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Jiang C, Zhang Y, Fu F, Deng P, Chen H. A Shift in Paradigm: Selective Lymph Node Dissection for Minimizing Oversurgery in Early Stage Lung Cancer. J Thorac Oncol 2024; 19:25-35. [PMID: 37748691 DOI: 10.1016/j.jtho.2023.09.1443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 08/29/2023] [Accepted: 09/17/2023] [Indexed: 09/27/2023]
Abstract
Systematic lymph node dissection has been widely accepted and turned into a standard procedure for lung cancer surgery. In recent years, the concept of "minimal invasive surgery (MIS)" has greatly changed the surgical paradigm of lung cancer. Previous studies revealed that excessive dissection of lymph nodes without metastases had uncertain clinical benefit. Meanwhile, it leads to the elevated risk of postoperative complications including chylothorax and laryngeal nerve injury. In addition, dissection of nonmetastatic lymph nodes may disturb systematic immunity, resulting in the secondary effect on primary tumor or latent metastases. The past decades have witnessed the innovative strategies such as lobe-specific lymph node dissection and selective lymph node dissection. On the basis of evolution of lymph node dissection strategy, we discuss the negative effects of excessive nonmetastatic lymph node dissection and summarize the recent advances in the optimized dissection strategies, hoping to provide unique perspectives on the future directions.
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Affiliation(s)
- Chenyu Jiang
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Institute of Thoracic Oncology, Fudan University, Shanghai, People's Republic of China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Yang Zhang
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Institute of Thoracic Oncology, Fudan University, Shanghai, People's Republic of China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Fangqiu Fu
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Institute of Thoracic Oncology, Fudan University, Shanghai, People's Republic of China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Penghao Deng
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Institute of Thoracic Oncology, Fudan University, Shanghai, People's Republic of China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Haiquan Chen
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Institute of Thoracic Oncology, Fudan University, Shanghai, People's Republic of China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China.
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Zhu S, Zhang M, Liu X, Luo Q, Zhou J, Song M, Feng J, Liu J. Single-cell transcriptomics provide insight into metastasis-related subsets of breast cancer. Breast Cancer Res 2023; 25:126. [PMID: 37858183 PMCID: PMC10588105 DOI: 10.1186/s13058-023-01728-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023] Open
Abstract
Breast cancer metastasis is a complex, multi-step process, with high cellular heterogeneity between primary and metastatic breast cancer, and more complex interactions between metastatic cancer cells and other cells in the tumor microenvironment. High-resolution single-cell transcriptome sequencing technology can visualize the heterogeneity of malignant and non-malignant cells in the tumor microenvironment in real time, especially combined with spatial transcriptome analysis, which can directly compare changes between different stages of metastatic samples. Therefore, this study takes single-cell analysis as the first perspective to deeply explore special or rare cell subpopulations related to breast cancer metastasis, systematically summarizes their functions, molecular features, and corresponding treatment strategies, which will contribute to accurately identify, understand, and target tumor metastasis-related driving events, provide a research basis for the mechanistic study of breast cancer metastasis, and provide new clues for its personalized precision treatment.
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Affiliation(s)
- Shikun Zhu
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Sichuan Province Engineering Technology Research Center of Molecular Diagnosis of Clinical Diseases, Molecular Diagnosis of Clinical Diseases Key Laboratory of Luzhou, Sichuan, China
| | - Mi Zhang
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Sichuan Province Engineering Technology Research Center of Molecular Diagnosis of Clinical Diseases, Molecular Diagnosis of Clinical Diseases Key Laboratory of Luzhou, Sichuan, China
| | - Xuexue Liu
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Sichuan Province Engineering Technology Research Center of Molecular Diagnosis of Clinical Diseases, Molecular Diagnosis of Clinical Diseases Key Laboratory of Luzhou, Sichuan, China
| | - Qing Luo
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Sichuan Province Engineering Technology Research Center of Molecular Diagnosis of Clinical Diseases, Molecular Diagnosis of Clinical Diseases Key Laboratory of Luzhou, Sichuan, China
| | - Jiahong Zhou
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Sichuan Province Engineering Technology Research Center of Molecular Diagnosis of Clinical Diseases, Molecular Diagnosis of Clinical Diseases Key Laboratory of Luzhou, Sichuan, China
| | - Miao Song
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Sichuan Province Engineering Technology Research Center of Molecular Diagnosis of Clinical Diseases, Molecular Diagnosis of Clinical Diseases Key Laboratory of Luzhou, Sichuan, China
| | - Jia Feng
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Sichuan Province Engineering Technology Research Center of Molecular Diagnosis of Clinical Diseases, Molecular Diagnosis of Clinical Diseases Key Laboratory of Luzhou, Sichuan, China.
| | - Jinbo Liu
- Department of Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Sichuan Province Engineering Technology Research Center of Molecular Diagnosis of Clinical Diseases, Molecular Diagnosis of Clinical Diseases Key Laboratory of Luzhou, Sichuan, China.
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Abstract
Early engagement of the lymphatic system by solid tumors in peripheral, nonlymphoid tissues is a clinical hallmark of cancer and often forecasts poor prognosis. The significance of lymph node metastasis for distant spread, however, has been questioned by large-scale lymph node dissection trials and the likely prevalence of direct hematogenous metastasis. Still, an emerging appreciation for the immunological role of the tumor-draining lymph node has renewed interest in its basic biology, role in metastatic progression, antitumor immunity, and patient outcomes. In this review, we discuss our current understanding of the early mechanisms through which tumors engage lymphatic transport and condition tumor-draining lymph nodes, the significance of these changes for both metastasis and immunity, and potential implications of the tumor-draining lymph node for immunotherapy.
