de Widt-Levert Louise, Tjan-Heijnen Vivianne, Bult Peter, Ruers Theo, Wobbes Theo
Department of Surgery, University Medical Center, Nijmegen, The Netherlands.
Eur J Surg Oncol. 2003 Apr;29(3):216-20. doi: 10.1053/ejso.2002.1401.
Sentinel lymph node biopsy has replaced the axillary lymph node dissection (ALND) in primary surgery for breast cancer in many hospitals and is expected to become the standard of care in due time. Since the sentinel lymph node is subjected to more extensive pathologic examination than the lymph nodes in the axillary dissection specimen, more patients are found to be node positive (N+); however many of them contain micro-metastases (<or=2mm). The consequence may be an overshoot of therapy: additional surgery for non-metastatic lymph nodes or systemic adjuvant therapy.
We examined 34 (out of a series of 38) clinically T1 (cT1) patients who had a SLN biopsy with or without ALND and compared them to a matched historical control group.
Twenty-one of 34 (62%) patients showed tumour cells in their SLN's. From these 21 patients in 13 (62%) the SLNs contained isolated tumour cells, of which 10 (77%) were detected only by immunohistochemistry (IHC), in four (19%) the SLNs contained micrometastases, and in four (19%) macrometastases. From 16 patients with isolated tumour cells or micrometastases in the SLN who underwent a regular ALND one had an H&E detected isolated tumour cell in a non-SLN and one patient with isolated tumour cells in the SLN who did not get a regular ALND developed an axillary recurrence 11 months after the primary treatment. On the other hand, three of four (75%) patients with macrometastases in the SLN had pathologically involved non-SLNs. In the majority (70%) of patients of the historical control group no lymph node involvement was seen. The percentage of macrometastases staged as lymph node positive in the control group was the same as in the studied group.
Most patients with cT1 breast cancer with isolated tumour cells or micrometastases in the SLN will not benefit from additional axillary dissection; 88% had a negative ALND. Since we cannot select the group that will benefit from ALND, this is still indicated in case of isolated tumour cells or micrometastases in the SLN. Since most of the affected SLNs show isolated tumour cells and are classified as pN0(i+), stage migration due to more meticulous pathologic examination does not occur according to the TNM classification. However some patients do not benefit from the introduction of the SLN, due to the high incidence of isolated tumour cells or micrometastases in the SLN. Many more patients than expected still end up with an ALND.
在许多医院，前哨淋巴结活检已取代腋窝淋巴结清扫术（ALND）成为乳腺癌一期手术的术式，有望在适当时期成为标准治疗方法。由于前哨淋巴结比腋窝清扫标本中的淋巴结接受更广泛的病理检查，更多患者被发现为淋巴结阳性（N+）；然而其中许多患者存在微转移（≤2mm）。结果可能导致治疗过度：对无转移的淋巴结进行额外手术或进行全身辅助治疗。
我们检查了38例临床T1（cT1）患者中的34例，这些患者接受了前哨淋巴结活检，有的还同时进行了腋窝淋巴结清扫术，并将他们与一个匹配的历史对照组进行比较。
34例患者中有21例（62%）在前哨淋巴结中发现肿瘤细胞。在这21例患者中，13例（62%）的前哨淋巴结含有孤立肿瘤细胞，其中10例（77%）仅通过免疫组化（IHC）检测到，4例（19%）的前哨淋巴结含有微转移灶，4例（19%）含有大转移灶。16例前哨淋巴结中含有孤立肿瘤细胞或微转移灶且接受了常规腋窝淋巴结清扫术的患者中，1例在非前哨淋巴结中经苏木精-伊红染色（H&E）检测到孤立肿瘤细胞，1例前哨淋巴结中含有孤立肿瘤细胞但未接受常规腋窝淋巴结清扫术的患者在初次治疗11个月后发生腋窝复发。另一方面，前哨淋巴结中有大转移灶的4例患者中，3例（75%）病理检查发现非前哨淋巴结受累。历史对照组的大多数患者（70%）未见淋巴结受累。对照组中分期为淋巴结阳性的大转移灶百分比与研究组相同。
大多数前哨淋巴结中含有孤立肿瘤细胞或微转移灶的cT1期乳腺癌患者无法从额外的腋窝清扫术中获益；88%的腋窝淋巴结清扫术结果为阴性。由于我们无法选择能从腋窝淋巴结清扫术中获益的患者群体，因此在前哨淋巴结中存在孤立肿瘤细胞或微转移灶的情况下仍需进行腋窝淋巴结清扫术。由于大多数受累的前哨淋巴结显示孤立肿瘤细胞并被分类为pN0（i+），根据TNM分类，不会因更细致的病理检查而发生分期迁移。然而，由于前哨淋巴结中孤立肿瘤细胞或微转移灶的高发生率，一些患者并未从前哨淋巴结活检中获益。最终接受腋窝淋巴结清扫术的患者比预期的多得多。
