乳腺癌前哨淋巴结术中与术后病理学评估方法的优化性研究
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摘要
目的:第一部分将通过优化前哨淋巴结术中印片细胞学检测的方法,以提高前哨淋巴结活检术中病理学评估手段的灵敏度与准确性,减少术中检测假阴性的发生率,节约医疗资源与成本。第二部分将在术后同时利用免疫组化染色、逆转录聚合酶链反应以及流式细胞术检测前哨淋巴结内微转移情况,通过这三种方法分别与金标准的比较以及其三者间的比较,筛选出最佳的微转移检测技术,建立最佳的术后前哨淋巴结微转移评估的流程。
方法:
第一部分:前哨淋巴结术中印片细胞学检测的优化
从2005年02月至2008年02月,有366例患者进入本研究,其术中所获取的前哨淋巴结采用传统的印片制片方式,即沿前哨淋巴结的长轴,间隔2.0～3.0毫米进行切割;从2008年03月至2009年01月,有122例患者参与本研究,其术中所获取的前哨淋巴结采用新的印片制片方法进行,即利用我们自行设计制造的前哨淋巴结切割器沿前哨淋巴结的短轴,间隔1.5毫米进行切割。连续切片H&E染色将作为术中病理学评估的金标准。
第二部分:免疫组化染色、逆转录聚合酶反应以及流式细胞术在前哨淋巴结微转移检测中的应用
自2008年03月至2009年03月,术中获取的前哨淋巴结应用前哨淋巴结切割器,间隔1.5mm进行切割,各切面进行印片后,将第3n-1片、第3n-2片以及第3n片分送不同的检测方法进行淋巴结病理学检测,其中第3n片送检连续切片H&E染色及免疫组化染色,第3n-1片送检逆转录-聚合酶链式反应检测,第3n-2片送检流式细胞术检测。
结果
第一部分:新的多切面印片细胞学检测的灵敏度、特异度以及准确性以病例数为计算单位分别为92.0%、99.0%以及97.5%,优于传统的印片制片方法。新的印片制片方法与传统的印片制片方法间对于宏转移的检出能力有显著差异(p=0.023)。导管内癌、导管内癌伴浸润以及浸润性导管癌以病例数为单位计算的淋巴结转移率分别为4.4%、12.5%以及31.3%。有97.7%的存在有前哨淋巴结转移的患者,其第一枚有转移的前哨淋巴结出现在术中所获取的前三枚前哨淋巴结中。
第二部分:在所有的104枚前哨淋巴结中,连续切片H&E染色发现了11枚(10.6%)前哨淋巴结阳性,其中2枚(18.2%)前哨淋巴结为微转移。免疫组化染色证实这两枚前哨淋巴结为宏转移,并且进一步在H&E染色阴性的淋巴结中发现了11例微转移,1例宏转移。而RT-PCR以及流式细胞术分别在联合应用连续切片H&E染色和免疫组化染色均为阴性的淋巴结中检测出了5例(6.2%)与4例(4.9%)的淋巴结中存在有微小转移灶,其中有1例为RT-PCR与流式细胞术共同阳性。在所有的11例存在有微转移的前哨淋巴结中,有5枚前哨淋巴结,其患者同时存在有其他前哨淋巴结的转移。在免疫组化水平检测出的前哨淋巴结微转移,同一患者的其他淋巴结同时存在有转移的机会较前哨淋巴结阴性的患者高(p=0.007)。
结论:
第一部分:新的多切面印片细胞学检测方法优于传统的制片方法,尤其是在对于宏转移的检出能力上。只针对术中所获取的前三枚前哨淋巴结进行术中印片细胞学检测不会显著影响印片细胞学检测的准确性,还可降低病理科的工作负荷以及医疗成本。开放活检病理学诊断为单纯导管内癌的患者可以考虑省去术中前哨淋巴结病理学评估的步骤。
第二部分:连续切片免疫组化染色的灵敏度高于H&E染色,RT-PCR与流式细胞术的灵敏度更高于免疫组化染色,但目前并不能证实由RT-PCR或流式细胞术所检出的转移灶是否为真阳性,故连续切片免疫组化染色仍建议为术后前哨淋巴结病理学检验的金标准,而由后两者所检出的患者需要进行密切的腋窝随访。免疫组化染色检验水平检出的前哨淋巴结中存在有微转移的患者,其他前哨淋巴结中同时存在有转移或微转移的可能性较高,所以建议术中前哨淋巴结活检术至少获取两枚前哨淋巴结,以提高准确性。
Objective:The first part of the present study is to evaluate the clinical value of multiple cross-section touch imprint cytology(TIC) as the intraoperative assessment for sentinel lymph nodes(SLN).The second part of the present study is detect the micrometastasis foci in sentinel lymph node from patients with early-stage breast cancer with the varies methods,such as serial section with H&E staining,immunohistochemistry staining,RT-PCR and flow cytometry and to establish a suitable protocol on the pathologic evaluation of sentinel lymph nodes postoperatively in our own institute.
Methods:
Part one:The Optimization of Intraoperative Touch Imprint Cytology Evaluation of Sentinel Lymph Node for Breast Cancer 366 patients enrolled in the study between Feb-2005 and Feb-2008,whose SLNs captured in the surgery were sliced along the long axis at a 2.0～3.0mm interval. 122 patients participated in the study between Mar-2008 and Jan-2009,whose SLNs harvested were sliced along the short axis at a 1.5mm interval with our own designed cutter.Serial section at a 100μm interval with H&E staining was used as gold standard for pathologic diagnosis.