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Affiliation(s)
- Haley du Bois
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY 10016
| | - Taylor A. Heim
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY 10016
| | - Amanda W. Lund
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY 10016
- Department of Pathology, NYU Grossman School of Medicine, New York, NY 10016
- Laura and Isaac Perlmutter Cancer Center NYU Langone Health, New York, NY 10016
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Stadler R, Leiter U, Garbe C. Kein Überlebensvorteil beim Sentinel-Lymphknoten-positiven Melanom mit sofortiger kompletter Lymphadenektomie - eine Übersicht. J Dtsch Dermatol Ges 2019; 17:7-14. [DOI: 10.1111/ddg.13707_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/11/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Rudolf Stadler
- Universitätsklinik für Dermatologie; Klinikum Johannes Wesling in Minden; Universitätsklinikum Ruhr; Bochum
| | - Ulrike Leiter
- Zentrum für Dermatoonkologie; Universitäts-Hautklinik; Eberhard Karls Universität; Tübingen
| | - Claus Garbe
- Zentrum für Dermatoonkologie; Universitäts-Hautklinik; Eberhard Karls Universität; Tübingen
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Stadler R, Leiter U, Garbe C. Lack of survival benefit in sentinel lymph node-positive melanoma with immediate complete lymphadenectomy - a review. J Dtsch Dermatol Ges 2018; 17:7-13. [DOI: 10.1111/ddg.13707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/11/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Rudolf Stadler
- University Hospital for Dermatology; Johannes Wesling Clinical Centre in Minden; Ruhr University Hospital; Bochum Germany
| | - Ulrike Leiter
- Centre for Dermato-oncology; University Department of Dermatology, Eberhard Karls University; Tübingen Germany
| | - Claus Garbe
- Centre for Dermato-oncology; University Department of Dermatology, Eberhard Karls University; Tübingen Germany
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Belli F, Lenisa L, Clemente C, Tragni G, Mascheroni L, Gallino G, Cascinelli N. Sentinel Node Biopsy and Selective Dissection for Melanoma Nodal Metastases. TUMORI JOURNAL 2018; 84:24-8. [PMID: 9619709 DOI: 10.1177/030089169808400105] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Early detection of nodal metastases still represents an important goal in the management of melanoma patients. A sentinel node is defined as the first colored node in the regional lymphatic basin following injection of blue dye in the site of the primary melanoma. Sentinel node biopsy may represent a feasible technique for early identification of occult disease. A therapeutic dissection is then performed only in patients with proven nodal disease, thus introducing the concept of selective dissection. Methods At the National Cancer Institute of Milan from February 1994 to October 1996, 74 patients with a melanoma of the trunk or limbs and without clinically detectable node metastases were submitted to sentinel node biopsy and eventual selective dissection. Results The sentinel node was identified in 67 patients (90%). Nodal metastases were detected in 11 patients (16%); 5 of these were identified by an intraoperative frozen section examination. In all but one case, only the sentinel node was affected at radical dissection. Incidence of positive sentinel nodes was correlated with depth of infiltration of the primary lesion. Mapped nodal basin failures were observed in 3 patients with negative sentinel node biopsy. All patients but one, presenting distant metastases, are alive at this writing and free of disease with a follow-up ranging from 2 to 34 months. Conclusions Our study adds to accumulating evidence supporting the efficacy of sentinel node biopsy in detecting occult localizations and the potential of the technique to better select the group of patients that may benefit from nodal dissection.
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Affiliation(s)
- F Belli
- Department of General Surgery B, National Cancer Institute, Milan, Italy
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Cigna E, Gradilone A, Ribuffo D, Gazzaniga P, Fino P, Sorvillo V, Scuderi N. Morbidity of Selective Lymph Node Biopsy for Melanoma: Meta-Analysis of Complications. TUMORI JOURNAL 2018; 98:94-8. [DOI: 10.1177/030089161209800113] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Aim Intraoperative lymphatic mapping and selective lymph node biopsy is accepted worldwide as the standard procedure for staging regional lymph nodes of 1–4 mm thick melanomas, as well as for other neoplasms. Although it is often stated that selective lymph node biopsy is a minimally invasive procedure associated with few complications, few data exist concerning the morbidity associated with the procedure. The present analysis was performed to evaluate the morbidity associated with selective lymph node biopsy in a long-term follow-up. Materials and Methods The study provides a review of 437 selective lymph node biopsies on 269 patients, operated on between the 1994 and the 2009, for the lymph node biopsy of head and neck, groin, axilla, upper and lower limbs and nodal basins. Patients’ history and follow-up were reviewed for 2 weeks after surgery, every 3 months for the first 2 years, every 4 months during the third year, and every 6 months subsequently, and postoperative morbidity was evaluated. Results After sentinel node biopsy, 14 patients developed one of the following complications: hematoma, 1 case (0.30%); lymphedema, 1 case (0.30%); seroma, 2 cases (0.61%); wound infection, 6 cases (1.83%); keloid scar, 2 cases (0.61%); and postoperative pain, 2 cases (0.61%). The total complication rate was 4.26%. Conclusions Selective lymph node biopsy for melanoma, as for other tumors, in respect to radical lymphadenectomy, is not a complications-free procedure but is usually not severe.
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Affiliation(s)
- Emanuele Cigna
- Department of Plastic and Reconstructive Surgery, Sapienza University of Rome
| | - Angela Gradilone
- Department of Experimental Medicine, Sapienza University of Rome
| | - Diego Ribuffo
- Unit of Plastic Surgery, Cagliari University Hospital, Monserrato, Italy
| | - Paola Gazzaniga
- Department of Experimental Medicine, Sapienza University of Rome
| | - Pasquale Fino
- Department of Plastic and Reconstructive Surgery, Sapienza University of Rome
| | - Valentina Sorvillo
- Department of Plastic and Reconstructive Surgery, Sapienza University of Rome
| | - Nicolò Scuderi
- Department of Plastic and Reconstructive Surgery, Sapienza University of Rome
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An indigenous single-vial kit formulation of human serum albumin nanocolloid for use in sentinel lymph node detection. Nucl Med Commun 2016; 36:848-53. [PMID: 25932533 DOI: 10.1097/mnm.0000000000000333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In-situ sentinel lymph node (SLN) detection is an important component in staging cancers of various origins. At present, technetium-99m (Tc)-labeled nanoparticle formulations like sulfur colloid and human serum albumin (HSA) nanocolloid are used in the clinic as SLN tracers. In India, HSA nanocolloid cold kits have so far been imported. This study aims to develop and evaluate an indigenous alternative to imported HSA nanocolloid cold kits for SLN detection/imaging. MATERIALS AND METHODS Production of cold kits was standardized and the product was characterized for its suitability in terms of particle size. Tc-labeling of an in-house HSA nanocolloid was optimized, and the yield and stability of the product were assessed. Animal studies were performed in Wistar rats using the footpad model. Clinical evaluation was performed in 54 patients using a combination of scintigraphic imaging and a hand-held gamma probe. RESULTS AND CONCLUSION With the optimized protocol, HSA nanocolloids with particle sizes ranging from 50 to 200 nm were obtained. Greater than 90% Tc-labeling yield was obtained in 15 min reactions, and the radiopharmaceutical was stable for up to 24 h after preparation. The animal studies showed similar SLN uptake and improved retention pattern compared with those of the imported Nanocoll radiopharmaceutical. Clinical studies showed detectable 'hot' nodes in 53 of 54 patients, demonstrating sensitivity of the product for clinical utility. In conclusion, this indigenous HSA nanocolloid cold kit is proposed as a logistically favorable alternative to imported kits for SLN detection in the Indian clinical scenario.
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Scheri RP, Essner R. Lymphatic mapping and sentinel lymphadenectomy in primary cutaneous melanoma. Expert Rev Anticancer Ther 2014; 6:1105-10. [PMID: 16831081 DOI: 10.1586/14737140.6.7.1105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The management of clinically normal regional lymph nodes in early-stage melanoma has been controversial for over 100 years. Lymphatic mapping and sentinel lymphadenectomy has been developed as a minimally invasive surgical technique to stage regional lymph nodes without the associated morbidity of complete lymph node dissection. Multiple retrospective studies have validated the accuracy of lymphatic mapping and sentinel lymphadenectomy and the importance of the sentinel lymph node as a prognostic tool for melanoma. Several multicenter, prospective, randomized trials are underway to validate the data of the Phase II studies and determine the therapeutic benefit of lymphatic mapping and sentinel lymphadenectomy.
