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High-resolution three-dimensional imaging for precise staging in melanoma. Eur J Cancer 2021; 159:182-193. [PMID: 34773902 DOI: 10.1016/j.ejca.2021.09.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/16/2021] [Accepted: 09/22/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Many cancer guidelines include sentinel lymph node (SLN) staging to identify microscopic metastatic disease. Current SLN analysis of melanoma patients is effective but has the substantial drawback that only a small representative portion of the node is sampled, whereas most of the tissue is discarded. This might explain the high clinical false-negative rate of current SLN diagnosis in melanoma. Furthermore, the quantitative assessment of metastatic load and microanatomical localisation might yield prognosis with higher precision. Thus, methods to analyse entire SLNs with cellular resolution apart from tedious sequential physical sectioning are required. PATIENTS AND METHODS Eleven melanoma patients eligible to undergo SLN biopsy were included in this prospective study. SLNs were fixed, optically cleared, whole-mount stained and imaged using light sheet fluorescence microscopy (LSFM). Subsequently, compatible and unbiased gold standard histopathological assessment allowed regular patient staging. This enabled intrasample comparison of LSFM and histological findings. In addition, the development of an algorithm, RAYhance, enabled easy-to-handle display of LSFM data in a browsable histologic slide-like fashion. RESULTS We comprehensively quantify total tumour volume while simultaneously visualising cellular and anatomical hallmarks of the associated SLN architecture. In a first-in-human study of 21 SLN of melanoma patients, LSFM not only confirmed all metastases identified by routine histopathological assessment but also additionally revealed metastases not detected by routine histology alone. This already led to additional therapeutic options for one patient. CONCLUSION Our three-dimensional digital pathology approach can increase sensitivity and accuracy of SLN metastasis detection and potentially alleviate the need for conventional histopathological assessment in the future. GERMAN CLINICAL TRIALS REGISTER: (DRKS00015737).
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Vuoristo M, Muhonen T, Koljonen V, Juteau S, Hernberg M, Ilmonen S, Jahkola T. Long-term prognostic value of sentinel lymph node tumor burden in survival of melanoma patients. Acta Oncol 2021; 60:803-807. [PMID: 33656957 DOI: 10.1080/0284186x.2021.1892820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Mikko Vuoristo
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Timo Muhonen
- Department of Oncology, University of Helsinki, Helsinki, Finland
| | - Virve Koljonen
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Susanna Juteau
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Micaela Hernberg
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Oncology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Suvi Ilmonen
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tiina Jahkola
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Abstract
PURPOSE OF REVIEW This review describes the long scientific background followed to design guidelines and everyday clinical practice applied to melanoma patients. Surgery is the first option to cure melanoma patients (PTS) at initial diagnosis, since primary cutaneous lesions are usually easily resectable. An excisional biopsy of the lesion, with minimal clear margins, can be obtained in the vast majority of cases. Punch biopsies may be proposed only in case of large lesions located on specific cosmetic or functional areas like the face, extremities, or genitals where a mutilating complete resection would not be performed without prior histological diagnosis. RECENT FINDINGS After the histologic confirmation of melanoma, definite surgical excision of the scar and surrounding tissue is planned, to obtain microsatellite free margins. The width of these margins has been identified following the results of several clinical trials and it is either 1 or 2 cm, depending on the Breslow thickness of the primary tumor. Following the latest staging system proposed by the American Joint Cancer commission (AJCC), a sentinel node biopsy (SNB) is usually performed in case of a primary lesion > 0.8 mm thickness or for high-risk thinner lesions, if no evidence of nodal involvement has been identified clinically or radiographically. Surgical management of primary melanoma is well established. There is debate on the optimal surgical margins for 1-2 mm melanomas. There are specific considerations for special primaries (bulky, extremity, mucosal). Sentinel node (SN) evaluation does not improve survival, but is routinely used as staging.
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Affiliation(s)
- Alessandro A E Testori
- Dermatology, Fondazione IRCCS policlinico San Matteo, Fondazione IRCCS San Matteo, Pavia, Italy.
| | - Stephanie A Blankenstein
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, Netherlands
| | - Alexander C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, Netherlands
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Cook MG, Massi D, Szumera-Ciećkiewicz A, Van den Oord J, Blokx W, van Kempen LC, Balamurugan T, Bosisio F, Koljenović S, Portelli F, van Akkooi AC. An updated European Organisation for Research and Treatment of Cancer (EORTC) protocol for pathological evaluation of sentinel lymph nodes for melanoma. Eur J Cancer 2019; 114:1-7. [DOI: 10.1016/j.ejca.2019.03.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 02/13/2019] [Accepted: 03/10/2019] [Indexed: 10/27/2022]
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Weidele K, Stojanović N, Feliciello G, Markiewicz A, Scheitler S, Alberter B, Renner P, Haferkamp S, Klein CA, Polzer B. Microfluidic enrichment, isolation and characterization of disseminated melanoma cells from lymph node samples. Int J Cancer 2019; 145:232-241. [PMID: 30586191 DOI: 10.1002/ijc.32092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/22/2018] [Accepted: 12/12/2018] [Indexed: 11/10/2022]
Abstract
For the first time in melanoma, novel therapies have recently shown efficacy in the adjuvant therapy setting, which makes companion diagnostics to guide treatment decisions a desideratum. Early spread of disseminated cancer cells (DCC) to sentinel lymph nodes (SLN) is indicative of poor prognosis in melanoma and early DCCs could therefore provide important information about the malignant seed. Here, we present a strategy for enrichment of DCCs from SLN suspensions using a microfluidic device (Parsortix™, Angle plc). This approach enables the detection and isolation of viable DCCs, followed by molecular analysis and identification of genetic changes. By optimizing the workflow, the established protocol allows a high recovery of DCC from melanoma patient-derived lymph node (LN) suspensions with harvest rates above 60%. We then assessed the integrity of the transcriptome and genome of individual, isolated DCCs. In LNs of melanoma patients, we detected the expression of melanoma-associated transcripts including MLANA (encoding for MelanA protein), analyzed the BRAF and NRAS mutational status and confirmed the malignant origin of isolated melanoma DCCs by comparative genomic hybridization. We demonstrate the feasibility of epitope-independent isolation of LN DCCs using Parsortix™ for subsequent molecular characterization of isolated single DCCs with ample application fields including the use for companion diagnostics or subsequent cellular studies in personalized medicine.
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Affiliation(s)
- Kathrin Weidele
- Division of Personalized Tumour Therapy, Fraunhofer Institute for Toxicology and Experimental Medicine, 93053, Regensburg, Germany
| | - Nataša Stojanović
- Division of Personalized Tumour Therapy, Fraunhofer Institute for Toxicology and Experimental Medicine, 93053, Regensburg, Germany
| | - Giancarlo Feliciello
- Division of Personalized Tumour Therapy, Fraunhofer Institute for Toxicology and Experimental Medicine, 93053, Regensburg, Germany
| | - Aleksandra Markiewicz
- Experimental Medicine and Therapy Research, University of Regensburg, 93053, Regensburg, Germany
| | - Sebastian Scheitler
- Division of Personalized Tumour Therapy, Fraunhofer Institute for Toxicology and Experimental Medicine, 93053, Regensburg, Germany
| | - Barbara Alberter
- Division of Personalized Tumour Therapy, Fraunhofer Institute for Toxicology and Experimental Medicine, 93053, Regensburg, Germany
| | - Philipp Renner
- Department of Surgery, University Medical Center, 93053, Regensburg, Germany
| | - Sebastian Haferkamp
- Department of Dermatology, University Hospital Regensburg, 93053, Regensburg, Germany
| | - Christoph A Klein
- Division of Personalized Tumour Therapy, Fraunhofer Institute for Toxicology and Experimental Medicine, 93053, Regensburg, Germany.,Experimental Medicine and Therapy Research, University of Regensburg, 93053, Regensburg, Germany
| | - Bernhard Polzer
- Division of Personalized Tumour Therapy, Fraunhofer Institute for Toxicology and Experimental Medicine, 93053, Regensburg, Germany
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Perissinotti A, Rietbergen DDD, Vidal-Sicart S, Riera AA, Olmos RA. Melanoma & nuclear medicine: new insights & advances. Melanoma Manag 2018; 5:MMT06. [PMID: 30190932 PMCID: PMC6122522 DOI: 10.2217/mmt-2017-0022] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 03/29/2018] [Indexed: 12/16/2022] Open
Abstract
The contribution of nuclear medicine to management of melanoma patients is increasing. In intermediate-thickness N0 melanomas, lymphoscintigraphy provides a roadmap for sentinel node biopsy. With the introduction of single-photon emission computed tomography images with integrated computed tomography (SPECT/CT), 3D anatomic environments for accurate surgical planning are now possible. Sentinel node identification in intricate anatomical areas (pelvic cavity, head/neck) has been improved using hybrid radioactive/fluorescent tracers, preoperative lymphoscintigraphy and SPECT/CT together with modern intraoperative portable imaging technologies for surgical navigation (free-hand SPECT, portable gamma cameras). Furthermore, PET/CT today provides 3D roadmaps to resect 18F-fluorodeoxyglucose-avid melanoma lesions. Simultaneously, in advanced-stage melanoma and recurrences, 18F-fluorodeoxyglucose-PET/CT is useful in clinical staging and treatment decision as well as in the evaluation of therapy response. In this article, we review new insights and recent nuclear medicine advances in the management of melanoma patients.