Part two:The Application of Serial Section,IHC,RT-PCR and Flow Cytometry in Detection of Micrometastasis in SLN for Breast Cancer From May-2008 to May-2009,sentinel lymph nodes captured in the surgery,which were sliced with the sentinel lymph node cutter into pieces at a thickness of 1.5mm,were divided into three groups,every third slices were sent for evaluation by serial section with H&E staining and IHC staining,every(3n-1) slices were sent for evaluation by RT-PCR to detect micrometastasis while every (3n-2) sliced were sent for flow cytometry.
Results:
Part one:Multiple cross-section TIC has a sensitivity,specificity and overall accuracy rate of 92.0%,99.0%and 97.5%,respectively on a per patient basis superior to the standard proposal for preparing imprints.The ability to detect macrometastasis on a per patient base between two proposals had significant difference(p=0.023).The metastasis rates of patients with DCIS, DCIS-Mi and IDC were 4.4%,12.5%and 31.3%,respectively.97.7%of the patients with node involved,whose first involved SLN appeared within the first three SLNs harvested.
Part two:Among all the 104 sentinel lymph nodes,serial section with H&E staining discovered 11(10.6%) involved nodes,among which,2 nodes contained micrometastasis.Consequent IHC staining ensured that the 2 nodes mentioned before were macrometastasis and discovered another 11 micrometastasis and 1 macrometastasis nodes among the H&E staining negative nodes.Further more, RT-PCR and flow cytometry discovered another 5(6.2%) and 4(4.9%) nodes, respectively that contained cancer cells.About 40%sentinel lymph nodes micrometastasises detected by IHC staining were accompanied by additional sentinel lymph nodes metastases or micrometastasis(p=0.007).
Conclusion:
Part one:Multiple cross-section TIC is superior to the standard proposal, especially for the ability to locate macrometastasis.To limit the intraoperative assessment to the first three retrieved nodes may reduce the pathology laboratory and expanse.It could be taken into consideration to spare intraoperative assessment of SLNs for patients with DCIS diagnosed by open biopsy.
Part two:The sensitivity of serial section with IHC staining was higher than that of serial section with H&E staining,while RT-PCR and flow cytometry were proved to be more sensitivity.However,no further evidence could proved whether the positive result was a real one.Therefore,serial section with IHC staining was still suggested to be the gold standard for pathologic evaluation of sentinel lymph node postoperatively.The patients with positive nodes only detected by RT-PCR or flow cytometry should be close follow-up. The micrometastasises detected by IHC staining were likely to accompanied by additional sentinel lymph nodes metastases or micrometastasis,therefore,the number of sentinel lymph node captured with the surgery was suggested to be at least two in order to increase the overall accuracy.
方法:
第一部分:前哨淋巴结术中印片细胞学检测的优化
从2005年02月至2008年02月,有366例患者进入本研究,其术中所获取的前哨淋巴结采用传统的印片制片方式,即沿前哨淋巴结的长轴,间隔2.0～3.0毫米进行切割;从2008年03月至2009年01月,有122例患者参与本研究,其术中所获取的前哨淋巴结采用新的印片制片方法进行,即利用我们自行设计制造的前哨淋巴结切割器沿前哨淋巴结的短轴,间隔1.5毫米进行切割。连续切片H&E染色将作为术中病理学评估的金标准。
第二部分:免疫组化染色、逆转录聚合酶反应以及流式细胞术在前哨淋巴结微转移检测中的应用
自2008年03月至2009年03月,术中获取的前哨淋巴结应用前哨淋巴结切割器,间隔1.5mm进行切割,各切面进行印片后,将第3n-1片、第3n-2片以及第3n片分送不同的检测方法进行淋巴结病理学检测,其中第3n片送检连续切片H&E染色及免疫组化染色,第3n-1片送检逆转录-聚合酶链式反应检测,第3n-2片送检流式细胞术检测。
结果
第一部分:新的多切面印片细胞学检测的灵敏度、特异度以及准确性以病例数为计算单位分别为92.0%、99.0%以及97.5%,优于传统的印片制片方法。新的印片制片方法与传统的印片制片方法间对于宏转移的检出能力有显著差异(p=0.023)。导管内癌、导管内癌伴浸润以及浸润性导管癌以病例数为单位计算的淋巴结转移率分别为4.4%、12.5%以及31.3%。有97.7%的存在有前哨淋巴结转移的患者,其第一枚有转移的前哨淋巴结出现在术中所获取的前三枚前哨淋巴结中。
第二部分:在所有的104枚前哨淋巴结中,连续切片H&E染色发现了11枚(10.6%)前哨淋巴结阳性,其中2枚(18.2%)前哨淋巴结为微转移。免疫组化染色证实这两枚前哨淋巴结为宏转移,并且进一步在H&E染色阴性的淋巴结中发现了11例微转移,1例宏转移。而RT-PCR以及流式细胞术分别在联合应用连续切片H&E染色和免疫组化染色均为阴性的淋巴结中检测出了5例(6.2%)与4例(4.9%)的淋巴结中存在有微小转移灶,其中有1例为RT-PCR与流式细胞术共同阳性。在所有的11例存在有微转移的前哨淋巴结中,有5枚前哨淋巴结,其患者同时存在有其他前哨淋巴结的转移。在免疫组化水平检测出的前哨淋巴结微转移,同一患者的其他淋巴结同时存在有转移的机会较前哨淋巴结阴性的患者高(p=0.007)。
结论:
第一部分:新的多切面印片细胞学检测方法优于传统的制片方法,尤其是在对于宏转移的检出能力上。只针对术中所获取的前三枚前哨淋巴结进行术中印片细胞学检测不会显著影响印片细胞学检测的准确性,还可降低病理科的工作负荷以及医疗成本。开放活检病理学诊断为单纯导管内癌的患者可以考虑省去术中前哨淋巴结病理学评估的步骤。