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Affiliation(s)
- Randall P Scheri
- Division of Surgical Oncology, John Wayne Cancer Institute, 2200 Santa Monica Boulevard, Santa Monica, CA 90404, USA.
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Abstract
Although melanoma represents only 10% of all skin cancer diagnoses, it accounts for at least 65% of all skin cancer-related deaths. The number of new cutaneous melanoma cases projected during 2010 was 68,000-a 23% increase from the 2004 prediction of 55,100 cases. In 2015, the lifetime risk of developing melanoma is estimated to increase to 1 in 50. As the incidence of melanoma continues to rise, now more than ever, clinicians and histopathologists must have familiarity with the various clinical and pathologic features of cutaneous melanoma.
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Affiliation(s)
- Clay J Cockerell
- Department of Dermatology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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Martinez SR, Tseng WH, Young SE. Outcomes for lymph node-positive cutaneous melanoma over two decades. World J Surg 2011; 35:1567-72. [PMID: 21559997 PMCID: PMC3109242 DOI: 10.1007/s00268-010-0903-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Our aim was to demonstrate that, despite advances in treatment and surveillance of node-positive cutaneous melanoma, rates of overall survival (OS) and melanoma-specific survival (MSS) have not changed over the last two decades. METHODS We used the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute to identify patients with node-positive cutaneous melanoma. Patients were categorized by treatment era; the first era encompassed patients diagnosed from 1988 to 1999 and the second era 2000 to 2006. Multivariate Cox proportional hazards models compared rates of OS and MSS between treatment eras while controlling for known prognostic factors. We reported risks of death as hazard ratios (HR) with 95% confidence intervals (CI) and set significance at P≤0.05. RESULTS Entrance criteria were met by 6,868 patients, 1,631 (23.8%) treated in era I and 5,237 (76.3%) treated in era II. On multivariate analysis, era II patients did not demonstrate a significantly different risk of death from any cause (HR 0.89, CI 0.79-1.01; P<0.08), but they did have a lower risk of melanoma-specific mortality (HR 0.81, CI 0.71-0.93; P=0.003) relative to their era I counterparts. CONCLUSIONS Over nearly two decades, MSS but not OS has improved for AJCC stage III melanoma patients. Stage migration is likely responsible for any improvement in MSS among patients in the most recently diagnosed era.
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Affiliation(s)
- Steve R Martinez
- Department of Surgery, Division of Surgical Oncology Sacramento, University of California at Davis, 4501 X Street, Suite 3010, Sacramento, CA 95817, USA.
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Goldberg BB, Merton DA, Liu JB, Forsberg F, Zhang K, Thakur M, Schulz S, Schanche R, Murphy GF, Waldman SA. Contrast-enhanced ultrasound imaging of sentinel lymph nodes after peritumoral administration of Sonazoid in a melanoma tumor animal model. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2011; 30:441-453. [PMID: 21460143 DOI: 10.7863/jum.2011.30.4.441] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES The purpose of this study was to compare lymphosonography (ie, contrast-enhanced ultrasound imaging [US] after interstitial injection of a US contrast agent) for the detection of sentinel lymph nodes (SLNs) in swine with naturally occurring melanoma tumors to lymphoscintigraphy using blue dye-guided surgical dissection as the reference standard. Also, we sought to determine if lymphosonography can be used to characterize SLNs. METHODS Sixty-three swine with 104 melanomas were evaluated. Contrast-specific US was performed after peritumoral injection (1 mL dose) of Sonazoid (GE Healthcare, Oslo, Norway). Lymphoscintigraphy was performed after peritumoral injections of technetium Tc 99m sulfur colloid. Peritumoral injection of 1% Lymphazurin (Ben Venue Labs, Inc, Bedford, OH) was used to guide SLN resection. The accuracy of SLN detection with the two imaging modalities was compared using the McNemar test. The SLNs were qualitatively and quantitatively characterized as benign or malignant based on the lymphosonography results with histopathology and RNA analyses used as the reference standards. RESULTS Blue dye-guided surgery identified 351 SLNs. Lymphosonography detected 293 SLNs and 11 false-positives, while lymphoscintigraphy detected 231 SLNs and 20 false-positives. The accuracy of SLN detection was 81.8% for lymphosonography, which was significantly higher than the 63.2% achieved with lymphoscintigraphy (P < .0001). The accuracy of lymphosonography for SLN characterization was 80%. When the size of the enhanced SLN was taken into consideration to characterize SLNs, the accuracy was 86%. CONCLUSIONS Lymphosonography is statistically better than lymphoscintigraphy for the detection of SLNs in this animal model. The ability to use lymphosonography as a means to characterize SLNs as benign or malignant is limited.
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Affiliation(s)
- Barry B Goldberg
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
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White V, Harvey JR, Griffith CDM, Youssef M, Carr M. Sentinel lymph node biopsy in early breast cancer surgery--working with the risks of vital blue dye to reap the benefits. Eur J Surg Oncol 2010; 37:101-8. [PMID: 21195576 DOI: 10.1016/j.ejso.2010.12.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 11/21/2010] [Accepted: 12/06/2010] [Indexed: 11/24/2022] Open
Abstract
AIMS Sentinel lymph node biopsy (SLNB) is an important method of staging early breast cancer because of the inherent benefits it confers on patients in terms of arm function and quality of life. Its success depends on a high level of accuracy in detecting the sentinel node. This is achieved by a dual mapping technique that employs a radio-labelled nanocolloid and a vital blue dye. The vital dyes however carry the risk of anaphylaxis, and as more surgeons employ SLNB in their daily practice, a proportionate rise in the number of anaphylactic reactions can be expected. A comprehensive review of risks and benefits associated with using vital blues dyes has not been published and therefore a retrospective review was undertaken of the different levels of anaphylaxis associated with vital dyes as well as their benefits in SLNB. METHODS An OVID MEDLINE search was performed of the English published literature using appropriate search terms to find published trial data and case series that focused on adverse reactions to vital blue dyes. RESULTS The risk of severe anaphylaxis (grade 3) can be as low as 0.06%, and up to 0.4% for patients undergoing SLNB when data is analysed from large trials. Furthermore, adverse reactions associated with blue dyes are reversible with appropriate management. CONCLUSIONS Surgeons should continue to use vital dyes to ensure that SLNB remains a highly sensitive procedure.
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Affiliation(s)
- V White
- Department of Breast Surgery, Wansbeck General Hospital, Woodhorn Lane, Ashington NE63 9JJ, United Kingdom.
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Essner R. Lymphatic mapping and sentinel lymphadenectomy in primary cutaneous melanoma. Expert Rev Anticancer Ther 2010; 10:723-8. [PMID: 20470004 DOI: 10.1586/era.10.65] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The management of clinically normal regional lymph nodes in early-stage melanoma has been controversial for over a century. Lymphatic mapping and sentinel lymphadenectomy (LM/SL) has been developed as a minimally invasive surgical technique to stage the regional lymph nodes without the associated morbidity of elective complete lymph node dissection. Multiple retrospective studies have validated the accuracy of LM/SL and the importance of the sentinel nodes as a staging tool for melanoma. Two multicenter, prospective, randomized trials have been performed to validate the data from the Phase II studies and determine if a therapeutic benefit exists for LM/SL.
