Critical study of our initial experience of 993 sentinel node biopsies for breast surgery
Critical study of our initial experience of 993 sentinel node biopsies for breast surgery
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DOI：
10.1684/bdc.2008.0640
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发表时间：
2008-07-01
影响因子：
1.2
通讯作者：
Querleu, Denis
中科院分区：
文献类型：
--
作者：
Martel, Pierre;Capdet, Jerome;Querleu, Denis
目的：通过对乳腺外科前哨淋巴结（sentinel node，SN）取样病例的研究，确定SN受累预测因素、非SN受累预测因素、各组患者的选择性预后。研究方法：对2001年1月至2005年10月期间常规采集的993个前哨淋巴结样本进行前瞻性单中心登记，涵盖检测的技术方面（比色和放射性同位素），病理结果（连续切片5 M mu厚，然后进行苏木精-伊红-伊红染色，必要时进行免疫组织化学细胞角蛋白高分子量染色）、治疗和随访（平均期限：32个月（3-69）。结果：716例（72.1%）患者前哨淋巴结未受累。前哨淋巴结阳性者占27.9%。14.5%出现大转移。11%微转移和2.4%孤立的肿瘤细胞（CTI）。前哨淋巴结受累的危险因素包括：与临床特征、年龄相关（微转移组比大转移组年轻2岁）：与肿瘤特征、大小有关（SN阴性组为12.15 mm，微转移组为15.4 mm，大转移组为16.25 mm），分级（大多数I级患者出现微转移与大转移）和多灶性（77.8%的巨转移SN伴多房性肿瘤，22.2%的微转移SN伴多房性肿瘤，6.7%的转移SN阴性）。微转移和大转移的预测因素无差异。在继发性腋窝淋巴结清扫中，47.1%（66/140）的大转移性腋窝淋巴结清扫阳性，12.1%（13/107）的小转移性腋窝淋巴结清扫阳性。二次腋窝淋巴结清扫阳性的预测因素为肿瘤大小、分级、微转移灶大小及多灶性。平均随访32个月，微转移阳性亚组（有或无二次腋窝淋巴结清扫阳性）仅1例转移复发（0.9%），相反，3例患者（2.1%）出现大转移复发。SN阴性组717例中仅1例发生腋窝局部复发（0.14%），30例无继发腋窝淋巴结清扫者（CTI组22例，SN微转移组5例，大转移组3例）无腋窝复发。结论：第一，72.1%的TO或TI肿瘤，避免了腋窝淋巴结清扫的不良影响。其次，微转移累及的预测因素与大转移的预测因素没有区别，并且在微转移SN中，阳性二次腋窝淋巴结清扫的预测因素没有明确显示：腋窝复发的风险较低：最多，似乎可以提出一个安全的指南，仅对选定的低风险患者组避免二次腋窝淋巴结清扫：肿瘤大小< 10 mm，1级，单中心SN受累。第三，不可能区分阴性、CTI、微转移和大转移SN亚组之间的选择性预后，这可能是因为随访时间短。第四，通过陪伴进行教学是完全有效的，因为腋窝复发率很低。
Objective : Identification of sentinel node (SN) involvement predictive factors, non-sentinel node involvement predictive factors, selective prognosis of each group of patients by study of breast surgery cases with sentinel node sampling. Methods : Prospective monocentirc registering of 993 sentinel node samples routinely taken between January 2001 and October 2005, covering technical aspects of detection (colorimetric and radio-isotope), pathological results (serial sections 5M mu thick prior to staining hematoxylin-eosine-saffron and if necessary, by immine histochemistry cytokeratine high molecular weight), therapeutics and follow-up (average period: 32 months (3-69). Results : Seven hundred and sixteen patients (72.1%) were free of sentinel node involvement. Among positive sentinel node patients (27.9%). 14.5% presented macrometastasis. 11% micrometastasis and 2.4% isolated tumor cells (CTI). Sentinel node involvement risk factors included: related to clinical features, age (2 years younger in the micrometastatic group compared to the macrometastatic group): related to tumore caracteristics, size (12.15 mm for the negative SN group, 15.4 mm for the micrometastatic group and 16.25 mm for the macrometastatic group), grading (a majority of grade I encountered with micrometastasis versus macrometastasis) and multifocality (macrometastasis SN associated with multilocular tumore in 77.8% cases, micro metastasis SN in 22.2% cases and negative SN in 6.7% cases). Predictive factors do not differe for micro- or macrometastasic involvement. Among features concerning secondary axillary dissection, 47.1% (66/140) were positive with a macrometastatic SN, 12.1% (13/107) with micrometastic SN. Predictive factors of positive secondary axillary dissection were tumor size, grading, micrometastasis size and micrometastasis multifocality. With a 32 months mean follow-up the positive micrometastasis sub-group (wtih or without positive secondary axillary dissection) expressed one only metastatic arecurrence (0.9%); on the contrary, three patients (2.1%) issued from the macrometastatic recurrence. One only local axillary recurrence (0.14%) occured among negative SN (717 cases): no axillary recurrence occured among the 30 patients without secondary axillary dissecction (CTI {22 cases}, micrometastatic SN group {5 cases} and macrometastatic group {3 cases}). Conclusion: First, 72.1% of TO or TI tumors, avoid adverse axillary dissection effects. Second, micrometastatic involvement predictive factors do not differ from macrometastatic ones and those of positive secondary axillary dissection among micrometastatic SN do not appear clearly: the risk of axillary recurrence is low: at the very most, it seems possible to propose a safe guideline, avoiding secondary axillary dissection only for selected group of lower risk patiens: tumoral size < 10 mm, grade 1, monocentric SN involvement. Third, it is not possible to differentiate a selective prognosis between negative, CTI, micrometastatic and macrometastatic SN subgroups probably because of a short follow-up. Fourht, teaching through companionship is fully valided by the secondary minimal rate of axillary recurrence.