Clinical Research Of Sentinel Lymph Node Biopsy And Metastases In Breast Cancer

Axillary lymph node dissection which is a key component of modified radical mastectomy, providing axillary lymph node staging and status, is important for the formulation of postoperative treatment plan and evaluation of prognosis. However, because of big trauma, ALND is easy to cause intractable upper limb lymph edema, sensory dysfunction and psychological trauma and other complications of ALND. With the progress of breast cancer research, the case-finding rate of early breast cancer was significantly increased. In fact, approximately 70% of early breast cancer patients is not find local lymph node involved at the time of surgery. Incomplete statistics showd that of 58 clinical axillary lymph node negative palpation of breast cancer patients,only 20.68% of them were pathological lymph node positive at last. From here we see that most breast cancer patients need not receive ALND.Sentinel lymph node is the first lymph node receiving lymphatic drainage and lymph node metastasis of primary tumor, the histological status can indicate the status of other region lymph nodes. Comparing with the axillary lymph node, the number of SLN is little, so SLN can predict the metastasis status of axillary lymph node of breast cancer more accurately.Long term follow-up of NSABP B-32 clinical trial results have shown that, for patients with negative sentinel lymph node biopsy, further axillary dissection does not improve patient survival.Theoretically, the SLN pathological negative person may avoid the ALND, the axillary recurrence rate is low. There are two main types of tracer for sentinel lymph node biopsy in breast cancer. In 2011, China anticancer association clearly pointed out that breast cancer SLNB tracers including blue dye and radioisotope marker, recommended preferred combination of blue dye and radioisotope tracer, SLNB improve success rate and reduce the false negative rate.After a rigorous learning curve and skilled operation, you can use a single blue dye or radionuclide tracer. Methylene blue tracer has been recognized as an effective method for tracing SLN of breast cancer.Methylene blue method does not need special equipment, simple, security, blue stained lymph node at a glance, easy popularization and is suitable for work in different hospitals, but also suitable for all kinds of patients, no clear contraindication.The diagnosis of SLN includes intraoperative and postoperative diagnosis. Intraoperative SLN biopsy can rapidly and accurately help surgeons judging the SLN metastasis. If intraoperative SLN is positive, immediate ALND can ben carried out, avoiding reoperation. So, the intraoperative diagnosis of ALND is extremly important.But the accuracy of SLN intraoperative diagnosis is low, and the standard method of rapid diagnosis is still lacking. The afteroperative diagnostic results of SLN were also uncertain, due to the high false negative rate of SLNB which caused by the difficulty of SLN micro metastasis diagnosis, and the result is not stable.Conventional pathological detection of SLN easily missed some part of the micro metastasis, with a high false negative rate, limiting the clinical application of SLNB So at present, there are some controversies on the optimal tracer of SLNA, detection standards and detection methods of SLN micro metastasis in breast cancer. This topic analyzes and discusses the above problems.Part 1 Methylene blue dye to sentinel lymph node biopsy in breast cancerObjective:To investigate the clinical value of sentinel lymph node biopsy using the methylene blue dye tracer and sentinel lymph node biopsy of breast cancer (SLN) in breast cancer surgery.Method:Of the 170 breast cancer patients with clinically negative axillary lymph nodes undergoing modified radical mastectomy, injection positioning was finished with 4ml 0.5% methylene blue near the areola and/or the mass. Intraoperative SLN biopsy and paraffin section routine pathological examination were carried out. Serial section was done in the negative SLN to detecte the micrometastasis.Routine axillary lymph node dissection was also completed. The detection rate, accuracy, sensitivity and false negative rate of methylene blue tracer method of SLNB were calculated through comparing the pathologic results of SLN with and non SLN pathological results. The detection rate and the corresponding clinical pathological parameters of the patients were analyzed, and the possible factors which affecting the detection rate were analyzed.Results:157 cases of patient SLN were successfully detected in 170, the detection rate was 92.35%(157/170); the false negative rate was 14.5%(9/62); the accuracy rate was 94.3%(148/157); the sensitivity was 85.5%(53/62). SLN micrometastasis rate was 22.2%using series section in negative SLN (2/9), the false negative rate of SLN serial sections was 11.3%(7/62).Using periareolar injection, detection rate of SLN (85.7%) in breast primary malignant tumors which located in the outer quadrant group was significantly lower than that of the non-outer upper quadrant group (96.6%). In 130 cases of periareolar injection group, detection rate of SLN was 93.0%; in 40 cases of injection group of perimass, detection rate of SLN was 90.0%, the difference was not significant.121 cases of SLNB were succed in periareolar injection group,43 cases of SLN was positive,7 cases of SLN negative and 7 cases were false negative and false negative rate was 14.0%; 36 cases of SLNB were succed in peri-mass injection group,10 cases of SLN