Contemporary controversies and perspectives in the staging and treatment of patients with lymph node metastasis from melanoma,especially with regards positive sentinel lymph node biopsy

The management of melanoma lymph node metastasis particularly when detected by sentinel lymph node biopsy (SLNB) is still controversial. Results of the only randomized trial conducted to assess the therapeutic value of SLNB, the Multicenter Selective Lymphadenectomy Trial (MSLT-1), have not conclusively proven the effectiveness of this procedure but are interpreted by the authors and guidelines as indicating SLNB is standard of care. After surgery, interferon alpha had a small survival benefit and radiotherapy has limited effectiveness for patient at high-risk of regional recurrence. New drugs, including immune modulating agents and targeted therapies, already shown to be effective in patients with distant metastasis, are being evaluated in the adjuvant setting. In this regard, ensuring high quality of surgery through the identification of reliable quality assurance indicators and improving the homogeneity of prognostic stratification of patients entered onto clinical trials is paramount. Here, we review the controversial issues regarding the staging and treatment of melanoma patients with lymph node metastasis, present a summary of important and potentially practice changing ongoing research and provide a commentary on what it all means at this point in time.     

Accuracy of the non-sentinel node risk score (N-SNORE) in patients with cutaneous melanoma and positive sentinel lymph nodes: A retrospective study

Background

Sentinel node (SLN) biopsy in patients with melanoma permits identification of those at risk for further metastases in non-sentinel lymph nodes (NSLN). However, a mere 20% of SLN-positive patients have metastases in NSLN. Therefore we need criteria to predict NSLN-positivity. A new score system known as the non-sentinel risk score, (N-SNORE) based on five clinical and pathological characteristics (gender, regression in primary melanoma, proportion of SNs containing melanoma, perinodal lymphatic invasion, and SN tumor burden), was first published in 2010. In this study, the accuracy of N-SNORE was validated in melanoma patients with positive SLN.

Methods

A total of 106 melanoma patients with positive SLN, who had undergone complete lymph node dissection (CLND) subsequently, were included in the study. The N-SNORE was calculated in all patients, and the risk was compared to the frequency of NSLN metastases. Statistical analysis of the data was performed.

Results

Thirteen patients were at very low risk for NSN metastasis (score 0), 63 patients at low risk (score 1–3), 19 at intermediate risk (score 4–5), 6 at high risk (score 6–7), and 5 at very high risk (score >8). NSLN positivity rates for these 5 risk groups were 7.7%, 18.2%, 21.1%, 33.3%, and 80%, respectively. According to Fisher's exact test, the contingency coefficient was .322; the p-value was .025.

Conclusion

An increasing N-SNORE was clearly correlated with a higher risk of NSLN positivity. Based on the p-value and the contingency coefficient, the overall accuracy of the N-SNORE was proven on statistical calculation.     

Long-term follow-up reveals that ulceration and sentinel lymph node status are the strongest predictors for survival in patients with primary cutaneous melanoma

Purpose

To assess the long-term outcome after sentinel lymph node biopsy (SLNB) in melanoma patients.

Methods

Between 1995-2009 450 melanoma patients underwent SLNB in a single center. Survival and prognostic factors were analyzed for 429 patients.

Results

Median age was 53 (range 11-84) years. Median Breslow thickness was 2.4 (range 1-20) mm and 36% were ulcerated melanomas. Median follow-up time was 64.8 (range 2-174) months. A tumor-positive SLN was present in 140 patients (31%). Completion lymph node dissection (CLND) was performed in 119 patients and these patients were analyzed for recurrence and survival.124 Patients (29%) relapsed during follow-up; 55 in the node-positive group who underwent CLND (55/119; 46%) and 69 in the node-negative group (69/310; 22%; p < 0.001). In the node-negative group 17 patients developed recurrence in the regional node field; false-negative rate 11%.On multivariate analysis strongest prognostic factors for disease free survival (DFS) were primary melanoma ulceration and SLN positivity (Hazard Ratio (HR) of 2.2 and 2.3; p < 0.001). For disease specific survival (DSS) the same was found to be true with an HR of 2.1 for ulceration and 2.0 for SLN positivity (p = 0.001 and p = 0.002 respectively). 10-Year DFS was 71% for node-negative patients compared with 48% for node-positive patients (p < 0.001). 10-Year DSS was 77% for node-negative patients compared to 60% for node-positive patients (p < 0.001).

