临床腋淋巴结阴性乳腺癌前哨淋巴结研究

目的：探讨前哨淋巴结活检术（ｓｅｎｔｉｎｅｌ ｌｙｍｐｈ ｎｏｄｅ ｂｉｏｐｓｙ, ＳＬＮＢ）在乳腺癌治疗中的应用。方法：使用专利蓝和美蓝染色,对１９９９年９月～２００１年４月连续收治的１４５例临床查体腋窝淋巴结阴性乳腺癌病人行前哨淋巴结活检术。结果：ＳＬＮＢ成功率为９６．５％（１４０／１４５）,假阴性率为２３．５％,准确率为９１．４％。病人年龄、肿瘤最大径、肿瘤部位、注射染料类型及是否活检对成功率和假阴性率无影响。结论：ＳＬＮＢ能够准确预测腋窝淋巴结的转移状况,在缩小手术范围、减少术后并发症的同时,提高了腋窝淋巴结分期的准确性;美蓝与专利蓝均可成功确定ＳＬＮ。     

Breast Cancer Sentinel Lymph Node Identification Rates: The Influence of Radiocolloid Mapping,Case Volume,and the Place of the Procedure

Background We hypothesized that high-volume surgeons performing sentinel lymph node (SLN) biopsy at an academic medical center (AMC) would have the same identification rates at suburban surgical centers (SSCs). Methods Twenty-one surgeons performed 1199 SLN biopsies in 1187 clinically node-negative patients with an intraoperative gamma probe (IOGP) plus blue dye (at AMC) or blue dye alone (at SSCs). Demographic, radiologic, and pathological data were analyzed by generalized estimating equations logistic regression models. Results Four surgeons (group 1) performed 877 procedures (361, 247, 152, and 117 cases each), 426 with and 451 without IOGP. Seventeen surgeons (group 2) performed 322 procedures (2–92 cases each), 173 with and 149 without IOGP. Group 1 found 411 SLNs (96.5%) with and 419 (92.9%) without IOGP (P = .024). Group 2 found 163 (94.2%) with and 117 (78.5%) without IOGP (P < .0001). The odds of finding the SLN was 2.9 times higher with IOGP (95% confidence interval [95% CI], 1.8, 4.7; P < .001) and 2.7 times higher by group 1 than group 2 surgeons (95% CI, 1.7, 4.3; P < .001), controlling for tumor size and surgery type. Conclusions High-volume surgeons identified more SLNs with IOGP (at the AMC) than without (at the SSCs). They also were more efficient than low-volume surgeons when blue dye alone was used. Low-volume surgeons were almost as efficient as high-volume surgeons when they used IOGP. Optimal identification of SLNs requires nuclear medicine facilities. Presented in part at the 59th Annual Cancer Symposium of the Society of Surgical Oncology, San Diego, CA, March 25, 2006.     

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 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.     

Intradermal Radiocolloid and Intraparenchymal Blue Dye Injection Optimize Sentinel Node Identification in Breast Cancer Patients

Background: Radiotracer and blue dye mapping of sentinel lymph nodes (SLN) have been advocated as accurate methods to stage the clinically negative axilla in breast cancer patients. The technical aspects of SLN biopsy are not fully characterized. In this study we compare the results of intraparenchymal (IP) and intradermal (ID) injection of Tc-99m sulfur colloid, to establish an optimal method for SLN localization.Methods: 200 consecutive patients had SLN biopsy performed by a single surgeon. Of these, 100 (Group I) had IP injection and 100 (Group II) had ID injection of Tc-99m sulfur colloid. All patients had IP injection of blue dye as well. Endpoints included (1) successful SLN localization by lymphoscintigraphy, (2) successful SLN localization at surgery, and (3) blue dye–isotope concordance (uptake of dye and isotope by the same SLN).Results: Isotope SLN localization was successful in 78% of Group I and 97% of group II patients (P < .001). When isotope was combined with blue dye, SLN were found in 92% of group I and 100% of Group II (P < .01). In cases where both dye and isotope were found in the axilla, dye mapped the same SLN as radiotracer in 97% of Group I and 95% of Group II patients.Conclusions: The dermal and parenchymal lymphatics of the breast drain to the same SLN in most patients. Because ID injection is easier to perform and more effective, this technique may simplify and optimize SLN localization.     

