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。     

子宫内膜癌前哨淋巴结检测及微转移的临床意义

虽然前哨淋巴结(Sentinel lymph node,SLN)检测在子宫内膜癌领域还属于探索阶段,但多项研究表明SLN检测在早期子宫内膜癌是可行的.蓝染和放射性胶体联合检测方法可以提高SLN检出率;子宫体多点注射法和经宫腔镜子宫内膜注射法较宫颈注射法比较,可以提高SLN检出率和主动脉旁SLN阳性率.此外SLN检出率还与示踪物剂量、注射到检测的间隔时间以及肿瘤浸润子宫肌层深度有关.连续切片及抗细胞角蛋白免疫组化方法的联合应用可以提高SLN微转移(MM)的检出率.SLN的重要意义不仅是替代淋巴结切除术,更多在于它能够检测出传统的病理学检查不能发现的MM.其"超"分期作用可以诊断出中危度子宫内膜癌患者并对其提供及时的辅助治疗,减少复发.     

子宫内膜癌前哨淋巴结应用的研究进展与展望

前哨淋巴结（sentinel lymph node,SLN）检测为子宫内膜癌患者的精准淋巴结切除提供了选择,极具应用前景,但仍有部分问题和争议亟待解决,如SLN检测在高危患者中的标准临床应用规范、SLN最佳算法、评估SLN的最佳方式、低体积转移的临床意义,均值得探究。目前子宫颈注射吲哚菁绿为最常用的示踪方法,病理学超分期可提高对低体积转移的检出率,但病理学超分期操作流程、应用指征及低体积转移的临床管理需进一步规范。此外,高危型子宫内膜癌并非SLN检测的绝对禁忌证,但此类患者行SLN检测的标准临床应用规范有待进一步研究。现就近年来子宫内膜癌SLN检测研究现状及进展进行综述。     

前哨淋巴结定位在高级别子宫内膜癌手术中的价值

近年来,前哨淋巴结（sentinel lymph node, SLN）定位在妇科恶性肿瘤尤其是子宫内膜癌手术中广泛开展,与系统性的淋巴切除术相比,其能缩短手术时间、减少创伤及降低手术并发症发生率。然而,目前SLN主要应用于低级别子宫内膜癌,在高级别子宫内膜癌中的应用尚具争议。本文综述了SLN在高级别子宫内膜癌中的研究进展,以期对临床工作有参考和指导意义。     

纳米碳在子宫内膜癌前哨淋巴结检测中的应用

目的:探讨纳米碳在子宫内膜癌前哨淋巴结检测中的可行性及应用价值。方法:选择25例经手术治疗的子宫内膜癌患者,术中于子宫前壁、后壁、宫底两侧共4点处注射纳米碳混悬液,识别黑染的淋巴结,并记录前哨淋巴结相关信息,淋巴结分开单独送病理检查行HE染色。结果:25例子宫内膜癌患者均出现子宫浆膜面黑染,前哨淋巴结检出率为84%（21/25）,共计114枚,其中盆腔双侧检出率为81%,盆腔一侧检出率为19%。3例患者发生淋巴结转移,均为SLN转移。结论:纳米碳作子宫内膜癌前哨淋巴结的示踪剂具有可行性,对于子宫内膜癌淋巴结转移判断有一定的临床应用价值。     

前哨淋巴结在88例早期子宫内膜癌术中的应用

摘 要：［目的］ 分析前哨淋巴结（sentinel lymph node,SLN）在早期子宫内膜癌术中的应用价值。［方法］ 将88例行手术治疗的早期子宫内膜癌患者纳入研究,行亚甲蓝注射液前哨淋巴结显影探查;记录SLN检出情况和盆腔淋巴结转移情况。［结果］ ①前哨淋巴结检出率（SLN阳性率）为94.32%。②肿瘤直径≤2cm 的患者SNL检出率为100.00%,肿瘤直径＞2cm 的患者SLN检出率为87.00%。SNL检出率在不同注射位置及不同年龄段中无明显差异。③SLN与盆腹腔淋巴结分布：45.76%SLN分布在髂外,其次为闭孔（23.99%）;37.99%的盆腹腔淋巴结分布在髂外,29.06%分布在闭孔。④亚甲蓝注射液示踪SNL诊断盆腔淋巴结转移特异性、敏感度分别为95.58%和100.00%。 ［结论］ 示踪前哨淋巴结用于早期子宫内膜癌术中能清晰显影淋巴管,能辅助判断盆腹腔淋巴结是否转移,对淋巴结精准清扫、治疗及预后有指导意义。     