第二部分:连续切片免疫组化染色的灵敏度高于H&E染色,RT-PCR与流式细胞术的灵敏度更高于免疫组化染色,但目前并不能证实由RT-PCR或流式细胞术所检出的转移灶是否为真阳性,故连续切片免疫组化染色仍建议为术后前哨淋巴结病理学检验的金标准,而由后两者所检出的患者需要进行密切的腋窝随访。免疫组化染色检验水平检出的前哨淋巴结中存在有微转移的患者,其他前哨淋巴结中同时存在有转移或微转移的可能性较高,所以建议术中前哨淋巴结活检术至少获取两枚前哨淋巴结,以提高准确性。
Objective:The first part of the present study is to evaluate the clinical value of multiple cross-section touch imprint cytology(TIC) as the intraoperative assessment for sentinel lymph nodes(SLN).The second part of the present study is detect the micrometastasis foci in sentinel lymph node from patients with early-stage breast cancer with the varies methods,such as serial section with H&E staining,immunohistochemistry staining,RT-PCR and flow cytometry and to establish a suitable protocol on the pathologic evaluation of sentinel lymph nodes postoperatively in our own institute.
Methods:
Part one:The Optimization of Intraoperative Touch Imprint Cytology Evaluation of Sentinel Lymph Node for Breast Cancer 366 patients enrolled in the study between Feb-2005 and Feb-2008,whose SLNs captured in the surgery were sliced along the long axis at a 2.0～3.0mm interval. 122 patients participated in the study between Mar-2008 and Jan-2009,whose SLNs harvested were sliced along the short axis at a 1.5mm interval with our own designed cutter.Serial section at a 100μm interval with H&E staining was used as gold standard for pathologic diagnosis.
Part two:The Application of Serial Section,IHC,RT-PCR and Flow Cytometry in Detection of Micrometastasis in SLN for Breast Cancer From May-2008 to May-2009,sentinel lymph nodes captured in the surgery,which were sliced with the sentinel lymph node cutter into pieces at a thickness of 1.5mm,were divided into three groups,every third slices were sent for evaluation by serial section with H&E staining and IHC staining,every(3n-1) slices were sent for evaluation by RT-PCR to detect micrometastasis while every (3n-2) sliced were sent for flow cytometry.
Results:
Part one:Multiple cross-section TIC has a sensitivity,specificity and overall accuracy rate of 92.0%,99.0%and 97.5%,respectively on a per patient basis superior to the standard proposal for preparing imprints.The ability to detect macrometastasis on a per patient base between two proposals had significant difference(p=0.023).The metastasis rates of patients with DCIS, DCIS-Mi and IDC were 4.4%,12.5%and 31.3%,respectively.97.7%of the patients with node involved,whose first involved SLN appeared within the first three SLNs harvested.
Part two:Among all the 104 sentinel lymph nodes,serial section with H&E staining discovered 11(10.6%) involved nodes,among which,2 nodes contained micrometastasis.Consequent IHC staining ensured that the 2 nodes mentioned before were macrometastasis and discovered another 11 micrometastasis and 1 macrometastasis nodes among the H&E staining negative nodes.Further more, RT-PCR and flow cytometry discovered another 5(6.2%) and 4(4.9%) nodes, respectively that contained cancer cells.About 40%sentinel lymph nodes micrometastasises detected by IHC staining were accompanied by additional sentinel lymph nodes metastases or micrometastasis(p=0.007).
Conclusion:
Part one:Multiple cross-section TIC is superior to the standard proposal, especially for the ability to locate macrometastasis.To limit the intraoperative assessment to the first three retrieved nodes may reduce the pathology laboratory and expanse.It could be taken into consideration to spare intraoperative assessment of SLNs for patients with DCIS diagnosed by open biopsy.
Part two:The sensitivity of serial section with IHC staining was higher than that of serial section with H&E staining,while RT-PCR and flow cytometry were proved to be more sensitivity.However,no further evidence could proved whether the positive result was a real one.Therefore,serial section with IHC staining was still suggested to be the gold standard for pathologic evaluation of sentinel lymph node postoperatively.The patients with positive nodes only detected by RT-PCR or flow cytometry should be close follow-up. The micrometastasises detected by IHC staining were likely to accompanied by additional sentinel lymph nodes metastases or micrometastasis,therefore,the number of sentinel lymph node captured with the surgery was suggested to be at least two in order to increase the overall accuracy.