S-Classification of Sentinel Lymph Node Predicts Axillary Nonsentinel Lymph Node Status in Patients with Breast Cancer

Background One-half of breast cancer patients with positive sentinel lymph node (SN) have no further metastases in the axillary lymph node basin. The aim of the present study was to identify patients with positive SN who are unlikely to have further metastases in the axillary lymph node basin, using a new classification of SN, namely the S-classification. Methods Specimens of positive SN were subjected to a pathological review according to the previously published S-classification. S-stages of positive SN were correlated with the status of further metastases in the axillary lymph node basin after axillary lymph node dissection (ALND). Results Of 117 patients who underwent sentinel lymph node biopsy, 36 (30.8%) had a positive SN and were subjected to level I and II ALND. The occurrence of positive nonsentinel nodes was significantly related to the S-stage of SN. No patient with stage SI had additional metastases in the nonsentinel lymph nodes, while 14.3% of patients with SII stage disease and 60.9 % of patients with SIII disease had other non-SN that were metastatic. Conclusion S-stages of positive SN are highly predictive for axillary nonsentinel node status. Especially patients with SI sentinel node metastases appear to be at low risk for further nonsentinel node metastases.     

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。     

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 Metastasis in Microinvasive Breast Cancer

Background:Ductal carcinoma in situ with microinvasion (DCISM) is a separate pathological entity, distinct from pure ductal carcinoma in situ (DCIS). DCISM is a true invasive breast carcinoma with a well-known metastatic potential. Currently, there is controversy regarding the indication for complete axillary dissection (CAD) to stage the axilla in patients with DCISM. The role of CAD is questioned given its morbidity and reported low incidence of axillary involvement. Sentinel lymph node biopsy (SLNB) may obviate the need for CAD in these patients without compromising the staging of the axilla and the important prognostic information.Methods:From March 1996 to December 2002, 4602 consecutive patients with invasive breast carcinoma underwent SLN biopsy. Of these, 41 patients with DCISM were selected.Results:Metastasis in the SLN were detected in 4 of 41 (9.7%) patients. Two of the 4 patients had only micrometastasis in the SLN. In three patients, the SLN was the only positive node after CAD.Conclusions:SLN biopsy should be considered as a standard procedure in DCISM patients. SLNB can detect nodal micrometastasis and accurately stage the axilla avoiding the morbidity of a CAD. Complete AD may not be mandatory if only the SLN contains micrometastatic disease. Informed consent is very important in the decision not to undergo CAD.     

Laparoscopic Sentinel Node Procedure Using a Combination of Patent Blue and Radiocolloid in Women With Endometrial Cancer

Background: We assessed the feasibility of a laparoscopic sentinel node (SN) procedure based on the combined use of radiocolloid and patent blue labeling in patients with endometrial cancer.Methods: Seventeen patients (median age, 69 years) with endometrial cancer of stage I (16 patients) or stage II (1 patient) underwent a laparoscopic SN procedure based on combined radiocolloid and patent blue injected pericervically. After the SN procedure, all patients underwent complete laparoscopic pelvic lymphadenectomy and either laparoscopically assisted vaginal hysterectomy (16 patients) or laparoscopic radical hysterectomy (1 patient).Results: SNs (mean number per patient, 2.6; range, 1–4) were identified in 16 (94.1%) of the 17 patients. Macrometastases were detected in three SNs from two patients by hematoxylin and eosin staining. In three other patients, immunohistochemical analysis identified six micrometastatic SNs and one SN containing isolated tumor cells. No false-negative SN results were observed.Conclusions: An SN procedure based on a combination of radiocolloid and patent blue is feasible in patients with early endometrial cancer. Combined use of laparoscopy and this SN procedure permits minimally invasive management of endometrial cancer.     

