单光子发射计算机断层显像/CT在乳腺癌前哨淋巴结探测中的应用
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摘要
目的探讨用放射性硫胶体(SC)单光子发射计算机断层显像(SPECT)/CT探测乳腺癌前哨淋巴结(SLN)的应用价值。方法按照入组和排除标准,收集2015年4~8月在青岛大学附属医院确诊的118例女性乳腺癌患者临床资料进行回顾性分析。患者术前行~(99)Tc~m-SC SPECT/CT联合术中蓝染法定位SLN,以联合法(SPECT/CT+蓝染法)检出结果为标准,比较单纯平面显像、蓝染法、SPECT/CT3种方法对SLN的检出率,并对所有检出的SLN送病理检查。组间SLN检出率(以病例数分析)的比较采用Fisher精确概率法,SLN检出率(以淋巴结数分析)的比较及SLN病理阳性率的比较采用配对χ~2检验。结果以联合法(SPECT/CT+蓝染法)检出结果为标准,从病例数角度分析,平面显像、SPECT/CT及蓝染法的SLN检出率分别为91.53%(108/118)、97.46%(115/118)和97.46%(115/118),差异有统计学意义(P=0.020),SPECT/CT及蓝染法的SLN检出率高于平面显像(χ~2=5.143、5.143,P=0.023、0.023)。从淋巴结数的角度分析,平面显像、SPECT/CT及蓝染法的SLN检出率分别为61.72%(158/256)、96.88%(248/256)和95.70%(245/256),差异有统计学意义(χ~2=158.072,P<0.001),SPECT/CT与蓝染法的SLN检出率也高于平面显像(χ~2=90.000、87.000,P<0.001)。对于腋窝区SLN,平面显像、SPECT/CT及蓝染法的检出率分别为64.44%(154/239)、96.65%(231/239)和100.00%(239/239),差异有统计学意义(χ~2=163.312,P<0.001),SPECT/CT与蓝染法均高于平面显像(χ~2=77.000、85.000,P均<0.001),蓝染法高于SPECT/CT(χ~2=6.125,P=0.013)。对于非腋窝区SLN,平面显像、SPECT/CT及蓝染法的检出率分别为4/17、17/17和6/17,差异有统计学意义(χ~2=23.139,P<0.001),SPECT/CT高于平面显像及蓝染法(χ~2=11.077、9.091,P=0.001、0.003)。SPECT/CT与蓝染法检出的SLN病理阳性率分别为24.22%(62/256)和21.09%(54/256),差异无统计学意义(χ~2=3.500,P=0.061)。对于腋窝区淋巴结,蓝染法比SPECT/CT多发现8枚,其中3枚SPECT/CT阴性的淋巴结经病理证实为淋巴结宏转移,另5枚均为非转移淋巴结。对于非腋窝区淋巴结,SPECT/CT比蓝染法多发现11枚(3枚内乳淋巴结,5枚胸肌间淋巴结,3枚乳腺内淋巴结),病理证实9枚微转移淋巴结,2枚宏转移淋巴结。结论 SPECT/CT的应用能够更精确地指导SLN活组织检查定位,而且在提高病理阳性SLN的检出率,尤其是探测非腋窝SLN方面,SPECT/CT较蓝染法有较大优势。
Objective To evaluate the application of SPECT/CT with radioactive sulfur colloid(~(99) Tc~m-SC) in detecting sentinel lymph nodes( SLNs) in breast cancer patients. Methods According to the inclusion and exclusion criteria,a total of 118 breast cancer patients in the Affiliated Hospital of Qingdao University from April 2015 to August 2015 were enrolled in this retrospective study. All patients underwent preoperative~(99) Tc~m-SC SPECT/CT combined with intraoperative blue dye tracing to detect SLNs. With the results of SPECT/CT plus blue dye tracing as the gold standard,the detection rate of SLNs by planar imaging,SPECT/CT or blue dye tracing alone was compared. All detected SLNs were sent to the pathologic examination.The detection rate of SLNs( based on cases) was compared using Fisher exact probability method,the detection rate of SLNs( based on node number) was compared using paired χ~2 test,and the detection rate of pathologically positive SLNs by SPECT/CT and blue dye tracing was compared using paired χ~2 test.Results With the results of SPECT/CT plus blue dye tracing as the gold standard,the detection rate of SLNs( based on cases) by planar imaging,SPECT/CT or blue dye tracing alone was 91. 