Bertoglio Sergio, Sandrucci Sergio, Percivale Pierluigi, Goss Matteo, Gipponi Marco, Moresco Luciano, Mussa Baudolino, Mussa Antonio
Gastrointestinal Surgery Unit, Department of Oncology, Biology and Genetics, University of Genoa, School of Medicine, Genoa, Italy.
J Surg Oncol. 2004 Mar;85(3):166-70. doi: 10.1002/jso.20030.
Over the last decade, lymphatic mapping and sentinel lymph node (sN) biopsy have greatly increased the possibility of identifying nodal metastasis in clinically node-negative patients with melanoma and breast cancer, thus improving the accuracy of pathologic staging. Recently, sN biopsy has been applied also in colorectal cancer. This prospective study aimed to assess its feasibility and accuracy in predicting regional lymph nodes metastases in colorectal cancer patients as well as the impact on treatment decision-making.
Lymphatic mapping was accomplished by means of blue dye, which was intraoperatively injected into the subserosa overlying the tumor site in 26 patients undergoing colorectal cancer surgery. Following bowel resection, the operative specimen was inspected to identify each blue-stained node, the sN, which was sent separately to the pathologist. One half of each sN was examined by multiple 200 microm sections, while the second half was examined by standard bi-valving technique with hematoxylin-eosin (H and E) staining; all the other regional non-sentinel nodes were routinely examined by standard bi-valving technique and H and E staining.
At least one sN was detected in 24 of 26 patients (92.3%); two patients with rectal cancer had no sN identified. Overall, 70 sN were retrieved into the operative specimens, with a mean of 2.9 sNs/patient, and 19 sNs were tumor-positive. An agreement between sN and regional lymph-node status was observed in 20 of 24 patients (83.4%). The sN was histologically negative in two of nine patients with positive regional nodes (sensitivity = 77.8%; false-negative rate of 22.2%); in two of seven patients with tumor-positive sN (28.6%), the sN was the exclusive site of regional nodal metastasis. The negative predictive value was 88.2% (15 of 17 patients), and the overall accuracy was 91.7% (22 of 24 patients). As regards the contribution to the detection of nodal metastasis according to the pathologic technique, standard H and E bi-valving technique detected 16 of 19 tumor-positive sNs (84.2%) while, by means of serial sectioning, metastases were detected in the remaining 3 of 19 sNs (15.8%).
The sN biopsy proved feasible, with a rather short learning curve. The focused analysis of the sN by means of serial sectioning improved the detection rate of nodal metastasis compared to standard bi-valving examination, so that a more accurate nodal staging should be expected; finally, an elective localization of metastasis within the sN was observed in almost one third of regional node-positive patients.
在过去十年中，淋巴绘图和前哨淋巴结（sN）活检极大地提高了在临床淋巴结阴性的黑色素瘤和乳腺癌患者中识别淋巴结转移的可能性，从而提高了病理分期的准确性。最近，sN活检也已应用于结直肠癌。这项前瞻性研究旨在评估其在预测结直肠癌患者区域淋巴结转移方面的可行性和准确性，以及对治疗决策的影响。
通过蓝色染料进行淋巴绘图，术中将其注射到26例接受结直肠癌手术患者肿瘤部位上方的浆膜下层。肠切除术后，检查手术标本以识别每个蓝色染色的淋巴结，即sN，并将其分别送病理科医生检查。每个sN的一半通过多个200微米切片进行检查，另一半通过苏木精-伊红（H&E）染色的标准双瓣技术进行检查；所有其他区域非前哨淋巴结通过标准双瓣技术和H&E染色进行常规检查。
26例患者中有24例（92.3%）检测到至少一个sN；2例直肠癌患者未识别出sN。总体而言，手术标本中回收了70个sN，平均每位患者2.9个sN，其中19个sN为肿瘤阳性。24例患者中有20例（83.4%）观察到sN与区域淋巴结状态一致。9例区域淋巴结阳性患者中有2例sN组织学检查为阴性（敏感性 = 77.8%；假阴性率为22.2%）；7例sN肿瘤阳性患者中有2例（28.6%），sN是区域淋巴结转移的唯一部位。阴性预测值为88.2%（17例患者中有15例），总体准确率为91.7%（24例患者中有22例）。关于根据病理技术对淋巴结转移检测的贡献，标准H&E双瓣技术检测到19个肿瘤阳性sN中的16个（84.2%），而通过连续切片，在19个sN中的其余3个（15.8%）中检测到转移。
sN活检被证明是可行的，学习曲线相当短。与标准双瓣检查相比，通过连续切片对sN进行重点分析提高了淋巴结转移的检测率，因此有望实现更准确的淋巴结分期；最后，在近三分之一的区域淋巴结阳性患者中观察到转移在前哨淋巴结内的选择性定位。