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Affiliation(s)
- Richard Essner
- Departments of Surgical Oncology and Molecular Therapeutics, California Oncology Research Institute, Santa Monica, CA, USA
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Hayashi T, Furukawa H, Tsutsumida A, Yoshida T. A false-negative sentinel lymph node in the parotid gland of a melanoma patient: a new algorithm for SLN biopsy in the parotid gland. Int J Clin Oncol 2010; 15:504-7. [DOI: 10.1007/s10147-010-0063-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 02/05/2010] [Indexed: 11/28/2022]
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Lewis JM, Zager JS, Yu D, Pelaez D, Riker AI, Dessureault S, Cruse CW, Reintgen DS, Puleo CA, Sondak VK. Full-Thickness Grafts Procured from Skin Overlying the Sentinel Lymph Node Basin; Reconstruction of Primary Cutaneous Malignancy Excision Defects. Ann Surg Oncol 2008; 15:1733-40. [DOI: 10.1245/s10434-008-9887-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Revised: 02/17/2008] [Accepted: 02/17/2008] [Indexed: 11/18/2022]
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Denninghoff VC, Falco J, Kahn AG, Trouchot V, Curutchet HP, Elsner B. Sentinel node in melanoma patients: triple negativity with routine techniques and PCR as positive prognostic factor for survival. Mod Pathol 2008; 21:438-44. [PMID: 18223554 DOI: 10.1038/modpathol.3801020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Lymph node mapping and sentinel lymph node biopsy are currently used to stage patients with cutaneous malignant melanoma. Immunohistochemical stains contribute to the detection of micrometastases; however, molecular biology techniques are associated with better diagnostic sensitivity. Sixty sentinel lymph nodes were included in this study. The primary lesions were malignant melanoma stage I or II, with a follow-up of longer than 2 years. Sentinel lymph nodes were studied with hematoxylin-eosin, immunohistochemistry for S-100 and HMB-45, and molecular biology techniques (reverse transcription (RT)-PCR) for the detection of tyrosinase messenger RNA. In 15 of 60 cases (25%), tyrosinase was detected by RT-PCR; three of these cases were also positive by immunohistochemistry. The population was divided into three groups: (i) hematoxylin-eosin-/immunohistochemistry+/molecular biology techniques+ (3 cases); (ii) hematoxylin-eosin-/immunohistochemistry-/molecular biology techniques+ (12 cases); (iii) hematoxylin-eosin-/immunohistochemistry-/molecular biology techniques- (45 cases). Correlation of the groups with overall survival showed the following: (i) 2 of 3 patients died (67%); (ii) 5 of 12 died (42%), and (iii) all 45 patients are alive, with no lymphadenectomy and a median follow-up of 84 months. The inclusion of molecular biology techniques appears to be of great value for the detection of sentinel lymph node micrometastases in patients with cutaneous malignant melanoma. In our series, those patients who showed negativity with all the three methods had a null recurrence rate. Therefore, this triple negativity could be a positive prognostic factor for overall survival. Our findings suggest the possibility of molecular oncological staging, which would allow the selection of patients with submicroscopic metastases for a complete treatment.
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Affiliation(s)
- Valeria C Denninghoff
- Department of Pathology, Center for Medical Education and Clinical Investigation, Buenos Aires, Argentina.
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Young SE, Martinez SR, Faries MB, Essner R, Wanek LA, Morton DL. Can surgical therapy alone achieve long-term cure of melanoma metastatic to regional nodes? Cancer J 2006; 12:207-11. [PMID: 16803679 DOI: 10.1097/00130404-200605000-00009] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anecdotal reports of melanoma recurrence 15 years after complete lymphadenectomy have led to claims that the onset of nodal metastasis invariably signals systemic metastases and a terminal diagnosis. Few series in the literature are able to refute this assertion. We therefore examined rates of long-term (> 15-25 years) survival for patients with regional (nodal) melanoma. PATIENTS AND METHODS We performed an analysis of patients with American Joint Committee on Cancer stage III melanoma entered into a prospective database for the last 30 years. All patients were seen at the treating institution within 4 months of their diagnosis and monitored thereafter. All patients underwent complete lymphadenectomy. Patients receiving melanoma vaccines were excluded. Statistical comparisons used Chi-square analysis and the log-rank test. RESULTS At a maximum follow up of 386 months (32 years) for the population of 1422 patients, rates of 15-, 20-, and 25-year melanoma-specific survival were 36% +/- 1%, 35% +/- 1%, and 35% +/- 1%, respectively. When patients were stratified by clinical status of regional lymph nodes, survival rates were significantly lower (P = 0.001) if nodes were palpable. The number of tumor-positive nodes (P < 0.0001), the pathological primary tumor stage (P = 0.005), age (P = 0.0001), and gender (P = 0.002) also were significantly related to long-term survival. DISCUSSION Long-term survivors of melanoma metastatic to regional lymph nodes are not uncommon, and the extremely low rate of recurrence beyond 15 years suggests that this disease-free interval is usually synonymous with cure. Although some risk factors decrease the likelihood of long-term survival, the high overall rates of extended survival in all risk groups clearly support surgical management as the primary treatment for regional metastatic melanoma.
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Affiliation(s)
- Shawn E Young
- Division of Surgical Oncology and the Roy E. Coates Research Laboratories, John Wayne Cancer Institute at St. John's Health Center, Santa Monica, California, USA
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Goldberg BB, Merton DA, Liu JB, Murphy G, Forsberg F. Contrast-enhanced sonographic imaging of lymphatic channels and sentinel lymph nodes. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2005; 24:953-65. [PMID: 15972710 DOI: 10.7863/jum.2005.24.7.953] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVE The purpose of this study was to determine whether lymphatic channels (LCs) and sentinel lymph nodes (SLNs) could be detected on sonographic imaging after subcutaneous, submucosal, or parenchymal injections of a sonographic contrast agent (ie, lymphosonography) in a variety of anatomic locations in several animal models. METHODS Eight swine, 7 canines, 4 rabbits, and a monkey were used for these evaluations. Gray scale pulse inversion harmonic imaging of the LCs and the SLNs was performed after subcutaneous (n = 58), submucosal (n = 14), or parenchymal (n = 8) injections of a tissue-specific sonographic contrast agent (Sonazoid; GE Healthcare, Oslo, Norway). In many instances, blue dye was injected into the same locations as Sonazoid, and surgical dissection of the SLNs and LCs was performed for comparison. Scanning electron microscopy (SEM) of contrast-enhanced and control lymph nodes from 2 rabbits was performed to determine the mechanism of contrast agent uptake and retention within SLNs. RESULTS After subcutaneous, submucosal, or parenchymal contrast agent injections, gray scale pulse inversion harmonic imaging could be used to identify the number and location(s) of LCs and SLNs. After subcutaneous, submucosal, or parenchymal contrast agent injections, Sonazoid was confined to the SLNs (ie, contrast enhancement was not detected in the second-echelon nodes). There was good agreement between the results of lymphosonography and blue dye with surgical dissection in identifying the regional LCs and SLNs. Scanning electron microscopy identified vacuoles representing intact contrast microbubbles within contrast-enhanced SLN macrophages, which were not present in the control lymph nodes. CONCLUSIONS Lymphosonography can be used to detect lymphatic drainage pathways and SLNs in a variety of animal models.