Conclusions

This study shows a remarkably high percentage of tumor-positive SLN. The long-term follow-up data confirm that tumor-positive SLN patients have a worse DFS and DSS than tumor-negative SLN patients. Ulceration and SLN status proved to be the strongest prognostic factors for long-term DFS and DSS.     

Prognostic heterogeneity after the excision of lymph node metastases in patients with cutaneous melanoma

Background

The aim of this study was to compare the overall survival (OS) of different groups of AJCC 2002 stage III cutaneous melanoma patients and to prove that patients with positive sentinel lymph node (SN) are heterogenic group with very different survival rates.

Methods

A total of 325 patients with stage III melanoma were identified from the prospective melanoma database at the Institute of Oncology Ljubljana, Slovenia; 164 had delayed therapeutic lymph node dissection (DLND), 111 had a positive sentinel lymph node biopsy followed by completion lymph node dissection (CLND) and 50 had synchronous primary melanoma and regional lymph node metastases that were treated with radical excision of the primary tumor and therapeutic lymph node dissection (TLND). Univariate and multivariate analyses were used for the assessment of the factors associated with OS and for comparison of OS between different subgroups of patients.

Results

The worst 5-year OS had the patients with synchronous primary melanoma and regional lymph node metastases. The patients with SN metastases with a diameter of 5.0 mm or less had significantly better OS than those with DLND, while the patients with SN metastases with a diameter of more than 5.0 mm had similar survival to those patients with synchronous primary melanoma and regional lymph node metastases.

Conclusion

Melanoma patients within AJCC 2002 stage III group have very different survival rates. The group of patients with positive SN is also prognostically heterogenic because it contains patients that have better survival than those after DLND as well as patients with more aggressive disease, that have similar survival as those with synchronous primary melanoma and regional lymph node metastases.     

Sentinel node biopsy versus elective lymph node dissection in patients with cutaneous melanoma in a Japanese population

Background In Japan, elective lymph node dissection (ELND) has been the standard treatment for patients with possible nodal melanoma. Sentinel node biopsy (SNB) has now replaced ELND, not only in Japan but also worldwide. The objective of this study was to compare the interim outcomes of SNB and ELND. Methods A retrospective study was conducted among patients with clinically node-negative disease treated at our institute with either SNB (n = 30) or ELND (n = 72). Results The background was similar in the two groups. Nodal metastases were found in 40.0% of patients in the SNB group, but in only 26.4% in the ELND group (P = 0.173). The median follow-up was 31.5 months for the SNB group and 82 months for the ELND group. The incidence of locoregional recurrence and distant metastasis in the SNB group was 10.0% and 16.7%, respectively, and for the ELND group the incidence was 5.6% and 31.9%, respectively. The 3-year disease-free survival rate was similar in the two groups (P = 0.280), and the 3-year disease-free survival rates for node-positive patients were also similar in the two groups (P = 0.90), as were the 3-year disease-free survival rates for node-negative patients (P = 0.193). Conclusion This interim result in a Japanese melanoma population with clinically node-negative disease demonstrated that SNB identified more nodal micrometastases than ELND. This increase in accurate staging likely resulted from the reliable identification of the lymph node field by lymphoscintigraphy, as well as the more detailed pathologic examination of the nodes removed in SNB. It is quite reasonable to perform SNB instead of ELND in this population.     