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Affiliation(s)
- Andrés Perissinotti
- Department of Nuclear Medicine, Hospital Clinic, C/Villarroel 170, 08036 Barcelona, Spain
| | - Daphne DD Rietbergen
- Nuclear Medicine Section & Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Centre, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Sergi Vidal-Sicart
- Department of Nuclear Medicine, Hospital Clinic, C/Villarroel 170, 08036 Barcelona, Spain
| | - Ana A Riera
- Department of Nuclear Medicine, Hospital Universitario Nuestra Señora de la Candelaria, Carretera del Rosario 145, 08010 SC de Tenerife, Spain
| | - Renato A Valdés Olmos
- Nuclear Medicine Section & Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Centre, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Nuclear Medicine, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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Patients with sentinel lymph node positive melanoma: Who needs completion lymph node dissection? Am J Surg 2018; 215:868-872. [PMID: 29397888 DOI: 10.1016/j.amjsurg.2018.01.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/21/2018] [Accepted: 01/22/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Completion lymph node dissection (CLND) for melanoma after positive sentinel lymph node biopsy (SLNB) was recently shown to improve regional but not overall survival, likely due to the majority of patients harboring no further nodal disease. We sought to determine predictors of non-sentinel node (NSN) positivity. METHODS Retrospective review of prospectively collected data on melanoma patients undergoing SLNB. RESULTS 116 patients underwent 119 CLNDs. The incidence of NSN positivity was 17.6%; the average number of positive NSNs in those cases was 1.5. Cervical and inguinofemoral location were most likely to yield positive NSN(s) (40% each). Conversely, the axilla was least likely at 18% (p < 0.001). The average number of nodes harvested was 13 for NSN negative cases and 20 for NSN positive cases (p = 0.005). Tumor thickness increased the probability of positive NSN(s) (OR 1.2, p = 0.02). CONCLUSIONS Tumor thickness and nodal basin were predictors of NSN metastasis, factors that could help determine which patients may benefit from CLND. Further, CLNDs with fewer nodes may inadequately clear residual nodal disease.
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Zugna D, Senetta R, Osella-Abate S, Fierro MT, Pisacane A, Zaccagna A, Sapino A, Bataille V, Maurichi A, Picciotto F, Cassoni P, Quaglino P, Ribero S. Favourable prognostic role of histological regression in stage III positive sentinel lymph node melanoma patients. Br J Cancer 2017; 118:398-404. [PMID: 29123256 PMCID: PMC5808022 DOI: 10.1038/bjc.2017.397] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 09/22/2017] [Accepted: 10/11/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Sentinel lymph node (SLN)-positive melanoma patients are a heterogeneous group of patients with survival rates ranging from ∼20 to over 80%. No data are reported concerning the role of histological regression on survival in stage III melanoma. METHODS The study included 365 patients with positive SLN from two distinct hospitals. The model was developed on patients from 'AOU Città della Salute e della Scienza di Torino', and externally validated on patients from IRCCS of Candiolo. Survival analyses were carried out according to the presence of regression and adjusted for all other prognostic factors. RESULTS Among patients followed at 'AOU Città della Salute e della Scienza di Torino' (n=264), the median follow-up time to death or censoring (whatever two events occurred earlier) was 2.7 years since diagnosis (interquartile range: 1.3-5.8). In all, 79 patients died from melanoma and 11 from other causes. Histological regression (n=43) was associated with a better prognosis (sub-HR=0.34, CI 0.12-0.92), whereas the other factors above showed an inverse association. In the external validation, the concordance index was 0.97 at 1 year and decreased to 0.66 at 3 years and to 0.59 at 5 years. Adding histological regression in the prognostic model increased the discriminative ability to 0.75 at 3 years and to 0.62 at 5 years. Finally, using a cutoff of 20% for the risk of death led to a net re-classification improvement of 15 and 11% at 3 and 5 years after diagnosis, respectively. CONCLUSIONS Histological regression could lead to an improvement in prognostic prediction in patients with stage III-positive SLN melanoma.
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Affiliation(s)
- D Zugna
- Department of Medical Sciences, Unit of Cancer Epidemiology, CERMS, University of Turin, C.So Dogliotti, 14, Torino 10126, Italy
| | - R Senetta
- Department of Medical Sciences, Section of Surgical Pathology, University of Turin, C.So Dogliotti, 14, Torino 10126, Italy
| | - S Osella-Abate
- Department of Medical Sciences, Section of Surgical Pathology, University of Turin, C.So Dogliotti, 14, Torino 10126, Italy
| | - M T Fierro
- Department of Medical Sciences, Section of Dermatology, University of Turin, C.So Dogliotti, 14, Torino 10126, Italy
| | - A Pisacane
- Pathology Unit, Fondazione del Piemonte per l'Oncologia (FPO), Candiolo Cancer Institute (IRCCS), Km 3,95, SP142, 10060 Candiolo, Torino Italy
| | - A Zaccagna
- Dermatologic Surgery Section, Fondazione del Piemonte per l'Oncologia (FPO), Candiolo Cancer Institute (IRCCS), Km 3,95, SP142, 10060 Candiolo, Torino, Italy
| | - A Sapino
- Pathology Unit, Fondazione del Piemonte per l'Oncologia (FPO), Candiolo Cancer Institute (IRCCS), Km 3,95, SP142, 10060 Candiolo, Torino Italy
| | - V Bataille
- Mount Vernon Cancer Centre, Rickmansworth Road, Northwood HA6 2RN, UK.,Department of Twin Research and Genetic Epidemiology, King's College London, South Wing Block D, Westminster Bridge Road, London SE1 7EH, UK
| | - A Maurichi
- Melanoma and Sarcoma Surgery Unit, Fondazione IRCCS Istituto Nazionale Tumouri, Via Giacomo Venezian, 1, 20133 Milan, Italy
| | - F Picciotto
- Dermatologic Surgery Section, Department of Oncology, AOU Città della Salute e della Scienza di Torino, Via Cherasco 23, 10123 Torino, Italy
| | - P Cassoni
- Department of Medical Sciences, Section of Surgical Pathology, University of Turin, C.So Dogliotti, 14, Torino 10126, Italy
| | - P Quaglino
- Department of Medical Sciences, Section of Dermatology, University of Turin, C.So Dogliotti, 14, Torino 10126, Italy
| | - S Ribero
- Department of Medical Sciences, Section of Dermatology, University of Turin, C.So Dogliotti, 14, Torino 10126, Italy
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Moody JA, Botham SJ, Dahill KE, Wallace DL, Hardwicke JT. Complications following completion lymphadenectomy versus therapeutic lymphadenectomy for melanoma - A systematic review of the literature. Eur J Surg Oncol 2017; 43:1760-1767. [PMID: 28756017 DOI: 10.1016/j.ejso.2017.07.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 05/24/2017] [Accepted: 07/11/2017] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Completion lymph node dissection (CLND) following a positive sentinel lymph node biopsy (SLNB) has been reported to be less morbid than lymphadenectomy for palpable disease (therapeutic lymph node dissection; TLND). The reporting of morbidity data can be heterogeneous, and hence no 'average' surgical complication rates of these procedures has been reported. This review aims to determine complications rates to inform patients undergoing surgery for metastatic melanoma. METHODS A systematic review of English-language literature from 2000 to 2017, reporting morbidity information about CLND and TLND for melanoma, was performed. The methodological quality of the included studies was performed using the methodological index for non-randomised studies (MINORS) instrument and Detsky score. Pooled proportions of post-operative complications were constructed using a random effects statistical model. RESULTS After application of inclusion and exclusion criteria, 18 articles progressed to the final analysis. In relation to TLND (1627 patients), the overall incidence of surgical complications was 39.3% (95% CI 32.6-46.2); including wound infection/breakdown 25.4% (95% CI: 20.9-30.3); lymphoedema 20.9% (95% CI: 13.8-29.1); and seroma 20.4% (95% CI: 15.9-25.2). For CLND (1929 patients), the overall incidence of surgical complications was 37.2% (95% CI 27.6-47.4); including wound infection/breakdown 21.6% (95% CI: 13.8-30.6); lymphoedema 18% (95% CI: 12.5-24.2); and seroma 17.9% (95% CI: 10.3-27). The complication rate was marginally lower for CLND but not to statistical significance. DISCUSSION This study provides information about the incidence of complications after CLND and TLND. It can be used to counsel patients about the procedures and it sets a benchmark against which surgeons can audit their practice.
