Pendas S, Dauway E, Cox C E, Giuliano R, Ku N N, Schreiber R H, Reintgen D S
Comprehensive Breast Cancer Clinic, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida 33612, USA.
Am Surg. 1999 Jun;65(6):500-5; discussion 505-6.
Sentinel lymph node (SLN) mapping is an effective and accurate method of sampling the axillary nodal basin for metastatic disease. The SLN is the first node to receive afferent lymphatic drainage from the primary tumor. Lymphatic mapping and SLN biopsy have allowed pathologists to perform a more detailed examination of the SLN(s) and, therefore, provide more accurate staging of the regional lymphatic basin. Recently, more sensitive assays have been developed to increase the detection rate of micrometastatic to the axillary lymph nodes. Cytokeratin (CK) immunohistochemical (IHC) staining of the SLN detects micrometastatic disease, which is frequently missed on routine hematoxylin and eosin (H&E) histology. Therefore, lymphatic mapping combined with CK IHC staining of the SLN provides more accurate staging of the regional lymph nodes in patients with breast cancer. At Moffitt Cancer Center, 478 patients with newly diagnosed breast cancer underwent intraoperative lymphatic mapping using a combination of vital blue dye and technetium-labeled sulfur colloid. The excised SLNs were examined grossly, by intraoperative imprint cytology, by standard H&E histology, and by IHC stains for CK. SLNs that were only CK positive were confirmed malignant by sectioning the block, staining with H&E and finding cells with malignant cytology. Lymphatic mapping and CK IHC staining of the SLNs was successfully performed in 478 newly diagnosed breast cancer patients. Twenty-eight patients had unsuccessful lymphatic mapping for an overall failure rate of 5.5 per cent. A total of 134 (28%) patients had positive nodes (N1) detected. Ninety-three of these patients had both H&E and CK-positive lymph nodes, and an additional 41 patients had only CK-positive SLN(s). A total of 385 patients had H&E-negative SLNs, but only 344 patients had negative SLN(s) defined as both H&E and CK negative. Therefore, 41 (10.6%) of the 385 H&E-negative patients were upstaged, because of the detection of malignant cells by cytokeratin IHC staining of the SLN. Microstaging of SLNs with CK has shifted 10.6 per cent of our patient population from stage I to stage II disease. Undetected micrometastatic disease to the regional lymph nodes may account for the significant proportion of stage I breast cancer treatment failures. Furthermore, the ability to accurately stage the axilla by using lymphatic mapping techniques, SLN biopsy, and more sensitive assays may help identify a subgroup of truly node-negative patients with invasive breast cancer who can avoid the morbidity associated with a complete axillary dissection or systemic chemotherapy. Finally, those patients found to have micrometastatic disease to the regional lymph nodes can be treated appropriately in a more selective fashion.
前哨淋巴结（SLN）定位是一种有效且准确的对腋窝淋巴结转移疾病进行取样的方法。前哨淋巴结是第一个接收来自原发肿瘤输入淋巴引流的淋巴结。淋巴绘图和前哨淋巴结活检使病理学家能够对前哨淋巴结进行更详细的检查，从而对区域淋巴结进行更准确的分期。最近，已经开发出更敏感的检测方法以提高腋窝淋巴结微转移的检出率。前哨淋巴结的细胞角蛋白（CK）免疫组化（IHC）染色可检测微转移疾病，这在常规苏木精和伊红（H&E）组织学检查中经常被漏诊。因此，淋巴绘图结合前哨淋巴结的CK IHC染色可为乳腺癌患者的区域淋巴结提供更准确的分期。在莫菲特癌症中心，478例新诊断的乳腺癌患者在术中使用活性蓝色染料和锝标记的硫胶体联合进行淋巴绘图。切除的前哨淋巴结进行大体检查、术中印片细胞学检查、标准H&E组织学检查以及CK的IHC染色。仅CK阳性的前哨淋巴结通过对组织块切片、H&E染色并发现具有恶性细胞学特征的细胞来确诊为恶性。478例新诊断的乳腺癌患者成功进行了前哨淋巴结的淋巴绘图和CK IHC染色。28例患者淋巴绘图未成功，总体失败率为5.5%。共有134例（28%）患者检测到阳性淋巴结（N1）。其中93例患者的H&E和CK均为阳性淋巴结，另外41例患者仅前哨淋巴结CK阳性。共有385例患者的前哨淋巴结H&E阴性，但只有344例患者的前哨淋巴结定义为H&E和CK均阴性。因此，385例H&E阴性患者中有41例（10.6%）因前哨淋巴结的细胞角蛋白IHC染色检测到恶性细胞而被重新分期。用CK对前哨淋巴结进行微分期使我们10.占6%的患者群体从I期转变为II期疾病。区域淋巴结未被检测到的微转移疾病可能是I期乳腺癌治疗失败的很大一部分原因。此外，通过使用淋巴绘图技术、前哨淋巴结活检和更敏感的检测方法来准确分期腋窝淋巴结，可能有助于识别一组真正腋窝淋巴结阴性的浸润性乳腺癌患者，他们可以避免与完整腋窝清扫或全身化疗相关的发病率。最后，那些被发现区域淋巴结有微转移疾病的患者可以以更有选择性的方式进行适当治疗。