前哨淋巴结活检在皮肤型和肢端型黑色素瘤临床诊疗中的价值

背景与目的：前哨淋巴结活检（sentinel lymph node biopsy,SLNB）是评估皮肤型和肢端型黑色素瘤区域淋巴结转移情况及病理学分期的重要手段。SLNB作为外科诊疗规范的重要环节,已在各大诊疗指南中被推荐,也已在中国临床应用近10年。自2017年靶向和免疫治疗应用于中国黑色素瘤治疗领域,患者预后得到显著改善。本研究旨在分析复旦大学附属肿瘤医院近5年恶性黑色素瘤患者的临床资料,评估在新药治疗时代前哨淋巴结（sentinel lymph node,SLN）状态在临床应用的价值和对预后的影响。方法：对2017—2021年在复旦大学附属肿瘤医院黑色素瘤诊治中心接受诊治的381例恶性黑色素瘤患者的临床资料进行回顾性分析。每例患者均接受原发灶扩大切除和相应的SLNB,手术后随访至少6个月。SLN定位使用美兰染色或同位素示踪。结果：本研究共入组381例恶性黑色素瘤患者,平均Breslow浸润深度为3.10 mm,69.8%为肢端型,溃疡率为57.1%,SLN阳性率为34.6%,中位无复发生存率（relapse-free survival,RFS）为17个月。SLN状态是显著影响患者预后的独立危险因素。在N_1a和T₄亚组,SLN活检数>2枚的患者具有更好的RFS。接受完整的区域淋巴结清扫（complete lymph node dissection,CLND）和未清扫患者的RFS差异无统计学意义,在SLN活检数>2枚和SLN微转移直径<1 mm的亚组未清扫者反而具有更优的RFS。结论：SLN状态仍是影响临床无显性转移的黑色素瘤预后的重要因素,对于恶性黑色素瘤患者应常规开展SLNB,在保证微创的前提下,提高SLN定位的准确性,保证SLNB充分。SLN阳性后行即刻CLND对于皮肤型和肢端型黑色素瘤患者未能带来进一步的预后改善。     

The use of indocyanine green and near-infrared fluorescence imaging to assist sentinel lymph node biopsy in cutaneous melanoma: A systematic review

Background and objectivesDespite the use of blue dye and radioisotopes, sentinel lymph node biopsy (SLNB) is still associated with a high false-negative rate (FNR). The off-label use of indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging has been introduced with the objective of assisting SLNB and thereby improving regional control in melanoma. The objective of this study was to review and summarize the general experience, protocols and outcomes of the use of ICG and NIRF to assist SLNB in melanoma.MethodsA systematic literature review was performed in December 2019 as per the PRISMA guidelines. Inclusion criteria were articles written in English describing the applications of ICG in patients with melanoma. Systematic reviews, animal studies, case reports and letters to editors were excluded.ResultsOf the 585 studies retrieved, 13 articles met the inclusion criteria. The reported sentinel lymph node (SLN) detection rate using ICG was between 86 and 100% of nodes identified by lymphoscintigraphy. The average number of nodes per patient detected using ICG was 2. ICG fluorescence imaging contributed to the identification of 2.0% of the total number of SLNs harvested.ConclusionsICG fluorescence may be a useful adjunct to lymphoscintigraphy, although high-level comparative data is lacking. It was found to be superior to blue dye at detecting sentinel lymph nodes.     

