Fujisawa Yasuhiro, Yoshino Koji, Kiyohara Yoshio, Kadono Takafumi, Murata Yozo, Uhara Hisashi, Hatta Naohito, Uchi Hiroshi, Matsushita Shigeto, Takenouchi Tatsuya, Hayashi Toshihiko, Fujimoto Manabu, Ohara Kuniaki
University of Tsukuba, Japan.
Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan.
J Dermatol Sci. 2015 Jul;79(1):38-42. doi: 10.1016/j.jdermsci.2015.03.014. Epub 2015 Apr 18.
Although extramammary Paget's disease (EMPD) mostly presents as intraepithelial carcinoma, we sometimes encounter patients with invasive EMPD (iEMPD) who have lymph node metastasis and may develop distant metastasis. Although sentinel lymph node biopsy (SLNB) is widely accepted for various cancers, there is no large study that has assessed its role in iEMPD.
The main objective of this study is to assess the role of SLNB in patients with iEMPD.
We retrospectively collected data on 151 iEMPD patients treated from 1998 to 2012 in 11 institutes in Japan. All 151 patients received curative surgery for their primary tumor and none of them had distant metastasis. SLNB was performed on the 107 patients without lymphadenopathy to determine their LN status. The 44 other patients with lymphadenopathy underwent one of the following procedures to determine their LN status: SLNB in 22 cases, immediate LN dissection in 21, and LN biopsy in 1.
Compared to those without lymphadenopathy, patients with lymphadenopathy had advanced primary tumors (nodule in the primary tumor, thicker tumor, deeper invasion level, and lymphovascular invasion). The rate of LN metastasis in patients with lymphadenopathy was 80%, compared to 15% in patients without lymphadenopathy who underwent SLNB. Compared to those with negative SLN, patients with positive SLN had advanced primary tumors (nodule in the primary tumor, deeper invasion level, and lymphovascular invasion). Multivariate analysis revealed that dermal invasion (odds ratio 5.8, p=0.04) and lymphovascular invasion (odds ratio 18.0, p=0.0023) were independent factors associated with SLN positivity. Notably, there was no difference in survival between patients with or without SLN metastasis (p=0.71). On the other hand, patients with lymphadenopathy showed worse survival than those with positive SLN (p=0.045).
Clinical lymphadenopathy was strongly correlated with pathological LN metastasis and also associated with worse survival than absence of lymphadenopathy. The rate of occult LN metastasis detected by SLNB was 15%. Survival was not affected by SLN status even when an advanced primary tumor was present in patients with positive SLN. Our results raise the possibility that SLNB and subsequent LN dissection improved the survival of patients with early stage lymphatic spread. Our study indicates that SLNB should be considered for iEMPD if lymphadenopathy is not apparent.
尽管乳腺外佩吉特病（EMPD）大多表现为上皮内癌，但我们有时会遇到侵袭性EMPD（iEMPD）患者，这些患者有淋巴结转移且可能发生远处转移。尽管前哨淋巴结活检（SLNB）已被广泛应用于各种癌症，但尚无大型研究评估其在iEMPD中的作用。
本研究的主要目的是评估SLNB在iEMPD患者中的作用。
我们回顾性收集了1998年至2012年在日本11家机构接受治疗的151例iEMPD患者的数据。所有151例患者均接受了原发性肿瘤的根治性手术，且均无远处转移。对107例无淋巴结肿大的患者进行SLNB以确定其淋巴结状态。另外44例有淋巴结肿大的患者接受了以下程序之一以确定其淋巴结状态：22例行SLNB，21例行即刻淋巴结清扫，1例行淋巴结活检。
与无淋巴结肿大的患者相比，有淋巴结肿大的患者原发性肿瘤进展（原发性肿瘤有结节、肿瘤更厚、浸润深度更深、有淋巴管浸润）。有淋巴结肿大的患者淋巴结转移率为80%，而无淋巴结肿大且接受SLNB的患者为15%。与SLN阴性的患者相比，SLN阳性的患者原发性肿瘤进展（原发性肿瘤有结节、浸润深度更深、有淋巴管浸润）。多因素分析显示，真皮浸润（比值比5.8，p = 0.04）和淋巴管浸润（比值比18.0，p = 0.0023）是与SLN阳性相关的独立因素。值得注意的是，SLN转移患者与未转移患者的生存率无差异（p = 0.71）。另一方面，有淋巴结肿大的患者生存率比SLN阳性的患者差（p = 0.045）。
临床淋巴结肿大与病理淋巴结转移密切相关，且与无淋巴结肿大相比生存率更差。SLNB检测到的隐匿性淋巴结转移率为15%。即使SLN阳性患者存在进展期原发性肿瘤时，生存率也不受SLN状态的影响。我们的结果提示SLNB及随后的淋巴结清扫有可能提高早期淋巴转移患者的生存率。我们的研究表明，如果没有明显的淋巴结肿大，iEMPD患者应考虑行SLNB。