Sentinel Lymph Node Biopsy for Local Recurrence of Breast Cancer After Breast-Conserving Therapy

Background Lymphatic mapping (LM) with sentinel lymph node (SLN) biopsy has revolutionized the surgical staging of primary breast cancer, but its utility and feasibility have not been established in patients with ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery (BCS) and radiation. Methods We reviewed our breast cancer database to identify all patients who underwent preoperative lymphoscintigraphy for IBTR and whose primary tumor had been managed by BCS, SLN biopsy and/or axillary node dissection, and adjuvant breast irradiation. Results Preoperative lymphoscintigraphy identified migration to the regional nodal drainage basins in 11 (73%) of 15 patients, as follows: 5 ipsilateral axillary, 1 supraclavicular, 2 internal mammary, 2 interpectoral, and 3 contralateral axillary. Two patients demonstrated drainage to two nodal basins. In four patients, no drainage was observed. Intraoperative LM with radioisotope plus blue dye identified at least 1 SLN in 11 of 14 patients, and histopathologic evaluation revealed metastasis in 3 patients (2 contralateral axillary and 1 ipsilateral axillary). During preoperative lymphoscintigraphy, the radiocolloid migration time tended to be longer and the drainage pathways more variable than those associated with primary tumors. Conclusions LM/SLN biopsy can be successfully performed in patients with IBTR after prior BCS, axillary surgical staging, and adjuvant radiation. This approach illustrates variations in the lymphatic drainage of recurrent breast tumors and may permit the identification of regional metastasis not noted with conventional imaging techniques.     

Sentinel Node Positivity Rates With and Without Frozen Section for Breast Cancer

Background Sentinel lymph node biopsy (SLNB) is used to detect breast cancer axillary metastases. Some surgeons send the sentinel lymph node (SLN) for intraoperative frozen section (FS) to minimize delayed axillary dissections. There has been concern that FS may discard nodal tissue and thus underdiagnose small metastases. This study examines whether evaluation of SLN by FS increases the false-negative rate of SLNB. Methods A retrospective analysis of SLNB from 659 patients was conducted to determine the frequency of node positivity among SLNB subjected to both FS and permanent section (PS) versus PS alone. Statistical analysis was performed by the χ² square test, and a logistic regression model was applied to estimate the effect of final node positivity between the two groups. Results FS was performed in 327 patients and PS was performed in all 659 patients. Among patients undergoing both FS and PS (n = 327), the final node positivity rate was 33.0% compared with 19.6% among patients undergoing PS alone (n = 332). After adjustment for patient age, tumor diameter, grade, and hormone receptor status in a multivariate logistic regression model, there remained an increased likelihood of final node positivity for patients undergoing both procedures relative to PS alone (adjusted odds ratio, 2.1; 95% confidence interval, 1.3–3.6; P = .005). Conclusions There was a higher rate of SLN positivity in specimens evaluated by both FS and PS. Therefore, evaluating SLN by FS does not underdiagnose small metastases nor produce a higher false-negative rate. Intraoperative FS offers the advantage of less delayed axillary dissections. Presented in part at the 2007 New York Surgical Scientific Society Session.     

Touch Preparation or Frozen Section for Intraoperative Detection of Sentinel Lymph Node Metastases From Breast Cancer

Background:The preferred technique for intraoperative evaluation of the sentinel lymph node has not been determined. The purpose of this study was to compare the sensitivity and accuracy of intraoperative evaluation of the sentinel lymph node by touch preparation cytology and frozen section.Methods:A total of 117 patients with clinically node-negative breast cancer or ductal carcinoma-in-situ undergoing sentinel lymph node biopsy had intraoperative evaluation of the sentinel node by touch preparation, frozen section, or both. The results of the intraoperative evaluation were compared with the final histological results of hematoxylin and eosin (H&E) paraffin section and immunohistochemistry (IHC).Results:Twenty-six (57%) of the 46 patients with nodal involvement had metastases detected during surgery. The sensitivity of touch preparation for detecting macrometastases was 78%; for detecting all H&E metastases, including micrometastases, was 57%; and for detecting all metastases, including those seen on IHC, was 40%. The sensitivity of frozen section for detecting macrometastases was 83%; for detecting all H&E metastases, including micrometastases, was 78%; and for detecting all metastases, including those seen on IHC, was 64%. Both have a low sensitivity for micrometastases seen by H&E paraffin section: 57% and 78%, respectively. Neither detected micrometastases diagnosed by IHC only.Conclusions:Both touch preparation and frozen section seem to be accurate in detecting macrometastases, but not micrometastases. Intraoperative evaluation of the sentinel lymph node by touch preparation allows for a quick evaluation of the node without wasting significant tissue and without detecting occult microscopic metastases, which may be beneficial because the clinical importance of these has yet to be elucidated.     