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Affiliation(s)
- Barry B Goldberg
- The Jefferson Ultrasound Research and Education Institute, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
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Abrahamsen HN, Nexo E, Steiniche T, Hamilton-Dutoit SJ, Sorensen BS. Quantification of melanoma mRNA markers in sentinel nodes: pre-clinical evaluation of a single-step real-time reverse transcriptase-polymerase chain reaction assay. J Mol Diagn 2005; 6:253-9. [PMID: 15269303 PMCID: PMC1867641 DOI: 10.1016/s1525-1578(10)60518-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Although reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of melanocyte-associated mRNA can detect sentinel node melanoma metastases, most published assays are semi-quantitative methods of unknown sensitivity and precision, unsuitable for clinical use. We describe a single-step real-time quantitative RT-PCR assay for MART-1 and tyrosinase mRNAs, suitable for sentinel node analysis in a clinical setting. Using serial dilutions of melanoma cell line SK-MEL-28 RNA in water as a calibrator, we obtained linear calibration curves covering the range 0.5 to 10,000 arbitrary units (SK-MEL-28 melanoma cell equivalents). The sensitivity limit was 0.32 (MART-1) and 5 (tyrosinase) arbitrary units. Analytical imprecision was between 11% and 34%. MART-1 PCR efficiency was unaffected when samples were diluted with negative lymph node RNA rather than water, whereas tyrosinase PCR efficiency was halved. To evaluate the clinical suitability of our assay, we quantified melanocyte mRNAs in sentinel nodes with histologically verified micrometastases (n = 10) and benign nevus inclusions (n = 10), and in sentinel nodes without evidence of intranodal melanocytes (n = 10). We found significant differences in median melanocyte-derived mRNA levels comparing the three types of lymph nodes, suggesting that this quantitative molecular protocol may increase assay precision and be useful for the clinical evaluation of sentinel nodes.
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Affiliation(s)
- Helene N Abrahamsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Sygehus, Noerrebrogade 44, DK-8000 Aarhus C, Denmark.
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Goldberg BB, Merton DA, Liu JB, Thakur M, Murphy GF, Needleman L, Tornes A, Forsberg F. Sentinel lymph nodes in a swine model with melanoma: contrast-enhanced lymphatic US. Radiology 2004; 230:727-34. [PMID: 14990839 DOI: 10.1148/radiol.2303021440] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine if lymphatic channels and sentinel lymph nodes (SLNs) with and without metastases can be detected with lymphatic ultrasonography (US) after peritumoral injection of a US contrast agent and to determine if lymphatic US can be used to assess SLNs for the presence of metastatic infiltration. MATERIALS AND METHODS Six swine with 17 melanomas were evaluated. Conventional gray-scale, color flow, and gray-scale phase-inversion harmonic US examinations were performed. A US contrast agent was administered in four sites around each melanoma (1-mL total dose). Lymphoscintigraphy was followed by injection of a blue dye and then dissection. SLNs identified at lymphatic US were characterized by two readers in consensus as normal or as having metastases; results were compared with histologic findings. Statistical analyses included the sign test and the kappa statistic. RESULTS Lymphatic US depicted 28 SLNs, while lymphoscintigraphy depicted 27 "hot spots" suspected of representing SLNs (including two false-positive findings). Dissection after blue dye injection helped identify 31 SLNs. There were no false-positive US findings for SLN detection. Five of six nodes not seen with lymphoscintigraphy were detected with lymphatic US. The accuracy of SLN detection was 90% (28 of 31) for lymphatic US and 81% (25 of 31) for lymphoscintigraphy (P =.29). Lymphatic US correctly depicted metastases in 19 of 20 SLNs, and five of the eight normal SLNs were correctly characterized, with an accuracy of 86% (kappa = 0.62). CONCLUSION Detection of SLNs with lymphatic US compared favorably with that at lymphoscintigraphy. Lymphatic US can depict metastases within the SLN, which was not possible with lymphoscintigraphy.
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Affiliation(s)
- Barry B Goldberg
- Department of Radiology, Thomas Jefferson University Hospital, 7th Floor Main Bldg, 132 S 10th St, Philadelphia, PA 19107, USA.
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Cochran A, Bailly C, Luo F, Binder S. Prediction of outcome for patients with cutaneous melanoma. ACTA ACUST UNITED AC 2003. [DOI: 10.1016/s0968-6053(03)00051-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Li LXL, Scolyer RA, Ka VSK, McKinnon JG, Shaw HM, McCarthy SW, Thompson JF. Pathologic review of negative sentinel lymph nodes in melanoma patients with regional recurrence: a clinicopathologic study of 1152 patients undergoing sentinel lymph node biopsy. Am J Surg Pathol 2003; 27:1197-202. [PMID: 12960803 DOI: 10.1097/00000478-200309000-00002] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A sentinel lymph node (SLN) that is melanoma negative by pathologic examination implies absence of melanoma metastasis to that regional lymph node field. However, a small proportion of patients develop regional node field recurrence after a negative SLN biopsy. In this study, we reviewed the histopathology of negative SLNs from such patients to determine whether occult melanoma cells were present in the SLNs, to characterize the pathologic features of false-negative SLNs, and to provide recommendations for the histopathologic examination of these specimens. Between March 1992 and June 2001, of 1152 patients who had undergone SLN biopsy for primary melanomas at the Sydney Melanoma Unit, 976 were diagnosed with negative SLNs by initial pathologic examination (using 2 hematoxylin and eosin stained sections, and 2 immunostained sections for S-100 protein and HMB45), and follow-up was available in 957. Of these, 26 (2.7%) developed regional lymph node recurrence during a median follow-up period of 35.7 months. For 22 of them, the original slides and tissue blocks were available for reexamination. The original slides of each block were reviewed. Multiple further sections were cut from each block and stained with hematoxylin and eosin, for S-100, HMB45, and Melan A. Deposits of occult melanoma cells were detected in 7 of the 22 cases (31.8%). In 5 of the 7 cases, deposits of melanoma cells were present only in the recut sections. There were no significant differences in clinical and pathologic variables for those patients in whom occult melanoma cells were found by pathologic reexamination of their SLNs, compared with those in whom no melanoma cells were detected. The detection of melanoma cell deposits in only 7 of 22 false-negative SLNs suggests that mechanisms other than failure of histopathologic examination may contribute to the failure of the SLN biopsy technique in some patients. The failure rate for melanoma detection in SLNs by our routine pathologic examination, using the current protocol at our institution, was <1% (7 of 957 patients). Routinely performing more intensive histopathologic examination of SLNs is difficult to justify from a cost benefit perspective; we therefore recommend examining two hematoxylin and eosin stained sections and two immunostained sections (for S-100 and HMB45) routinely on SLNs from melanoma patients.
