암 수술시 Sentinel Lymph Node 의 임상적 유용성

임채춘(Chae Chun Rhim),황성진(Seong Jin Hwang),박종섭(Jong Sup Park),남궁성은(Sung Eun Namkoong) 대한산부인과학회 2002 Obstetrics & Gynecology Science Vol.45 No.6

목적 : 이 연구의 목적은 외음부 암 환자의 수술시 sentinel lymph node를 탐색하고 동결절편의 조직병리학적 결과를 통해 수술을 최소화 할 수 있는지에 대한 임상적 적용가능성을 평가하는 데 있다. 연구 대상 및 방법 : 2001년 3월부터 2002년 1월까지 가톨릭대학교 강남성모병원에서 외음부 암 확진 후 근치적 외음부 절제술 및 일측 또는 양측 서혜 대퇴부 임파절 절제술을 시행한 4명의 환자를 대상으로 하였으며, 수술전 technetium-99 m colloid albumin의 주입과 수술중 isosulfan blue dye를 주사한 후 sentinel lymph node를 찾아낸 뒤 이를 임상병리과에 보내고 그 동결생검 결과를 얻는다. 결과 : 4명의 환자에서 총 10개의 sentinel lymph node와 110개의 non-sentinel lymph node를 얻었다. 동결생검 결과 10개의 sentinel lymph node는 모두 음성 (benign)이었고 sentinel lymph node가 음성일 때 영구 조직검사 결과가 양성 (malignant)으로 나온 경우는 없었다. 결론 : 외음부 암 환자에서 sentinel lymph node를 찾아 이를 제거한 후, 동결절편의 조직병리학적 결과가 음성 (benign)일 경우에는 더 이상의 광범위한 서혜 대퇴부 임파 절제술을 피함으로써, 수술 후 합병증을 최소화하고 삶의 질을 향상시키는 데 임상적 유용성이 있을 것으로 생각된다. Objective : The purpose of this study is to evaluate the validity of sentinel lymph node detection and the possibility of clinical application in treatment of vulvar cancer patients. Patients and Methods : From March 2001 to January 2002, four patients with vulvar cancer were eligible for this study. All the patients were preoperative technetium-99 m colloid albumin and intraoperative isosulfan blue dye injection intradermally at the junction of tumor mass and normal skin. Superficial lymphatic channels and groin lymph node dissections were made to detect sentinel lymph node and then complete inguinofemoral lymph nodes dissection was performed. All the sentinel lymph nodes were sent to pathologic department for frozen biopsy. Results : Ten sentinel lymph nodes were identified in one-hundred and ten groin lymph nodes. All the ten sentinel lymph nodes showed benign. There was no case that non-sentinel lymph nodes were positive in the presence of negative sentinel lymph nodes by frozen biopsy (negative predictive value was 100%). Conclusion : Sentinel lymph nodes detection by combination use of technetium-99 m colloid albumin and isosulfan blue dye injection was simple and accurate in our preliminary study. To reduce postoperative morbidity, lymphedema and to minimize extensive inguinofemoral lymph nodes dissection, sentinel lymph node frozen biopsy may be a reasonable alternatives and a suitable method for limited control of vulvar cancer. This preliminary study showed the possibility of clinical application of sentinel lymph node detection in vulvar cancer surgery.