前哨淋巴结识别技术在子宫内膜癌的研究

目的 :探讨在子宫内膜癌淋巴结切除术中进行前哨淋巴结(SLN)识别的可行性。 方法 :选择接受手术治疗的临床Ⅰ、Ⅱ期子宫内膜癌患者31例。术中将示踪剂亚甲蓝分多点注射于子宫浆膜下,进而追踪识别蓝染的淋巴结为SLN。切取SLN后再行其它淋巴结切除,SLN与其它淋巴结分送常规病理检查。 结果 :31例中4例(12.9%)在注射亚甲蓝过程中发生泄漏,无淋巴管着色。其余27例(87.1%)均有子宫浆膜面及双侧骨盆漏斗韧带内的淋巴管着色,其中22例盆腔内淋巴管同时着色。27例淋巴管着色的病例中23例(85.2%)识别出SLN,共计90枚,平均每例3.9枚(1～10枚)。除1枚(1.1%)SLN位于腹主动脉旁区域外,其余89枚(98.9%)分布于盆腔的各组淋巴结中,主要为闭孔38枚(42.2%)、髂内19枚(21.1%)。本组中27例(87.1%)患者接受了盆腔淋巴结清扫术,4例(12.9%)行盆腔淋巴结取样术。31例中7例(22.6%)同期行腹主动脉旁淋巴结取样术。手术共切除淋巴结926枚,平均每例29.8枚(14～55枚)。3例(9.7%)患者发生淋巴结转移,其中2例SLN转移,另1例转移患者无SLN检出。未发现与本研究相关的损伤及不良反应。 结论 :应用亚甲蓝在子宫内膜癌术中进行SLN识别具有可行性,此技术简便、安全,值得进一步探讨。     

前哨淋巴结检测技术在子宫内膜癌中的应用

子宫内膜癌是女性常见的恶性肿瘤,手术是子宫内膜癌的主要治疗手段,除了不能耐受手术或晚期无法进行手术的患者外,其他患者均应进行全面的分期手术。随着精准化治疗时代的到来,前哨淋巴结(SLN)检测技术在子宫内膜癌中的应用日趋成熟,但关于SLN显像染料和注射部位的选择及病理超分期技术的临床意义仍未达成共识。吲哚菁绿(ICG)相比于其他染料能提高双侧盆腔SLN的检出率,且不良反应发生率低。宫颈注射具有操作方便和盆腔SLN检出率高的优势;病理超分期技术能提高微转移病灶的检出率,但临床意义尚未明确。如何更好地提高SLN的检出率、降低SLN的假阴性率、避免不必要的全面淋巴结清扫术并指导临床预后成为当前研究的重点。本文就SLN技术在子宫内膜癌中的应用情况进行阐述。     

影响子宫内膜癌淋巴结转移的预后因素

子宫内膜癌的腹膜后淋巴结转移是直接影响患者预后的重要因素。我们通过对 15 6例子宫内膜癌患者腹膜后淋巴结清扫或活检的临床病理资料进行回顾性分析。材料与方法收集我院 1994～ 1999年间手术治疗的 15 6例内膜癌患者资料 ,所有病例均经病理证实。年龄在 37～ 72岁 ,平均年龄 5 5 2岁 ,按 1971年ＦＩＧＯ临床分期 ,Ⅰ期 96例 ,Ⅱ期 6 0例。腺癌 119例 ,腺鳞癌 2 5例 ,透明细胞癌 12例。所有病例首次治疗均采用手术治疗 ,手术方式为子宫广泛切除加盆腔或腹主动脉旁淋巴结清扫 ,子宫次广泛切除或筋膜外子宫切除加盆腔或腹主动脉旁淋巴结清…     

子宫内膜癌的淋巴结转移及手术范围初探

国际妇产科联盟（ＦＩＧＯ）于１９８８年将子宫内膜癌的临床分期改为手术病理学分期,其中将腹膜后淋巴清扫及转移纳入手术及分期范围（１）。我们通过对手术治疗并行腹膜后淋巴清扫或活检的８５例子宫内膜癌患者的临床病理资料进行回顾性分析,初步探讨子宫内膜癌的手术...     