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Affiliation(s)
- Ling-Xi L Li
- Melanoma and Skin Cancer Research Institute, Sydney Melanoma Unit, Royal Prince Alfred Hospital, Camperdown, NWS, Australia
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Abstract
The surgical management of melanoma has evolved over the last 100 years. when early concepts of lymphatic permeation of the tumors and metastases led surgeons to perform radical operative procedures. Wide excision of primary melanoma is now performed with 1- to 2-cm radial margins, significantly reducing the need for complex plastic closures, skin grafts. and hospital admissions. Although elective lymph node dissection remains controversial as a therapeutic procedure, the development of SL has improved the staging of the regional lymph nodes and diminished the morbidity of lymph node dissection. The role of SL for routine care of melanoma patients remains unknown. Metastasectomy, which is the surgical resection of distant metastases with tumor-free surgical margins, has not been popular for AJCC stage IV patients with multiple metastases, because surgery is considered a local therapy and therefore of little value for management of disseminated disease. Nevertheless, the many reports of long-term survival after resection of distant melanoma metastases to diverse soft tissue and organ sites clearly indicate that this form of cytoreductive surgery can be extremely successful in carefully selected patients. Unlike chemotherapy, complete surgical metastasectomy can rapidly render a patient disease-free with only a short period of postoperative morbidity. Most patients fully recover from the surgical procedure within 6 weeks, returning to most or all activities. The ability to select patients for surgery is based on the development of more sophisticated imaging techniques, which allow better preoperative differentiation of patients with single versus multiple metastases and improve the surgeon's ability to identify and resect multiple metastatic sites. The overall data suggest that patients whose metastases can be completely resected will experience improved overall survival and occasional long-term cure regardless of the metastatic organ site and number of metastases. We believe that increased understanding of the biology of the primary and metastases, dramatic improvement in the accuracy of staging metastatic disease, and better techniques of surgical resection provide the best chance for long-term palliation or cure of melanoma. Cytoreductive surgery should be considered a form of immunotherapy. The long-term clinical benefit of this therapy depends on the patient's immune response to, the surgical reduction in tumor burden: an immune response that controls subclinical micrometastases should optimize postoperative survival.
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Affiliation(s)
- Richard Essner
- John Wayne Cancer Institute, 2200 Santa Monica Boulevard, Santa Monica, CA 90404, USA.
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Abstract
The management of clinically negative regional lymph nodes in early-stage melanoma has been controversial for at least a century. While some surgeons offer elective lymph node dissection (ELND), others recommend treatment of the primary alone and only perform a therapeutic dissection (TLND) for cases of recurrence in the nodal basin. The rationale for ELND is based on the concept that metastases occur via the sequential passage of tumor from the primary site to the regional lymph nodes and then to more distant sites. If this theory is correct then early dissection of the regional lymph nodes will disrupt the metastatic cascade and prevent further spread of disease. On the other hand, advocates of the "wait and watch" approach suggest that metastases to the regional lymph node basin are only a marker of disease progression and that distant disease can occur in the absence of lymph node metastases. Four randomized prospective studies have examined the efficacy of ELND versus TLND. While all four studies have failed to demonstrate a survival advantage of ELND, there is some suggestion that patients with metastases in the regional basin may benefit from ELND. As an alternative approach to this controversy, Morton and associates at the John Wayne Cancer Institute devised the technique of intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL). This minimally invasive operative procedure allows the surgeon to identify the first or sentinel lymph (SN) in the regional basin. The technique is predicated on accurate mapping of the cutaneous lymphatics by lymphoscintigraphy and the intraoperative use of a vital blue dye to lead the surgeon to the SN and allow the pathologists to identify metastases in the lymph nodes. Patients with tumor-positive dissections would undergo complete lymph node dissection (CLND), and for those without metastases the complications and costs associated with CLND could be avoided. The success of the procedure depends on the completion of a learning phase and on the cooperation of nuclear medicine physicians, surgeons, and pathologists. While this technique has become almost standard practice in the United States and around the world, we await the results of several important clinical trials to determine whether LM/SL will replace ELND or the wait and watch approach in the management of early-stage melanoma.
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Affiliation(s)
- Richard Essner
- John Wayne Cancer Institute, Santa Monica, CA 90404, USA
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28
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Abstract
Melanoma is a significant health problem. Despite public education and free cancer screenings, the incidence and mortality of melanoma continues to rise; however, many currently diagnosed melanomas are thin lesions, suggesting that education and awareness is having an impact. In addition, there are still subsets of patients who need increased surveillance in order to increase their survival. Although large congenital nevi may be precursors of melanoma, small and medium congenital nevi have an insignificant risk for melanoma development. Large congenital nevi, which are axial in location, appear to be more likely to develop melanoma and are associated with melanocytosis and melanoma of the CNS, both of which portend a poor prognosis. Recently, the recommended margins of excision have become more conservative so that many of the surgical defects can be closed primarily. Lymphoscintigraphy and sentinel node biopsy have replaced elective node dissections, thus decreasing the morbidity associated with the surgical management of melanoma. Although controversy still exists as to whether or not sentinel lymph node biopsy alters a patient's prognosis, it has been shown to be a powerful prognostic indicator. Although most melanomas are managed by routine surgical excision, other modalities are sometimes employed. For example, cryosurgery or radiation therapy may be indicated in the frail, elderly individual with a large facial lentigo maligna. Mohs surgery is the treatment of choice for head and neck melanomas and those located in areas where maximum preservation of tissue is required and for desmoplastic and acral lentiginous melanomas. Much more work remains in the area of adjuvant therapy, chemotherapy, and immunotherapy. Dacarbazine remains the drug of choice in disseminated melanoma, but remissions are usually short lived. Interleukin and biochemotherapy has yielded good results but the percentage benefiting is small. Although high dose interferon increases disease-free and overall survival in some patients, it remains a controversial drug which is not easily tolerated. In the new staging system for melanoma, ulceration is second only to Breslow's thickness. In transit (satellite) lesions have also been included in this new system. The new system also recognizes that patients with only microscopic metastatic nodal disease fare better than patients with clinically enlarged metastatic nodes and that it is the number of nodes involved with metastases, not their size, that determines the patient's prognosis. Except for lesions <1mm thick, the Clark's level of invasion has been de-emphasized.