Efficacy of Different Technical Procedures for Sentinel Lymph Node Biopsy in Gastric Cancer Staging

BACKGROUND: The clinical impact of sentinel lymph node biopsy (SLNB) in gastric cancer is controversial. We performed a prospective trial to compare different methods: radiocolloid method (RM), dye method (DM), and both methods simultaneously (dual method, or DUM) for reliability and therapeutic consequences. METHODS: RM and DM were applied in 35 gastric cancer patients. After endoscopic peritumoral injection of (99m)Tc-colloid and Patent Blue V, the positions of all blue sentinel lymph nodes (SLNs) were recorded, and the SLNs microscopically examined by hematoxylin and eosin, step sections, and immunohistochemistry. RESULTS: RM, DM, and DUM identified the SLNs in 34 (97%) of 35 patients. The sensitivity for the prediction of positive lymph node status for RM was 22 (92%) of 24, for DM 16 (66%) of 24, and for DUM 22 (92%) of 24. In 7 of 17 (RM), 5 of 15 (DM), and 7 of 17 (DUM) patients classified as N0 by routine hematoxylin and eosin staining, micrometastases or isolated tumor cells were found in the SLN (upstaging) after focused examination. If only a limited lymph node dissection of the SLN basins would have been performed in patients, residual lymph node metastases were left in 9 of 24 (RM), in 7 of 34 (DM), and in 5 of 24 (DUM) of patients with node-positive disease. CONCLUSIONS: Use of RM was superior. DUM did not further increase the sensitivity. A limited lymph node dissection-i.e., lymphatic basin in patients with SLN-positive disease-is associated with a high risk of residual metastases. Patients with negative SLNs may be selected for a limited surgical procedure if they meet certain criteria.     

Role of Combined Sentinel Lymph Node Biopsy and Axillary Node Sampling in Clinically Node-Negative Breast Cancer

Axillary lymph node status is a prognostic marker in breast cancer management, and axillary surgery plays an important role in staging and local control. This study aims to assess whether a combination of sentinel lymph node biopsy (SLNB) using patent blue dye and axillary node sampling (ANS) offers equivalent identification rate to dual tracer technique. Furthermore, we aim to investigate whether there are any potential benefits to this combined technique. Retrospective study of 230 clinically node-negative patients undergoing breast-conserving surgery for single T1–T3 tumours between 2006 and 2011. Axillae were staged using a combined blue dye SLNB/ANS technique. SLNs were localized in 226/230 (identification rate 98.3 %). Three of one hundred ninety-two patients with a negative SLN were found to have positive ANS nodes and 1/4 failed SLNB patients had positive ANS nodes. Thirty-four of two hundred twenty-six patients had SLN metastases and 11/34 (32.4 %) also had a positive non-sentinel lymph node on ANS. Twenty-one of twenty-four (87.5 %) node-positive T1 tumours had single node involvement. Nine of thirty-eight node-positive patients progressed to completion axillary clearance (cALND), and the rest were treated with axillary radiotherapy. Axillary recurrence was nil at median 5 year follow-up. Complementing SLNB with axillary node sampling (ANS) decreases the unavoidable false-negative rate associated with SLNB. Appropriate operator experience and technique can result in an SLN localization rate of 98 %, rivalling a dual tracer technique. The additional insight offered by ANS into the status of non-sentinel nodes has potential applications in an era of less frequent cALND.     

腔镜下乳腺癌前哨淋巴结活检临床应用及效果分析

目的探讨在腔镜下进行乳腺癌前哨淋巴结活检(SLNB)的可行性及手术效果。方法分析笔者所在医院2009年1月至2012年3月期间行乳腺癌SLNB病例,其中腔镜下活检107例,开放活检303例,采用放射性核素+亚甲蓝联合法与单用亚甲蓝法进行前哨淋巴结(SLN)探测。结果开放组SLN检出率联合法为94.56%(139/147),亚甲蓝法为88.46%(138/156);腔镜组联合法为94.25%(82/87),亚甲蓝法为85.00%(17/20)。检出前哨淋巴结数量,开放组联合法平均1.90枚/例,亚甲蓝法平均1.98枚/例;腔镜组则分别为1.91枚/例和1.82枚/例。SLN阳性率联合法及亚甲蓝法开放组分别为22.30%(31/139)和25.36%(35/138);腔镜组分别为19.51%(16/82)和23.53%(4/17)。上述各指标2组间的差异均无统计学意义(P>0.05)。术后并发症:腔镜组发生皮下积液的比例(5/107)高于开放组(0/303),P=0.001;其他并发症发生情况2组间比较差异均无统计学意义(P>0.05)。结论腔镜下SLNB与传统SLNB可达到相似的安全性与临床效果,但前者表现出较优越的美容效果,腔镜下SLNB可作为乳腺癌SLNB手术技术进行推广应用。     

