Guidelines for sentinel node biopsy and lymphatic mapping of patients with breast cancer
Guidelines for sentinel node biopsy and lymphatic mapping of patients with breast cancer
复制标题
DOI：
10.1097/00000658-199805000-00005
复制
发表时间：
1998-05-01
影响因子：
9
通讯作者：
Reintgen, DS
中科院分区：
文献类型：
--
作者：
Cox, CE;Pendas, S;Reintgen, DS
目的为乳腺癌患者使用淋巴标测技术确定初步指导原则。概要背景资料淋巴标测技术有可能改变乳腺癌患者的外科护理标准。方法466例新诊断乳腺癌的连续患者接受了一项前瞻性试验，使用活性蓝染料和过滤锝的组合进行术中淋巴标测。标记的硫胶体。前哨淋巴结（SLN）定义为SLN与非SLN的离体γ探针比例为10：1的蓝色淋巴结和/或热淋巴结。所有的SLN被双瓣，阶梯切片，并检查常规苏木精和伊红（H&E）染色和免疫组化染色的细胞角蛋白。一个细胞角蛋白阳性的SLN被定义为任何SLN与一个明确的集群的阳性染色细胞，可以确认组织学上H&E section.ResultsFine-needle抽吸（FNA）或立体定向核心活检被用来诊断195 422例（46.2%）乳腺癌; 227 422例（53.8%）被诊断切除活检。466例患者中有440例（94.4%）成功识别出SLN。466例患者中有26例（5.6%）术中未能识别腋窝SLN。在所有淋巴结定位失败的患者中，进行了完全腋窝淋巴结清扫，其中26例患者中有4例（15.4%）记录了转移性疾病。在26例淋巴结定位失败的患者中，11/227（4.8%）例通过切除活检确诊，15/195（7.7%）例通过细针穿刺或立体定向空芯针活检确诊。值得注意的是，在既往切除活检的患者中仅有1例跳跃转移（定义为阴性SLN，链中较高的淋巴结为阳性）。每例患者平均获得1.92个SLN。在440例患者中，105例（23.8%）切除的SLN中有20%为转移性疾病阳性。对844个SLN的描述性信息进行了评价：844个SLN中有339个（40.2%）是热的，844个SLN中有272个（32.2%）是蓝色的，844个SLN中有233个（27.6%）既热又蓝。在87例非浸润性（导管癌ii，原位）肿瘤患者中，4例（4.6%）至少发现一个阳性SLN。在浸润性肿瘤大小增加的患者中发现阳性SLN的发生率更高：112例肿瘤大小在0.1 mm至1 cm之间的患者中有18例（16%）有阳性SLN。然而，显著更高百分比的患者（131例中43例[32.8%]肿瘤大小在1和2 cm之间，76例中31例[40.8%]肿瘤大小在2和5 cm之间）具有阳性SLN。肿瘤大小大于5cm的患者中阳性SLN的发生率最高;在该组中，12例患者中有9例（75结论本研究表明，当所有蓝淋巴结和热淋巴结作为前哨淋巴结时，可获得准确的前哨淋巴结识别;因此，当结合使用活性蓝染料和放射性标记的硫胶体时，淋巴映射和SLN活检是最有效的。此外，这些数据表明，导管原位癌或小肿瘤的患者表现出较低但显著的腋窝淋巴结转移性疾病的发生率，并可能从选择性淋巴结切除术中获益最多，避免了完全腋窝淋巴结切除术的不必要并发症。
ObjectiveTo define preliminary guidelines for the use of lymphatic mapping techniques in patients with breast cancer.Summary Background DataLymphatic mapping techniques have the potential of changing the standard of surgical care of patients with breast cancer.MethodsFour hundred sixty-six consecutive patients with newly diagnosed breast cancer underwent a prospective trial of intraoperative lymphatic mapping using a combination of vital blue dye and filtered technetium-labeled sulfur colloid. A sentinel lymph node (SLN) was defined as a blue node and/or a hot node with a 10:1 ex vivo gamma probe ratio of SLN to non-SLN. All SLNs were bivalved, step-sectioned, and examined with routine hematoxylin and eosin (H&E) stains and immunohistochemical stains for cytokeratin. A cytokeratin-positive SLN was defined as any SLN with a defined cluster of positive-staining cells that could be confirmed histologically on H&E sections.ResultsFine-needle aspiration (FNA) or stereotactic core biopsy was used to diagnose 195 of the 422 patients (46.2%) with breast cancer; 227 of 422 patients (53.8%) were diagnosed by excisional biopsy. The SLN was successfully identified in 440 of 466 patients (94.4%). Failure to identify an SLN to the axilla intraoperatively occurred in 26 of 466 patients (5.6%). In all patients who failed lymphatic mappings, a complete axillary dissection was performed, and metastatic disease was documented in 4 of 26 (15.4%) of these patients. Of the 26 patients who failed lymphatic mapping, 11 of 227 (4.8%) were diagnosed by excisional biopsy and 15 of 195 (7.7%) were diagnosed by FNA or stereotactic core biopsy. Of interest, there was only one skip metastasis (defined as a negative SLN with higher nodes in the chain being positive) in a patient with prior excisional biopsy. A mean of 1.92 SLNs were harvested per patient. Twenty percent of the SLNs removed were positive for metastatic disease In 105 of 440 (23.8%) of the patients. Descriptive information on 844 SLNs was evaluated: 339 of 844 (40.2%) were hot, 272 of 844 (32.2%) were blue, and 233 of 844 (27.6%) were both hot and blue. At least one positive SLN was found in 4 of 87 patients (4.6%) with noninvasive (ductal carcinoma ii, situ) tumors. A greater incidence of positive SLNs was found in patients who had invasive tumors of increasing size: 18 of 112 patients (16%) with tumor size between 0.1 mm and 1 cm had positive SLNs. However, a significantly greater percentage of patients (43 of 131 [32.8%] with tumor size between 1 and 2 cm and 31 of 76 [40.8%] with tumor size between 2 and 5 cm) had positive SLNs. The highest incidence of positive SLNs was seen with patients of tumor size greater than 5 cm; in this group, 9 of 12 (75%) had a positive SLN (p < 0.001).ConclusionsThis study demonstrates that accurate SLN identification was obtained when all blue and hot lymph nodes were harvested as SLNs; Therefore, lymphatic mapping and SLN biopsy is most effective when a combination of vital blue dye and radio-labeled sulfur colloid is used. Furthermore, these data demonstrate that patients with ductal carcinoma in situ or small tumors exhibit a low but significant incidence of metastatic disease to the axillary lymph nodes and may benefit most from selective lymphadenectomy, avoiding the unnecessary complications of a complete axillary lymph node dissection.