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Affiliation(s)
- J A Moody
- GKT School of Medical Education, King's College London, Great Maze Pond, London, SE1 9RT, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - S J Botham
- Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, United Kingdom
| | - K E Dahill
- Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, United Kingdom
| | - D L Wallace
- Department of Plastic Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom
| | - J T Hardwicke
- Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, United Kingdom; Department of Plastic Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, United Kingdom.
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Escobedo LA, Crew A, Eginli A, Peng D, Cousineau MR, Cockburn M. The role of spatially-derived access-to-care characteristics in melanoma prevention and control in Los Angeles county. Health Place 2017; 45:160-172. [PMID: 28391127 PMCID: PMC5470843 DOI: 10.1016/j.healthplace.2017.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 11/05/2016] [Accepted: 01/09/2017] [Indexed: 12/17/2022]
Abstract
Among 10,068 incident cases of invasive melanoma, we examined the effects of patient characteristics and access-to-care on the risk of advanced melanoma. Access-to-care was defined in terms of census tract-level sociodemographics, health insurance, cost of dermatological services and appointment wait-times, clinic density and travel distance. Public health insurance and education level were the strongest predictors of advanced melanomas but were modified by race/ethnicity and poverty: Hispanic whites and high-poverty neighborhoods were worse off than non-Hispanic whites and low-poverty neighborhoods. Targeting high-risk, underserved Hispanics and high-poverty neighborhoods (easily identified from existing data) for early melanoma detection may be a cost-efficient strategy to reduce melanoma mortality.
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Affiliation(s)
- Loraine A Escobedo
- Spatial Sciences Institute, Dana and David Dornsife College of Letters, Arts and Sciences, University of Southern California, Los Angeles, United States.
| | - Ashley Crew
- Keck School of Medicine, University of Southern California, United States
| | - Ariana Eginli
- Keck School of Medicine, University of Southern California, United States
| | - David Peng
- Keck School of Medicine, University of Southern California, United States
| | - Michael R Cousineau
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, United States
| | - Myles Cockburn
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, United States
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Schuitevoerder D, Leong SPL, Zager JS, White RL, Avisar E, Kosiorek H, Dueck A, Fortino J, Kashani-Sabet M, Hart K, Vetto JT. Is pelvic sentinel node biopsy necessary for lower extremity and trunk melanomas? Am J Surg 2017; 213:921-925. [PMID: 28411863 DOI: 10.1016/j.amjsurg.2017.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 01/17/2017] [Accepted: 03/21/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE There is currently no consensus regarding how to address pelvic sentinel lymph nodes (PSLNs) in melanoma. Thus, our objectives were to identify the incidence and clinical impact of PSLNs. METHODS Retrospective review of a prospectively collected multi-institutional melanoma database. RESULTS Of 2476 cases of lower extremity and trunk melanomas, 227 (9%) drained to PSLNs (181 to both PSLNs and superficial (inguinal or femoral) sentinel lymph nodes (SSLN) and 46 to PSLNs alone). Seventeen (7.5%) of 227 PSLN cases were positive for nodal metastasis, 8 of which drained to PSLNs only while 9 drained to both PSLNs and SSLNs. Complication rates between PSLN and SSLN biopsy were similar (15% vs. 14% respectively). In 181 cases with drainage to both SSLNs and PSLNs, PSLN biopsy upstaged one patient (0.6%), and completion dissection based on a positive PSLN did not upstage any. CONCLUSIONS PSLN biopsy is safe, however in the setting of negative SSLNs there is minimal clinical impact. We therefore recommend PSLN biopsy when the SSLNs are positive or when the tumor drains to PSLNs alone.
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Affiliation(s)
| | - Stanley P L Leong
- Center for Melanoma Research and Treatment, Department of Surgery, California Pacific Medical Center, San Francisco, CA, USA
| | - Jonathan S Zager
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Richard L White
- Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC, USA
| | - Eli Avisar
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Heidi Kosiorek
- Section of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Amylou Dueck
- Section of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Jeanine Fortino
- Department of Surgery, Division of Surgical Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Mohammed Kashani-Sabet
- Center for Melanoma Research and Treatment, Department of Surgery, California Pacific Medical Center, San Francisco, CA, USA
| | - Kyle Hart
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - John T Vetto
- Department of Surgery, Division of Surgical Oncology, Oregon Health & Science University, Portland, OR, USA
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Baum C, Weiss C, Gebhardt C, Utikal J, Marx A, Koenen W, Géraud C. Sentinel node metastasis mitotic rate (SN-MMR) as a prognostic indicator of rapidly progressing disease in patients with sentinel node-positive melanomas. Int J Cancer 2017; 140:1907-1917. [PMID: 27935036 DOI: 10.1002/ijc.30563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 11/25/2016] [Accepted: 11/30/2016] [Indexed: 11/11/2022]
Abstract
Risk stratification of sentinel lymph node biopsy (SNB)-positive patients with malignant melanoma differs among current classification systems. To improve classification of patients with rapidly progressive disease who may profit from adjuvant therapy with novel immune or targeted treatment modalities, a single-center retrospective analysis was performed including all melanoma patients diagnosed with a positive SN at a university-based skin cancer center over a 10-year period (2002-2012) (96 of 419 patients). Sentinel node metastasis mitotic rate (SN-MMR) and further histologic parameters were determined by blinded histological re-evaluation and correlated with clinical follow-up (overall [OS], melanoma-specific [MSS], and disease-free survival [DFS]). Median follow-up was 53 months. In univariate analyses, SN tumor penetrative depth (TPD), maximum tumor diameter (MTD), number of positive SN, SN-MMR and the S-, Rotterdam, RDC, Hannover I and II classification systems correlated with OS, MSS and DFS. Multivariate Cox regression analyses showed that a binary classification system based only on the SN-MMR (<1 vs. ≥1 mitoses/mm2 ) was the strongest independent prognostic indicator for all endpoints analyzed. Kaplan-Meier analyses confirmed binary SN-MMR to be superior to stratify patients into high- and low-risk groups (45.45% vs. 87.92% 5-yr MSS). The general prognostic validity of the published SN classification systems was confirmed. The novel SN-MMR classification system may improve discrimination of patients with slowly and rapidly progressive disease. We therefore propose its implementation into clinical practice as the SN-MMR can be easily and reliably determined in routine pathology reports. Its prognostic value for the selection of patients amenable to adjuvant therapies should be studied in clinical trials.
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Affiliation(s)
- Cornelia Baum
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christel Weiss
- Department for Medical Statistics and Biomathematics, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoffer Gebhardt
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jochen Utikal
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Alexander Marx
- Institute of Pathology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Wolfgang Koenen
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Cyrill Géraud
- Department of Dermatology, Venereology and Allergology, University Medical Center and Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Exhaustive pathologic work-up in sentinel lymph node biopsy for melanoma: is it necessary? Melanoma Res 2016; 27:116-120. [PMID: 28030434 DOI: 10.1097/cmr.0000000000000319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of this study is to determine whether a less exhaustive pathologic work-up to detect melanoma metastasis is clinically useful and does not affect patient prognosis. The success and evolution of the sentinel lymph node (SLN) depends on histological techniques. Several exhaustive protocols of SLN analysis have been published, but are time and cost consuming, with slight increases in the rates of metastasis detection. From 281 patients with SLN biopsy, each SLN was sectioned every 2 mm and from each paraffin block, 2-3 histological sections were evaluated. The patients were divided as follows: the first group (n=185) was subjected to extensive SLN examination (eSLNe) and the second group (n=96) was not subjected to an extensive SLN examination (wSLNe). The average SLN resected was 2 (range: 1-7), evaluating one in 50.9%. The SLN metastasis detection rate was 28.5%, whereas eSLNe increased by 3.2%. During follow-up, 4/26 (17.4%) cases in the wSLNe group showed recurrence in the SLN basin. Factors associated with decreased survival in univariant analysis were recurrence, Breslow thickness, advanced clinical stage, ulceration, and SLN metastasis. eSLNe did not affect disease-specific survival. Multivariate analysis showed recurrence (hazard ratio 23.475, 95% confidence interval: 1903-4559, P<0.001) and Breslow thickness of more than 3.5 mm (hazard ratio 15.222, 95% confidence interval: 1448-3059, P<0.001) as independent risk factors for decreased survival. Our routine for SLN examination enabled an adequate rate of SLN metastasis detection and the eSLNe increased the rate of detection in 3.2%, but did not affect the survival. We did not find any benefit from performing the eSLNe in patients with Breslow thickness less than 3.5 mm.