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Affiliation(s)
- Pearon G Lang
- Medical University of South Carolina, Charleston, South Carolina 29925, USA
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29
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Bland KI. Utilization of sentinel lymph node mapping to determine pathologic outcomes for patients receiving neoadjuvant chemotherapy for locally advanced breast cancer. Ann Surg Oncol 2002; 9:217-9. [PMID: 11923125 DOI: 10.1007/bf02573056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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30
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Cascinelli N, Belli F, Santinami M, Fait V, Testori A, Ruka W, Cavaliere R, Mozzillo N, Rossi CR, MacKie RM, Nieweg O, Pace M, Kirov K. Sentinel lymph node biopsy in cutaneous melanoma: the WHO Melanoma Program experience. Ann Surg Oncol 2000; 7:469-74. [PMID: 10894144 DOI: 10.1007/s10434-000-0469-z] [Citation(s) in RCA: 256] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND We report the experience of the World Health Organization (WHO) Melanoma Program concerning sentinel lymph node (SLN) biopsy for detecting patients with occult regional nodal metastases to submit to selective regional node dissection. METHODS From February 1994 to August 1998, in 12 centers of the WHO Melanoma Program, 892 SLN biopsies were performed in 829 patients with clinical stage I melanoma (male: 370; female: 459; median age: 50 years old). The location of the primary melanoma was as follows: trunk 35%; lower limbs, 45%; upper limbs, 18%; and head and neck, 2%. Blue dye injection for SLN identification was performed in all cases; preoperative lymphoscintigraphy was done in 440 patients, and an intra-operative probe for a radio-guided biopsy was used in 141 cases. Overall, the SLN identification rate was 88%. In 68% of the patients, only one SLN was identified, whereas two and three or more SLN were detected in 24% and 8% of the remaining cases, respectively. RESULTS Overall SLN positivity rate was 18%. Intra-operative frozen section examination was performed in 39% of the cases and was helpful in detecting occult localizations only in 47% of the positive SLNs. Distribution of positive cases by primary thickness was as follows: < 1mm: 2%; 1-1.99 mm: 7%; 2-2.99 mm: 13%; and > or = 3 mm: 31%. Positive nonsentinel lymph nodes were found in 22% of cases with positive SLN submitted for selective dissection. No complications due to the procedure were registered. Of 710 patients who were evaluated, 40 (6%) presented a regional nodal relapse after a negative SLN biopsy and underwent a delayed therapeutic dissection. From the 710 enrolled cases, 638 (88.5%) were alive without evidence of disease at the time of this writing. A multivariate analysis showed SLN status as one of the most significant prognostic factors (P = .000) along with thickness (P = .001) and ulceration (P = .015) of primary tumor. CONCLUSIONS These data confirm the feasibility and safety of the SLN technique for selecting patients to submit to a radical node dissection. The data represent the basis for a future trial by the WHO Melanoma Program in this field to evaluate the most appropriate surgical approach for treating patients with occult regional nodal metastases.
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Affiliation(s)
- N Cascinelli
- Department of Surgery, Istituto Nazionale Tumori, Milan, Italy
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31
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Abstract
The initial application of intraoperative lymphatic mapping and sentinel lymphadenectomy followed by selective complete lymphadenectomy (LM/SL/SCLND) was in melanoma. This arose as a solution to the ongoing debate concerning immediate vs. delayed lymph node dissection. Acceptance of the concept and advances in nuclear medicine, surgery, and pathology aspects of the sentinel node procedure have brought it into widespread use for melanoma and have expanded its application for other solid tumors that progress through the lymphatic route. Although the diagnostic accuracy of the procedure has been demonstrated in multicenter trials, caution should be exercised regarding therapeutic aspects until definitive benefit can be shown from well-designed clinical trials. Current issues of active discussion and debate are reviewed including ideal nomenclature, clinical significance of occult metastatic disease, quality assurance, and the role of LM/SL/SCLND outside high-volume melanoma centers.
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Affiliation(s)
- A D Chan
- John Wayne Cancer Institute, Santa Monica, CA 90404-2302, USA
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33
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Morton DL, Chan AD. Current status of intraoperative lymphatic mapping and sentinel lymphadenectomy for melanoma: is it standard of care? J Am Coll Surg 1999; 189:214-23. [PMID: 10437845 DOI: 10.1016/s1072-7515(99)00129-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- D L Morton
- John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA 90404-2302, USA
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34
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Abstract
The incidence of malignant melanoma is increasing at a rate greater than any other cancer occurring in humans. In this era of managed care, patients with a suspicious pigmented lesion may first present to their primary care physician for evaluation. Therefore it is mandatory that the primary care physician be capable of distinguishing between benign and malignant pigmented lesions, know how to evaluate such patients, and know when to refer patients with suspicious or malignant pigmented lesions. Surgical removal remains the mainstay of treatment for patients with melanoma. Thus, to increase the cure rate for melanoma, both the public and nondermatologists need to be educated regarding the prevention and early detection of melanoma. Only in this way can the diagnosis of melanoma be made early before deep invasion has occurred and the patient placed at risk for systemic spread. In recent years, the surgical management of melanoma has become more conservative and rational. Limb amputation, arbitrary 5-cm margins of excision, and elective lymph node dissections are no longer performed. The recommended margins of excision are now based on objective pathologic and clinical data and are more conservative, and the sentinel node biopsy is now used to determine which high-risk patients should undergo a formal lymph node dissection. Although encouraging results are being seen with immunotherapy protocols, to date the only adjunctive therapy shown to increase survival in patients at high risk for systemic spread is alpha-interferon. With this drug, the improved survival is modest at best; it is expensive and a minority of patients can tolerate it in the doses recommended. Although response rates of 20% are seen with chemotherapy in patients with disseminated disease, these responses are short-lived, and there is no associated increased survival. Except for lentigo maligna, radiation therapy, even when its delivery is modified, still is useful only as an adjunct to surgery or for palliation.
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Affiliation(s)
- P G Lang
- Department of Dermatology, Medical University of South Carolina, Charleston, USA
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Lingam MK, Mackie RM, McKay AJ. Intraoperative identification of sentinel lymph node in patients with malignant melanoma. Br J Cancer 1997; 75:1505-8. [PMID: 9166945 PMCID: PMC2223508 DOI: 10.1038/bjc.1997.257] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
We report our experience with the technique of lymphatic mapping using patent blue V dye in patients with limb malignant melanoma. The technique is based on the hypothesis that embolic metastases occur along lymphatic channels to a 'sentinel' lymph node: the draining lymph node nearest the site of the primary malignant melanoma. Patent blue V dye (0.5-1.0 ml) is injected intradermally around the site of the melanoma. Immediately the groin or axilla is opened and the blue lymphatic channels followed to the sentinel node. The node is removed and examined by both haematoxylin and eosin (H&E) and immunohistochemical staining. We have carried out this technique in 35 patients, all of whom had 'clinically assessed' stage I disease. In all 35 patients, sentinel nodes were identified, and nine were found to contain unsuspected micrometastases. Our initial evaluation of intraoperative lymphatic mapping is very promising. The technique is practicable and easy to master. If 25% of patients with cutaneous malignant melanoma who are clinically stage I have nodal disease, this has great importance not only for staging and treatment but also for all future therapeutic trials.
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Affiliation(s)
- M K Lingam
- Department of Surgery, Gartnavel General Hospital, West Glasgow Hospitals University NHS Trust
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36
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Abstract
Subungual melanoma is a rare but well-recognized tumor of the hand. Its management is ill defined and the factors influencing prognosis have not been well described. The clinicopathologic features of a series of 38 patients with subungual melanoma of the hand are reported. The median thickness was 3 mm, and only seven patients presented with pathologic stage I disease (American Joint Committee on Cancer [AJCC] system). Ulceration and lack of pigmentation were the only significant univariate prognostic indicators. There was no significant difference in local recurrence rates among patients whose amputation was carried out proximal or distal to the interphalangeal joint of the thumb or the middle of the middle phalanx in the other fingers. Management of the regional lymph node field based on the use of selective lymphadenectomy is described.
