子宫恶性肿瘤前哨淋巴结检测76例临床分析

摘要

目的 探讨前哨淋巴结(SLN)检测在子宫恶性肿瘤患者中应用的可行性及临床价值.方法 收集北京大学人民医院自2015年7月至2016年9月行手术治疗的子宫恶性肿瘤患者76例,其中早期(Ⅰa1~Ⅱa期)子宫颈癌39例、子宫内膜癌37例,术前分别将不同的SLN示踪剂[纳米炭、吲哚菁绿(ICG)、纳米炭联合ICG]注射至患者子宫颈的4个部位(纳米炭注射于子宫颈3、6、9、12点,ICG注射于子宫颈2、4、8、10点),术中观察并切除示踪的SLN,再根据美国国立综合癌症网络(NCCN)指南进一步行系统淋巴清扫及子宫切除术.术后经病理检查判断SLN及盆腔淋巴结转移情况,并计算SLN的检出率以及SLN检测的敏感度和阴性预测值.结果 (1)76例患者的SLN总检出率为95%(72/76),双侧检出率为74%(56/76).ICG、纳米炭、纳米炭联合ICG 3种示踪方法的SLN总检出率分别为91%(48/53)、85%(57/67)、98%(43/44),纳米炭联合ICG的SLN双侧检出率显著高于单独示踪法(P<0.05).子宫颈癌及子宫内膜癌的SLN总检出率分别为95%(37/39)、95%(35/37),两者比较,差异无统计学意义(P>0.05).(2)子宫颈癌的SLN主要位于闭孔淋巴结(32.4%,115/355)和髂外淋巴结(32.1%,114/355),子宫内膜癌的SLN主要位于髂外淋巴结(41.2%,91/221)和闭孔淋巴结(39.4%,87/221).(3)76例患者中,55例行系统腹膜后淋巴清扫术.这55例患者SLN检测的敏感度为75%,阴性预测值为96%;其中38例双侧检出SLN,其敏感度为100%,阴性预测值为100%.结论 子宫恶性肿瘤使用纳米炭联合ICG示踪的SLN检出率高于单独示踪法.子宫颈癌与子宫内膜癌的SLN主要位于髂外和闭孔淋巴结区域.SLN检测的敏感度及阴性预测值均较高,有一定的临床应用前景.%Objective To evaluate the feasibility and clinical value of identifying sentinel lymph node (SLN) and to assess possible factors associated with detection rate in both cervical cancer and endometrial cancer. Methods Retrospective study of 76 cases (39 with cervical cancer and 37 with endometrial cancer) were conducted in Peking University People′s Hospital. All patients underwent SLN biopsy with tracers of indocyanine green (ICG) and (or) carbon nanoparticles. All mapped SLN was resected and followed by procedures that systematic pelvic lymphadenectomy and hysterectomy according to National Comprehensive Cancer Network (NCCN) guidelines. All the lymph nodes were examined postoperatively for the routine paraffin section of hematoxylin and eosin (HE) staining. Detection rate, sensitivity and negative predictive value of SLN were calculated and factors associated with the detection rate were analyzed. Results The overall detection rate was 95%(72/76), with 74%(56/76) positive bilaterally. The bilateral detection rate of SLN with combined technique was significantly higher than that with single technique (P<0.05). The difference of SLN detection rate between cervical and endometrial cancer patients were not significant (P>0.05). SLN were mostly recognized in obturator (32.1%, 114/355) and external iliac areas (32.4%, 115/355) in cervical cancer, and in external iliac (41.2%, 91/221) and obturator areas (39.4%, 87/221) in endometrial cancer. Among 55 patients underwent systematic pelvic lymphadenectomy, the sensitivity of SLN detection was 75% and the negative predictive value was 96%. The sensitivity and negative predictive value were both 100% in patients with successfully bilateral mapped of SLN. Conclusions The overall detection rate of SLN in cervical and endometrial cancer is the highest with the combined technique of ICG and carbon nanoparticles. The detection rate and located regions of SLN are similar between cervical and endometrial cancer,and SLN are mostly recognized in the external iliac and obturator areas. The sensitivity and negative predictive value of SLN detection are high, especially when SLN are bilateral mapped.