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Abstract
Sentinel lymph nodes (SLNs), the initial site of regional metastases, directly receive lymph containing immune-modulatory cytokines and tumor cells from primary melanomas. Immune-suppressed SLNs are ideal for studies of tissue susceptibility to metastases. They show reduced antigen-presenting dendritic cells, activated T cells, high endothelial venules, and transvenular immigration of T cells. Tumor-induced immune suppression contributes to establishment of nodal metastases. SLNs may serve as an effective model to study reversal of tumor-induced immune suppression. We reviewed this topic in Nature Reviews of Immunology in 2006. We here summarize the Nature paper and provide additional results from ongoing studies and the recent literature.
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Perissinotti A, Vidal-Sicart S, Nieweg O, Valdés Olmos R. Melanoma and nuclear medicine. Melanoma Manag 2014; 1:57-74. [PMID: 30190811 DOI: 10.2217/mmt.14.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Supported by a large body of published work, the contribution of nuclear medicine technologies to the assessment of melanoma has been increasing in recent years. Lymphoscintigraphy-assisted sentinel lymph node biopsy and PET are in continuous evolution with the aid of technological imaging advances, making it possible to fuse functional and anatomic images (e.g., with SPECT/CT, PET/CT and 3D rendering systems). The development of hybrid fluorescent-radioactive tracers that enable high-quality preoperative lymphoscintigraphy and SPECT/CT, and the optimization of modern intraoperative portable imaging technologies, such as free-hand SPECT and portable γ-cameras, are important innovations that have improved sentinel lymph node identification in complex anatomical areas, such as the pelvis and head and neck. Concurrently, 18F-fluorodeoxyglucose-PET has proved its usefulness in the clinical staging and treatment decision-making process, and there is also emerging evidence regarding its utility in the evaluation of therapeutic response. The potential uses of other novel PET radiotracers could open up a new field of use for this technique. In this article, we review the current and future role of nuclear medicine in the management of melanoma.
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Affiliation(s)
- Andrés Perissinotti
- Nuclear Medicine Department, Hospital Clinic, C/Villarroel 170, 08036 Barcelona, Spain.,Nuclear Medicine Department, Hospital Clinic, C/Villarroel 170, 08036 Barcelona, Spain
| | - Sergi Vidal-Sicart
- Nuclear Medicine Department, Hospital Clinic, C/Villarroel 170, 08036 Barcelona, Spain.,Nuclear Medicine Department, Hospital Clinic, C/Villarroel 170, 08036 Barcelona, Spain
| | - Omgo Nieweg
- Melanoma Institute Australia, 40 Rocklands Road, North Sydney, NSW 2060, Australia.,Melanoma Institute Australia, 40 Rocklands Road, North Sydney, NSW 2060, Australia
| | - Renato Valdés Olmos
- Nuclear Medicine Department, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.,Interventional Molecular Imaging Laboratory & Nuclear Medicine Section, Department of Radiology, Leiden University Medical Hospital, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, The Netherlands.,Nuclear Medicine Department, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.,Interventional Molecular Imaging Laboratory & Nuclear Medicine Section, Department of Radiology, Leiden University Medical Hospital, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, The Netherlands
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Pflugfelder A, Kochs C, Blum A, Capellaro M, Czeschik C, Dettenborn T, Dill D, Dippel E, Eigentler T, Feyer P, Follmann M, Frerich B, Ganten MK, Gärtner J, Gutzmer R, Hassel J, Hauschild A, Hohenberger P, Hübner J, Kaatz M, Kleeberg UR, Kölbl O, Kortmann RD, Krause-Bergmann A, Kurschat P, Leiter U, Link H, Loquai C, Löser C, Mackensen A, Meier F, Mohr P, Möhrle M, Nashan D, Reske S, Rose C, Sander C, Satzger I, Schiller M, Schlemmer HP, Strittmatter G, Sunderkötter C, Swoboda L, Trefzer U, Voltz R, Vordermark D, Weichenthal M, Werner A, Wesselmann S, Weyergraf AJ, Wick W, Garbe C, Schadendorf D. S3-guideline "diagnosis, therapy and follow-up of melanoma" -- short version. J Dtsch Dermatol Ges 2014; 11:563-602. [PMID: 23721604 DOI: 10.1111/ddg.12044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Ribero S, Osella-Abate S, Sanlorenzo M, Savoia P, Astrua C, Cavaliere G, Tomasini C, Senetta R, Macripò G, Bernengo M, Quaglino P. Favourable prognostic role of regression of primary melanoma in AJCC stage I-II patients. Br J Dermatol 2013; 169:1240-5. [DOI: 10.1111/bjd.12586] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2013] [Indexed: 01/18/2023]
Affiliation(s)
- S. Ribero
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
- Section of Dermatologic Surgery; Department of Oncology and Haematology via Cherasco 23; AOU Città della Salute e della Scienza di Torino; 10126 Turin Italy
| | - S. Osella-Abate
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
| | - M. Sanlorenzo
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
| | - P. Savoia
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
| | - C. Astrua
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
| | - G. Cavaliere
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
| | - C. Tomasini
- Division of Anatomic Pathology IV, via Cherasco; AOU Città della Salute e della Scienza di Torino; 23, 10126 Turin Italy
| | - R. Senetta
- Section of Surgical Pathology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
- Department of Laboratory Diagnostics; AOU Città della Salute e della Scienza di Torino, via Santena 7; 10126 Turin Italy
| | - G. Macripò
- Section of Dermatologic Surgery; Department of Oncology and Haematology via Cherasco 23; AOU Città della Salute e della Scienza di Torino; 10126 Turin Italy
| | - M.G. Bernengo
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
| | - P. Quaglino
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
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Migliano E, Bellei B, Govoni FA, Paolino G, Catricalà C, Bucher S, Donati P. SLN melanoma micrometastasis predictivity of nodal status: a long term retrospective study. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2013; 32:47. [PMID: 23902987 PMCID: PMC3737095 DOI: 10.1186/1756-9966-32-47] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 07/26/2013] [Indexed: 02/05/2023]
Abstract
Background Completion lymph node dissection (CLND) is the gold standard treatment for patients with a positive sentinel lymph node (SLN) biopsy. Considering the morbidity associated with CLND it is important to identify histological features of the primary tumor and/or of SLN metastasis that could help to spare from CLND a subset of patients who have a very low risk of non-SLN metastasis. The objective of this study is to identify patients with a very low risk to develop non-SLNs recurrences and to limit unnecessary CLND. Methods A retrospective long-term study of 80 melanoma patients with positive SLN, undergone CLND, was assessed to define the risk of additional metastasis in the regional nodal basin, on the basis of intranodal distribution of metastatic cells, using the micro-morphometric analysis (Starz classification). Results This study demonstrates that among the demographic and pathologic features of primary melanoma and of SLN only the Starz classification shows prognostic significance for non-SLN status (p<0.0001). This parameter was also significantly associated with disease-free survival rate (p<0.0013). Conclusion The Starz classification can help to identify, among SLN positive patients, those who can have a real benefit from CLND. From the clinical point of view this easy and reliable method could lead to a significant reduction of unnecessary CLND in association with a substantial decrease in morbidity. The study results indicate that most of S1 subgroup patients might be safely spared from completion lymphatic node dissection. Furthermore, our experience demonstrated that Starz classification of SLN is a safe predictive index for patient stratification and treatment planning.
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Affiliation(s)
- Emilia Migliano
- Department of Plastic and Reconstructive Surgery, San Gallicano Dermatologic Institute, Rome, Italy.
