Dias Moreira R, Altino de Almeida S, Maliska Guimarães C M, Resende J F, Gutfilen B, Barbosa da Fonseca L M
Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Brasil.
J Exp Clin Cancer Res. 2005 Jun;24(2):181-5.
In melanoma patients lymph node metastasis is an important prognostic factor that indicates the need for therapeutic lymph node dissection. Preoperative lymphoscintigraphy mapping associated with radioguided sentinel lymph node biopsy has become a well established procedure for cutaneous melanoma patients without clinically detectable lymph node metastases (stage I, II). This technique is a versatile way of characterizing the lymphatic basin at risk for metastases and identifying involved lymph nodes. The purpose of the present study was to examine the reproducibility of lymphoscintigraphy and sentinel lymph node biopsy in detecting micro metastases in cutaneous melanoma. The study was a single-institution prospective analysis of 74 melanoma patients, with primary tumors having Breslow thickness > 0.7 mm, who underwent lymphoscintigraphies between May 2002 and September 2003. Technetium-99m sulfur colloid was injected intradermally at the primary tumor site and dynamic images were obtained for 40 minutes. Two observers evaluated the images. One to two weeks after the first lymphoscintigraphy, radioguided lymph node biopsy was performed. For the biopsy, technetium-99m sulfer colloid was injected intradermally in the same manner as performed before. Lymph nodes were identified and removed with the aid of a gamma ray detecting probe (GDP), and were submitted to histopathological analysis. The histopathological analysis of the sentinel lymph nodes collected during surgery was performed in a sequential manner. First, frozen sections were analyzed during surgery. The lymph nodes considered negative by frozen section were analyzed by H&E staining. Subsequently, the slides considered negative with H&E were sent for immunohistochemical analysis. Lymphoscintigraphy identified at least one sentinel lymph node in all patients. Sentinel node biopsy detected metastases in 20 patients (27.2%). In all cases the lymph node basins identified during lymphoscintigraphy were found to have at least one sentinel lymph node during surgery. Frozen section analysis of the lymph node was only able to identify the disease in 35% of the patients eventually found to have micrometastases with H&E and immunohistochemistry. Two lymph nodes were negative with H&E and positive with immunohistochemical analysis. In conclusion, lymphoscintigraphy is a simple procedure that is well tolerated by patients. It is useful in locating sentinel lymph nodes in patients with melanoma and is an important tool in the clinical practice of oncology. We recommend performing H&E, and if necessary, immunohistochemical analysis of all sentinel lymph nodes because of the high rate of false negative results with frozen sections alone.
在黑色素瘤患者中，淋巴结转移是一个重要的预后因素，提示需要进行治疗性淋巴结清扫。术前淋巴闪烁显像与放射性引导前哨淋巴结活检已成为无临床可检测淋巴结转移（I、II期）的皮肤黑色素瘤患者的成熟程序。该技术是一种表征有转移风险的淋巴引流区并识别受累淋巴结的通用方法。本研究的目的是检验淋巴闪烁显像和前哨淋巴结活检在检测皮肤黑色素瘤微转移方面的可重复性。该研究是对74例黑色素瘤患者进行的单机构前瞻性分析，这些患者的原发性肿瘤 Breslow 厚度>0.7 mm，于2002年5月至2003年9月期间接受了淋巴闪烁显像。将99m锝硫胶体皮内注射到原发性肿瘤部位，并采集40分钟的动态图像。由两名观察者评估图像。在首次淋巴闪烁显像后1至2周，进行放射性引导淋巴结活检。活检时，以与之前相同的方式皮内注射99m锝硫胶体。借助γ射线探测探头（GDP）识别并切除淋巴结，并进行组织病理学分析。对手术中采集的前哨淋巴结进行的组织病理学分析按顺序进行。首先，在手术期间分析冰冻切片。经冰冻切片判定为阴性的淋巴结通过苏木精和伊红（H&E）染色进行分析。随后，将经H&E染色判定为阴性的玻片送去进行免疫组织化学分析。淋巴闪烁显像在所有患者中均识别出至少一个前哨淋巴结。前哨淋巴结活检在20例患者（27.2%）中检测到转移。在所有病例中，淋巴闪烁显像期间识别出的淋巴引流区在手术中均发现至少有一个前哨淋巴结。淋巴结的冰冻切片分析仅能在最终经H&E染色和免疫组织化学检测发现有微转移的患者中35%的病例中识别出疾病。有两个淋巴结H&E染色为阴性，但免疫组织化学分析为阳性。总之，淋巴闪烁显像是一种简单的程序，患者耐受性良好。它有助于定位黑色素瘤患者的前哨淋巴结，是肿瘤临床实践中的一项重要工具。由于仅冰冻切片的假阴性率较高，我们建议对所有前哨淋巴结进行H&E染色分析，必要时进行免疫组织化学分析。