결장직장암에서 체외 감시림프절의 의의

김형진,이인규,이윤석,강원경,안창혁,오승택 대한대장항문학회 2008 Annals of Coloproctolgy Vol.24 No.1

The presence of lymph-node metastases is one of the most important prognostic factors for patients with a colorectal carcinoma. The sentinel lymph node is the first lymph node that receives afferent lymphatic drainage from a primary tumor, and thus has the highest risk of harboring metastatic disease. Methods: Twenty- eight patients with an adenocarcinoma of the colon or the rectum were investigated. After resection of the specimen in standard oncologic fashion, the specimen was dissected longitudinally along the antimesenteric border, and methylene blue was injected around the tumor submucosally. After 5 minutes, the mesentery was meticulously examined, and blue-stained lymphatics and lymph nodes were carefully dissected and harvested. Results: Sentinel lymph nodes were identified in all cases. The average number of sentinel nodes identified was 3 (range, 1∼6), and the average number of lymph nodes retrieved was 20.8 (range, 6∼42). Of the fifteen patients (53.6%) identified to be positive for lymph-node metastasis 10 showed nonsentinel nodal metastasis without sentinel nodal involvement. No additional isolated tumor cells were found by immunohistochemical staining in 13 patients who had no lymph-node metastasis on conventional pathologic examination. Conclusions: In colorectal cancer, the sentinel-lymph-node sampling method is easy and can be performed for the purpose of finding lymph nodes easily. However, applying the sentinel-lymph-node sampling method for the purpose of minimizing lymph node dissection, as in breast cancer, is not recommended because of the high probability of missing metastasis.

Lymphoscintigraphy와 Gamma-probe를 이용한 악성흑색종의 전초 림프절 생검 및 병기결정

김홍석 ( Kim Hong Seok ),송기훈 ( Song Ki Hoon ),심승주 ( Sim Seung Joo ),강도영 ( Kang Do Yeong ),김기호 ( Kim Ki Ho ) 대한피부과학회 2003 대한피부과학회지 Vol.41 No.12

N/A Background: In malignant melanoma, the regional nodal status is acknowledged as the most powerful indicator of prognosis. Sentinel lymph node status was formally adopted in 2002 AJCC melanoma staging system. However, there has been no clinical study on sentinel lymph node evaluation, especially using lymphoscintigraphy and gamma probe in melanoma patients in Korea. Objective: Our purpose was to assess the usefulness of lymphoscintigraphy and intraoperative gamma probe for the detection of sentinel lymph node in melanoma patients. Methods: In eight malignant melanoma patients (7 stage Ⅰ/Ⅱ, 1 stage 3), a lymphoscintigraphy with ^99m Tc-radiocolloids were injected peritumoral area and the identified first lymph node was considered to be a sentinel node. Once the sentinel lymph node was identified using a hand-held gamma probe for intraoperative mapping, it was excised. And the sentinel node was examined by routine hematoxylin-eosin and immunohistochemical stain (HMB45, S-100). Results: Sentinel nodes were identified in 8 patients all using lymphoscintigraphy and intraope-rative gamma probe. Nine sentinel nodes were found in 8 patients, and sentinel lymph node biopsies showed micrometases in 5(55.5%). The location of sentinel nodes was that 3(33.3%) were located in axilla, and 6(66.6%) in grion. The case that had melanoma on back revealed dual lymphatic pathway with 2 sentinel nodes on axilla and inguinal area. Conclusions: We conclude that preoperative lymphoscintigraphy and intraoperative gamma-probe guided sentinel lymph node biopsy is useful for acute staging and prediction of prognosis for melanoma patients. (Korean J Dermatol 2003;41(12):1575~1582)