Sentinel Lymph Node Mapping in High-Grade Endometrial Cancer

Sentinel lymph node (SLN) mapping is becoming an acceptable alternative to full lymphadenectomy for evaluating lymphatic spread in clinical stage I endometrial cancer (EC). While the assessment of pelvic and para-aortic lymph nodes is part of the surgical staging of EC, there is a long-standing debate over the therapeutic value of full lymphadenectomy in this setting. Although lymphadenectomy offers critical information on lymphatic spread and prognosis, most patients will not derive oncologic benefit from this procedure as the majority of patients do not have lymph node involvement. SLN mapping offers prognostic information while simultaneously avoiding the morbidity associated with an extensive and often unnecessary lymphadenectomy. A key factor in the decision making when planning for EC surgery is the histologic subtype. Since the risk of lymphatic spread is less than 5% in low-grade EC, these patients might not benefit from lymph node assessment. Nonetheless, in high-grade EC, the risk for lymph node metastases is much higher (20–30%); therefore, it is crucial to determine the spread of disease both for determining prognosis and for tailoring the appropriate adjuvant treatment. Studies on the accuracy of SLN mapping in high-grade EC have shown a detection rate of over 90%. The available evidence supports adopting the SLN approach as an accurate method for surgical staging. However, there is a paucity of prospective data on the long-term oncologic outcome for patients undergoing SLN mapping in high-grade EC, and more trials are warranted to answer this question.     

Sentinel Lymph Node Identification in Endometrial Cancer

OBJECTIVE To evaluate the feasibility of intra-operative detection of sentinel lymph nodes (SLN) in the patient with endometrial cancer (EC).METHODS Thirty-one patients with Stage Ⅰ and Ⅱ endometrial cancer, who underwent a hysterectomy and a lymphadenectomy,were enrolled in the study. At laparotomy, methylene blue dye tracer was injected into the subserosal myometrium of corpus uteri at multiple sites, and dye uptake into the lymphatic channels was observed. The blue nodes which were identified as SLNs were traced and excised. The other nodes were then removed. All of the excised nodes were submitted for pathological hematoxylin and eosin (H&E) staining examination.RESULTS Failure of dye uptake occurred in 4 of the 31 cases (12.9%) because of spillage, and no lymphatic coloration was observed there. Lymphatic staining was clearly observable as blue dye diffused to the lymphatic channels of the uterine surface and the infundibulopelvic ligaments in 27 (87.1%) cases. Concurrent coloration in the pelvic lymphatic vessels was also observed in 22of the 27 patients. The SLNs were identified in 23 of the 27 (85.2%)cases with a lymphatic staining, with a total number of 90 SLNs,and a mean of 3.9 in each case (range, 1-10). Besides one SLN (1.1%)in the para-aortic area, the other 89 (98.9%) were in the nodes of the pelvis. The most dense locations of SLNs included obturator in 38 (42.2%) and interiliac in 19 (21.1%) cases. In our group, pelvic lymphadenectomy was conducted in 27 (87.1%) patients and pelvic nodal sampling in 4 (12.9%). Of the 31 cases, a concurrent abdominal para-aortic lymph node sampling was conducted in 7. A total of 926 nodes were harvested, with an average of 39.8 in each case (range, 14-55). Nodal metastases occurred in 3 patients (9.7%), 2 of them with SLN involvement and the other without SLN involvement. Adverse reactions or injury related to the study was not found.CONCLUSION Application of methylene blue dye is feasible in an intra-operative SLN identification of endometrial cancer. The technology is convenient, safe, and worth further investigation.     

Current Controversies Concerning Sentinel Lymph Node Biopsy for Breast Cancer

BACKGROUND AND METHODS: The objectives of this article are to review existing controversies regarding sentinel lymph node (SLN) biopsy and to identify potential areas of consensus in order to eliminate routine axillary lymph node dissection (ALND). RESULTS: A combination of peritumoral injection with radioisotopes and subdermal or subareolar injection with blue dye may result in enhanced success rates of SLN identification. Preoperative lymphoscintigraphy is most useful for detecting an internal mammary SLN, but the practicability of internal mammary SLN biopsy is still in the investigative stage. Intraoperative diagnosis of SLN is useful because patients with SLN metastases may be treated immediately with ALND, but it is unreasonable to expect that either examination of frozen sections or imprint cytology will detect every metastatic disease. SLN micrometastases may be of prognostic importance and these can be identified with H and E staining on permanent sections of 200 micro m intervals. While ALND is preferable for patients even with a small tumor (T1) and SLN micrometastases, radiation therapy is an acceptable alternative. SLN biopsy may be indicated for patients with DCIS detected as a palpable mass or those with large calcification areas in the breast. The accuracy of SLN biopsy after neoadjuvant chemotherapy is considered to be unproven. CONCLUSION: Since SLN biopsy has been adopted by surgeons around the world, consistency of technique and case selection has attained great significance.     

