Pelizzo M R, Merante Boschin I, Piotto A, Bernante P, Pagetta C, Rubello D, Toniato A
Dipartimento di Patologia Speciale Chirurgica, Università di Padova, Padova, Italy.
Minerva Chir. 2006 Feb;61(1):25-9.
How far to extend surgical treatment of papillary thyroid carcinoma (PTC) is still an open question. A contribution may derive from intraoperative lymphatic mapping because, in other malignancies, the procedure has become an important aid in defining lymph node status. The aim of this study was to evaluate the feasibility of sentinel lymph node (SLN) mapping performed by intratumoural injection of vital blue dye to guide nodal dissection in PTC.
One hundred and ten patients were selected for the study, all of them had a preoperative diagnosis of PTC, but no clinical or ultrasonographic evidence of nodal involvement. Following cervicotomy and exposition of the thyroid gland, vital blue dye was injected into the malignant thyroid nodule. Subsequently, total thyroidectomy and lymph node dissection were carried out, and the thyroid, the SLN(s) and the other lymph nodes were sent for frozen section and definitive histologic evaluation.
Intraoperative lymphatic mapping located sentinel lymph nodes in 74 cases (67.3%); the SLN was detected in the laterocervical compartment (LC) in 4 cases (5.4%), with the ''sick'' of the CC. In 23 of these 74 patients (31.1%) the SLN(s) were positive for micro-metastases and in 15 cases (65.2%) both the SLN and other resected nodes were found positive. In the 51 cases in whom the SLN was disease-free, the other nodes were also negative. Of the 36 cases in whom the SLN was not detected, in 4 cases (11.1%) a parathyroid gland was stained and in 1 case (2.8%) fibroadipous tissue was stained. To date, of the 23 patients with positive-SLN 22 patients are living without disease (95.6%), 1 patient is living with disease (4.4%); all patients with negative SLN are living without disease; of the 36 patients without staining of the SLN, 35 are living without disease (97.2%) and 1 patient is deceased for reasons different from PTC (2.8%).
On the basis of this study, we underline some disadvantages in using Blue Patent V dye in SLN biopsy procedure as: a) the risk of disruption and interruption of the lymphatics from the tumour; b) blue dye uptake by a parathyroid gland which is successively mistakenly removed; c) the ''seak'' of the CC that doesn't permit to disclose SLN that lies outside the central compartment.
甲状腺乳头状癌（PTC）手术治疗的扩大范围仍存在争议。术中淋巴管造影或许能提供一些帮助，因为在其他恶性肿瘤中，该方法已成为确定淋巴结状态的重要辅助手段。本研究旨在评估通过向肿瘤内注射活性蓝色染料进行前哨淋巴结（SLN）造影以指导PTC淋巴结清扫的可行性。
选取110例患者进行研究，所有患者术前均诊断为PTC，但无临床或超声检查提示淋巴结受累。行颈前切开并暴露甲状腺后，将活性蓝色染料注入甲状腺恶性结节。随后进行甲状腺全切及淋巴结清扫，并将甲状腺、SLN及其他淋巴结送检做冰冻切片和最终组织学评估。
术中淋巴管造影在74例（67.3%）患者中定位到了前哨淋巴结；在颈外侧区（LC）发现4例（5.4%）SLN，伴有中央区（CC）“病变”。在这74例患者中的23例（31.1%），SLN存在微转移，15例（65.2%）SLN及其他切除的淋巴结均呈阳性。在SLN无病变的51例患者中，其他淋巴结也为阴性。在未检测到SLN的36例患者中，4例（11.1%）甲状旁腺被染色，1例（2.8%）纤维脂肪组织被染色。迄今为止，23例SLN阳性患者中，22例（95.6%）无病存活，1例（4.4%）带病存活；所有SLN阴性患者均无病存活；36例未发现SLN染色的患者中，35例（97.2%）无病存活，1例因非PTC相关原因死亡（2.8%）。
基于本研究，我们强调在SLN活检过程中使用专利蓝色染料存在一些缺点，如：a）肿瘤淋巴管破裂和中断的风险；b）甲状旁腺摄取蓝色染料，随后被误切除；c）CC的“渗漏”，无法发现位于中央区以外的SLN。