수술 전 항암화학요법 후 임상적으로 림프절 음성인 환자에서 감시림프절 생검

한세환 한국유방암학회 2007 Journal of breast cancer Vol.10 No.4

Purpose: We wanted to evaluate the accuracy of sentinel lymph node biopsy (SLNB) in patients with clinically negative lymph node after neoadjuvant chemotherapy. Methods: Fifty-nine women underwent 4 cycles of neoadjuvant chemotherapy with epirubicin (75mg/m2) plus docetaxel (75mg/m2), or with doxorubicin (50mg/m2), cyclophosphamide (600mg/m2)and 5-fluorouracil (500mg/m2) for their primary breast cancer. Their median age was 41 years (range: 29-62) and all the tumors were larger than 3 cm in maximum diameter. SLNB was performed 3 min after periareolar injection of 1% isosulfan blue dye. All the patients underwent lymph node dissection at the level 1 and 2 axillary areas irrespective of their nodal status. Results: A clinical response after neoadjuvant chemotherapy was observed in 46 patients (88%) and 11 (18.7%) patients had a complete pathologic response. Thirty-five patients (62.7%) underwent breast conserving surgery. The sentinel lymph node was identified in 96.6% and the median number of sentinel nodes was 3 (range: 1-6). The median number of dissected nodes was 14 (range: 11-47). Metastasis to the lymph node was observed in 56% of the patients. The sentinel lymph node was the only metastatic node in 12 patients. Three patients with a negative sentinel lymph node were confirmed to have metastasis to non-sentinel nodes after the final histologic examination (false negative rate: 9.1%). The overall accuracy of SLNB was 94.7%. Conclusion: SLNB after neoadjuvant chemotherapy was a safe method in patients with clinically negative lymph node.

감시림프절 생검을 이용한 악성흑색종의 치험례

오동석,노태석,유원민,박철,박병윤 대한성형외과학회 2003 Archives of Plastic Surgery Vol.30 No.5

The single most powerful prognostic factor in malignant melanoma is the status of the regional lymph node metastases. The surgical excision of involved node is the most effective treatment for local disease control. Surgical management of malignant melanoma has been the therapeutic value of elective lymph node dissection in the clinically node-negative individual. However, more recent prospective randomized trials have failed to demonstrate an overall survival benefit for patients undergoing prophylactic elective lymph node dissection.The histologic status of the sentinel lymph node reflects the status of the total nodal basin. Therefore the status of the regional lymph node metastases was confirmed by the sentinel lymph node biopsy in malignant melanoma without lymphedema and nerve injury in the patients undergoing elective lymph node dissection. In this case, we performed sentinel lymph node biopsy using lymphoscintigram and radioactive materials and confirmed no evidence of regional lymph node metastases. After wide excision of the primary tumor, the soft tissue defect with bone exposure on the heel was reconstructed with skin-grafted muscle free flap. There is no evidence of recurrence or distant metastases in this patient 1 year after excision.

Sentinel Node Mapping of VX2 Carcinoma in Rabbit Thigh with CT Lymphography Using Ethiodized Oil

이윤진,김영훈,이경호,박지훈,이혜승,정승채,주승문 대한영상의학회 2014 Korean Journal of Radiology Vol.15 No.1

Objective: To assess the feasibility of computed tomography (CT) lymphography using ethiodized oil for sentinel node mapping in experimentally induced VX2 carcinoma in the rabbit thigh. Materials and Methods: This experiment received approval from the institutional animal use and care administrative advisory committee. Twenty-three rabbits with VX2 carcinoma in the thigh underwent CT before and after (1 hour, 2 hour) peritumoral injection of 2 mL ethiodized oil. After the CT examination, sentinel nodes were identified by peritumoral injection of methylene blue and subsequently removed. The retrieved sentinel and non-sentinel lymph nodes were investigated with radiographic and pathologic examinations. Based on the comparison of CT findings with those of radiographic and pathologic examinations, the diagnostic performance of CT for sentinel node identification was assessed. Results: All 23 rabbits showed 53 ethiodized oil retention nodes on post-injection CT and specimen radiography, and 52 methylene blue-stained nodes at the right femoroiliac area. Of the 52 blue-stained sentinel nodes, 50 nodes demonstrated ethiodized oil retention. Thus, the sentinel node detection rate of CT was 96% (50 of 52). On pathologic examination, 28 sentinel nodes in 17 rabbits (nodes/rabbit, mean ± standard deviation, 1.7 ± 0.6) harbored metastasis. Twenty seven of the 28 metastatic sentinel nodes were found to have ethiodized oil retention. Conclusion: Computed tomography lymphography using ethiodized oil may be feasible for sentinel node mapping in experimentally induced VX2 carcinoma in the rabbit thigh.