皮肤恶性黑素瘤的前哨淋巴结活检技术

目的:评估前哨淋巴结活检(sentinel lymph node biopsy,SLNB)应用于皮肤恶性黑素瘤诊断和治疗中的临床价值。方法:对18例临床评估无区域淋巴结转移的皮肤恶性黑素瘤患者,应用淋巴核素显像以及术中核素扫描等方法定位前哨淋巴结(sentinel lymph node,SLN);切除SLN后进行快速冰冻和常规石蜡切片病理检查,若SLN为阳性,则加行相应区域淋巴结清扫。结果:18例患者中共检出SLN34枚,其中阳性7枚(20.6%)。5例SLN阳性患者加行区域淋巴结清扫,包括3例腹股沟清扫、1例腋窝清扫和1例颈部清扫;除SLN以外,共清扫淋巴结84枚,其中阳性39枚(46.4%)。结论:SLNB有助于诊断皮肤恶性黑素瘤的淋巴转移,为实施区域淋巴清扫提供重要的临床依据。     

Desmoplastic melanoma: A 12-year experience with sentinel lymph node biopsy

Aims

Given the paucity of data regarding nodal involvement in desmoplastic melanoma (DM), we decided to review the incidence of nodal metastasis in our patients with DM to better define guidelines regarding the performance of sentinel lymph node biopsy (SLNB) in this specific melanoma subtype.

Methods

Using a prospectively maintained database, we reviewed all patients who underwent treatment for melanoma at the Yale Melanoma Unit in a twelve-year period (1998–2010), during which 3531 cases were treated. We identified 24 patients (0.7%) diagnosed with DM. These patients' records were studied for clinical and histologic parameters and clinical outcomes.

Results

Twenty-two patients from the DM group had SLNB, of which four (18%) were diagnosed with micro-metastasis. These four patients were all treated with completion lymphadenectomy and none had additional positive nodes in the remainder of the nodes. Patients were followed after surgery for a median of 25 months (range 2–60 months). Two patients (9%) developed local recurrence, two (9%) in-transit recurrence, and six (27%) showed distant metastases (three patients were pure DM and three patients showed mixed morphology). Patients with mixed DM had a higher rate of nodal metastasis (25%) vs those with pure DM (14%).

Conclusions

Other authors have reported that patients diagnosed with pure DM were less likely to have a positive SLN (0–2%) than those patients with the mixed DM subtype (12–16%). Our findings of higher incidence rates of regional lymph node metastases in both the pure and mixed DM subtypes (14% and 25%) compel us to continue to still recommend that SLNB be considered in patients with both subcategories, pure and mixed DM.

Level of evidence

Level IV.     

The prognostic significance of sentinel node tumour burden in melanoma patients: An international,multicenter study of 1539 sentinel node-positive melanoma patients

IntroductionSentinel node (SN) biopsy (SNB) and completion lymph node dissection (CLND) when SN-positive have become standard of care in most cancer centres for melanoma. Various SN tumour burden parameters are assessed to determine the heterogeneity of SN-positivity. The aim of the present study was to validate the prognostic significance of various SN tumour burden micromorphometric features and classification schemes in a large cohort of SN-positive melanoma patients.MethodsIn 1539 SN-positive patients treated between 1993 and 2008 at 11 melanoma treatment centres in Europe and Australia, indices of SN tumour burden (intranodal location, tumour penetrative depth (TPD) and maximum size of SN tumour deposits) were evaluated.ResultsNon-subcapsular location, increasing TPD and increasing maximum size were all predictive factors for non-SN (NSN) status and were independently associated with poorer melanoma-specific survival (MSS). Patients with subcapsular micrometastases <0.1 mm in maximum dimension had the lowest frequency of NSN metastasis (5.5%). Despite differences in SN biopsy protocols and clinicopathologic features of the patient cohorts (between centres), most SN parameters remained predictive in individual centre populations. Maximum SN tumour size > 1 mm was the most reliable and consistent parameter independently associated with higher non-SN-positivity, poorer disease-free survival (DFS) and poorer MSS.ConclusionsIn this large retrospective, multicenter cohort study, several parameters of SN tumour burden including intranodal location, TPD and maximum size provided prognostic information, but their prognostic significance varied considerably between the different centres. This could be due to sample size limitations or to differences in SN detection, removal and examination techniques.     