引文
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37.Cote RJ,Peterson HF,Chaiwun B,et al.Role of immunohistochemical detection of lymph-node metastases in management of breast cancer.International Breast Cancer Study Group.Lancet.1999,354(9182):896-900
38.Kahn HJ,Hanna WM,Chapman JA,et al.Biological significance of occult micrometastases in histologically negative axillary lymph nodes in breast cancer patients using the recent American Joint Committee on Cancer breast cancer staging system.Breast J.2006,12(4):294-301
39.Umekita Y,Ohi Y,Sagara Y,et al.Clinical significance of occult micrometastases in axillary lymph nodes in "node-negative" breast cancer patients.Jpn J Cancer Res.2002,93(6):695-698
40.Chen SL,Hoehne FM,Giuliano AE.The Prognostic Significance of Micrometastases in Breast Cancer:A SEER Population-Based Analysis.Ann Surg Oncol.2007,14(12):3378-3384
41.Kuijt GP,Voogd AC,van de Poll-Franse LV,et al.The prognostic significance of axillary lymph-node micrometastases in breast cancer patients.Eur J Surg Oncol.2005,31(5):500-505
42.张杰,沈坤炜,吴炅,陆劲松,刘邦令,周决,沈瑾,沈镇宙,邵志敏.乳腺癌前哨淋巴结及骨髓中微转移的联合检测.肿瘤学杂志,2002,8(6):328-331
43.Rosen PP,Saigo PE,Braun DW,et al.(1981) Prognosis in stage Ⅱ(T1N1M0) breast cancer.Ann Surg 194:576-584
44.McGuckin MA,Cummings MC,Walsh MD,et al.(1996) Occult axillary node metastases in breast cancer:their detection and prognostic signifi cance.Br J Cancer 73:88-95
45.Nasser IA,Lee AK,Bosari S,et al.(1993) Occult axillary lymph node metastases in "node-negative" breast carcinoma.Hum Pathol 24:950-957
46.Liu LH,et al.Evaluation of axillary sentinel lymph node biopsy by immunohistochemistry and multilevel sectioning in patients with breast carcinoma.Arch Pathol Lab Med 2000;124:1670-3
47.Schoenfeld A,Luqmani Y,Smith D,et al.(1994) Detection of breast cancer micrometastases in axillary lymph nodes by using polymerase chain reaction.Cancer Res 54:2986-2990
48.Wada N,Imoto S.Clinical evidence of breast cancer micrometastasis in the era of sentinel node biopsy.Int J Clin Oncol.2008 Feb;13(1):24-32.Epub 2008 Feb 29.49.Schoenfeld A,Luqmani Y,Smith D,et al.(1994) Detection of breast cancer micrometastases in axillary lymph nodes by using polymerase chain reaction.Cancer Res 54:2986-2990
50.Van der Velde-Zimmermann D,Roijers JF,Bouwens-Rombouts A,et al.(1996) Molecular test for the detection of tumor cells in blood and sentinel nodes of melanoma patients.Am J Pathol 149:759-764
51.Shivers SC,Wang X,Li W,et al.(1998) Molecular staging of malignant melanoma:correlation with clinical outcome.JAMA 280:1410-1415
52.Hatta N,Fujimoto A,Takehara K,et al.(1999) Mapping of occult melanoma micrometastases in the inguinal lymph node basin by immunohistochemistry and RT-PCR.Melanoma Res 9:401-406
53.Bieligk SC,Ghossein R,Bhattacharya S,et al.(1999) Detection of tyrosinase mRNA by reverse transcription-polymerase chain reaction in melanoma sentinel nodes.Ann Surg Oncol 6:232-240
54.Blaheta HJ,Schittek B,Breuninger H,et al.(1999) Detection of melanoma micrometastasis in sentinel nodes by reverse transcription-polymerase chain reaction correlates with tumor thickness and is predictive of micrometastatic disease in the lymph node basin.Am J Surg Pathol 23:822-828
1.Tjan-Heijnen VC,Buit P,de Widt-Evert LM,et al.Micro-metastases in axillary lymph nodes:an increasing classification and treatment dilemma in breast cancer due to the introduction of the sentinel lymph node procedure.Breast Cancer Res Treat.2001,70(2):81-88 PMID:11768607
2.Brogi E,Torres-Matundan E,Tan LK,et al.The results of frozen section,touch preparation,and cytological smear are comparable for intraoperative examination of sentinel lymph nodes:a study in 133 breast cancer patients.Ann Surg Oncol.2005,12(2):173-180 PMID:15827799
3.Veronesi U,Paganelli G,Galimberti V,et al.Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes.Lancet.1997,349(9069):1864-1867 PMID:9217757
4.Celebioglu F,Sylvan M,Perbeck L,et al.Intraoperative sentinel lymph node examination by frozen section,immunohistochemistry and imprint cytology during breast surgery—a prospective study.Eur J Cancer.2006,42(5):617-620 PMID:16446084
5.Ratanawichitrasin A,Biscotti CV,Levy L,et al.Touch imprint cytological analysis of sentinel lymph nodes for detecting axillary metastases in patients with breast cancer.Br J Surg.1999,86(10):1346-1348 PMID:10540148
6.Ollila DB,Stitzenberg KB.Breast cancer sentinel node metastases:histopathologic detection and clinical significance.Cancer Control.2001, 8(5):407-414 PMID:11579336
7.Diel IJ,Kaufmann M,Goerner R,et al.Detection of tumor cells in bone marrow of patients with primary breast cancer:a prognostic factor for distant metastasis.J Clin Oncol.1992,10(10):1534-1539 PMID:1403032