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Ohlfest JR, Andersen BM, Litterman AJ, Xia J, Pennell CA, Swier LE, Salazar AM, Olin MR. Vaccine injection site matters: qualitative and quantitative defects in CD8 T cells primed as a function of proximity to the tumor in a murine glioma model. THE JOURNAL OF IMMUNOLOGY 2012; 190:613-20. [PMID: 23248259 DOI: 10.4049/jimmunol.1201557] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Malignant gliomas are lethal brain tumors for which novel therapies are urgently needed. In animal models, vaccination with tumor-associated Ags efficiently primes T cells to clear gliomas. In clinical trials, cancer vaccines have been less effective at priming T cells and extending survival. Generalized immune suppression in the tumor draining lymph nodes has been documented in multiple cancers. However, a systematic analysis of how vaccination at various distances from the tumor (closest to farthest) has not been reported. We investigated how the injection site chosen for vaccination dictates CD8 T cell priming and survival in an OVA-transfected murine glioma model. Glioma-bearing mice were vaccinated with Poly:ICLC plus OVA protein in the neck, hind leg, or foreleg for drainage into the cervical, inguinal, or axillary lymph nodes, respectively. OVA-specific CD8 T cell number, TCR affinity, effector function, and infiltration into the brain decreased as the vaccination site approached the tumor. These effects were dependent on the presence of the tumor, because injection site did not appreciably affect CD8 T cell priming in tumor-free mice. Our data suggest the site of vaccination can greatly impact the effectiveness of cancer vaccines. Considering that previous and ongoing clinical trials have used a variety of injection sites, vaccination site is potentially a critical aspect of study design that is being overlooked.
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Affiliation(s)
- John R Ohlfest
- Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA
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Radiographically negative, asymptomatic, sentinel lymph node positive cutaneous T-cell lymphoma in a 3-year-old male: a case report. Case Rep Pediatr 2012; 2012:791602. [PMID: 23150841 PMCID: PMC3488386 DOI: 10.1155/2012/791602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 10/02/2012] [Indexed: 12/03/2022] Open
Abstract
We present a case of a 3-year-old male originally diagnosed with a CD30+ anaplastic cutaneous T-cell lymphoma with no evidence of systemic disease after CT scan, PET scan, and bone marrow aspiration. Sentinel lymph node biopsy (SLNB) was performed as an additional step in the workup and showed microscopic disease. Current management/recommendations for cutaneous T-cell lymphoma do not include SLNB. Medical and surgical management of cutaneous malignancies is dramatically different for local versus advanced disease. Therefore adequate evaluation is necessary to properly stage patients for specific treatment. Such distinction in extent of disease suggests more extensive therapy including locoregional radiation and systemic chemotherapy versus local excision only. Two international case reports have described SLNB in cutaneous T-cell lymphoma with one demonstrating evidence of node positive microscopic disease despite a negative metastatic disease workup. This case is being presented as a novel case in a child with implications including lymphoscintigraphy and SLNB as a routine procedure for evaluation and staging of cutaneous T-cell lymphoma if the patient does not demonstrate evidence of metastatic disease on routine workup.
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Lévy-Sitbon C, Barbe C, Granel-Brocard F, Lipsker D, Aubin F, Dalac S, Truchetet F, Michel C, Mitschler A, Arnoult G, Le Clainche A, Dalle S, Bernard P, Grange F. Diagnosis and management of melanoma with regional lymph node metastases: a population-based study in France. J Eur Acad Dermatol Venereol 2012; 27:1081-7. [PMID: 22845015 DOI: 10.1111/j.1468-3083.2012.04652.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Stage III melanoma represents a borderline situation regarding the potential curability of this potentially aggressive cancer and consequently, regional lymph node metastases (RLNM) are a major challenge for melanoma management. OBJECTIVE To describe the management of melanoma with RLNM as practised in France in 2008 and compare results with previous data from 2004, considering that new French recommendations were published in 2005. METHODS Retrospective population-based study in five regions of France totalling 8.3 million inhabitants, targeting all incident cases of RLNM diagnosed in 2008. Questionnaires were mailed to physicians to identify cases and collect data, with verification by cancer registries for cases diagnosed concomitantly with the primary tumour using sentinel lymph node biopsies (SLNB). RESULTS Data were collected for 101 patients in 2008, and compared to 89 cases treated in 2004. Palpation by a dermatologist was the most common circumstance of diagnosis of RLNM in 2008 (36%), followed by SLNB (29%), self-palpation by the patient (16%) and lymph node ultrasonography (6%), without significant modification from 2004. After lymphadenectomy an adjuvant therapy was proposed in 62% of cases, mainly consisting in high-dose interferon (HD-IFN) (80%). Overall, HD-IFN was proposed in 49% of cases, but effectively started in only 40% of cases after being proposed, and prematurely withdrawn in 28%, showing major changes as compared with 2004 (33%, 77% and 67%, respectively, P < 0.05). Adjuvant chemotherapy was not proposed to any patients in 2008, compared to 29% in 2004. Surveillance procedures included medical imaging less often in 2008 (76%) than in 2004 (92%) (P = 0.004), but more often included FDG-PET (23% vs. 12%, P = 0.09). CONCLUSION Overall, actual practice was in accordance with French recommendations. The main developments from 2004 to 2008 were the disappearance of adjuvant chemotherapies and a more accurate selection of patients for adjuvant interferon.
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Affiliation(s)
- C Lévy-Sitbon
- Service de Dermatologie, Hôpital Robert Debré, Reims, France
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Starz H, Welzel J. Commentary on C. Garbe et al.: "Histopathological diagnostics of malignant melanomas in accordance with the AJCC classification 2009: Revision of the literature and recommendations for general practice". J Dtsch Dermatol Ges 2012; 10:203-4; author reply 205. [PMID: 22380835 DOI: 10.1111/j.1610-0387.2011.07906.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Aquino JU, Pinheiro LGP, Vasques PHD, Rocha JIX, Cruz DA, Beserra HEO, Cavalcante RV. Experimental canine model for sentinel lymph node biopsy in the vulva using technetium and patent blue dye. Acta Cir Bras 2012; 27:102-8. [PMID: 22378363 DOI: 10.1590/s0102-86502012000200002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 12/12/2011] [Indexed: 02/06/2023] Open
Abstract
PURPOSE This paper aims to study and define the experimental model of sentinel lymph node biopsy of the vulva in bitches. METHODS 0.2 ml of 99mTc phytate was injected intradermally, using a fine gauge insulin needle in the anterior commissure of the vulva. Thirty minutes after 99mTc injection, the inguinal mapping was performed using a gamma probe. After this, 0.5 ml of blue dye (bleu patenté V Guerbet 2.5%) was injected in the same place. After 15 minutes, a 3 cm long inguinal incision was made at point maximum uptake followed by careful dissection, guided by visualization of a bluish afferent lymphatic system that points to the sentinel lymph node (SLN). RESULTS It was observed that 88% of SLN were identified. It wasn't found a significant difference among the presence or not of sentinel lymph node in the sides, which is an indication of a good consistency. It was observed a high (88%) and significant (χ2=12.89 and p=0.0003) intercession between both methods (blue dye and radiation). CONCLUSION The experimental model adopted is feasible, becoming advantageous in applying the association of Patent blue and 99mTc.
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Quaglino P, Ribero S, Osella-Abate S, Macrì L, Grassi M, Caliendo V, Asioli S, Sapino A, Macripò G, Savoia P, Bernengo M. Clinico-pathologic features of primary melanoma and sentinel lymph node predictive for non-sentinel lymph node involvement and overall survival in melanoma patients: A single centre observational cohort study. Surg Oncol 2011; 20:259-64. [DOI: 10.1016/j.suronc.2010.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 10/04/2010] [Accepted: 11/03/2010] [Indexed: 10/18/2022]
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Baehner FL, Li R, Jenkins T, Hwang J, Kashani-Sabet M, Allen RE, Leong SPL. The impact of primary melanoma thickness and microscopic tumor burden in sentinel lymph nodes on melanoma patient survival. Ann Surg Oncol 2011; 19:1034-42. [PMID: 21989664 DOI: 10.1245/s10434-011-2095-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND The primary objectives of this work are to (1) quantitate tumor burden in sentinel lymph nodes (SLNs), and (2) assess the independent contributions of SLN tumor burden and primary melanoma thickness (PMT) with respect to progression-free survival (PFS) and overall survival (OS). METHODS Sixty-three patients (41 male and 22 female) with one or more positive SLNs were available for review in this study, with median follow-up of 6.8 years. PMT was measured and SLN metastases were assessed for size, as maximum metastasis size (MMS) in mm, by hematoxylin and eosin (H&E) and immunohistochemistry (S100 and HMB45). PFS and OS were calculated from time of SLN resection until melanoma recurrence or death. Univariate and multivariate analyses and trend test were performed. RESULTS Kaplan-Meier estimates of PFS and OS differed significantly by MMS (log-rank P = 0.031 for PFS and P = 0.016 for OS) and PMT (log-rank P = 0.036 for PFS and P < 0.001 for OS). After adjusting for age and gender, the hazard ratio (HR) associated with MMS was 1.09 per mm increase (P = 0.05) for PFS, and 6.30 (P = 0.014) and 5.41 (P = 0.048) for OS in patients, respectively, with MMS of 0.6-5.5 mm and MMS ≥5.5 mm compared with those with MMS <0.6 mm. When patients were stratified by their tumor characteristics of PMT, the risk for disease progression and worse OS was substantially higher for the group with PMT ≥ 4.5 mm (HR = 13.10 and P = 0.022 for PFS; HR = 17.26 and P < 0.001 for OS) relative to the baseline group with PMT <1.6 mm. All patients had completion lymph node dissection (CLND) except for four patients. Patients with positive CLND (14, 22.2%) showed significant worse PFS (P = 0.002) and OS (P = 0.0003) than the negative CLND group (45, 71.4%). CONCLUSIONS PMT and MMS were independently prognostic of PFS and OS in melanoma patients. Patients with negative CLND had significantly better PFS and OS than those with positive CLND.