53%( 108/118),97. 46%( 115/118)and 97. 46%( 115/118) respectively,indicating a significant difference( P = 0. 020),and the detection rate by SPECT/CT or blue dye tracing was significantly higher than that by planar imaging( χ~2= 5. 143,5. 143; P =0. 023,0. 023). The detection rate of SLNs( based on node number) by planar imaging,SPECT/CT and blue dye tracing was 61. 72%( 158/256),96. 88%( 248/256) and 95. 70%( 245/256) respectively,indicating a significant difference( χ~2= 158. 072,P<0. 001). The detection rates by SPECT/CT and blue dye tracing was significantly higher than that by plane imaging( χ~2= 90. 000,87. 000; both P< 0. 001). The detection rate of SLNs in axillary region by planar imaging,SPECT/CT and blue dye tracing was 64. 44%( 154/239),96. 65%( 231/239) and 100. 00%( 239/239) respectively,indicating a significant difference( χ~2= 163. 312,P <0. 001). The detection rate of SLNs in axillary region by SPECT/CT and blue dye tracing was significantly higher than that by planar imaging( χ~2= 77. 000,85. 000; both P<0. 001),while the detection rate of SLNs in axillary region by blue dye tracing was significantly higher than that by by SPECT/CT( χ~2= 6. 125,P = 0. 013).The detection rate of SLNs in non-axillary region by planar imaging,SPECT/CT and blue dye tracing was 4/17,17/17 and 6/17 respectively,indicating a significant difference( χ~2= 23. 139,P < 0. 001). The detection rate of SLNs in non-axillary region by SPECT/CT was significantly higher than that by planar imaging and blue dye tracing( χ~2= 11. 077,9. 091; P = 0. 001,0. 003). The pathologically positive rate of SLNs detected by SPECT/CT and blue dye tracing was 24. 22%( 62/256) and 21. 09%( 54/256) respectively,indicating no significant difference( χ~2= 3. 500,P = 0. 061). For axillary lymph nodes,eight SLNs which were not detected by SPECT/CT were found by blue dye tracing,including 3 with macrometastasis and 5 without metastasis in the pathological examination. For non-axillary lymph nodes,11 SLNs( 3 internal mammary nodes,5 interpectoral lymph nodes,3 intramammary nodes) which were not detected by blue dye tracing were found by SPECT/CT,including 9 with micrometastasis and 2 with macrometastasis in pathological examination.Conclusions SPECT/CT can provide guidance for accurate detection of SLNs and precise positioning of SLN biopsy. Furthermore,it can improve the detection rate of pathologically positive SLNs,especially for nonaxillary SLNs,superior to blue dye tracing.
