metastasis of ten or more lymph nodes (pathologic N3a).     

Internal mammary lymph node recurrence: rare but characteristic metastasis site in breast cancer

Background  

To assess the frequency of IMLN recurrence, its associated risk factors with disease-free interval (DFI) and its predicting factors on overall survival time.     

Ratio of marked and excised sentinel lymph nodes and scintigraphic appearance time in melanoma patients with negative sentinel lymph node

Aim

Metastases can occur in up to 15% of all melanoma patients with negative sentinel lymph node examination (SN –). We retrospectively investigated the number of preoperatively marked sentinel lymph nodes (SNs) with lymphoscintigraphy and effectively surgically removed SNs in SN – patients with cutaneous melanoma ≥0.5 mm. Ratio of these parameters was calculated and impact of this ratio as well as impact of scintigraphic appearance time (SAT) on disease progression was studied.

Materials and methods

Data on 122 SN – patients — 70 women (58%), mean age 56.5 years — were analyzed. Mean follow-up time was 58 months.

Results

Mean tumour thickness of all patients was 2.3 mm. In 51 patients (42%) the number of SNs marked in lymphoscintigraphy was higher than excised in surgery, in 47 patients (38%) the same number as marked was excised and in 24 patients (20%) a lower number was marked than excised. Metastases occurred in 17 patients (14%) after a mean time of 24.8 months. Mean tumour thickness (5.4 mm) was significantly higher in these patients than in the other patients (p = 0.000). Ratio of marked and excised SNs had no influence on disease progression; the only parameter influencing outcome was tumour thickness (p = 0.000). Short SAT was significantly associated with higher tumour thickness (p = 0.004).

Conclusion

Our study indicates that, in routine clinical practice, it suffices to harvest the first SN, as the ratio of marked and excised SNs has no impact on disease progression.     

The prognostic significance of isolated tumor cells in the lymph nodes of gastric cancer patients

Background  

The clinical significance of isolated tumor cells (ITC) detected immunohistochemically in the lymph nodes of gastric cancer patients is controversial. The aim of this study was to examine the prognostic impact of ITC in patients with gastric cancer.     

Log odds of positive lymph nodes

BACKGROUND:

Log odds of positive lymph nodes (LODDS) is defined as the log of the ratio between the probability of being a positive lymph nodes and the probability of being a negative lymph nodes when one lymph node is retrieved. The value of LODDS staging system on prognostic assessment for gastric cancer patients with R0 resection is still unclear.

METHODS:

Clinicopathologic and prognostic data of 2547 gastric cancer patients underwent D2 or D3 lymphadenectomy with R0 surgery were retrospectively studied.

RESULTS:

Multivariate analysis indentified LODDS stage was an independent prognostic factor, but not pN classification or rN classification. The scatter plots of the relationship between LODDS and the number, the ratio of nodes metastasis, suggested that the LODDS stage had power to divide patients with the same number or ratio of nodes metastasis into different groups. For patients in each of the pN or rN classifications, significant differences in survival could always be observed among patients in different LODDS stages. However, for patients in each LODDS stage, prognosis was highly homologous between those in different pN or rN classifications. A minimum number of 10, 15, 20, 25, and 10 nodes retrieved should be met for patients in the pN0, pN1, pN2, pN3, and rN0‐3 classifications, respectively, unless the hazard risks of death would be underestimated or overestimated. However, LODDS stage could discriminate among 5 groups of patients with highly homologous prognosis, regardless how many nodes retrieved.

CONCLUSIONS:

The LODDS system is more reliable than the Union Internationale Contre le Cancer and American Joint Committee on cancer pN system and the rN system for prognostic assessment. Cancer 2010. © 2010 American Cancer Society.     

Raloxifene inhibits tumor growth and lymph node metastasis in a xenograft model of metastatic mammary cancer

Background  

The effects of raloxifene, a novel selective estrogen receptor modulator, were studied in a mouse metastatic mammary cancer model expressing cytoplasmic ERα.     

Metastatic lymph node ratio versus number of metastatic lymph nodes as a prognostic factor in gastric cancer

Objective

Knowledge of prognostic factors in gastric cancer is essential to decide on single patient management. We aim to establish the value of lymph node ratio compared to lymph node involvement in the prediction of gastric cancer survival and treatment approach.

Methods

Charts of ninety-six consecutive patients undergoing gastrectomy for resectable gastric cancer were reviewed between January 1996 and December 2005. Receiver operating characteristic (ROC) curves were plotted to verify the accuracy of metastatic lymph node ratio (MLNR) and number of metastatic lymph node (NMLN) cut-off values for survival prediction. Patients were divided into two groups according to ROC curve cut-offs and accuracy in prognosis was reviewed.

Results

ROC curves showed that 5 metastatic nodes and a node ratio value of 20% had the best survival prognostic correlation. The median survival of patients with MLNR and NMLN were similar according to cut-off determinations (≤5/>5 metastatic nodes and ≤20/>20% lymph node ratio). Five-year survival rates were 70.9% vs 17.1% and 72.4% vs 15.6%, respectively (p < 0.001). Positive correlation coefficient was found between the number of excised nodes and the number of metastatic nodes.

Conclusion

Number of metastatic lymph nodes showed greater accuracy than lymph node ratio for survival prediction in gastric cancer.     

Correlation between load of HPV 16 DNA in cervical cancer and HPV 16 DNA in lymph nodes

OBJECTIVE To determine the association between viral load of human papillomavirus 16 （HPV16） DNA in the primary focus of cervical carcinoma and HPV16 DNA in pelvic lymph nodes. METHODS The HPV16 DNA load was measured by fluorescent quantitation polymerase chain reaction （FQ-PCR） in 17 primary foci. HPV16 DNA was detected by polymerase chain reaction （PCR） using HPV16 type-specific primers in 296 pelvic lymph nodes which were from 17 cases of cervical cancer. RESULTS The viral load of HPV16 DNA showed statistically significant differences between tumors with a diameter of 〈 4 cm and ≥ 4 cm （P 〈 0.05）. Seven of 17 cervical cancer cases had HPV16 DNA positive lymph nodes, designated as the positive group, while the remaining 10 without positive lymph nodes was designated the negative group. The average load of HPV16 DNA showed no significant difference between the 2 groups （P 〉 0.05）. The load of HPV16 in the primary lesion was not associated with that in the lymph nodes. There were 38 HPV16 DNA positive nodes in the total 296 nodes. The rate of positivity of HPV16 DNA in lymph nodes showed statistically significant differences in consideration of maximum tumor diameter, tumor differentiation, histologic type, depth of myometial infiltration and the metastatic status of the nodes, respectively （P 〈 0.05）. CONCLUSION Viral load of HPV16 in the primary cancer focus correlated with the quantity of tumor cells in the primary focus but not with the existence of HPV DNA positive lymph nodes. Detection of HPV DNA may help to find the early metastases that cannot be evaluated histopathologically, but the prognostic value of HPV positive lymph nodes needs further examination.