Dye-guided sentinel lymphadenectomy in clinically node-negative and node-positive breast cancer patients

Background  Sentinel lymphadenectomy has been used to assess the axillary nodal status in patients with breast cancer in an attempt to avoid unnecessary axillary dissection. Most studies have examined the utility of this procedure in clinically node-negative patients. However, the clinical evaluation of axillary nodes is often inaccurate for both clinically node-negative and clinically node-positive patients. Methods  We performed dye-guided sentinel lymphadenectomy in both clinically node-negative and clinically node-positive patients with breast cancer. All patients also underwent a formal axillary dissection. The results of imprint cytology, frozen sections, and permanent sections of the sentinel lymph node (SLN) were compared with each other and with histologic findings of the nonsentinel nodes. Results  The SLN was identified in 30 (79%) of 38 patients with clinically negative nodes, and in 11 (92%) of 12 patients with clinically positive nodes. For clinically node-negative patients, SLN evaluation yielded a diagnostic accuracy of 90%, a sensitivitiy of 72%, and a specificity of 100%. For clinically node-positive patients, these values were 100%, 100% and 100%, respectively. These values were not significantly different for the two groups of patients. Conclusions  Sentinel lymphadenectomy may be useful in assessing the axillary nodal status of both clinically node-positive and clinically node-negative breast cancer patients.     

Clinical utilities and biological characteristics of melanoma sentinel lymph nodes

An estimated 73870 people will be diagnosed with melanoma in the United States in 2015, resulting in 9940 deaths. The majority of patients with cutaneous melanomas are cured with wide local excision. However, current evidence supports the use of sentinel lymph node biopsy (SLNB) given the 15%-20% of patients who harbor regional node metastasis. More importantly, the presence or absence of nodal micrometastases has been found to be the most important prognostic factor in early-stage melanoma, particularly in intermediate thickness melanoma. This review examines the development of SLNB for melanoma as a means to determine a patient’s nodal status, the efficacy of SLNB in patients with melanoma, and the biology of melanoma metastatic to sentinel lymph nodes. Prospective randomized trials have guided the development of practice guidelines for use of SLNB for melanoma and have shown the prognostic value of SLNB. Given the rapidly advancing molecular and surgical technologies, the technical aspects of diagnosis, identification, and management of regional lymph nodes in melanoma continues to evolve and to improve. Additionally, there is ongoing research examining both the role of SLNB for specific clinical scenarios and the ways to identify patients who may benefit from completion lymphadenectomy for a positive SLN. Until further data provides sufficient evidence to alter national consensus-based guidelines, SLNB with completion lymphadenectomy remains the standard of care for clinically node-negative patients found to have a positive SLN.     

Factors affecting false-negative rates on ex vivo sentinel lymph node mapping in colorectal cancer

Purpose

Despite the increasing use of sentinel lymph node (SLN) mapping after colorectal cancer resection, reported node identification and false-negative rates vary considerably. The main aim of this prospective study was to quantify the false-negative rates on SLN mapping after resection and to evaluate factors influencing them.

Methods

Sixty-nine patients with biopsy-proven cancer of the colon and rectum underwent SLN mapping according to a protocol involving the ex vivo submucosal and peritumoral injection of 2–4 ml of Patent Blue V dye. All lymph nodes visualized were marked as SLN and totally embedded, then two 4 μm sections were cut for hematoxylin and eosin staining, and cytokeratin (AE1/AE3) immunostaining. A standard examination of the whole specimen and of the regional non-sentinel lymph nodes was also performed.

Results

SLNs were identified in 97.3% of the evaluable cases. A mean of 5.0 SLNs were removed per patient (SD ± 4.2). Nine false negatives were identified. Rectal cancer, tumor size > 60 mm, number of metastatic non-sentinel lymph nodes, and mucinous tumors were associated with false-negative SLNs. At multivariate analysis, a rectal location and mucinous differentiation were independently associated with false-negative SLNs.