8.Zhang T,Zhang BN,Zhang HT,et al.Detection of micrometastases in sentinel lymph nodes of breast cancer.Zhonghua Zhong Liu Za Zhi.2007,29(2):116-118 PMID:17645847
9.Abdul-Rasool S,Kidson SH,Panieri E,et al.An evaluation of molecular markers for improved detection of breast cancer metastases in sentinel nodes.J Clin Pathol.2006,59(3):289-297 PMID:16505281
10.李金锋,张蕾,孙素莲等.利用逆转录酶聚合酶链反应及DNA印迹杂交技术检测乳腺癌腋窝淋巴结微转移.中华普通外科杂志,2001,16(3):164-167
11.Blumencranz P,Whitworth PW,Deck K,et al.Sentinel node staging for breast cancer:intraoperative molecular pathology overcomes conventional histologic sampling errors.Am J Surg.2007,194(4):426-432 PMID:17826050
12.Rostagno P,Moll JL,Bisconte JC,et al.Detection of rare circulating breast cancer cells by filtration cytometry and identification by DNA content:sensitivity in an experimental model.Anticancer Res.1997,17(4A):2481-2485 PMID:9252667
13.Leers MPG,Schoffelen R,Hoop JGM,et al.Multiparameter flow cytometry as a tool for the detection of micrometastatic of tumor cells in the sentinel lymph node procedure of patients with breast cancer.J Clin Pathol.2002,55(5):359-366.PMID:11986342
14.Cote RJ,Peterson HF,Chaiwun B,et al.Role of immunohistochemical detection of lymph-node metastases in management of breast cancer.International Breast Cancer Study Group.Lancet.1999,354(9182):896-900PMID:10489948
15.Dowlatshahi K,Fan M,Bloom KJ,et al.Occult metastases in the sentinel lymph nodes of patients with early stage breast carcinoma:A preliminary study.Cancer.1999,86(6):990-996 PMID:10491525
16.Kahn HJ,Hanna WM,Chapman JA,et al.Biological significance of occult micrometastases in histologically negative axillary lymph nodes in breast cancer patients using the recent American Joint Committee on Cancer breast cancer staging system.Breast J.2006,12(4):294-301 PMID:16848838
17.Umekita Y,Ohi Y,Sagara Y,et al.Clinical significance of occult micrometastases in axillary lymph nodes in “node-negative” breast cancer patients.Jpn J Cancer Res.2002,93(6):695-698 PMID:12079518
18.Ishida M,Kitamura K,Kinoshita J,et al.Detection of micrometastasis in the sentinel lymph nodes in breast cancer.Surgery,2002,131(1 Suppl):S211-216.PMID:11821813
19.Abdul-Rasool S,Kidson SH,Panieri E,et al.An evaluation of molecular markers for improved detection of breast cancer metastases in sentinel nodes.J Clin Pathol 2006,59(3):289-297 PMID:16505281
20.Chen SL,Hoehne FM,Giuliano AE.The Prognostic Significance of Micrometastases in Breast Cancer:A SEER Population-Based Analysis.Ann Surg Oncol.2007,14(12):3378-3384 PMID:17899293
21.Kuijt GP,Voogd AC,van de Poll-Franse LV,et al.The prognostic significance of axillary lymph-node micrometastases in breast cancer patients.Eur J Surg Oncol.2005,31(5):500-505 PMID:15922886
22.Fournier K,Schiller A,Perry RR,et al.Micrometastasis in the sentinel lymph node of breast cancer does not mandate completion axillary dissection.Ann Surg,2004,239:859-865 PMID:15166965
23.Gipponi M;Canavese G;Lionetto R;The role of axillary lymph node dissection in breast cancer patients with sentinel lymph node micrometastases.Eur J Surg Oncol,2006,32(2):143-147 PMID:16300921
24.Carcoforo P,Bergossi L,Basaglia E,et al.Prognostic and therapeutic impact of sentinel node micrometastasis in patients with invasive breast cancer.Tumori.2002,88(3):S4-5.PMID:12365385
25.Krauth JS;Charitansky H;Isaac S;et al.Clinical implications of axillary sentinel lymph node 'micrometastases' in breast cancer.Eur J Surg Oncol.2006,32(4):400-404 PMID:16504456
26.Noguchi M.Surgical Centre,Therapeutic relevance of breast cancer micrometastases in sentinel lymph nodes.Br J Surg.2002,89(12):1505-1515.PMID:12445058
27.Ryden L,Chebil G,Sjostrom L,et al.Determination of sentinel lymph node(SLN) status in primary breast cancer by prospective use of immunohistochemistry increases the rate of micrometastases and isolated tumour cells:analysis of 174 patients after SLN biopsy.Eur J Surg Oncol.2007,33(1):33-38 PMID:17174513
2.Mansel RE,et al.Randomized multicenter trial of sentinel node biopsy versus standeard axillary treastment in operable breast cancer:the ALMANAC Trial.J Natl Cancer Inst 98:599-609,2006
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5.Aihara T,Munakata S,Morino H,Takatsuka Y.Comparison of frozen section and touch imprint cytology for evaluation of sentinel lymph node metastasis in breast cancer.Ann Surg Oncol.2004 Aug;11(8):747-50.Epub 2004 Jul 12.
6.Motomura K,Inaji H,Komoike Y,et al.Intraoperative sentinel lymph node examination by imprint cytology and frozen sectioning during breast surgery.Br J Surg.2000 May;87(5):597-601.
