纳米炭前哨淋巴结绘图在早期子宫内膜癌中的应用

Application of Nano-Carbon SLN Mapping in Early Stage Endometrial Cancer

摘要: 目的：探讨在早期子宫内膜癌患者中，应用纳米炭通过宫颈注射进行前哨淋巴结绘图的可行性及临床价值。方法：选择2019年6月至2021年9月在青岛大学附属医院妇科因早期子宫内膜癌需要行手术治疗的患者68例，术后病理证实共有高分化(G1)患者22例，中分化(G2)患者31例，低分化(G3)患者9例，特殊类型患者6例。按照欧洲肿瘤医学会议(ESMO)及我国妇科肿瘤分会的标准对早期子宫内膜癌的危险度分层，共计低危患者51例，中高危患者17例。将所有纳入研究的患者在腹腔镜直视下采用纳米炭(25 mg/0.5ml)注射液稀释至1 ml，分别于宫颈3点、9点处各注射0.5 ml。注射纳米炭30 min内在腹腔镜下识别出显影的前哨淋巴结，切除并行冰冻病理检查，无论前哨淋巴结冰冻结果是否为阳性均行系统的盆腔淋巴结清扫术，若前哨淋巴结冰冻结果为阳性或肿瘤病灶侵及深肌层等高危因素存在，加行高位腹主动脉旁淋巴结清扫，否则行低位腹主动脉旁淋巴结清扫。将其余标本送检常规病理检查。对患者的前哨淋巴结(sentinel lymph node, SLN)总检出率、双侧盆腔检出率、灵敏度、阴性预测值及分布部位等指标进行计算。结果：① 本研究68例患者SLN总检出率为91.18% (62/68)，双侧盆腔检出率为72.06% (49/68)。② 腹主动脉旁SLN的总检出率为30.88% (21/68)。③ 9例患者术后病理证实淋巴结转移，其中8例SLN阳性，1例假阴性，灵敏度为88.89% (8/9)，阴性预测值为98.33% (59/60)。④ 51例低危患者中，仅1例淋巴结阳性，转移率为1.96%，SLN灵敏度和阴性预测值均为100%；17例中高危患者中，8例淋巴结阳性，其中1例SLN假阴性，灵敏度为87.5% (7/8)，阴性预测值90% (9/10)。中高危组淋巴结转移率为47.06% (8/17)，其中孤立的腹主动脉旁淋巴结转移2例，发生率11.76% (2/17)。⑤ 本研究共检出SLN 399枚，其中显影最多的部位为髂外40.35% (161/399)，其次为闭孔29.07% (116/399)、腹主动脉旁14.04% (56/399)、骶前8.52% (34/399)和髂总8.02% (32/399)。结论：宫颈注射纳米炭前哨淋巴结示踪对早期子宫内膜癌患者具有较高的灵敏度和阴性预测值，可作为低危患者系统性淋巴结清扫的替代方案。对于高危子宫内膜癌患者谨慎使用。

Abstract: Objective: To explore the feasibility and clinical value of nano-carbon for sentinel lymph node mapping through cervical injection in patients with early endometrial cancer. Methods: From June 2019 to September 2021 in the Department of Gynecology of Qingdao University Affiliated Hospital, 68 patients were included who required surgery for early endometrial cancer, the postoperative pathology confirmed that there were 22 patients with high differentiation (G1), 31 patients with medium differentiation (G2), 9 patients with low differentiation (G3), and 6 patients with special type. The risk of early endometrial cancer was stratified according to the standards of the European Medical Conference of Oncology (ESMO) and the Chinese Branch of Gynecological Oncology. A total of 51 patients were at low risk and 17 were at medium risk. All enrolled patients were dilute to 1 mL by carbon nanoparticles (25 mg/0.5ml) injection under laparoscopic vision, and injected 0.5 ml at 3 and 9 points of the cervix respectively. Injection of nano carbon laparoscopic identified within 30 min of sentinel lymph node and frozen pathological examination and excision, regardless of the sentinel lumph node frozen results if they are positive for pelvic lymph node cleaning line system, if the sentinel lymph node freezing result is positive or tumor lesion invasion and deep muscularis risk factors exist, such as line with high lymph node cleaning the abdominal aorta, otherwise, low para-aortic lymph node dissection was performed. Other specimens were sent for routine pathological examination. Overall sentinel lymph node (SLN) detection rate, bilateral pelvic detection rate, sensitivity, negative predictive value and distribution of SLN were calculated. Results: ① In this study, the total detection rate of SLN in 68 patients was 91.18% (62/68), and the bilateral pelvic detection rate was 72.06% (49/68). ② The total detection rate of PARa-aortic SLN was 30.88% (21/68). ③ Lymph node metastasis was confirmed by postoperative pathology in 9 patients, of which 8 were SLN positive and 1 was false negative, with a sensitivity of 88.89% (8/9) and a negative predictive value of 98.33% (59/60). ④ Among the 51 low-risk patients, only 1 had positive lymph node, the metastasis rate was 1.96%, SLN sensitivity and negative predictive value were 100%. Among the 17 medium-high risk patients, 8 were lymph node positive, including 1 false negative SLN, with a sensitivity of 87.5% (7/8) and a negative predictive value of 90% (9/10). The incidence of lymph node metastasis was 47.06% (8/17) in the middle and high risk groups, including 2 isolated para-aortic lymph node metastasis 11.76% (2/17). ⑤ A total of 399 SLNS were detected in this study, of which the most developed sites were external iliac 40.35% (161/399), followed by obturator foram 29.07% (116/399), para-aortic 14.04% (56/399), anterior sacral 8.52% (34/399) and total iliac 8.02% (32/399). Conclusions: Sentinel lymph node mapping has high sensitivity and negative predictive valuein patients with early endometrial cancer and can be used as an alternative to systematic lymph node dissection in low-risk patients. It should be used with caution in patients at high risk for endometrial cancer.