Conclusions

Ex vivo SLN mapping after colorectal cancer surgery is technically feasible with a high identification rate. Tumor size and stage, rectal involvement and a mucinous histology seem to interfere with the reliability of SLN staging. It is mandatory to standardize the procedure and selection criteria in order to deal with the question of the reliability of SLN mapping in colorectal cancer.     

Prognostic value of sentinel node biopsy in 327 prospective melanoma patients from a single institution

Aim

To confirm the accuracy of sentinel node biopsy (SNB) procedure and its morbidity, and to investigate predictive factors for SN status and prognostic factors for disease-free survival (DFS) and disease-specific survival (DSS).

Materials and methods

Between October 1997 and December 2004, 327 consecutive patients in one centre with clinically node-negative primary skin melanoma underwent an SNB by the triple technique, i.e. lymphoscintigraphy, blue-dye and gamma-probe. Multivariate logistic regression analyses as well as the Kaplan–Meier were performed.

Results

Twenty-three percent of the patients had at least one metastatic SN, which was significantly associated with Breslow thickness (p < 0.001). The success rate of SNB was 99.1% and its morbidity was 7.6%. With a median follow-up of 33 months, the 5-year DFS/DSS were 43%/49% for patients with positive SN and 83.5%/87.4% for patients with negative SN, respectively. The false-negative rate of SNB was 8.6% and sensitivity 91.4%. On multivariate analysis, DFS was significantly worsened by Breslow thickness (RR = 5.6, p < 0.001), positive SN (RR = 5.0, p < 0.001) and male sex (RR = 2.9, p = 0.001). The presence of a metastatic SN (RR = 8.4, p < 0.001), male sex (RR = 6.1, p < 0.001), Breslow thickness (RR = 3.2, p = 0.013) and ulceration (RR = 2.6, p = 0.015) were significantly associated with a poorer DSS.

Conclusion

SNB is a reliable procedure with high sensitivity (91.4%) and low morbidity. Breslow thickness was the only statistically significant parameter predictive of SN status. DFS was worsened in decreasing order by Breslow thickness, metastatic SN and male gender. Similarly DSS was significantly worsened by a metastatic SN, male gender, Breslow thickness and ulceration. These data reinforce the SN status as a powerful staging procedure.     

Validation of a clinicopathological and gene expression profile model to identify patients with cutaneous melanoma where sentinel lymph node biopsy is unnecessary

BackgroundIn patients with cutaneous melanoma, sentinel lymph node biopsy (SLNB) serves as an important technique to asses disease stage and to guide adjuvant systemic therapy. A model using clinicopathologic and gene expression variables (CP-GEP; Merlin Assay) has recently been introduced to identify patients that may safely forgo SLNB. Herein we present data from an independent validation cohort of the CP-GEP model in Swedish patients.MethodsArchival histological material (primary melanoma tissue) from a prospectively collected cohort of 421 consecutive patients with pT1-T4 melanoma undergoing SLNB between 2006 and 2014 was analyzed using the CP-GEP model. CP-GEP combines Breslow thickness and patient age with the expression levels of eight genes from the primary melanoma. Stratification is based on their risk for nodal metastasis: CP-GEP Low Risk or CP-GEP High Risk.ResultsThe SLNB positivity rate was 13%. Of 421 primary melanomas, the CP-GEP model identified 86 patients as having a low risk for nodal metastasis. In patients with pT1-2 melanomas, the SLNB reduction rate was 35.4% (95% CI: 29.4–41.8) with a negative predictive value (NPV) of 96.5% (95% CI: 90.0–99.3). Among patients with pT1-3 melanomas, CP-GEP suggested a SLNB reduction rate of 24.0% (95% CI: 19.7–28.8) and a NPV of 96.5% (95% CI: 90.1–99.3). Only one of 118 pT3 tumors was classified as CP-GEP Low Risk, and all pT4 tumors were classified as being high risk for nodal metastasis.ConclusionThis study demonstrates that CP-GEP can identify patients with a low risk for nodal metastasis. Patients with pT1-2 melanomas have the highest clinical benefit from using the test, where 35% of the patients could forgo a SLNB procedure.     