Objective To evaluate the application of SPECT/CT with radioactive sulfur colloid(~(99) Tc~m-SC) in detecting sentinel lymph nodes( SLNs) in breast cancer patients. Methods According to the inclusion and exclusion criteria,a total of 118 breast cancer patients in the Affiliated Hospital of Qingdao University from April 2015 to August 2015 were enrolled in this retrospective study. All patients underwent preoperative~(99) Tc~m-SC SPECT/CT combined with intraoperative blue dye tracing to detect SLNs. With the results of SPECT/CT plus blue dye tracing as the gold standard,the detection rate of SLNs by planar imaging,SPECT/CT or blue dye tracing alone was compared. All detected SLNs were sent to the pathologic examination.The detection rate of SLNs( based on cases) was compared using Fisher exact probability method,the detection rate of SLNs( based on node number) was compared using paired χ~2 test,and the detection rate of pathologically positive SLNs by SPECT/CT and blue dye tracing was compared using paired χ~2 test.Results With the results of SPECT/CT plus blue dye tracing as the gold standard,the detection rate of SLNs( based on cases) by planar imaging,SPECT/CT or blue dye tracing alone was 91. 53%( 108/118),97. 46%( 115/118)and 97. 46%( 115/118) respectively,indicating a significant difference( P = 0. 020),and the detection rate by SPECT/CT or blue dye tracing was significantly higher than that by planar imaging( χ~2= 5. 143,5. 143; P =0. 023,0. 023). The detection rate of SLNs( based on node number) by planar imaging,SPECT/CT and blue dye tracing was 61. 72%( 158/256),96. 88%( 248/256) and 95. 70%( 245/256) respectively,indicating a significant difference( χ~2= 158. 072,P<0. 001). The detection rates by SPECT/CT and blue dye tracing was significantly higher than that by plane imaging( χ~2= 90. 000,87. 000; both P< 0. 001). The detection rate of SLNs in axillary region by planar imaging,SPECT/CT and blue dye tracing was 64. 44%( 154/239),96. 65%( 231/239) and 100. 00%( 239/239) respectively,indicating a significant difference( χ~2= 163. 312,P <0. 001). The detection rate of SLNs in axillary region by SPECT/CT and blue dye tracing was significantly higher than that by planar imaging( χ~2= 77. 000,85. 000; both P<0. 001),while the detection rate of SLNs in axillary region by blue dye tracing was significantly higher than that by by SPECT/CT( χ~2= 6. 125,P = 0. 013).The detection rate of SLNs in non-axillary region by planar imaging,SPECT/CT and blue dye tracing was 4/17,17/17 and 6/17 respectively,indicating a significant difference( χ~2= 23. 139,P < 0. 001). The detection rate of SLNs in non-axillary region by SPECT/CT was significantly higher than that by planar imaging and blue dye tracing( χ~2= 11. 077,9. 091; P = 0. 001,0. 003). The pathologically positive rate of SLNs detected by SPECT/CT and blue dye tracing was 24. 22%( 62/256) and 21. 09%( 54/256) respectively,indicating no significant difference( χ~2= 3. 500,P = 0. 061). For axillary lymph nodes,eight SLNs which were not detected by SPECT/CT were found by blue dye tracing,including 3 with macrometastasis and 5 without metastasis in the pathological examination. For non-axillary lymph nodes,11 SLNs( 3 internal mammary nodes,5 interpectoral lymph nodes,3 intramammary nodes) which were not detected by blue dye tracing were found by SPECT/CT,including 9 with micrometastasis and 2 with macrometastasis in pathological examination.Conclusions SPECT/CT can provide guidance for accurate detection of SLNs and precise positioning of SLN biopsy. Furthermore,it can improve the detection rate of pathologically positive SLNs,especially for nonaxillary SLNs,superior to blue dye tracing.
引文
[1]Lauridsen MC,Garne JP,Srensen FB,et al.Sentinel lymph node biopsy in breast cancer-experience with the combined use of dye and radioactive tracer at Aarhus University Hospital[J].Acta Oncol,2004,43(1):20-26.
[2]Gillard C,Franken P,Darcourt J,et al.Surgical guidance by freehand SPECT for sentinel lymph node biopsy in early stage breast cancer:A preliminary study[J].Gynecol Obstet Fertil,2016,44(9):487-491.
[3]Rauch P,Merlin JL,Leufflen L,et al.Limited effectiveness of patent blue dye in addition to isotope scanning for identification of sentinel lymph nodes:cross-sectional real-life study in 1 024 breast cancer patients[J].Int J Surg,2016,9(33):177-181.
[4]王磊,胡旭东,李济宇,等.术前淋巴显像在乳腺癌前哨淋巴结活检中的作用[J/CD].中华乳腺病杂志(电子版),2008,2(2):157-164.
