Glass L F, Fenske N A, Messina J L, Cruse C W, Rapaport D P, Berman C, Puleo C A, Heller R, Miliotes G, Albertini J
Division of Dermatology and Cutaneous Surgery, James A. Haley Veterans Administration Hospital, Tampa, Florida, USA.
Dermatol Surg. 1995 Nov;21(11):979-83. doi: 10.1111/j.1524-4725.1995.tb00537.x.
A novel surgical technique based on selective lymphadenectomy was used to stage 132 patients with intermediate and thick cutaneous malignant melanoma. Preoperative and intraoperative lymph node mapping techniques were used to ascertain regional lymph node basins at risk for metastasis, and to identify the first node(s) the afferent lymphatics encounter in the basin, defined as the "sentinel" node(s). It has been shown that the histology of the sentinel node reflects the histology of the rest of the nodal bain, and according to preliminary studies using this technique, the likelihood of bypassing the sentinel node(s) to "higher" level nodes is less than 2%. Epidemiologic studies indicate that the long-term survival of patients with melanomas of intermediate thickness or greater is significantly compromised if regional lymph nodes are involved. Yet, the utility of performing lymph node dissections for the purposes of staging only is controversial, not only because of the morbidity and expense of the procedure, but the lack of proven survival benefit.
In the present study, we performed preoperative and intraoperative lymphatic mapping, harvested clinically normal sentinel nodes, and examined them for micrometastasis by light microscopy. Both conventional stains and immunocytochemistry for S-100 protein and HMB-45 antibodies were performed, and only those patients with documented micrometastasis received complete lymph node dissections.
The sentinel node(s) was identified in each of the patients. Micrometastatic disease was detected in 31 (23%) of the patients by selective lymphadenectomy, and the sentinel node(s) was the only node involved in 83% of the cases upon subsequent complete nodal dissection.
Our preliminary results suggest that selective lymphadenectomy following lymphatic mapping is an effective procedure for staging melanoma patients with lesions of intermediate thickness or greater. Our results indicate that sentinel lymph nodes may be successfully identified and harvested in the majority of patients, and that they may be examined for the first evidence of micrometastasis without the need of a complete nodal dissection. Information as to whether micrometastases are present in the sentinel node would be valuable in staging patients, and identifying candidates for complete nodal dissections. We are participating in a National Cancer Institute-sponsored multicenter trial to ascertain whether this surgical approach can impact on the recurrence rate and survival of patients with stage 1 and 2 melanoma.
一种基于选择性淋巴结清扫术的新型外科技术被用于对132例中度和厚皮恶性黑色素瘤患者进行分期。术前和术中淋巴结定位技术被用于确定有转移风险的区域淋巴结组，以及识别该组中传入淋巴管首先遇到的第一个淋巴结，即“前哨”淋巴结。研究表明，前哨淋巴结的组织学反映了其余淋巴结组的组织学，并且根据使用该技术的初步研究，越过前哨淋巴结转移至“更高”级淋巴结的可能性小于2%。流行病学研究表明，如果区域淋巴结受累，中度或更厚厚度黑色素瘤患者的长期生存率会显著降低。然而，仅为分期目的而进行淋巴结清扫术的实用性存在争议，这不仅是因为该手术的发病率和费用，还因为缺乏已证实的生存获益。
在本研究中，我们进行了术前和术中淋巴管造影，获取临床上正常的前哨淋巴结，并通过光学显微镜检查微转移情况。同时进行了常规染色以及针对S-100蛋白和HMB-45抗体的免疫细胞化学检测，只有那些有微转移记录的患者才接受完整的淋巴结清扫术。
每位患者均成功识别出前哨淋巴结。通过选择性淋巴结清扫术在31例（23%）患者中检测到微转移疾病，在随后的完整淋巴结清扫术中，83%的病例中前哨淋巴结是唯一受累的淋巴结。
我们的初步结果表明，淋巴管造影后进行选择性淋巴结清扫术是对中度或更厚厚度黑色素瘤患者进行分期的有效方法。我们的结果表明，大多数患者可以成功识别并获取前哨淋巴结，并且可以对其进行微转移的首次证据检查，而无需进行完整的淋巴结清扫术。前哨淋巴结中是否存在微转移的信息对于患者分期以及确定完整淋巴结清扫术的候选者具有重要价值。我们正在参与一项由美国国立癌症研究所资助的多中心试验，以确定这种手术方法是否会影响I期和II期黑色素瘤患者的复发率和生存率。
