Sentinel lymph node biopsy in patients with cutaneous melanoma: outcome after 3-year follow-up

Utility of sentinel lymph node biopsy in papillary thyroid microcarcinoma

PURPOSE

There are many studies on sentinel lymph node (SLN) biopsy in thyroid carcinoma but SLN biopsy (SLNB) in papillary thyroid carcinoma (PTC) remains open to debate. Therefore in this retrospective study, the usefulness of SLNB in thyroid carcinoma patients who had micro-PTC without cervical lymphadenopathy was assessed.

METHODS

SLNB was performed in 114 patients who were diagnosed with micro-PTC in a single lobe without palpable or ultrasound-detected lymph node at the tertiary center between January 2012 and December 2013. After SLNB, all patients underwent total thyroidectomy and central neck dissection or thyroid lobectomy and central neck dissection of the single side.

RESULTS

SLNs were identified in 112 of 114 patients with 41 positive SLNs and 71 negative SLNs on intraoperative frozen sections. However, eight negative patients were found to be positive in the final pathology. Sentinel node identification rate and false negative value of SLNB were 98.2% and 11.3%, respectively. In the univariate analysis, higher lymph node metastasis was detected in men than in women. Higher detection number of SLN showed higher probability of lymph node metastasis.

CONCLUSION

SLNB may be helpful in papillary thyroid cancer, especially in male patients. Also, it is useful for the staging of nodal status and clearance of persistent disease.

The long-term prognostic impact of sentinel lymph node biopsy in patients with primary cutaneous melanoma: a prospective study with 10-year follow-up

Purpose

Sentinel lymph node (SLN) biopsy (SLNB) is widely accepted for staging of melanoma patients. It has been shown that clinico-pathological features such as Breslow thickness, ulceration, age, and sex are better predictors of relapse and survival than SLN status alone. The aims of this study were to evaluate the long-term (10-year) prognostic impact of SLNB and to determine predictive factors associated with SLN metastasis, relapse, and melanoma specific mortality (MSM).

Methods

This was a prospective observational study on 289 consecutive patients with primary cutaneous melanoma who underwent SLNB from January 2000 to December 2007, and followed until January 2014, at an Italian academic hospital.

Results

SLN was positive in 64 patients (22.1%). The median follow-up was 116 months (79–147 months). Ten-year disease-free survival and melanoma specific survival were poor in patients with positive SLN (58.7% and 66.4%, respectively). Only the increasing Breslow thickness resulted independently associated to an increased risk of SLN metastasis. Cox regression analysis showed that a Breslow thickness >2 mm was an independent predictor of relapse, and male sex and Breslow thickness >2 mm was a predictor of MSM. At 10 years, SLN metastasis was not significantly associated to either relapse or MSM.

Conclusion

After the fifth year of follow-up, SLN metastasis is not an independent predictive factor of relapse or mortality which are mainly influenced by the characteristics of the primary tumor and of the patient. Patients with a Breslow thickness >2 mm regardless of the SLN status should be considered at high risk for 10-year relapse and mortality.

Role of sentinel node in differentiated thyroid cancer: a prospective study comparing patent blue injection technique, lymphoscintigraphy and the combined technique

PURPOSE

The purpose of the present study was to evaluate the feasibility and reproducibility of the sentinel lymph node (SLNs) biopsy in differentiated thyroid cancer using patent blue injection, lymphoscintigraphy and the combined techniques.

METHODS

Between January 2011 and January 2013, 82 consecutive patients were enrolled in our prospective multicentre study. Inclusion criteria were 18 years of age, preoperative diagnosis of differentiated thyroid carcinoma, no evidence of lymph node enlargement and multifocal neoplasm. To investigate the benefits of each procedure, all patients underwent total thyroidectomy plus central compartment lymphadenectomy, and in all cases, the SLN was identified via one of three techniques using the same protocol.

RESULTS

Lymphoscintigraphy was used in five patients, patent blue injection was used in 40 patients, and a combined technique was used in 40 patients to identify sentinel lymph nodes (SLN). SLNs were identified in 61 cases. In the patent blue injection technique, the sensitivity, specificity and false negative rates were 88.9, 94.4 and 3.8%, respectively. In the lymphoscintigraphy technique, the percentages of sensitivity and specificity were 100%, and the percentage false negative was 0%. For the combined techniques, the corresponding values were, respectively, 69.2, 90, and 17.4%. Metastases were detected in nine cases of lateral-cervical nodes, ipsilateral tumour metastases were observed in eight cases, and contralateral tumour metastasis was observed in one case.

CONCLUSION

Additional well-designed randomized studies are needed to validate and further optimize the SLN biopsy in patients with differentiated thyroid cancer.