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Affiliation(s)
- Frederick L Baehner
- Department of Pathology, University of California, San Francisco and UCSF Comprehensive Cancer Center, San Francisco, CA, USA
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Mu E, Lange JR, Strouse JJ. Comparison of the use and results of sentinel lymph node biopsy in children and young adults with melanoma. Cancer 2011; 118:2700-7. [DOI: 10.1002/cncr.26578] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 08/19/2011] [Accepted: 09/02/2011] [Indexed: 12/27/2022]
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Egberts F, Hartje C, Schafmayer C, Kaehler KC, von Schönfels W, Hauschild A, Becker T, Egberts JH. Risk evaluation in cutaneous melanoma patients undergoing lymph node dissection: impact of POSSUM. Ann R Coll Surg Engl 2011; 93:514-22. [PMID: 22004633 PMCID: PMC3604920 DOI: 10.1308/147870811x13137608455019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2011] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION When lymphatic metastasis occurs, surgery is the primary treatment modality in melanoma patients. Depending on the tumour stage, patients receive a completion lymph node dissection (CLND) when a positive sentinel node is detected. Patients with clinically evident disease of the regional lymph nodes are recommended to undergo a therapeutic lymph node dissection (TLND). The aim of this study was to assess the morbidity of CLND and TLND and to evaluate the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) for preoperative risk adjustment of postoperative morbidity. METHODS The hospital files of 143 patients who underwent CLND and TLND for malignant melanoma were analysed. The POSSUM score was used to predict morbidity rates after surgery for the total patient group as well as separated for CLND and TLND patients. RESULTS The overall complication rate was 28.0% and the mortality rate was 0%. The morbidity rate predicted by POSSUM was 32.9%, the mortality 8.3%. Morbidity in patients undergoing CLND was significantly higher with regard to overall wound complications compared with patients with TLND. In these subgroups, POSSUM failed to predict the rates precisely. CONCLUSIONS The POSSUM score predicted the morbidity of the total patient group accurately but failed to predict the rates in the TLND and CLND subgroups. Patients receiving CLND showed the highest morbidity rates. Preoperative sentinel lymph node biopsy therefore has more influence on postoperative morbidity than the physiological parameters represented in the POSSUM physiological score.
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Affiliation(s)
- F Egberts
- University Hospital Schleswig-Holstein, Kiel, Germany
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Lourari S, Paul C, Gouraud PA, Tavitian S, Viraben R, Leccia MT, Saiag P, Lebbe C, Meyer N. Sentinel lymph node biopsy for melanoma is becoming a consensus: a national survey of French centres involved in melanoma care in 2008. J Eur Acad Dermatol Venereol 2011; 26:1230-5. [DOI: 10.1111/j.1468-3083.2011.04267.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Wen DR, Cochran AJ, Huang RR, Itakura E, Binder S. Clinically relevant information from sentinel lymph node biopsies of melanoma patients. J Surg Oncol 2011; 104:369-78. [DOI: 10.1002/jso.21818] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Leong SPL, Zuber M, Ferris RL, Kitagawa Y, Cabanas R, Levenback C, Faries M, Saha S. Impact of nodal status and tumor burden in sentinel lymph nodes on the clinical outcomes of cancer patients. J Surg Oncol 2011; 103:518-30. [PMID: 21480244 DOI: 10.1002/jso.21815] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The validation of sentinel lymph node (SLN) concept in melanoma and breast cancer has established a new paradigm in cancer metastasis that, in general, cancer cells spread in a orderly fashion from the primary site to the SLNs in the regional nodal basin and then to the distant sites. In this review article, we examine the development of SLN concept in penile carcinoma, melanoma and breast carcinoma and its application to other solid cancers with emphasis of the relationship between micrometastasis in SLNs and clinical outcomes.
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Affiliation(s)
- Stanley P L Leong
- Center for Melanoma Research and Treatment, Department of Surgery, California Pacific Medical and Research Institute, San Francisco, California 94115, USA.
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Scolyer RA, Prieto VG. Melanoma pathology: important issues for clinicians involved in the multidisciplinary care of melanoma patients. Surg Oncol Clin N Am 2011; 20:19-37. [PMID: 21111957 DOI: 10.1016/j.soc.2010.09.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Histologic analysis remains the gold standard for diagnosis of melanoma. The pathology report should document those histologic features important for guiding patient management, including those characteristics on which the diagnosis was based and also prognostic factors. Pathologic examination of sentinel lymph nodes provides very important prognostic information. New techniques, such as comparative genomic hybridization and fluorescence in situ hybridization are currently being studied to determine their usefulness in the diagnosis of melanocytic lesions. Recent molecular studies have opened new avenues for the treatment of patients with metastatic melanoma (ie, targeted therapies) and molecular pathology is likely to play an important role in the emerging area of personalized melanoma therapy.
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Affiliation(s)
- Richard A Scolyer
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney, NSW 2050, Australia.
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Stoffels I, Dissemond J, Schulz A, Hillen U, Schadendorf D, Klode J. Reliability and cost-effectiveness of complete lymph node dissection under tumescent local anaesthesia vs. general anaesthesia: a retrospective analysis in patients with malignant melanoma AJCC stage III. J Eur Acad Dermatol Venereol 2011; 26:200-6. [PMID: 21414036 DOI: 10.1111/j.1468-3083.2011.04036.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Complete lymph node dissection (CLND) in melanoma patients with a positive sentinel lymph node (SLN) is currently being debated, as it is a cost-intensive surgical intervention with potentially high morbidity. OBJECTIVE This clinical study seeks to clarify the effectiveness, reliability and cost-effectiveness of CLND performed under tumescent local anaesthesia (TLA) compared with procedures under general anaesthesia (GA). METHODS We retrospectively analysed the data from 60 patients with primary malignant melanoma American Joint Committee on Cancer stage III who underwent CLND. RESULTS Altogether 26 (43.3%) patients underwent CLND under TLA and 34 (56.7%) patients underwent CLND under GA. Fifteen of 43 (34.9%) patients had a complication, such as development of seromas and/or wound infections. The rate of complications was 25.0% (3/12) in the axilla subgroup and 28.6% (4/14) in the groin subgroup of the TLA group. In the GA group, the complication rate was 31.3% (5/16) in the axilla subgroup and 44.4% (8/18) in the groin subgroup. The costs for CLND were significantly less for the CLND in a procedure room performed under TLA (mean €67.26) compared with CLND in an operating room under GA (mean €676.20, P < 0.0001). CONCLUSIONS In conclusion, this study confirms that TLA is an excellent, safe, effective and cost-efficient alternative to GA for CLND in melanoma patients.
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Affiliation(s)
- I Stoffels
- Department of Dermatology, Venerology and Allergology, University of Essen-Duisburg, Essen, Germany
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Stoffels I, Dissemond J, Poeppel T, Klötgen K, Hillen U, Körber A, Schadendorf D, Klode J. Advantages of preoperative ultrasound in conjunction with lymphoscintigraphy in detecting malignant melanoma metastases in sentinel lymph nodes: a retrospective analysis in 221 patients with malignant melanoma AJCC Stages I and II. J Eur Acad Dermatol Venereol 2011; 26:79-85. [PMID: 21395693 DOI: 10.1111/j.1468-3083.2011.04013.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Sentinel lymph node excision (SLNE) for the detection of regional nodal metastases and staging of malignant melanoma has resulted in some controversies in international discussions as it is a surgical intervention with potential morbidity. OBJECTIVE The present retrospective study seeks to clarify the reliability of preoperative ultrasonography (US) in direct comparison to the result of SLNE and seeks to identify potential advantages of preoperative ultrasound if performed in conjunction with lymphoscintigraphy in detecting malignant melanoma metastases in sentinel lymph node (SLN). PATIENTS We retrospectively analysed data from 221 patients with primary malignant melanoma with a Breslow index of ≥ 1.0 mm. RESULTS Of the 221 patients, 77.4% (n = 171) had a negative SLN. In 50 patients (22.6%), the histopathological investigation of 71 excised lymph nodes resulted in a positive SLN. The US examination demonstrated a sensitivity of 13.6%, a specificity of 96.9%, a positive predictive value of 97.2% and a negative predictive value of 12.6%. SLNE alone shows a sensitivity of 94%, a specificity of 98.6%, a positive predictive value of 100% and a negative predictive value of 98.3%. Preoperative US in conjunction with dynamic lymphoscintigraphy, followed by SLNE, demonstrated a detecting ratio of 100% (n = 28) for micrometastases and 98.6% (n = 42/43) for macrometastases. CONCLUSION In conclusion, this study confirms that preoperative US alone cannot replace the vital information obtained during dynamic lymphoscintigraphy. But preoperative US is an important component of the staging procedure in melanoma patients and has clear advantages when performed in conjunction with dynamic lymphoscintigraphy. Therefore, we recommend preoperative US before every SLNE.