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8.Motomura K,Inaji H,Komoike Y,et al.Intraoperative sentinel lymph node examination by imprint cytology and frozen sectioning during breast surgery.Br J Surg.2000 May;87(5):597-601.
9.Zgajnar J,Frkovic-Grazio S,Besic N,et al.Low sensitivity of the touch imprint cytology of the sentinel lymph node in breast cancer patients—results of a large series.J Surg Oncol.2004 Feb;85(2):82-6;discussion 87.
10.Menes TS,Tartter PI,Mizrachi H,et al.Touch preparation or frozen section for intraoperative detection of sentinel lymph node metastases from breast cancer.Ann Surg Oncol.2003 Dec;10(10):1166-70.
11.Celebioglu F,Sylvan M,Perbeck L,Bergkvist L,Frisell J.Intraoperative sentinel lymph node examination by frozen section,immunohistochemistry and imprint cytology during breast surgery-a prospective study.Eur J Cancer.2006 Mar;42(5):617-20.Epub 2006 Jan 30.
12.Creager A J,Geisinger KR.Intraoperative evaluation of sentinel lymph nodes for breast carcinoma:current methodologies.Adv Anat Pathol.2002 Jul;9(4):233-43.
13.Cserni G Effect of increasing the surface sampled by imprint cytology on the intraoperative assessment of axillary sentinel lymph nodes in breast cancer patients.Am Surg.2003 May;69(5):419-23.
14.Cserni G The potential value of intraoperative imprint cytology of axillary sentinel lymph nodes in breast cancer patients.Am Surg.2001 Jan;67(1):86-91.
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18.Zgajnar J,Frkovic-Grazio S,Besic N,et al.Low sensitivity of the touch imprint cytology of the sentinel lymph node in breast cancer patients-results of a large series.J Surg Oncol 2004;85:82-86.
19.Menes TS,Tartter PI,Mizrachi H,Smith SR,Estabrook A.Touch preparation or frozen section for intraoperative detection of sentinel lymph node metastases from breast cancer.Ann Surg Oncol 2003;10:1166-1170.
20.Cohen C,Alazraki N,Styblo T,Waldrop SM,Grant SF,Larsen T.Immunohistochemical evaluation of sentinel lymph nodes in breast carcinoma patients.Appl Immunohisto chem Mol Morphol 2002;10:296-303.
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22.Henry-Tillman RS,Korourian S,Rubio IT,Johnson AT,Mancino AT,Massol N et al. Intraoperative touch preparation for sentinel lymph node biopsy:a 4-year experience.Ann Surg Oncol 2002;9:333-339.
23.Motomura K,Inaji H,Komoike Y,Kasugai T,Nagumo S,Noguchi S et al.Intraoperative sentinel lymph node examination by imprint cytology and frozen sectioning during breast surgery.Br J Surg 2000;87:597-601.
24.Ratanawichitrasin A,Biscotti CV,Levy L,Crowe JP.Touch imprint cytological analysis of sentinel lymph nodes for detecting axillary metastases in patients with breast cancer.Br J Surg 1999;86:1346-1348.
25.Weaver DL.Sentinel lymph nodes and breast carcinoma:which micrometastases are clinically significant? Am J Surg Pathol.2003 Jun;27(6):842-5.
26.Tew K,Irwig L,Matthews A,Crowe P,Macaskill P.Meta-analysis of sentinel node imprint cytology in breast cancer.Br J Surg.2005 Sep;92(9):1068-80.
27.Martin RCG,Fey J,Yeung H,et al.Highest isotope count does not predict sentinel node positivity in all breast cancer patients.Ann Surg Oncol 2001;8:592-597
28.Leidenius MH,Krogerus LA,Toivonen TS,et al.The feasibility of intraoperative diagnosis of sentinel lymph node metastases in breast cancer.J Surg Oncol.2003 Oct;84(2):68-73.
29.Schueller G,Schueller-Weidekamm C,Helbich TH.Accuracy of ultrasound-guided,large-core needle breast biopsy.Eur Radiol.2008 Sep;18(9):1761-73.Epub 2008 Apr 15.
30.Tjan-Heijnen VC,Buit P,de Widt-Evert LM,et al.Micro-metastases in axillary lymph nodes:an increasing classification and treatment dilemma in breast cancer due to the introduction of the sentinel lymph node procedure.Breast Cancer Res Treat.2001,70(2):81-88
31.Celebioglu F,Sylvan M,Perbeck L,et al.Intraoperative sentinel lymph node examination by frozen section,immunohistochemistry and imprint cytology during breast surgery--a prospective study.Eur J Cancer.2006,42(5):617-620.
32.Ollila DB,Stitzenberg KB.Breast cancer sentinel node metastases:histopathologic detection and clinical significance.Cancer Control.2001,8(5):407-414
33.Zhang T,Zhang BN,Zhang HT,et al.Detection of micrometastases in sentinel lymph nodes of breast cancer.Zhonghua Zhong Liu Za Zhi.2007,29(2):116-118
34.Abdul-Rasool S,Kidson SH,Panieri E,et al.An evaluation of molecular markers for improved detection of breast cancer metastases in sentinel nodes.J Clin Pathol.2006,59(3):289-297
35.李金锋,张蕾,孙素莲等.利用逆转录酶聚合酶链反应及DNA印迹杂交技术检测乳腺癌腋窝淋巴结微转移.中华普通外科杂志,2001,16(3):164-167
36.Leers MP,Schoffelen RH,Hoop JG,Theunissen PH,Oosterhuis JW,vd Bijl H,Rahmy A,Tan W,Nap M.Multiparameter flow cytometry as a tool for the detection of micrometastatic tumour cells in the sentinel lymph node procedure of patients with breast cancer.J Clin Pathol.2002 May;55(5):359-66.