Radioguided sentinel lymph node biopsy in patients with papillary thyroid carcinoma

BACKGROUND

The ATA guidelines do not recommend prophylactic central compartment neck dissection in patients with T1-T2 papillary thyroid carcinoma (PTC) with no clinical evidence of lymph node metastasis, however patients' staging is recommended. Lymph node metastasis may be present also in small PTC, but preoperative ultrasound identifies suspicious cervical lymphadenopathy in 20-30% of patients. The role of sentinel lymph node biopsy (SLNB) remain open to debate. It has been shown that the identification rate of SLN in PTC patients is improved using a radiotracer compared to a dye technique. The aim of this systematic review was to evaluate the role of radioguided SLNB (rSLNB) in the treatment of PTC patients.

METHODS

A systematic search was performed in the PubMed and Embase database to identify all original articles regarding the application of rSLNB in PTC patients. The primary outcome was false negative rate (FNR) of the rSLNB; the secondary outcomes were SLN intraoperative identification rate (IIR), site of lymph node metastasis, and persistent disease during follow up.

RESULTS

Twelve studies were included. Most of PTC patients were T1-T2. The overall SLN IIR, SLN metastatic rate, and FNR were 92.1%, 33.6%, and 25.4%, respectively. Overall, lymph node metastasis were found in the central compartment (23.0%) and in the lateral compartments (10.6%). The persistent disease in patients who underwent SLNB associated to lymph node dissection (LND) in the same compartment of the SLN regardless of the SLN status was 0.6%.

CONCLUSIONS

In all PTC patients, also in T1-T2 stage, due to the high FNR the SLNB performed alone should be abandoned and converted into a technique to guide the lymphadenectomy in a specific neck compartment (i.e., central or lateral) based on the radioactivity, regardless of the SLN status, for better lymph node staging and selection of patients for postoperative radioiodine ablation.

Identification of Patients with Intermediate Thickness Melanoma at Low Risk for Sentinel Lymph Node Positivity

INTRODUCTION

Sentinel lymph node (SLN) biopsy is recommended for all patients with intermediate-thickness melanomas. We sought to identify such patients at low risk of SLN positivity.

METHODS

All patients with intermediate-thickness melanomas (1.01-4 mm) undergoing SLN biopsy at a single institution from 1995-2011 were included in this retrospective cohort study. Univariate and multivariate logistic regression determined factors associated with a low risk of SLN positivity. Classification and regression tree (CART) analysis was used to stratify groups based on risk of positivity.

RESULTS

Of the 952 study patients, 157 (16.5 %) had a positive SLN. In the multivariate analysis, thickness <1.5 mm (odds ratio [OR] 0.29), age ≥60 (OR 0.69), present tumor-infiltrating lymphocytes (OR 0.60), absent lymphovascular invasion (OR 0.46), and absent satellitosis (OR 0.44) were significantly associated with a low risk of SLN positivity. CART analysis identified thickness of 1.5 mm as the primary cut point for risk of SLN metastasis. Patients with a thickness of <1.5 mm represented 36 % of the total cohort and had a SLN positivity rate of 6.6 % (95 % confidence interval 3.8-9.4 %). In patients with melanomas <1.5 mm in thickness, the presence of additional low risk factors identified 257 patients (75 % of patients with <1.5 mm melanomas) in which the rate of SLN positivity was <5 %.

CONCLUSIONS

Despite a SLN positivity rate of 16.5 % overall, substantial heterogeneity of risk exists among patients with intermediate-thickness melanoma. Most patients with melanoma between 1.01 and 1.5 mm have a risk of SLN positivity similar to that in patients with thin melanomas.

Radio-guided selective compartment neck dissection improves staging in papillary thyroid carcinoma: a prospective study on 345 patients with a 3-year follow-up

BACKGROUND

Prospective uncontrolled study to investigate in papillary thyroid carcinoma (PTC) patients: (1) Distribution of lymph node metastases within the neck compartments, (2) factors predicting lymph nodes metastases, and (3) disease recurrence after thyroidectomy associated with radio-guided selective compartment neck dissection (RSCND).

METHODS

We studied 345 consecutive PTC patients operated on between February 2004 and October 2011 at the S. Anna University Hospital, Ferrara (Italy). Patients with cervical lymph node metastases on preoperative ultrasonography and fine needle aspiration cytology were excluded. All patients underwent total thyroidectomy associated with SLN identification followed by RSCND in the SLN compartment, without SLN frozen section.

RESULTS

In patients with lymph node metastases, metastatic nodes were not in the central neck compartment in 22.6% of the cases. The presence of infiltrating or multifocal PTC was a predicting factor for lymph nodes metastases. The median follow-up was 35.5 months. RSCND was associated with a false-negative rate of 1.1%, a persistent disease rate of 0.6%, and a recurrent disease rate of 0.9%. The permanent dysphonia rate was 1.3%.