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Affiliation(s)
- I Stoffels
- Department of Dermatology, Venerology and Allergology, University of Essen-Duisburg, Essen, Germany
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NORO S, YAMAZAKI N, NAKANISHI Y, YAMAMOTO A, SASAJIMA Y, KAWANA S. Clinicopathological significance of sentinel node biopsy in Japanese patients with cutaneous malignant melanoma. J Dermatol 2010; 38:76-83. [DOI: 10.1111/j.1346-8138.2010.01002.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Increased detection of metastatic melanoma in pediatric sentinel lymph node biopsies using RT-PCR on paraffin-embedded tissue. Appl Immunohistochem Mol Morphol 2010; 18:365-70. [PMID: 20571343 DOI: 10.1097/pai.0b013e3181ce1e61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sentinel lymph node (SLN) biopsy has become integral in the staging of patients with melanoma, and entails detailed histologic examination with immunohistochemistry. Reverse transcriptase-polymerase chain reaction (RT-PCR) for tyrosinase transcripts has been used to increase sensitivity but requires a dedicated piece of tissue that does not undergo histologic examination. We developed a nested RT-PCR assay for tyrosinase applicable on paraffin-embedded tissue and applied this to a series of SLNs from pediatric patients with melanoma. Thirty-six SLNs from 4 females and 4 males were included in the study. Eight lymph nodes with reactive changes were included as controls. SLNs were examined histologically and immunohistochemically for S100, tyrosinase, and MART1. Seven patients had between 1 and 4 morphologically-positive SLNs and one patient had negative SLNs (HISTO+; 12/36, 33%). Three lymph nodes were excluded from molecular analysis owing to inadequate RNA, and 29 of the remaining 33 nodes were positive (MOL+; 88%). All patients had at least 1 SLN positive by RT-PCR. Twelve were HISTO+/MOL+; 17 were HISTO-/MOL+; and 4 were HISTO-/MOL-. All control lymph nodes were negative for tyrosinase transcripts. The application of RT-PCR for tyrosinase to paraffin-embedded tissue significantly increased the number of positive SLNs and upstaged one patient from negative to positive. The prognostic implications of such findings require further investigation, especially in the pediatric age group. Nonetheless, this technique provides a useful tool to determine the clinical significance of RT-PCR positivity in melanoma SLNs.
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Bagaria SP, Faries MB, Morton DL. Sentinel node biopsy in melanoma: technical considerations of the procedure as performed at the John Wayne Cancer Institute. J Surg Oncol 2010; 101:669-76. [PMID: 20512942 DOI: 10.1002/jso.21581] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Since its first description in 1990, sentinel node (SN) biopsy has become the standard for accurate staging of a melanoma-draining regional lymphatic basin. This minimally invasive, multidisciplinary technique can detect occult metastases by selective sampling and focused pathologic analysis of the first nodes on the afferent lymphatic pathway from a primary cutaneous melanoma. An understanding of preoperative lymphoscintigraphy, intraoperative lymphatic mapping, and the definition of SN are critical for surgical expertise with SN biopsy.
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Affiliation(s)
- Sanjay P Bagaria
- John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California 90404, USA
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Ellis MC, Weerasinghe R, Corless CL, Vetto JT. Sentinel lymph node staging of cutaneous melanoma: predictors and outcomes. Am J Surg 2010; 199:663-8. [PMID: 20466113 DOI: 10.1016/j.amjsurg.2010.01.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 01/07/2010] [Accepted: 01/07/2010] [Indexed: 01/13/2023]
Abstract
BACKGROUND The authors updated their experience with sentinel lymph node (SLN) biopsy of clinically node negative (N0) melanoma to clarify indications, predictive factors, and outcomes. METHODS A review of patients from the authors' institution's prospective database (n = 397) was performed; survival statistics were obtained from the institutional tumor registry. RESULTS The SLN-positive (SLN+) rate was 16% (47 of 282) for lesions >1 mm thick; only 2 of 105 T1 lesions were SLN+. Thickness >2 mm, upper extremity primary, and ulceration predicted SLN+ status. Most SLN+ patients underwent completion node dissection; 12% had additional positive nodes. The false-negative SLN biopsy rate was 4.0%; the majority involved lower extremity and head and neck primaries. The overall complication rate was 26%; all were minor and resolved within 6 months. Overall 5-year survival rates were 73% and 92% for SLN+ and SLN-negative patients, respectively. SLN status was the most significant predictor of survival. CONCLUSIONS SLN status, the most important determinant of outcome for clinically N0 melanoma, correlated with T stage, ulceration, and site. Staging of T1 lesions had low yield. A minority of completion node dissections yielded additional positive nodes.
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van Akkooi ACJ, Voit CA, Verhoef C, Eggermont AMM. New developments in sentinel node staging in melanoma: controversies and alternatives. Curr Opin Oncol 2010; 22:169-77. [DOI: 10.1097/cco.0b013e328337aa78] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Meier A, Satzger I, Völker B, Kapp A, Gutzmer R. Comparison of classification systems in melanoma sentinel lymph nodes-An analysis of 697 patients from a single center. Cancer 2010; 116:3178-88. [DOI: 10.1002/cncr.25074] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Klode J, Dissemond J, Grabbe S, Hillen U, Poeppel T, Boeing C. Sentinel Lymph Node Excision and PET-CT in the Initial Stage of Malignant Melanoma. Dermatol Surg 2010; 36:439-45. [DOI: 10.1111/j.1524-4725.2010.01479.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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[Tumour regression is not predictive for higher risk of sentinel node involvement in thin melanomas (Breslow thickness < or = 1 mm)]. Ann Dermatol Venereol 2010; 137:276-80. [PMID: 20417360 DOI: 10.1016/j.annder.2010.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 02/02/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND Thin melanomas (Breslow thickness < or = 1 mm) are considered highly curable. The aim of this study was to evaluate the correlation between histological tumour regression and sentinel lymph node (SLN) involvement in thin melanomas. PATIENTS AND METHODS This was a retrospective single-centre study of 34 patients with thin melanomas undergoing SLN biopsy between April 1998 and January 2005. RESULTS The study included 14 women and 20 men of mean age 56.3 years. Melanomas were located on the neck (n=3), soles (n=4), trunk (n=13) and extremities (n=14). Pathological examination showed 25 SSM, four acral lentiginous melanomas, three in situ melanomas, one nodular melanoma and one unclassified melanoma with a mean Breslow thickness of 0.57 mm. Histological tumour regression was observed in 26 over 34 cases and ulceration was found in one case. Clark levels were as follows: I (n=3), II (n=20), III (n=9), IV (n=2). Growth phase was available in 15 cases (seven radial and eight vertical). Mitotic rates, available in 24 cases, were: 0 (n=9), 1 (n=11), 2 (n=2), 3 (n=1), 6 (n=1). One patient with histological tumour regression (2.9% of cases and 3.8% of cases with regressing tumours) had a metastatic SLN. One patient negative for SLN had a lung relapse and died of the disease. Mean follow-up was 26.2 months. CONCLUSION The results of the present study and the analysis of the literature show that histological regression of the primary tumour does not seem predictive of higher risk of SLN involvement in thin melanomas. This suggests that screening for SLN is not indicated in thin melanomas, even those with histological regression.
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Abstract
Appropriate surgical management of regional lymph nodes is critical in patients with cutaneous melanoma. The use of intraoperative lymphatic mapping and sentinel lymph node biopsy (SLNB) has increased significantly in the past decade. SLNB is performed as minimally invasive procedure that provides accurate staging of melanoma patients with no clinically detectable nodal disease. In many melanoma units across the world, it became the standard for detection of occult regional node metastasis in patients with intermediate-thickness primary melanoma. Use of SLNB in patients with thin melanomas is still under evaluation. Although SLNB has been established as staging procedure in melanoma patients, its therapeutic role is still not clear. Large-scale ongoing randomized trials should elucidate whether SLNB with complete lymphadenectomy has a survival benefit in melanoma patients with early lymph node metastases compared to 'watch-and-wait' policy (observation).