Optimized Criteria for Sentinel Lymph Node Biopsy in Patients with Clinically Node Negative Breast Cancer

Jeong Suk Kim,Moo Hyun Lee,Sun Hee Kang,Jihyoung Cho 한국유방암학회 2021 Journal of Breast Disease Vol.9 No.1

Purpose: Sentinel lymph node biopsy (SLNB) is a well-established staging procedure for patients with early breast cancer who have clinically negative axillary lymph node. However, no consensus exists about the number of sentinel lymph nodes (SLN) that should be removed based on radioactivity counts in breast cancer. We reviewed and analyzed cases in which more than one SLN was detected and there was at least one pathologically positive node. Methods: We retrospectively studied breast cancer patients who underwent lymphoscintigraphy with injection of a radioactive colloid and SLNB along with intraoperative determination of radioactive counts of lymph nodes using a gamma probe between 2006 and 2018. In total 326 patients with more than one radioactive SLN were enrolled in this study. Results: Fifty-four patients had nodal metastases, of whom 46 (85.2%) had metastases in the hottest lymph node. All metastatic SLNs were identified as one of the first three lymph nodes dissected. The lowest radioactive count of a positive SLN corresponded to 10% of that of the hottest node. Conclusion: We suggest that removal of the first three lymph nodes or nodes covered by the “10% rule” is sufficient in SLNB for patients with breast cancer.

유방암 환자에서 전신 뼈 검사 후 감시림프절 위치 파악 검사의 유용성

장동근,반영각,정석,박훈희,강천구,임한상,김재삼,이창호,Jang, Dong-Gun,Bahn, Young-Kag,Chung, Seok,Park, Hoon-Hee,Kang, Chun-Goo,Lim, Han-Sang,Kim, Jae-Sam,Lee, Chang-Ho 대한핵의학기술학회 2010 핵의학 기술 Vol.14 No.2