were positive,2 cases of SLN negative,2 cases of false negative and false negative rate (16.7%), the difference was not significant (P> 0.05).When SLN was only 1, the false negative rate was as high as 16.7%, and when more than 4, the false negative rate was significantly lower(10%) and the difference was significant (P<0.05). The detection rate and false negative rate of SLNB were not significantly correlated with the age, stage, receptor status, histological grade and clinical pathological parameters of the patients with or without vascular invasion.Conclusion:Methylene blue tracer is safe and reliable in SLNB of breast cancer; According to the results of breast cancer SLNB with methylene blue tracer, we can decide whether the ALND is neede. However, high false negative rate of HE staining SLN pathology detection may limit SLNB in clinical routine application; the detection rate and false negative rate of SLNB were not affected by differrent injection site, but combination of two position or near mass injection was recommended for the mass which was located in upper outer quadrant.Part 2Frozen sections of sentinel lymph node biopsy in breast cancerObjective We aimed to investigate the clinical value for intraoperative rapid frozen section of sentinel lymph node for breast cancer.Methods Sixty-seven inpatients who diagnosed as breast cancer had been performed sentinel lymph node staining with methylene blue and dissection biopsy of sentinel lymph node successfully. Intraoperative rapid frozen sections were for all sentinel lymph nodes and the pathological results of frozen sections were recorded according to monolayer slice, trilaminar slice and six-layer slice respectively. The gold standard for evaluating the accuracy of rapid frozen sections was defined as routine paraffin sections. The sensitivity, specifity, coincidence rate of rapid frozen slices with three kinds of different layers were calculated and compared statistically.Results Sixty-seven inpatients were detected sentinel lymph nodes stained by methylene blue among seventy inpatients(67/70,95.7%).A total of 1,608 axillary lymph nodes was dissected and these 67 inpatients had an average of 21 axillary lymph nodes. The number of sentinel lymph nodes by dissection biopsy were 174 and the mean amount was 2.2 for per inpatient. Twenty-two inpatients were checked out positive axillary lymph nodes by routine paraffin sections among 67 inpatients(32.8%,22/67),but the positive rate of sentinel lymph nodes was 86.4%(19/22) by postoperative routine paraffin sections. By intraoperative rapid frozen sections, the positive rate of sentinel lymph nodes for monolayer slice, trilaminar slice and six-layer slice were 5.9%(4/67),10.4%(7/67),26.7%(18/67) respectively. Compared with postoperative routine paraffin sections of sentinel lymph nodes, the sensitivity, specifity, coincidence rate by intraoperative rapid frozen sections for monolayer slice were 21.1%(4/19),100%(45/45),73.1%(49/67) respectively, and for trilaminar slice were 31.6%(6/19),97.8%(44/45),76.1%(51/67) respectively, and for six-layer slice were 84.2%(16/19),95.6%(43/45),91.1%(61/67) respectively. The coincidence rate of six-layer slice showed higher than that of monolayer slice and trilaminar slice statistically,but it was no statistical difference between monolayer slice and trilaminar slice.Conclusions The result of intraoperative rapid frozen sections of sentinel lymph node for breast cancer presented high conformity to the report of postoperative routine paraffin sections. Six-layer rapid frozen slices of sentinel lymph node based on methylene blue by intradermal injection around arealo could increase the intraoperative diagnostic accuracy and could guide surgeons how to manage sentinel lymph nodes, so it was an effective, precise,cheap and easy method and deserved popularization in clinic.Part3 Clinical research of postoperative molecular assessment of sentinel lymph node in breast cancerObjective:To investigate the diagnostic value of quantum dots-immunohistochemistry (QDs-IHC) staining in detecting sentinel lymph nodes metastases or micrometastasis(positive SLNs) of breast cancer.Methods:Forty-five breast cancer patients underwent sentinel lymph node biopsy (SLNB). Immunohistochemistry and QDs-IHC were done to detect SLNs by testing the expressions of cytokerain-19 (CK19) and Her-2 status, and then the detection results were compared with the results of pathological biopsy. Chi-square test was used for statistical analysis.Results:SLNB was successful for the 45 breast cancer patients.Eighteen cases showed positive SLNs including 3 cases with SLN micrometastasis.The positivity rate was 40%(18/45) in total. The sensitivity rate of IHC was 88.9%(16/18),but was 94.4%(17/18) by QDs-IHC.Both of the two methods showed no significant advantage in detection of patients with positive SLNs(p>0.05). A total of 121 SLNs were resected for SLNB.Thirty-six positive SLNs were diagnosed. IHC detected 26 positive SLNs and the sensitivity was 72.2%.While QDs-IHC detected 33 positive SLNs, the sensitivity was 91.6%, QDs-IHC showed significantly advantage in detecting positive SLNs (p<0.05).There was no significant correlation between the SLNs metastases and age, tumor stage, histological grade,hormone receptor status and Her-2 status(p>0.05).Conclusion:The same application value was found between QDs-IHC and IHC. QDs-IHC double-labeling immunofluorescence detected co-location of two proteins simultaneously,which could obtain traces of protein and increased the detection rate of SLNs metastases.