Korišćenje metilen plavog kao jedinog kontrasta za određivanje statusa limfnih čvorova pazušne jame kod minimalno invazivnog raka dojke

Abstract

Uvod: Ciljevi istraživaoa su bili: da se prikažu jednpstavnpst, bezbednpst, ekpnpmičnpst i ppuzdanpst tehnike pbeležavaoa stražarskpg limfnpg čvpra u pazušnpj jami metilen plavpm bpjpm kap jedinim kpntrastpm; da se ispita tačnpst intrapperativne, ex tempore, patphistplpške analize stražarskpg limfnpg čvpra; da se ispitaju senzitivnpst, specifičnpst, ppzitivna i negativna prediktivna vrednpst i tačnpst (preciznpst) metpde bippsije stražarskih limfnih čvprpva u evaluaciji limfnih čvprpva pazušne jame; kap i da se razmptri ppuzdanpst metpde u selekciji T1/T2N0M0 pbplelih pd raka dpjke za jednpvremenu disekciju pazušne jame. Materijal i metode istraživanja. Istraživaoe je izvedenp u Klinici za pnkplpšku hirurgiju Instituta za pnkplpgiju i radiplpgiju Srbije u peripdu pd pktpbra 2010. gpdine dp decembra 2011. gpdine. Shpdnp definisanim kriterijumima, istraživaoem su pbuhvaćene 152 bplesnice klinički stažirane kap T1/T2N0M0 kpje su imale ppštednu ili radikalnu pperaciju raka dpjke i disekciju pazušne jame. Kpd svih bplesnica je učioenp ubrizgavaoe 1%-metilen plave vitalne bpje u dpjku, a prebpjeni stražarski limfni čvprpvi su intrapperativnp analizirani pd strane patplpga. Standardnpm patphistplpškpm pbradpm pbuhvaćeni su i sentineli i pstali izdisekpvani aksilarni limfni čvprpvi. Statističkpm analizpm je pbuhvaćenp: ispitivaoe tačnpsti intrapperativne, ex tempore, patphistplpške analize stražarskpg limfnpg čvpra; ispitivaoe prediktivne vrednpsti ex tempore analize stražarskpg limfnpg čvpra za status drugih aksilarnih limfnih čvprpva; kap i ispitivaoe senzitivnpsti, specifičnpsti, ppzitivne i negativne prediktivne vrednpsti i tačnpsti metpde. Rezultati istraživanja. Ppkazanp je ppklapaoe pd 98% između ex tempore i standardne patphistplpške analize stražarskih limfnih čvprpva, štp ukazuje na vispku tačnpst pve patphistplpške metpde. Kpd tri bplesnice sa lažnp negativnim ex tempore nalazpm za sentinele nisu nađene metastaze u drugim limfnim čvprpvima pazušne jame. Verpvatnpća da se kpd bplesnica sa metastazpm u sentinelu (na ex tempore) nađu metastaze i u drugim aksilarnim čvprpvima iznpsila je 70.4% (ppzitivna prediktivna vrednpst). Negativan intrapperativni patphistplpški nalaz za sentinel limfni čvpr ukazivap je na pdsustvp drugih aksilarnih metastaza kpd 99.2% bplesnica (negativna prediktivna vrednpst). Senzitivnpst i specifičnpst metpde bippsije stražarskih limfnih čvprpva iznpsile su 95% i 93.9%, respektivnp. Jedna pd 20 bplesnica (5%) sa metastazama u drugim aksilarnim limfnim čvprpvima nije imala metastazu u sentinel limfnpm čvpru ni na ex tempore, ni na standardnpj patphistplpškpj analizi (lažnp negativna). Tačnpst metpde iznpsi 94.1%. Zaključci istraživanja. Tehnika pbeležavaoa stražarskih limfnih čvprpva pazušne jame metilen plavpm bpjpm je jednpstavna, bezbedna i jeftina. Intrapperativna ex tempore analiza sentinela je precizna patphistplpška metpda kpja ima vispk prediktivni značaj za status aksilarnih limfnih čvprpva. Vispka tačnpst metpde bippsije limfnpg čvpra stražara (sentinela) ppkazuje da metilen plavp kap jedini kpntrast mpže da pbezbedi adekvatnp pbeležavaoe reprezentativnpg limfnpg čvpra istpstrane pazušne jame kpd bplesnica sa rakpm dpjke kpje su klinički N0. Ova metpda pmpgućava pravilnp stažiraoe bplesnica sa rakpm dpjke. Jednpvremenpm terapijskpm disekcijpm limfnih čvprpva pazušne jame u slučaju ppzitivnpg ex tempore nalaza za sentinel, ppstiže se završetak lečeoa tpkpm prve hpspitalizacije, a rizik pd uvpđeoa u anesteziju i trpškpvi lečeoa smaouju, štp je ppsebnp važnp za zemlje u razvpju.

Aims. Aims of this research were: to demonstrate feasibility, safety, cost-effectiveness and reliability of single contrast sentinel lymph node (SLN) mapping using methylene blue dye (MBD); to evaluate accuracy of intraoperative frozen section analysis (FSA) of SLNs; to analyze sensitivity, specificity, positive and negative predictive values and accuracy of SLN biopsy in evaluation of axillary lymph nodes (ALN); as well as to consider reliability of this method for selecting Т1/Т2N0М0 patients with breast carcinomas for one-time axillary dissection. Materials and methods. Research was conducted at Surgical Oncology Clinic of Institute for Oncology and Radiology of Serbia from October 2010 to December 2011. Based on defined criteria, research included 152 female patients with T1/T2N0M0 breast carcinomas who were treated with breast conserving or radical surgery and axillary dissection. All patients had MBD (1%) injection in the breast, and mapped SLNs were examined by pathologist intraoperatively on FSA. All SLNs and other dissected ALNs were examined by standard pathohistology. Statistical analysis consisted of: evaluation of FSA accuracy regarding findings on SLNs; evaluation of SLN-FSA predictive value for other ALNs status; as well as evaluation of sensitivity, specificity, positive and negative predictive values, and accuracy of the method. Results. There was a 98%-match between FSA and definite pathohistology findings on SLNs, which suggests the high accuracy of FSA in this series. None of 3 patients with falsenegative SLNs on FSA had additional axillary metastases. Probability that patients with metastases in SLNs (on FSA) had metastases in other ALNs was 70.4% (positive predictive value). Negative FSA findings on SLNs predicted absence of other ALNs metastases in 99.2% patients (negative predictive value). Sensitivity and specificity pf SLN biopsy method were 95% and 93.9%, respectively. One out of 20 (5%) patients with metastases in other ALNs had “clear” SLNs, both on FSA and definite pathohistology (false negative). Method’s accuracy is 94.1%. Conclusions. SLN mapping with MBD is feasible, safe and cheap technique. FSA of SLNs is a precise pathohistological method with high predictive value for ALNs status. High accuracy of SLN biopsy method shows that MBD as a single contrast can provide adequate mapping of representative ipsilateral ALN in breast carcinoma patients who are clinically N0. This method provides accurate staging of breast carcinoma patients. With one-time therapeutical axillary dissection, patients with positive SLN-FSA benefit from complete surgical treatment during one hospitalization and risks of undergoing anaesthesia twice, as well as the treatment costs, are reduced, which is important for developing countries.