[5]Estourgie SH,Nieweg OE,Olmos RA,et al.Lymphatic drainage patterns from the breast[J].Ann Surg,2004,239(2):232-237.
[6]杨国仁,王永胜,张鹏,等.99mTc-SC显像联合蓝染法探测乳腺癌前哨淋巴结[J].中华核医学杂志,2003,23(3):136-138.
[7]He PS,Li F,Li GH,et al.The combination of blue dye and radioisotope versus radioisotope alone during sentinel lymph node biopsy for breast cancer:a systematic review[J].BMC Cancer,2016,16:107.
[8]Zetterlund L,Gabrielson S,Axelsson R,et al.Impact of previous surgery on sentinel lymph node mapping:hybrid SPECT/CT before and after a unilateral diagnostic breast excision[J].Breast,2016,30:32-38.
[9]Frusciante V,Niccoli AA,Castriotta G,et al.Added value of SPECT/CT over planar imaging in improving sentinel node detection in breast cancer patients[J].Recenti Prog Med,2016,107(8):444-449.
[10]Lerman H,Lievshitz G,Zak O,et al.Improved sentinel node identification by SPECT/CT in overweight patients with breast cancer[J].J Nucl Med,2007,48(2):201-206.
[11]Lerman H,Metser U,Lievshitz G,et al.Lymphoscintigraphic sentinel node identification in patients with breast cancer:the role of SPECT-CT[J].Eur J Nucl Med Mol Imaging,2006,33(3):329-337.
[12]Lerch H,Jigalin A,Gasthaus K,et al.Three-dimensional localization of sentinel lymph nodes using combined emission and transmission SPECT data[J].Clin Nucl Med,2003,28(1):1-4.
[13]章英剑,潘张弛,周敏,等.乳腺癌前哨淋巴结显像研究[J].中华核医学杂志,2003,23(4):197-200.
[14]陈志军,谭丽玲,孙正魁,等.乳腺癌哨兵淋巴结核素显像的的影响因素[J].实用癌症杂志,2015,30(10):1449-1452.
[15]Kern KA.Lymphoscintigraphic anatomy of sentinel lymphatic channels after subareolar injection of Technetium 99m sulfur colloid[J].J Am Coll Surg,2001,193(6):601-608.
[16]Madsen E,Gobardhan P,Bongers V,et al.The impact on postsurgical treatment of sentinel lymph node biopsy of internal mammary lymph nodes in patients with breast cancer[J].Ann Surg Oncol,2007,14(4):1486-1492.
[17]Kawase K,Gayed IW,Hunt KK,et al.Use of lymphoscintigraphy defines lymphatic drainage patterns before sentinel lymph node biopsy for breast cancer[J].J Am Coll Surg,2006,203(1):64-72.
[18]Carcoforo P,Sortini D,Feggi L,et al.Clinical and therapeutic importance of sentinel node bioposy of the internal mammary chain in patients with breast cancer:a single-center study with long-term followup[J].Ann Surg Oncol,2006,13(10):1338-1343.
[19]Piato JR,Filassi JR,Dela Vega AJ,et al.SPECT-CT-guided thoracoscopic biopsy of sentinel lymph nodes in the internal mammary chain in patients with breast cancer:a pilot study[J].Innovations(Phila),2016,11(2):94-98.
[20]Pouw B,Hellingman D,Kieft M,et al.The hidden sentinel node in breast cancer:reevaluating the role of SPECT/CT and tracer reinjection[J].Eur J Surg Oncol,2016,42(4):497-503.
[2]Gillard C,Franken P,Darcourt J,et al.Surgical guidance by freehand SPECT for sentinel lymph node biopsy in early stage breast cancer:A preliminary study[J].Gynecol Obstet Fertil,2016,44(9):487-491.