前哨淋巴结活检在中国皮肤和肢端恶性黑色素瘤患者诊治中的临床意义

背景与目的：恶性黑色素瘤近年来在中国发病率呈上升趋势。前哨淋巴结活检（sentinel lymph node biopsy,SLNB）在欧美是皮肤恶性黑色素瘤外科诊治规范的重要环节,但在中国却未广泛开展。中国黑色素瘤具有多肢端亚型、浸润深度厚、溃疡率高和预后差等特点。但中国黑色素瘤外科治疗后的预后仍未明确。该研究旨在分析中国黑色素瘤患者的临床数据,评价SLNB的可行性及其对预后的影响。方法：回顾性分析2009—2017年在复旦大学附属肿瘤医院治疗的无临床淋巴转移和远处转移征象的黑色素瘤患者。每例患者在接受原发病灶扩大切除的同时,进行相应区域淋巴结的SLNB。前哨淋巴结（sentinel lymph node,SLN）的定位通过美兰染色和同位素示踪完成。所有患者术后均进行随访。结果：本研究共纳入452例黑色素瘤患者。平均Breslow浸润深度为3.29 mm,66.4%为肢端病灶,溃疡率达59.7%。SLN阳性率为26.8%,假阴性率为4%,淋巴结总转移率为30.8%。本组患者5年总生存率（overall survival,OS）和无病生存率（disease-free survival,DFS）分别为66.6%和55.8%。SLN状态是显著影响患者预后的独立危险因素,而Breslow浸润深度是预测SLN转移状态的独立危险因素。结论：对于无临床大体转移的中国黑色素瘤患者,应常规开展SLNB。SLN状态是影响复发和总体生存的重要因素,SLNB能提高淋巴结微转移患者的生存,提供准确的临床分期。     

前哨淋巴结活检指导保留乳房手术患者行选择性腋窝淋巴结清除术的研究

目的研究通过前哨淋巴通道（SLC）行前哨淋巴结活检（SLNB）以指导保留乳房手术（breast—conservingtherapy,BCT）患者行选择性腋窝淋巴结清除术（ALND）的可行性。方法采用非随机对照研究,在BCT患者中采用联合示踪法通过SLC行SLNB。对术中检出的前哨淋巴结（SLN）行细胞印片和冰冻切片检查,根据SLN的术中病理结果行选择性ALND,其中SI。N阳性、行ALND者为A组,SI。N阴性仅行SLNB者为B组。定性资料的比较选用Y。检验,两组均数的比较采用t检验。结果2009年1月至2009年12月采用联合示踪法行SLNB的BCT患者共43例,检出42例,A组28例,B组14例。两组患者的SLC均被显影。每例患者被检出SLN1～3枚,平均1．4枚,共被检出59枚。SLNB检出率为97．7％（42／43）。术后病理检查共检出阳性SI,N29例,其中术中细胞印片、冰冻切片及二者联合病理检测分别检出阳性淋巴结27、27、28例。A组ALND相关并发症发生率明显高于B组（P=0．003）。结论通过SLC行SLNB有助于准确定位SLN,能够指导BCT患者行选择性ALND,降低术后并发症。     

Isolated internal mammary sentinel lymph node metastasis in two breast cancer patients

 Lymphatic mapping with sentinel node biopsy may lead to more accurate staging of breast cancer patients. Two patients with sentinel nodes in the internal mammary node chain are described. These nodes were visualized on lymphoscintigraphy images and harvested by the surgeon. They were shown to contain tumor cells in the absence of axillary involvement. This led to upstaging and to a change in the subsequent management. Received: May 16, 2002 / Accepted: July 1, 2002 Correspondence to:S.J. Haryono