37.Cote RJ,Peterson HF,Chaiwun B,et al.Role of immunohistochemical detection of lymph-node metastases in management of breast cancer.International Breast Cancer Study Group.Lancet.1999,354(9182):896-900
38.Kahn HJ,Hanna WM,Chapman JA,et al.Biological significance of occult micrometastases in histologically negative axillary lymph nodes in breast cancer patients using the recent American Joint Committee on Cancer breast cancer staging system.Breast J.2006,12(4):294-301
39.Umekita Y,Ohi Y,Sagara Y,et al.Clinical significance of occult micrometastases in axillary lymph nodes in "node-negative" breast cancer patients.Jpn J Cancer Res.2002,93(6):695-698
40.Chen SL,Hoehne FM,Giuliano AE.The Prognostic Significance of Micrometastases in Breast Cancer:A SEER Population-Based Analysis.Ann Surg Oncol.2007,14(12):3378-3384
41.Kuijt GP,Voogd AC,van de Poll-Franse LV,et al.The prognostic significance of axillary lymph-node micrometastases in breast cancer patients.Eur J Surg Oncol.2005,31(5):500-505
42.张杰,沈坤炜,吴炅,陆劲松,刘邦令,周决,沈瑾,沈镇宙,邵志敏.乳腺癌前哨淋巴结及骨髓中微转移的联合检测.肿瘤学杂志,2002,8(6):328-331
43.Rosen PP,Saigo PE,Braun DW,et al.(1981) Prognosis in stage Ⅱ(T1N1M0) breast cancer.Ann Surg 194:576-584
44.McGuckin MA,Cummings MC,Walsh MD,et al.(1996) Occult axillary node metastases in breast cancer:their detection and prognostic signifi cance.Br J Cancer 73:88-95
45.Nasser IA,Lee AK,Bosari S,et al.(1993) Occult axillary lymph node metastases in "node-negative" breast carcinoma.Hum Pathol 24:950-957
46.Liu LH,et al.Evaluation of axillary sentinel lymph node biopsy by immunohistochemistry and multilevel sectioning in patients with breast carcinoma.Arch Pathol Lab Med 2000;124:1670-3
47.Schoenfeld A,Luqmani Y,Smith D,et al.(1994) Detection of breast cancer micrometastases in axillary lymph nodes by using polymerase chain reaction.Cancer Res 54:2986-2990
48.Wada N,Imoto S.Clinical evidence of breast cancer micrometastasis in the era of sentinel node biopsy.Int J Clin Oncol.2008 Feb;13(1):24-32.Epub 2008 Feb 29.49.Schoenfeld A,Luqmani Y,Smith D,et al.(1994) Detection of breast cancer micrometastases in axillary lymph nodes by using polymerase chain reaction.Cancer Res 54:2986-2990
50.Van der Velde-Zimmermann D,Roijers JF,Bouwens-Rombouts A,et al.(1996) Molecular test for the detection of tumor cells in blood and sentinel nodes of melanoma patients.Am J Pathol 149:759-764
51.Shivers SC,Wang X,Li W,et al.(1998) Molecular staging of malignant melanoma:correlation with clinical outcome.JAMA 280:1410-1415
52.Hatta N,Fujimoto A,Takehara K,et al.(1999) Mapping of occult melanoma micrometastases in the inguinal lymph node basin by immunohistochemistry and RT-PCR.Melanoma Res 9:401-406
53.Bieligk SC,Ghossein R,Bhattacharya S,et al.(1999) Detection of tyrosinase mRNA by reverse transcription-polymerase chain reaction in melanoma sentinel nodes.Ann Surg Oncol 6:232-240
54.Blaheta HJ,Schittek B,Breuninger H,et al.(1999) Detection of melanoma micrometastasis in sentinel nodes by reverse transcription-polymerase chain reaction correlates with tumor thickness and is predictive of micrometastatic disease in the lymph node basin.Am J Surg Pathol 23:822-828
1.Tjan-Heijnen VC,Buit P,de Widt-Evert LM,et al.Micro-metastases in axillary lymph nodes:an increasing classification and treatment dilemma in breast cancer due to the introduction of the sentinel lymph node procedure.Breast Cancer Res Treat.2001,70(2):81-88 PMID:11768607
2.Brogi E,Torres-Matundan E,Tan LK,et al.The results of frozen section,touch preparation,and cytological smear are comparable for intraoperative examination of sentinel lymph nodes:a study in 133 breast cancer patients.Ann Surg Oncol.2005,12(2):173-180 PMID:15827799
3.Veronesi U,Paganelli G,Galimberti V,et al.Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes.Lancet.1997,349(9069):1864-1867 PMID:9217757
4.Celebioglu F,Sylvan M,Perbeck L,et al.Intraoperative sentinel lymph node examination by frozen section,immunohistochemistry and imprint cytology during breast surgery—a prospective study.Eur J Cancer.2006,42(5):617-620 PMID:16446084
5.Ratanawichitrasin A,Biscotti CV,Levy L,et al.Touch imprint cytological analysis of sentinel lymph nodes for detecting axillary metastases in patients with breast cancer.Br J Surg.1999,86(10):1346-1348 PMID:10540148