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Affiliation(s)
- M J Quinn
- Sydney Melanoma Unit, Royal Prince Alfred Hospital, New South Wales, Australia
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37
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Papadopoulos T, Thompson JF, Quinn MJ. Melanoma of the lip. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1996; 66:327-30. [PMID: 8634055 DOI: 10.1111/j.1445-2197.1996.tb01198.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Melanoma of the lip is a very rare condition that tends to behave in an aggressive manner. Surgery remains the mainstay of treatment. Five patients with melanoma of the lip are reported, illustrating some of the difficulties that may be encountered in its management. Radical local treatment is necessary to minimize the risk of local recurrence, and flap reconstruction will usually be required to achieve acceptable aesthetic and functional results.
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Affiliation(s)
- T Papadopoulos
- Sydney Melanoma Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Jones WO, Cable RL, Gilling PJ. Laparoscopic pelvic lymphadenectomy for malignant melanoma. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1995; 65:765-7. [PMID: 7487722 DOI: 10.1111/j.1445-2197.1995.tb00555.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Therapeutic laparoscopic techniques are well accepted in many areas of general surgery. The use of laparoscopy for the staging of malignancy, in a diagnostic role, is not used widely. Urologists use pelvic lymph node dissection (LPLND) to define those patients who are suitable for curative local therapy in carcinoma of the prostate. We present a case of a patient with metastatic malignant melanoma in whom LPLND was employed as a minimally invasive way of staging and treating her disease.
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Affiliation(s)
- W O Jones
- Tauranga Public Hospital, New Zealand
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Rompel R, Garbe C, Büttner P, Teichelmann K, Petres J. Role of elective lymph node dissection in stage I malignant melanoma: evaluation by matched pair analysis. Recent Results Cancer Res 1995; 139:323-36. [PMID: 7597301 DOI: 10.1007/978-3-642-78771-3_25] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The role of elective lymph node dissection (ELND) in clinical stage I malignant melanoma continues to be controversial. We present a matched pair analysis of 375 patients treated in the Department of Dermatology in Kassel between 1979 and 1991 by wide local excision (WLE) plus ELND. Multivariate analysis revealed tumor thickness, level of invasion, age, sex, and localization as independent prognostic factors, and 375 patients treated by WLE alone were matched as controls to the patients treated by ELND and WLE. There was no significant benefit from WLE plus ELND compared to WLE alone in the total group as shown by the 5-year survival rates (87.3% versus 86.4%) and 10-year survival rates (80.1% versus 77.82%). Increased survival rates were noted for tumor thicknesses 1.51-4.0 mm for the WLE plus ELND group, as shown by the 10-year survival rates of 73.1% versus 60.3%. However, these data were not significant (p = 0.14). Disease-free survival rates were significantly higher in the group treated by additional ELND for all tumor thicknesses (p < 0.05) and even more in intermediate tumor thicknesses of 1.51-4.0 mm (p < 0.001). A significant benefit of elective lymph node dissection was detected for malignant melanoma of the trunk (all tumor thicknesses), as shown by the 5-year survival rates of 92.0% versus 79.7% and 10-year survival rates of 80.4% versus 45.16% (p < 0.05). Malignant melanoma of the extremities revealed no significant differences in survival rates. We conclude that there is a certain benefit from ELND in clinical stage I malignant melanoma for tumor thicknesses of 1.51-4.00 mm. Especially in malignant melanoma of the trunk, WLE plus ELND was more beneficious than WLE alone.
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Affiliation(s)
- R Rompel
- Department of Dermatology, Municipal Clinics of Kassel, Germany
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Doré JF, Berthier-Vergnes O, Zebda N, Bailly M, Thomas L, Bailly C, Cochran AJ. Selective expression of PNA-binding glycoconjugates by invasive human melanomas: a new marker of metastatic potential. PIGMENT CELL RESEARCH 1994; 7:461-4. [PMID: 7761355 DOI: 10.1111/j.1600-0749.1994.tb00076.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Alterations of cell-surface glycoconjugates have been associated with invasiveness and metastatic capacity in a number of experimental and human tumors (bladder and colon cancer). We have recently shown that human melanoma cells from variants selected for high metastatic potential in an animal model bind the lectin peanut agglutinin (PNA), and that human melanoma cell populations enriched for PNA binding cells generated a higher frequency of metastases when xenografted into immune suppressed neonatal rats. We have therefore sought cells binding PNA in biopsied human melanocytic tumors and compared frequencies of PNA binding by cells from benign nevi, early and late primary melanomas, and metastatic melanomas. Sections of conventionally processed tissues were deparaffinised and exposed to biotinylated PNA; PNA fixation was revealed by the avidine/peroxidase/AEC technique. In 51 specimens tested, PNA appears to react electively with invasive tumors, since only one of the 7 early primary melanomas (Clark I-II) reacted while 13/23 late primary melanomas (Clark III-V), and 4/21 melanoma metastases were reactive. In addition, only 1/17 benign nevi bound PNA. In primary tumors, the reactive cells were exclusively invasive tumors cells in the dermis. PNA reactive material was observed in the cytoplasm and plasma membrane of reactive cells. Hence, alterations in composition and cellular localisation of glycoconjugates detectable by lectin histochemistry in melanoma cells may be markers of metastatic potential that may be applicable on an individual patient basis.
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Affiliation(s)
- J F Doré
- INSERM U218, Centre Léon Bérard, Lyon, France
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Abstract
The role of elective lymph node dissection (ELND) in the management of primary melanoma of the skin is a controversial subject. Some authorities consider the indications for this procedure to be broad, whereas others rarely recommend ELND. Voluminous literature reflects these divergent opinions. Unfortunately, this can be confusing for the practitioner advising a patient with melanoma. We review arguments for and against ELND and review some of the most important studies of the effects of ELND on survival. We attempt to elucidate the sources of controversy inherent in these survival studies. Criteria for the selection of appropriate candidates for ELND are discussed. ELND with hyperthermic limb perfusion is also briefly reviewed.
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Affiliation(s)
- J H Lyons
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas 75235-9072
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Affiliation(s)
- K Horgan
- Department of Surgery, University of Wales College of Medicine, Cardiff
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Berthier-Vergnes O, Zebda N, Bailly M, Bailly C, Doré JF, Thomas L, Cochran AJ. Expression of peanut agglutinin-binding glycoconjugates in primary melanomas with high risk of metastases. Lancet 1993; 341:1292. [PMID: 8098445 DOI: 10.1016/0140-6736(93)91205-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Hohenberger P. [Axillary lymph node dissection in malignant melanoma]. LANGENBECKS ARCHIV FUR CHIRURGIE 1993; 378:1-3. [PMID: 8437495 DOI: 10.1007/bf00207986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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