Miliotes G, Albertini J, Berman C, Heller R, Messina J, Glass F, Cruse W, Rapaport D, Puleo C, Fenske N, Petsoglou C, Deconti R, Lyman G, Reintgen D
Cutaneous Oncology Program, Moffitt Cancer Center, Tampa, FL 33612-9497, USA.
Am Surg. 1996 Jan;62(1):81-8.
Approximately 20 per cent of melanomas greater than 0.76 mm in thickness will metastasize to the regional lymph nodes if treated with wide local excision alone (WLE). Elective lymph node dissection (ELND) is associated with significant morbidity, which includes lymphedema, wound complications, and paresthesias of the extremity. An alternative operative approach uses selective lymphadenectomy with the identification of the sentinel node, defined as the first node in the lymphatic basin that drains the primary cutaneous site. This study consisted of 132 patients with melanomas greater than 0.76 mm. One hundred nine patients (83%) had histologic negative sentinel nodes, and 23 patients (17%) had one or more sentinel nodes positive for disease. In patients with metastatic disease, 30/35 (86%) sentinel nodes were positive, and 25/357 (7%) nonsentinel nodes were positive (P < 0.001). In 18 patients (78%) of the 23 patients with metastatic disease, the sentinel node was the only node positive, strongly suggesting that there is an orderly progression of metastases. Two patients developed metastatic nodal disease after removal of a negative sentinel node (false negative rate = 1.5). The mean follow-up was 1 year. Sentinel node histology reflects the histology of the remainder of the nodes in the lymphatic basin and "skip" metastases, defined as a negative sentinel node but positive nodes higher in the regional chain positive for metastases or an axillary recurrence after a negative sentinel node biopsy, are rare for malignant melanoma. Harvesting the sentinel node in patients with intermediate or greater thickness melanoma will, therefore, identify a subset of patients with metastatic disease who have the most to benefit from a complete node dissection. This surgical approach allows for complete pathological staging and therapeutic management of patients while significantly reducing expense and overall morbidity.
厚度大于0.76毫米的黑色素瘤患者，若仅采用局部广泛切除（WLE）治疗，约20%会发生区域淋巴结转移。选择性淋巴结清扫术（ELND）会引发严重的并发症，包括淋巴水肿、伤口并发症以及肢体感觉异常。另一种手术方法是采用选择性淋巴结切除术并识别前哨淋巴结，前哨淋巴结定义为引流原发性皮肤部位的淋巴引流区域的首个淋巴结。本研究纳入了132例厚度大于0.76毫米的黑色素瘤患者。109例患者（83%）前哨淋巴结组织学检查为阴性，23例患者（17%）有一个或多个前哨淋巴结存在疾病阳性。在发生转移的患者中，35个前哨淋巴结中有30个（86%）呈阳性，357个非前哨淋巴结中有25个（7%）呈阳性（P<0.001）。在23例发生转移的患者中，有18例（78%）前哨淋巴结是唯一呈阳性的淋巴结，这强烈表明转移存在有序进展。2例患者在前哨淋巴结切除后出现转移性淋巴结疾病（假阴性率=1.5）。平均随访时间为1年。前哨淋巴结组织学反映了淋巴引流区域其余淋巴结的组织学情况，而“跳跃”转移（定义为前哨淋巴结阴性但区域链中更高位置的淋巴结转移阳性，或前哨淋巴结活检阴性后出现腋窝复发）在恶性黑色素瘤中很少见。因此，对于厚度中等或更大的黑色素瘤患者，切除前哨淋巴结将识别出一部分最能从完整淋巴结清扫术中获益的转移患者。这种手术方法能够对患者进行完整的病理分期和治疗管理，同时显著降低费用和总体并发症发生率。