6.Ollila DB,Stitzenberg KB.Breast cancer sentinel node metastases:histopathologic detection and clinical significance.Cancer Control.2001, 8(5):407-414 PMID:11579336
7.Diel IJ,Kaufmann M,Goerner R,et al.Detection of tumor cells in bone marrow of patients with primary breast cancer:a prognostic factor for distant metastasis.J Clin Oncol.1992,10(10):1534-1539 PMID:1403032
8.Zhang T,Zhang BN,Zhang HT,et al.Detection of micrometastases in sentinel lymph nodes of breast cancer.Zhonghua Zhong Liu Za Zhi.2007,29(2):116-118 PMID:17645847
9.Abdul-Rasool S,Kidson SH,Panieri E,et al.An evaluation of molecular markers for improved detection of breast cancer metastases in sentinel nodes.J Clin Pathol.2006,59(3):289-297 PMID:16505281
10.李金锋,张蕾,孙素莲等.利用逆转录酶聚合酶链反应及DNA印迹杂交技术检测乳腺癌腋窝淋巴结微转移.中华普通外科杂志,2001,16(3):164-167
11.Blumencranz P,Whitworth PW,Deck K,et al.Sentinel node staging for breast cancer:intraoperative molecular pathology overcomes conventional histologic sampling errors.Am J Surg.2007,194(4):426-432 PMID:17826050
12.Rostagno P,Moll JL,Bisconte JC,et al.Detection of rare circulating breast cancer cells by filtration cytometry and identification by DNA content:sensitivity in an experimental model.Anticancer Res.1997,17(4A):2481-2485 PMID:9252667
13.Leers MPG,Schoffelen R,Hoop JGM,et al.Multiparameter flow cytometry as a tool for the detection of micrometastatic of tumor cells in the sentinel lymph node procedure of patients with breast cancer.J Clin Pathol.2002,55(5):359-366.PMID:11986342
14.Cote RJ,Peterson HF,Chaiwun B,et al.Role of immunohistochemical detection of lymph-node metastases in management of breast cancer.International Breast Cancer Study Group.Lancet.1999,354(9182):896-900PMID:10489948
15.Dowlatshahi K,Fan M,Bloom KJ,et al.Occult metastases in the sentinel lymph nodes of patients with early stage breast carcinoma:A preliminary study.Cancer.1999,86(6):990-996 PMID:10491525
16.Kahn HJ,Hanna WM,Chapman JA,et al.Biological significance of occult micrometastases in histologically negative axillary lymph nodes in breast cancer patients using the recent American Joint Committee on Cancer breast cancer staging system.Breast J.2006,12(4):294-301 PMID:16848838
17.Umekita Y,Ohi Y,Sagara Y,et al.Clinical significance of occult micrometastases in axillary lymph nodes in “node-negative” breast cancer patients.Jpn J Cancer Res.2002,93(6):695-698 PMID:12079518
18.Ishida M,Kitamura K,Kinoshita J,et al.Detection of micrometastasis in the sentinel lymph nodes in breast cancer.Surgery,2002,131(1 Suppl):S211-216.PMID:11821813
19.Abdul-Rasool S,Kidson SH,Panieri E,et al.An evaluation of molecular markers for improved detection of breast cancer metastases in sentinel nodes.J Clin Pathol 2006,59(3):289-297 PMID:16505281
20.Chen SL,Hoehne FM,Giuliano AE.The Prognostic Significance of Micrometastases in Breast Cancer:A SEER Population-Based Analysis.Ann Surg Oncol.2007,14(12):3378-3384 PMID:17899293
21.Kuijt GP,Voogd AC,van de Poll-Franse LV,et al.The prognostic significance of axillary lymph-node micrometastases in breast cancer patients.Eur J Surg Oncol.2005,31(5):500-505 PMID:15922886
22.Fournier K,Schiller A,Perry RR,et al.Micrometastasis in the sentinel lymph node of breast cancer does not mandate completion axillary dissection.Ann Surg,2004,239:859-865 PMID:15166965
23.Gipponi M;Canavese G;Lionetto R;The role of axillary lymph node dissection in breast cancer patients with sentinel lymph node micrometastases.Eur J Surg Oncol,2006,32(2):143-147 PMID:16300921
24.Carcoforo P,Bergossi L,Basaglia E,et al.Prognostic and therapeutic impact of sentinel node micrometastasis in patients with invasive breast cancer.Tumori.2002,88(3):S4-5.PMID:12365385
25.Krauth JS;Charitansky H;Isaac S;et al.Clinical implications of axillary sentinel lymph node 'micrometastases' in breast cancer.Eur J Surg Oncol.2006,32(4):400-404 PMID:16504456
26.Noguchi M.Surgical Centre,Therapeutic relevance of breast cancer micrometastases in sentinel lymph nodes.Br J Surg.2002,89(12):1505-1515.PMID:12445058
27.Ryden L,Chebil G,Sjostrom L,et al.Determination of sentinel lymph node(SLN) status in primary breast cancer by prospective use of immunohistochemistry increases the rate of micrometastases and isolated tumour cells:analysis of 174 patients after SLN biopsy.Eur J Surg Oncol.2007,33(1):33-38 PMID:17174513