유방암은 다른 장기에 비하여 뼈 전이와 임파절 전이가 잘 일어나는 질환으로 알려져 있으며, 유방암 수술 전, 후로 핵의학 검사인 전신 뼈 검사와 감시림프절 검사가 많이 시행되고 있다. 감시림프절 위치 파악 검사는 감시림프절에 정확 위치를 파악을 위해 시행되며, 유방암 수술 시 감시림프절을 파악 하는데 중요한 정보를 제공해 주게 된다. 본 연구에서는 감시림프절 위치 파악 검사 시 해부학적인 위치정보를 좀 더 명확하게 하기 위해 감시림프절 위치 파악 검사 전날 전신 뼈 검사를 시행하여 기존에 Flood 선원을 이용한 방법과 비교 평가하여 영상의 유용성에대해 알아보고자 하였다. 2009년 1월부터 12월까지 본원에서 전신 뼈 검사와 감시 림프절 검사를 2일에 걸쳐 시행한 환자 22명(평균나이 $52{\pm}7.2$세)을 대상으로 하였고, 대조군으로는 $^{57}Co$ flood phantom을 이용하여 감시림프절에 위치를 파악한 환자 22명(평균나이 $57{\pm}6.5$세)을 대상으로 하였다. 정량적인 분석 방법으로 전신 뼈 검사 후에 감시림프절 검사를 시행한 영상에 감시림프절과 배후방사능에 관심영역을 그려 상대적 비율을 측정하였으며, 육안적인 분석 방법으로 전신 뼈 검사 후 감시림프절 검사를 진행한 영상과 $^{57}Co$ flood phantom을 이용한 영상을 핵의학과 전문의와 5년 이상의 실무경험을 가진 방사선사가 각각 5점 척도로 하여, Blind test하였다. 정량적인 분석 결과 감시림프절에 대해 배후방사능이 미치는 영향은 전면상에서 최대 14.2:1, 평균 8:1(SD${\pm}$3.48), 측면상에서 최대 14.7:1, 평균 8.5:1(SD${\pm}$3.42)값으로 감시림프절에 대해 배후방사능에 차이가 크게 나타났고, 전면상과 측면상에서도 큰 차이가 없었다. 육안적인 분석 결과 $^{57}Co$ flood phantom 영상과 뼈가 포함된 영상을 비교한 결과 $^{57}Co$ flood phantom 영상 $3.86{\pm}0.35$점, 뼈 영상이 $4.09{\pm}0.42$점으로 $^{57}Co$ flood phantom 영상 보다 높은 점수를 나타내었다. 감시림프절 위치 파악 검사에 경우 검사 전날 전신 뼈 검사를 진행하였을 때에 뼈의 배후방사능과 감시 림프절에 비율차이가 평균 8:1 이상으로 림프절에 위치를 파악 하는데 문제가 없었다. 또한 전신 뼈 영상을 체표윤곽도로 이용하게 되면, 다른 선원을 이용하지 않고도 감시림프절에 위치정보를 나타낼 수 있어서 술자와 환자의 불필요한 피폭을 방지하며, 영상의 질적 향상을 기대할 수 있을 것으로 사료 된다. Purpose: Breast cancer is known to be more vulnerable to bone metastasis and lymph node metastasis than other types of cancer, and nuclear examinations whole body bone scan and lymphoscintigraphy are performed commonly before and after breast cancer operation. In case whole body bone scan is performed on the day before lymphoscintigraphy, the radiopharmaceutical taken into and remaining in the bones provides anatomical information for tracking and locating sentinel lymph nodes. Thus, this study purposed to examine how much bone density affects in locating sentinel lymph nodes. Materials and Methods: The subjects of this study were 22 patients (average age $52{\pm}7.2$) who had whole body bone scan and lymphoscintigraphy over two days in our hospital during the period from January to December, 2009. In the blind test, 22 patients (average age $57{\pm}6.5$) who had lymphoscintigraphy using $^{57}Co$ flood phantom were used as a control group. In quantitative analysis, the relative ratio of the background to sentinel lymph nodes was measured by drawing ROIs on sentinel lymph nodes and the background, and in gross examination, each of a nuclear physician and a radiological technologist with five years' or longer field experience examined images through blind test in a five-point scale. Results: In the results of quantitative analysis, the relative ratio of the background to sentinel lymph nodes was 14.2:1 maximum and 8.5:1 ($SD{\pm}3.48$) on the average on the front, and 14.7:1 maximum and 8.5:1 ($SD{\pm}3.42$) on the average on the side. In the results of gross examination, when $^{57}Co$ flood phantom images were compared with images containing bones, the score was relative high as 3.86 ($SD{\pm}0.35$) point for $^{57}Co$ flood phantom images and 4.09 ($SD{\pm}0.42$) for bone images. Conclusion: When whole body bone scan was performed on the day before lymphoscintigraphy, the ratio of the background to sentinel lymph nodes was over 10:1, so there was no problem in locating lymph nodes. In addition, we expect to reduce examination procedures and improve the quality of images by indicating the location of sentinel lymph nodes using bone images as body contour without the use of a source.

Feasibility of Charcoal Tattooing of Cytology-Proven Metastatic Axillary Lymph Node at Diagnosis and Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer Patients

Park, Seho,Koo, Ja Seung,Kim, Gun Min,Sohn, Joohyuk,Kim, Seung Il,Cho, Young Up,Park, Byeong-Woo,Park, Vivian Youngjean,Yoon, Jung Hyun,Moon, Hee Jung,Kim, Min Jung,Kim, Eun-Kyung Korean Cancer Association 2018 Cancer Research and Treatment Vol.50 No.3

