Porter G A, Ross M I, Berman R S, Sumner W E, Lee J E, Mansfield P F, Gershenwald J E
Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston 77030, USA.
Surgery. 2000 Aug;128(2):306-11. doi: 10.1067/msy.2000.107418.
BACKGROUND: Sentinel lymph node (SLN) biopsy has been shown to reliably identify nodal metastases and the subsequent need for further surgical and adjuvant therapy in patients with cutaneous melanoma. Although SLN identification rates have improved with the addition of radioactive colloid to the blue dye technique, it remains unclear how many lymph nodes should be removed to accurately determine the histologic status of the nodal basin. The objective of this study was to determine the optimal extent of SLN biopsy in these patients. METHODS: The records of 633 consecutive patients with melanoma (765 nodal basins) whose primary treatment included SLN biopsy with the use of a combination of blue dye and technetium Tc 99 labeled sulfur colloid were reviewed. SLN biopsy consisted of the removal of all of the blue-stained nodes and all nodes with radiotracer uptake activity of at least twice background. RESULTS: SLN biopsy was successful in 765 of 772 basins (99%). A mean of 1.9 SLNs (median, 2 SLNs) per basin were excised. At least 3 SLNs were removed in 176 basins (23%). The overall histologic status of a basin was always established by the first or second SLN harvested (ie, in no patient was the third or subsequent SLN positive when 1 of the first 2 was not). Of the 124 basins containing lymphatic metastases, the SLN that contained the maximal radiotracer uptake (hottest) and/or stained blue was pathologically positive in 118 basins (95%). In only 6 of the 124 positive basins (5%) was the sole evidence of occult nodal metastases identified in an SLN that was neither blue-stained nor the hottest. All but 1 of these SLNs had counts that were at least 66% of the hottest node in the basin. CONCLUSIONS: With a combined modality approach to SLN biopsy, removal of more than 2 SLNs did not provide information that upstaged any patient with primary melanoma. Removal of additional nonblue SLN(s) that contained radioactive counts of at least twice background but lower than two thirds of the SLNs with maximal radiotracer uptake affected patient management in less than 0.2% of all cases. These findings may be helpful in minimizing the extent of surgery and perhaps in reducing the costs and resource use associated with operating room time and pathologic examination.
背景：前哨淋巴结（SLN）活检已被证明能够可靠地识别皮肤黑色素瘤患者的淋巴结转移情况以及后续进一步手术和辅助治疗的必要性。尽管在前哨淋巴结识别率方面，放射性胶体与蓝色染料技术联合使用后有所提高，但仍不清楚应切除多少枚淋巴结才能准确确定淋巴结区域的组织学状态。本研究的目的是确定这些患者前哨淋巴结活检的最佳范围。 方法：回顾了633例连续黑色素瘤患者（765个淋巴结区域）的记录，其初始治疗包括使用蓝色染料和锝Tc 99标记硫胶体联合进行前哨淋巴结活检。前哨淋巴结活检包括切除所有蓝色染色的淋巴结以及所有放射性示踪剂摄取活性至少为背景值两倍的淋巴结。 结果：772个淋巴结区域中有765个（99%）成功进行了前哨淋巴结活检。每个区域平均切除1.9枚前哨淋巴结（中位数为2枚）。176个区域（23%）切除了至少3枚前哨淋巴结。一个区域整体的组织学状态总是由切除的第一枚或第二枚前哨淋巴结确定（即，在前两枚前哨淋巴结中有一枚为阴性时，没有患者的第三枚或后续前哨淋巴结为阳性）。在124个存在淋巴转移的区域中，放射性示踪剂摄取量最高（最“热”）和/或被染成蓝色的前哨淋巴结在118个区域（95%）中病理检查为阳性。在124个阳性区域中，仅有6个区域（5%）隐匿性淋巴结转移的唯一证据出现在既未被蓝色染色也不是最“热”的前哨淋巴结中。除1枚外所有这些前哨淋巴结的计数至少为该区域最“热”淋巴结计数的66%。 结论：采用联合方式进行前哨淋巴结活检时，切除超过2枚前哨淋巴结并不能为任何原发性黑色素瘤患者提供分期上调的信息。切除额外的非蓝色前哨淋巴结（其放射性计数至少为背景值两倍但低于放射性示踪剂摄取量最高的前哨淋巴结计数的三分之二）对不到0.2%的所有病例的患者管理产生影响。这些发现可能有助于最小化手术范围，并可能降低与手术室时间和病理检查相关的成本及资源消耗。
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