乳腺癌患者前哨淋巴结活检术后生活质量研究

目的对比分析乳腺癌患者接受前哨淋巴结活检(SLNB)与腋窝淋巴清扫(ALND)术后的生活质量。方法选择山东省肿瘤医院乳腺病中心2004年1月至2006年12月期间收治的591例乳腺癌患者,均符合SLNB的适应证,无上肢关节、血管神经疾病和颈椎疾病,分为SLNB组(n=339)和ALND组(n=252)。结果①SLNB组上臂周径在术后第1、2、3周时均与术前接近(分别P=0.232、P=0.318及P=0.415);ALND组在术后第1、2周时均明显大于术前(分别P=0.011和P=0.041),第3周时与术前接近(P=0.290)。②SLNB组肩关节最大外展角度在术后第1、2周时均明显小于术前(分别P=0.031和P=0.043),第3周时恢复至术前水平(P=0.196);ALND组在术后第1、2、3周时均明显小于术前(均P<0.001)。③ALND组接受保乳手术和接受乳腺切除术的患者的引流管留置时间均明显长于SLNB组接受乳腺切除术的患者(均P<0.001)。④ALND组患者术后感染、上肢感觉功能障碍的发生率均明显高于SLNB组(分别P=0.002和P<0.001)。结论前哨淋巴结阴性患者,SLNB替代ALND可以明显降低术后并发症,改善患者的生活质量,缩短住院时间并降低医疗费用。     

乳腺癌前哨淋巴结活检研究现状及进展

目的探讨乳腺癌前哨淋巴结活检(SLNB)技术的研究现状和进展。方法复习近年来国内、外的有关文献,对乳腺癌SLNB的定位、检取、状态评估、适应证和并发症进行分析与综述。结果乳腺癌SLNB能够准确定位、检取前哨淋巴结(SLN)。影像学检查和病理检测技术的发展有助于SLN状态的评估,SLNB的适应证正在不断扩大。该技术并发症少,能够准确判定腋窝分期,指导选择性的腋窝淋巴结清扫。结论 SLNB技术已成为乳腺癌外科治疗的重要手段,但其操作尚需进一步规范,以降低假阴性的发生;假阳性和有争议的适应证问题仍需继续关注。     

Analysis of Clinical Applicability of the Breast Cancer Nomogram for Positive Sentinel Lymph Node: The Canadian Experience

Background  A Breast Cancer Nomogram (BCN) for predicting nonsentinel lymph node (NSLN) involvement has been developed and prospectively tested in several series. However, its clinical applicability has never been tested among surgeons. Methods  The BCN was applied to 209 SLN-positive patients. Its performance was assessed by the area under the receiver–operating characteristic (ROC) curve. Surgeons in Quebec were surveyed to determine the predicted NSLN positivity below which they would not dissect the axilla. The accuracy of the BCN was determined in this clinically relevant range. Results  The predictive accuracy of the BCN had an area under the ROC curve of 0.687. Almost half of interviewed surgeons treat over 20 breast cancer per year. Fourteen out of 82 surgeons questioned would never leave the patient without a completion axillary dissection after a positive SLN, regardless of the BCN result. Seventy one percent of them would not complete axillary dissection if the prediction of a positive NSLN was ≤10%. Only 37 of the 209 patients were in this 10% or less category, with a mean observed rate of positive NSLN of 13% (95% confidence interval [CI], 2–24%). Conclusion  The global performance of the BCN was fair. A majority of surgeons in Quebec would omit an axillary lymph node dissection (ALND) if the predicted probability of positive NSLN is 10% or less. Although useful, the BCN data should be used with caution at the low end of the scale. Because of some limitations in the performance in this category, other clinical factors and judgment must accompany its use.