[3]Rauch P,Merlin JL,Leufflen L,et al.Limited effectiveness of patent blue dye in addition to isotope scanning for identification of sentinel lymph nodes:cross-sectional real-life study in 1 024 breast cancer patients[J].Int J Surg,2016,9(33):177-181.
[4]王磊,胡旭东,李济宇,等.术前淋巴显像在乳腺癌前哨淋巴结活检中的作用[J/CD].中华乳腺病杂志(电子版),2008,2(2):157-164.
[5]Estourgie SH,Nieweg OE,Olmos RA,et al.Lymphatic drainage patterns from the breast[J].Ann Surg,2004,239(2):232-237.
[6]杨国仁,王永胜,张鹏,等.99mTc-SC显像联合蓝染法探测乳腺癌前哨淋巴结[J].中华核医学杂志,2003,23(3):136-138.
[7]He PS,Li F,Li GH,et al.The combination of blue dye and radioisotope versus radioisotope alone during sentinel lymph node biopsy for breast cancer:a systematic review[J].BMC Cancer,2016,16:107.
[8]Zetterlund L,Gabrielson S,Axelsson R,et al.Impact of previous surgery on sentinel lymph node mapping:hybrid SPECT/CT before and after a unilateral diagnostic breast excision[J].Breast,2016,30:32-38.
[9]Frusciante V,Niccoli AA,Castriotta G,et al.Added value of SPECT/CT over planar imaging in improving sentinel node detection in breast cancer patients[J].Recenti Prog Med,2016,107(8):444-449.
[10]Lerman H,Lievshitz G,Zak O,et al.Improved sentinel node identification by SPECT/CT in overweight patients with breast cancer[J].J Nucl Med,2007,48(2):201-206.
[11]Lerman H,Metser U,Lievshitz G,et al.Lymphoscintigraphic sentinel node identification in patients with breast cancer:the role of SPECT-CT[J].Eur J Nucl Med Mol Imaging,2006,33(3):329-337.
[12]Lerch H,Jigalin A,Gasthaus K,et al.Three-dimensional localization of sentinel lymph nodes using combined emission and transmission SPECT data[J].Clin Nucl Med,2003,28(1):1-4.
[13]章英剑,潘张弛,周敏,等.乳腺癌前哨淋巴结显像研究[J].中华核医学杂志,2003,23(4):197-200.
[14]陈志军,谭丽玲,孙正魁,等.乳腺癌哨兵淋巴结核素显像的的影响因素[J].实用癌症杂志,2015,30(10):1449-1452.
[15]Kern KA.Lymphoscintigraphic anatomy of sentinel lymphatic channels after subareolar injection of Technetium 99m sulfur colloid[J].J Am Coll Surg,2001,193(6):601-608.
[16]Madsen E,Gobardhan P,Bongers V,et al.The impact on postsurgical treatment of sentinel lymph node biopsy of internal mammary lymph nodes in patients with breast cancer[J].Ann Surg Oncol,2007,14(4):1486-1492.
[17]Kawase K,Gayed IW,Hunt KK,et al.Use of lymphoscintigraphy defines lymphatic drainage patterns before sentinel lymph node biopsy for breast cancer[J].J Am Coll Surg,2006,203(1):64-72.
[18]Carcoforo P,Sortini D,Feggi L,et al.Clinical and therapeutic importance of sentinel node bioposy of the internal mammary chain in patients with breast cancer:a single-center study with long-term followup[J].Ann Surg Oncol,2006,13(10):1338-1343.
[19]Piato JR,Filassi JR,Dela Vega AJ,et al.SPECT-CT-guided thoracoscopic biopsy of sentinel lymph nodes in the internal mammary chain in patients with breast cancer:a pilot study[J].Innovations(Phila),2016,11(2):94-98.
[20]Pouw B,Hellingman D,Kieft M,et al.The hidden sentinel node in breast cancer:reevaluating the role of SPECT/CT and tracer reinjection[J].Eur J Surg Oncol,2016,42(4):497-503.