Cochran A J
Department of Pathology and Laboratory Medicine, Jonsson Comprehensive Cancer Center, UCLA School of Medicine, Los Angeles, CA 90095-1732, USA.
Semin Nucl Med. 2000 Jan;30(1):11-7. doi: 10.1016/s0001-2998(00)80057-4.
Patients with high-risk (thick, deeply invasive) primary melanoma were, in the past, managed by wide local excision and elective node dissection or wide local excision alone, with subsequent lymphadenectomy if the regional nodes developed clinically detectable metastases. We recently developed a more logical approach called selective lymph node dissection. To be effective, this requires close collaboration of surgeons, pathologists, and nuclear medicine physicians. The draining lymph node basin is identified preoperatively by lymphoscintigraphy. During surgery, a marker dye (isosulfan blue) and radioactive technetium labeled albumin are injected intradermally around the primary melanoma and the afferent lymphatics are followed up to the first lymph nodes of the ipsilateral regional nodal basin. The surgeon excises the blue-colored and maximally radioactive sentinel nodes and the pathologist critically evaluates these for the presence of a metastatic tumor. If the sentinel nodes are tumor free, no further nodal dissection is undertaken; if a tumor is present, a complete dissection of the nodal basin is performed. We have examined 1,119 sentinel lymph nodes from 669 patients treated by selective lymph node dissection. We identified melanoma cells in sentinel nodes from 126 patients (17.8%). A single node contained tumors in 67% of patients, 2 nodes were positive in 25%, and the remaining 12% of patients had three tumor-containing nodes. Melanoma cells were dispersed singly or in variably sized groups, usually in the peripheral nodal sinus. In around 40% of patients, immunohistochemistry is required to identify minute numbers of tumor cells. With experience, pathologists identify tumors in hematoxylin and eosin (H&E) preparations in an increasing proportion of lymph nodes. Tumor cells are more frequent in the sentinel nodes of patients with primary tumors of deeper Clark level and greater Breslow thickness. Tumor cells must be discriminated from capsular nevus cells, interdigitating dendritic leukocytes, macrophages, and intranodal neural tissues.
过去，高危（厚度大、浸润深）原发性黑色素瘤患者采用广泛局部切除联合选择性淋巴结清扫术或单纯广泛局部切除术治疗，若区域淋巴结出现临床可检测到的转移灶，则随后进行淋巴结切除术。我们最近开发了一种更合理的方法，称为选择性淋巴结清扫术。要使其有效，这需要外科医生、病理学家和核医学医生密切合作。术前通过淋巴闪烁显像确定引流淋巴结区域。手术期间，在原发性黑色素瘤周围皮内注射标记染料（异硫蓝）和放射性锝标记白蛋白，并追踪输入淋巴管至同侧区域淋巴结区域的第一组淋巴结。外科医生切除蓝色且放射性最强的前哨淋巴结，病理学家对这些淋巴结进行严格评估，以确定是否存在转移性肿瘤。如果前哨淋巴结无肿瘤，则不再进行进一步的淋巴结清扫；如果存在肿瘤，则进行淋巴结区域的彻底清扫。我们检查了669例接受选择性淋巴结清扫术患者的1119个前哨淋巴结。我们在126例患者（17.8%）的前哨淋巴结中发现了黑色素瘤细胞。67%的患者单个淋巴结含有肿瘤，25%的患者2个淋巴结呈阳性，其余12%的患者有3个含肿瘤的淋巴结。黑色素瘤细胞单个或成大小不一的团块分布，通常位于周围淋巴结窦。在约40%的患者中，需要进行免疫组织化学检查以识别少量肿瘤细胞。随着经验的积累，病理学家在苏木精和伊红（H&E）染色切片中识别出肿瘤的淋巴结比例越来越高。在Clark分级较深、Breslow厚度较大的原发性肿瘤患者的前哨淋巴结中，肿瘤细胞更为常见。必须将肿瘤细胞与包膜痣细胞、交错突树突状白细胞、巨噬细胞和淋巴结内神经组织区分开来。
