Glass L F, Messina J L, Cruse W, Wells K, Rapaport D, Miliotes G, Berman C, Reintgen D, Fenske N A
Cutaneous Oncology Program, Moffitt Cancer Center, University of South Florida College of Medicine, Tampa 33612, USA.
Dermatol Surg. 1996 Aug;22(8):715-20. doi: 10.1111/j.1524-4725.1996.tb00623.x.
Selective lymphadenectomy or "sentinel node" biopsy has been introduced recently by Morton and colleagues (Arch Surg 1992;127:392-9) to stage patients with intermediate and thick malignant melanomas. It has proven to be an effective way to identify nodal basins at risk for metastasis without the morbidity of a complete lymph node dissection. The majority of biopsies can be performed under local anesthesia with small incisions, but technical difficulties occasionally result in unsuccessful explorations. Identification of the sentinel node can be enhanced by a intraoperative radiolymphoscintigraphy, a technique introduced Alex and Krag (Surg Oncol 1993;137-43) that uses radiolabeled sulfur colloid and a hand-held gamma probe.
We used intraoperative radiolymphoscintigraphy in conjunction with 1% lymphazurin blue dye to define the sentinel node(s) in 148 patients with greater than 0.76 mm in thickness or Clark level IV melanomas. Sentinel lymph nodes were isolated, harvested, and examined using conventional histopathology, and immunohistochemistry for S-100 and HMB-45 antibodies.
The overall success rate of sentinel lymph node localization was 97% using a combination of the two techniques. Twenty-one (14%) patients had micrometastasis, and 17 of these subsequently underwent complete lymph node dissection. A total of 220 of 275 (80%) sentinel nodes harvested were radioactive or "hot" compared with 165 of 275 (60%) with the blue dye alone. Four of the patients with micrometastasis had sentinel nodes positive by gamma probe, but negative by blue dye mapping techniques.
Our results suggest that intraoperative radiolymphoscintigraphy using a hand-held gamma detecting probe improves the identification of sentinel lymph nodes during selective lymphadenectomy. This may reduce the number of "unsuccessful explorations" using the vital blue dye technique for lymphatic mapping, and appeal to a greater variety of surgeons, including dermatologic surgeons.
莫顿及其同事（《外科学文献》1992年；127卷：392 - 399页）最近引入了选择性淋巴结切除术或“前哨淋巴结”活检，用于对中度和厚度较大的恶性黑色素瘤患者进行分期。事实证明，这是一种确定有转移风险的淋巴结区域的有效方法，且不会带来完整淋巴结清扫术的并发症。大多数活检可在局部麻醉下通过小切口进行，但技术难题偶尔会导致探查失败。术中放射性淋巴闪烁造影术可提高前哨淋巴结的识别率，这是亚历克斯和克拉格引入的一项技术（《外科肿瘤学》1993年；137 - 143页），该技术使用放射性标记的硫化胶体和手持式γ探测器。
我们将术中放射性淋巴闪烁造影术与1%的亚甲蓝染料联合使用，以确定148例厚度大于0.76毫米或处于克拉克四级的黑色素瘤患者的前哨淋巴结。分离、获取前哨淋巴结，并使用传统组织病理学以及针对S - 100和HMB - 45抗体的免疫组织化学方法进行检查。
两种技术联合使用时，前哨淋巴结定位的总体成功率为97%。21例（14%）患者存在微转移，其中17例随后接受了完整淋巴结清扫术。在获取的275个前哨淋巴结中，共有220个（80%）有放射性或“热”结节，而仅使用蓝色染料时，275个中有165个（60%）有放射性。4例有微转移的患者，其前哨淋巴结通过γ探测器检测为阳性，但通过蓝色染料标记技术检测为阴性。
我们的结果表明，使用手持式γ探测仪的术中放射性淋巴闪烁造影术可提高选择性淋巴结切除术中前哨淋巴结的识别率。这可能会减少使用活性蓝色染料技术进行淋巴绘图时“探查失败”的次数，并吸引更多外科医生，包括皮肤科外科医生。