<P><B>Purpose</B></P><P>Sentinel lymph node biopsy (SLNB) can be performed when node-positive disease is converted to node-negative status after neoadjuvant chemotherapy (NCT). Tattooing nodes might improve accuracy but supportive data are limited. This study aimed to investigate the feasibility of charcoal tattooing metastatic axillary lymph node (ALN) at presentation followed by SLNB after NCT in breast cancers.</P><P><B>Materials and Methods</B></P><P>Twenty patientswith cytology-proven node metastases prospectively underwent charcoal tattooing at diagnosis. SLNB using dual tracers and axillary surgery after NCT were then performed. The detection rate of tattooed node and diagnostic performance of SLNB were analyzed.</P><P><B>Results</B></P><P>All patients underwent charcoal tattooingwithout significant morbidity. Sentinel and tattooed nodes could be detected during surgery after NCT. Nodal pathologic complete response was achieved in 10 patients. Overall sensitivity, false-negative rate (FNR), negative predictive value, and accuracy of hot/blue SLNB were 80.0%, 20.0%, 83.3%, and 90.0%, respectively. Retrieving more nodes and favorable nodal response were associated with improved performance. The best accuracy was observed when excised tattooed node was calculated together (FNR, 0.0%). Cold/non-blue tattooed nodes of five patients were removed during non-sentinel axillary surgery but clinicopathological parameters did not differ compared to patients with hot/blue tattooed node detected during SLNB, suggesting the importance of the tattooing procedure itself to improve performance.</P><P><B>Conclusion</B></P><P>Charcoal tattooing of cytology-confirmed metastatic ALN at presentation is technically feasible and does not limit SLNB after NCT. The tattooing procedure without additional preoperative localization is advantageous for improving the diagnostic performance of SLNB in this setting.</P>

Sentinel Lymph Node Biopsy in Breast Cancer Patients With Pathological Complete Response in the Axillary Lymph Node After Neoadjuvant Chemotherapy

김현희,한재홍,김선영,이은숙,강한성,이시윤,정소연,이은경 한국유방암학회 2021 Journal of breast cancer Vol.24 No.6

Purpose: Sentinel lymph node biopsy (SLNB) alone following neoadjuvant chemotherapy (NAC) remains controversial in patients with breast cancer who are initially lymph node-positive. The present study aimed to evaluate the impact of SLNB and axillary lymph node dissection (ALND) on breast cancer recurrence and survival in patients who converted from lymph node-positive to pathological node-negative (ypN0) after NAC. Methods: This single-center retrospective study included 223 patients who converted to axillary lymph node-negative status after NAC and underwent breast and axillary surgery between January 2006 and December 2015. This study compared the overall survival (OS), disease-free survival (DFS), ipsilateral axillary lymph node recurrence rates and incidence of postoperative complications, especially, arm lymphedema and shoulder stiffness between SLNB and ALND. Results: This study included 223 patients with axillary pathological complete response (pCR) after NAC and surgery. The SLNB and ALND groups included 94 and 129 patients, respectively. The median follow-up time was 57 (range, 6–155) in the SLNB group and 99 (range 2–159) months in the ALND group. The corresponding 5-year OS and DFS rates were 96.3% and 94.2% (p = 0.392), and 89.2% and 86.4% (p = 0.671), respectively. Four patients (4.3%) in the SLNB group and nine (7.0%) in the ALND group developed locoregional recurrences. Ipsilateral axillary lymph node recurrence and distant metastasis were observed in one (1.1%) and three (2.3%) patients, and in 10 (10.6%) and 11 (8.5%) patients, respectively. Patients in the ALND group were more likely than their SLNB counterparts to experience complications, such as shoulder stiffness (9 [7.0%] vs. 4 [4.3%] patients, p = 0.57). The rate of lymphedema in the ALND group was three times that in the SLNB group (35 [27.1%] vs. 8 [8.5%] patients, p < 0.001). Conclusion: As an alternative to ALND, SLNB has oncological safety in patients with axillary pathological complete response after NAC.