Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
Division of Breast Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
Clin Breast Cancer. 2024 Dec;24(8):716-720. doi: 10.1016/j.clbc.2024.08.012. Epub 2024 Aug 23.
Sentinel lymph node biopsy (SLNB) for axillary staging in patients with ductal carcinoma in situ (DCIS) undergoing mastectomy is debated due to low nodal positivity rate and risk of morbidity. Standard SLNB entails removing all lymph nodes (LN) that have a radioactive count > 10% of the most radioactive node, contain blue dye or are palpably suspicious. In this study, we hypothesize that judicious SLNB with attempt to remove only the node with the highest radioactive count provides sufficient pathologic information while minimizing morbidity.
A single institution prospective database was retrospectively reviewed to identify women with DCIS who underwent mastectomy and SLNB between 2010 and 2022. Patient characteristics, number of SLNs retrieved, pathologic results and long-term upper extremity complications were analyzed.
A total of 743 LNs were removed in 324 pts. Median (IQR) age was 62 (51-70) years. Dual tracer technique, with technetium-99m labeled radiocolloid and blue dye, was used in 311 (96%) pts, whereas single agent (radioisotope or blue dye alone) was utilized in 9 (2.8%) and 4 (1.2%) patients, respectively. Median (IQR) number of SLN removed was 2 (1-3) (range 1-9). In 99% of cases, the SLN with the highest radioactive count was identified among the first 3 dissected LNs. Final pathology revealed upstaging to invasive cancer in 27.5% (n = 89) of the breasts and nodal positivity in 1.9% (n = 6) of the patients. In all 6 cases, metastatic disease was identified in the LN with highest radioactive count among the LNs retrieved. No additional metastatic nodes were identified after > 3 SLN had been removed. At median follow-up of 57 (range 28-87) months, 8.3% (n = 27) of pts complained of long-term upper extremity symptoms. 7.1% (23 pts) were referred to physical therapy for symptoms such as swelling, fullness, heaviness, stiffness, or sensory discomfort in the upper extremity and/or axillary cording. Long-term upper extremity complications were higher when > 3 SLNs compared to ≤ 3 SLNs were removed (10.4% vs. 6.5%, P = .005).
In this cohort of patients with DCIS undergoing mastectomy who were upstaged on final pathology to node positive invasive cancers, the SLN with the highest radioactive count provided sufficient information for axillary staging. Acknowledging that the "hottest" LN is not always the first 1 removed, these data support an increased likelihood of developing long-term complications when more than 3 SLNs are removed. Rather than comprehensive removal of all SLNs meeting the standard "10% rule," prioritizing the sequence of removal to the highest count provides the same prognostic information with reduced morbidity.
在接受乳房切除术的导管原位癌（DCIS）患者中，对于腋窝分期进行前哨淋巴结活检（SLNB）存在争议，因为淋巴结阳性率低且存在发病风险。标准的 SLNB 需要切除放射性计数>最放射性淋巴结 10%的所有淋巴结（LN），包含蓝色染料或可触及可疑的淋巴结。在这项研究中，我们假设通过尝试仅切除放射性计数最高的淋巴结进行明智的 SLNB，可以在最小化发病风险的同时提供足够的病理信息。
回顾性分析了 2010 年至 2022 年间在我院接受乳房切除术和 SLNB 的 DCIS 女性患者的单一机构前瞻性数据库。分析患者特征、切除的 SLN 数量、病理结果和长期上肢并发症。
在 324 例患者中切除了 743 个 LN。中位（IQR）年龄为 62（51-70）岁。311 例（96%）患者使用双示踪剂技术，即锝-99m 标记放射性胶体和蓝色染料，而 9 例（2.8%）和 4 例（1.2%）患者分别使用单一药物（放射性同位素或单独蓝色染料）。切除的 SLN 中位数（IQR）为 2（1-3）（范围 1-9）。在 99%的情况下，在解剖的前 3 个 LN 中识别到放射性计数最高的 SLN。最终病理显示，27.5%（n=89）的乳房升级为浸润性癌，1.9%（n=6）的患者淋巴结阳性。在所有 6 例中，在切除的 LN 中发现了放射性计数最高的转移性疾病。在切除>3 个 SLN 后，未发现其他转移性淋巴结。在中位随访 57（范围 28-87）个月时，8.3%（n=27）的患者报告有长期上肢症状。7.1%（23 例）因上肢和/或腋窝索带肿胀、饱满、沉重、僵硬或感觉不适等症状接受物理治疗。与切除≤3 个 SLN 相比，切除>3 个 SLN 时上肢长期并发症更高（10.4%vs.6.5%，P=0.005）。
在接受乳房切除术且最终病理升级为淋巴结阳性浸润性癌的 DCIS 患者队列中，放射性计数最高的 SLN 为腋窝分期提供了足够的信息。认识到“最热”的 LN 并不总是第一个被切除的 LN，当切除超过 3 个 SLN 时，发生长期并发症的可能性更高。与其全面切除符合标准“10%规则”的所有 SLN，优先按顺序切除放射性计数最高的 SLN 可以提供相同的预后信息，同时降低发病率。