乳腺癌前哨体淋巴结活检的研究

前哨淋巴结(SLN)的概念和前哨淋巴结活检(SLNB)的应用是在1977年被提出的,但由于当时淋巴结检测设备和技术尚不先进,使SLN的研究未能得到足够的重视.乳腺癌SLNB是在20世纪90年代兴起的,现已成为乳腺癌外科领域的研究热点,有望在早期乳腺癌治疗中取代常规的腋窝淋巴结解剖(ALND),降低上肢淋巴水肿和功能障碍的发生率.我国该项目研究起步较晚,目前已逐渐成为人们关注的热点.该项目还将继续进行多中心、大样本、前瞻性研究,最终达成共识,将给乳腺癌病人带来福音.     

乳腺癌前哨淋巴结活检

慨述乳腺癌前哨淋巴结活检(SLNB)的解剖生理基础、临床意义、影响因素、假阴性和乳腺癌前哨淋巴结的定位、微转移及病理诊断。SLNB常规应用于临床还有持进一步探讨。     

早期乳腺癌前哨淋巴结活检在简化腋清扫中的应用研究

[目的]探讨早期乳腺癌患者行前哨淋巴结活检（SLNB）为阴性,行简化腋窝淋巴结清扫替代腋窝淋巴结清扫术（ALND）的临床效果。[方法]采用1%亚甲蓝染色法对65例早期乳腺癌患者行SLNB,60例成功行SLNB,其中40例SLN无转移者行简化腋窝淋巴结清扫术（简化组）;20例SLN有转移者行ALND（标准组）,比较两组患者术后上肢并发症的发生情况、腋窝复发及全身转移情况。[结果]简化组手术时间和腋窝引流时间比标准组明显缩短,有统计学差异（P〈0.01）;简化组术后患侧上肢的疼痛、肿胀、麻木症状明显较标准组少（P〈0.01）。两组生存曲线没有差异。[结论]亚甲蓝染色法能够比较准确地定位乳腺癌的前哨淋巴结。简化ALND替代ALND手术时间和术后引流时间缩短,方便可行,并发症明显减少,腋窝复发率低,是早期乳腺癌患者的安全分期手术。     

乳腺癌前哨淋巴结的临床研究

目的：探讨前哨淋巴结活检（sentinel lymph node biopsy，SLNB）在乳腺癌临床应用中的可行性、准确性。方法：术前肿瘤表面或活检腔周围皮内注射99mTc-DX，进行前哨淋巴结（sentinel lymph node，SLN）显像、体表定位；术中r-探测仪识别SLN，先行SLNB，再行乳腺癌根治术或改良根治术，术后对SLN和腋窝淋巴结清扫（axillary Lymph Node Dissectio，ALND）的病理结果进行综合分析。结果：淋巴闪烁显像和r-探测器联合应用检测SLN准确率为96.9％，敏感度为90.9％，假阴性率为9.1％，假阳性率为0。结论：SLNB是乳腺癌治疗中的一项新技术，能高灵敏度反应腋淋巴结状态。     

胃癌前哨淋巴结定位及活检技术

目的：确定胃癌前哨淋巴结定位及活检技术的可行性及其预测各期胃癌淋巴结转移情况的准确性。方法：使用专利蓝染料，对45例胃癌病人进行术中及术后前哨淋巴结定位和活检。结果：在44例（97．78％）中找到前哨淋巴结。有15例前哨淋巴结存在转移，其中10例非前哨淋巴结亦存在转移。5例前哨淋巴结为胃周淋巴结的唯一转移部位。有29例前哨淋巴结无转移，其中4例非前哨淋巴结存在转移。由前哨淋巴结状态预测胃周淋巴结转移情况的敏感性为78．95％，特异性为100％，准确率为90．91％。随着肿瘤增大，浸润程度加深，其特异性不变，但准确率下降。结论：胃癌前哨淋巴结定位及活检技术是可行的，对于早期胃癌，前哨淋巴结的组织学状态可以准确反映胃周其余淋巴结的状况。将来治疗淋巴结转移阴性的胃癌中，这一技术有可能免除常规的淋巴结清扫。