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Affiliation(s)
- M Lens
- Genetic Epidemiology Unit, King's College, St Thomas' Hospital, London, UK.
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Chakera AH, Hesse B, Burak Z, Ballinger JR, Britten A, Caracò C, Cochran AJ, Cook MG, Drzewiecki KT, Essner R, Even-Sapir E, Eggermont AMM, Stopar TG, Ingvar C, Mihm MC, McCarthy SW, Mozzillo N, Nieweg OE, Scolyer RA, Starz H, Thompson JF, Trifirò G, Viale G, Vidal-Sicart S, Uren R, Waddington W, Chiti A, Spatz A, Testori A. EANM-EORTC general recommendations for sentinel node diagnostics in melanoma. Eur J Nucl Med Mol Imaging 2009; 36:1713-42. [PMID: 19714329 DOI: 10.1007/s00259-009-1228-4] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The accurate diagnosis of a sentinel node in melanoma includes a sequence of procedures from different medical specialities (nuclear medicine, surgery, oncology, and pathology). The items covered are presented in 11 sections and a reference list: (1) definition of a sentinel node, (2) clinical indications, (3) radiopharmaceuticals and activity injected, (4) dosimetry, (5) injection technique, (6) image acquisition and interpretation, (7) report and display, (8) use of dye, (9) gamma probe detection, (10) surgical techniques in sentinel node biopsy, and (11) pathological evaluation of melanoma-draining sentinel lymph nodes. If specific recommendations given cannot be based on evidence from original, scientific studies, referral is given to "general consensus" and similar expressions. The recommendations are designed to assist in the practice of referral to, performance, interpretation and reporting of all steps of the sentinel node procedure in the hope of setting state-of-the-art standards for good-quality evaluation of possible spread to the lymphatic system in intermediate-to-high risk melanoma without clinical signs of dissemination.
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Affiliation(s)
- Annette H Chakera
- Department of Plastic Surgery and Burns Unit, Rigshospitalet, Copenhagen, Denmark.
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Testori A, Rutkowski P, Marsden J, Bastholt L, Chiarion-Sileni V, Hauschild A, Eggermont AMM. Surgery and radiotherapy in the treatment of cutaneous melanoma. Ann Oncol 2009; 20 Suppl 6:vi22-9. [PMID: 19617294 PMCID: PMC2712595 DOI: 10.1093/annonc/mdp257] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Adequate surgical management of primary melanoma and regional lymph node metastasis, and rarely distant metastasis, is the only established curative treatment. Surgical management of primary melanomas consists of excisions with 1–2 cm margins and primary closure. The recommended method of biopsy is excisional biopsy with a 2 mm margin and a small amount of subcutaneous fat. In specific situations (very large lesions or certain anatomical areas), full-thickness incisional or punch biopsy may be acceptable. Sentinel lymph node biopsy provides accurate staging information for patients with clinically unaffected regional nodes and without distant metastases, although survival benefit has not been proved. In cases of positive sentinel node biopsy or clinically detected regional nodal metastases (palpable, positive cytology or histopathology), radical removal of lymph nodes of the involved basin is indicated. For resectable local/in-transit recurrences, excision with a clear margin is recommended. For numerous or unresectable in-transit metastases of the extremities, isolated limb perfusion or infusion with melphalan should be considered. Decisions about surgery of distant metastases should be based on individual circumstances. Radiotherapy is indicated as a treatment option in select patients with lentigo maligna melanoma and as an adjuvant in select patients with regional metastatic disease. Radiotherapy is also indicated for palliation, especially in bone and brain metastases.
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Affiliation(s)
- A Testori
- European Institute of Oncology, Division of Melanoma, Milan, Italy.
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Smylie M, Claveau J, Alanen K, Taillefer R, George R, Wong R, Mason WP. Management of malignant melanoma: best practices. J Cutan Med Surg 2009; 13:55-73. [PMID: 19459245 DOI: 10.2310/7750.2008.08029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Melanoma is a commonly occurring cancer in Canada, with an estimated age-standardized incidence of 10 to 13 per 100,000. An estimated 4,300 new cases were diagnosed, and there were 800 reported deaths in 2005. OBJECTIVE AND CONCLUSION The Canadian Expert Panel on Malignant Melanoma has developed best practices to improve the management of malignant melanoma. Sections include recommendations on primary diagnosis, dermatopathologic assessment, and reporting; use of preoperative lymphoscintigraphy and an intraoperative gamma probe to map and biopsy the sentinel lymph node; indications for surgical resection, sentinel node biopsy, and surgery for advance disease; use of interferon-alpha adjuvant therapy and treatment options for stage IV disease; and management of central nervous system metastases.
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El-Ghobashy A, Saidi S. Sentinel lymph node sampling in gynaecological cancers: Techniques and clinical applications. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2009; 35:675-85. [DOI: 10.1016/j.ejso.2008.09.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Revised: 09/02/2008] [Accepted: 09/03/2008] [Indexed: 11/26/2022]
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Is completion lymph node dissection needed in case of minimal melanoma metastasis in the sentinel node? Ann Surg 2009; 249:1003-7. [PMID: 19474678 DOI: 10.1097/sla.0b013e3181a77eba] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the micromorphometric Starz-classification in melanoma patients. SUMMARY BACKGROUND DATA The micromorphometric Starz-classification suggests that melanoma patients with a sentinel node metastasis invading no more than 0.3 mm (S-I) or 0.31 to 1.0 mm (S-II) below the capsular level can be spared further surgery, while invasion of the metastasis of more than 1.0 mm (S-III) implies a need for completion dissection. METHODS Seventy patients with sentinel node metastases were studied. Twenty patients with an S-I or S-II classification were spared further surgery and 50 S-III patients underwent completion dissection. The median follow-up time was 33 months. RESULTS No lymph node recurrences were detected in the 20 S-I, II patients. Six of the 50 S-III patients (12%) had additional involved nodes in the dissection specimen. In these patients no recurrences developed in the cleared regional basins. Overall 3-year survival was 100% in the S-I, II patients and 80% in the S-III patients (P = 0.04). Three-year disease-free survival rates were 83% and 60%, respectively (P = 0.40). CONCLUSIONS : This study suggests that further surgery is unnecessary in S-I and S-II patients, while it does seem prudent to carry out completion dissection in S-III patients. The distinct survival difference between the 2 groups of patients suggests that the S-classification also has prognostic implications.
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van der Ploeg IMC, Valdés Olmos RA, Kroon BBR, Wouters MWJM, van den Brekel MWM, Vogel WV, Hoefnagel CA, Nieweg OE. The yield of SPECT/CT for anatomical lymphatic mapping in patients with melanoma. Ann Surg Oncol 2009; 16:1537-42. [PMID: 19184226 DOI: 10.1245/s10434-009-0339-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Revised: 01/05/2009] [Accepted: 01/05/2009] [Indexed: 01/07/2023]
Abstract
BACKGROUND The hybrid single-photon emission computed tomography camera with integrated CT (SPECT/CT) fuses tomographic lymphoscintigrams with anatomical CT data. SPECT/CT shows the exact anatomical location of a sentinel node and may detect additional drainage. The purpose of this study was to explore its potential in patients with melanoma. METHODS We studied 85 patients with melanoma with conventional lymphoscintigrams that were difficult to interpret (51 patients), that showed an unusual drainage pattern (33 patients), or with nonvisualization (1 patient). Forty-one patients had melanoma on an extremity, 31 on the trunk, and 14 in the head and neck region. SPECT/CT was performed following late conventional imaging without reinjection of the radiopharmaceutical. RESULTS Conventional imaging suggested 214 sentinel nodes in 84 of the 85 patients (99%). SPECT/CT showed these same nodes and 12 extra sentinel nodes in seven patients (8%). Ten of these additional nodes were harvested, of which three nodes of two patients harbored metastases. There was a clear advantage of SPECT/CT in 30 patients (35%), resulting in a different incision in 17 patients, an incision at another site in 8, and an extra incision in 5 patients. The value was questionable in 19 patients (22%) in whom sentinel nodes were more clearly visualized by SPECT/CT, although the incision remained unchanged. There was no additional value of SPECT/CT in 36 patients (42%). CONCLUSIONS SPECT/CT detects additional drainage and shows the exact anatomical location of sentinel nodes in patients with inconclusive conventional lymphoscintigrams. SPECT/CT facilitates surgical exploration in difficult cases and may improve staging.
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Affiliation(s)
- Iris M C van der Ploeg
- Department of Surgery, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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