CONCLUSION

RSCND associated with total thyroidectomy may improve: (1) the locoregional lymph node staging, and (2) the identification of the site of lymphatic drainage within the neck compartments. Thus, considering the high false-negative rate of sentinel lymph node biopsy (SLNB), a radio-guided technique in PTC patients may guide the lymphadenectomy (ie, RSCND) to increase the metastatic yield and improve staging of the disease rather than avoid prophylactic lymphadenectomy (ie, SLNB).

One-year postoperative morbidity associated with near-infrared-guided indocyanine green (ICG) or ICG in conjugation with human serum albumin (ICG:HSA) sentinel lymph node biopsy

BACKGROUND

Sentinel lymph node biopsy (SLNB) is a standard staging procedure in breast cancer and skin melanoma patients. Radioactive colloid (RC) and blue dye are the routinely used markers for staining. The new dye used in this procedure, indocyanine green (ICG), seems to have true potential in near-infrared-guided SLNB. The aim of this study was to analyze 1-year morbidity after SLNB using RC and ICG or RC and ICG conjugated to human serum albumin (ICG:HSA) in breast cancer and skin melanoma patients.

METHODS

Forty-nine patients diagnosed with breast cancer and 10 patients with skin melanoma underwent SLNB using ICG with RC and ICG:HSA with RC. A total of 47 SLNB patients without the need for additional lymphadenectomy were evaluated approximately 1 year (11-13 months) for the presence of tattoo, extremity swelling, nerve dysfunction/pain, range of motion, and stiffness.

RESULTS

From the 47 patients examined, long-term morbidity was present in 3 (6.4%). In 1 patient, tattoo persisted for 11 months. Mild lymphedema was seen in 1 patient, and 1 patient exhibited minor functional deficit.

CONCLUSIONS

Using ICG or ICG:HSA seems to be safe, and long-term morbidity in SLNB patients is low. However, skin discoloration may appear as it does after the use of blue dye, and an increased number of harvested nodes might be associated with an increased number of iatrogenic lymphedema.

EANM-EORTC general recommendations for sentinel node diagnostics in melanoma

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.

Sentinel node biopsy for skin melanoma

BACKGROUND/AIM

Skin melanoma is one of the most malignant diseases with increasing incidence rate. Sentinel node biopsy (SNB) is very important for early detection of metastatic spread. The aim of the study was to analyze the first 40 patients with skin melanoma of 1 to 4 mm Breslow thickness when SNB was indicated.

METHODS

The patient characteristics, localization of the primary melanoma as well as histology grade were analyzed. SNB with intraoperative radiocolloid and methylene blue dye detection was performed.

RESULTS

Complication rate after SNB was analyzed and seroma was found in 5% of the patients. The therapeutic node dissection was performed in 10 patients with positive sentinel biopsy. The follow-up lasted two years. In five patients the false negative SNB was defined after the mean time of 11 months and the therapeutic dissection was performed.

CONCLUSION

SNB in melanoma patients is a useful diagnostic procedure. It is advised for melanoma of 1 to 4 mm Breslow thickness.

Imaging in cutaneous melanoma

Cutaneous melanoma (CM) is a common malignancy and imaging, particularly lymphoscintigraphy (LS), positron-emission tomography with 2-fluoro-2-deoxyglucose (FDG-PET), ultrasound, radiography computed tomography (CT) and magnetic resonance imaging have important roles in staging and restaging, surgical guidance, surveillance and assessment of recurrent disease. This review aims to summarize the available data regarding these and other imaging modalities in CM and provide the basis for subsequent formulation of guidelines regarding the use of imaging in CM. PubMed and Medline searches were performed and reference lists from publications were also searched. The published data were reviewed and tabulated. There is level I evidence supporting the use of LS and sentinel lymph node biopsy in nodal staging for CM. There is level III evidence demonstrating the superiority of ultrasound to palpation in the assessment of lymph nodes in CM. There is level IV evidence supporting FDG-PET in American Joint Committee on Cancer stage III/IV and recurrent CM and that FDG-PET/CT may be superior to FDG-PET. Level IV evidence also supports the use of CT in the same group of patients and the role of CT appears to be complementary to FDG-PET. Various imaging modalities, especially LS/sentinel lymph node biopsy and FDG-PET/CT, add incremental information in the management of CM and the various modalities have complementary roles depending on the clinical situation.

Validation of a nomogram to predict the presence of sentinel lymph node metastases in melanoma

BACKGROUND

Lymph node involvement is a very important prognostic factor for cutaneous melanoma. In this paper we try to validate a nomogram that was created at the Memorial Sloan-Kettering Cancer Center, New York, to predict the probability of metastases in the sentinel nodes of patients with cutaneous melanoma.

METHODS

Values of the following variables were collected in 218 patients with cutaneous melanoma and sentinel lymph node: age, thickness, level of Clark, location of the lesion, and ulceration or not, and the nomogram was applied to assess the probability of sentinel node involvement in each patient. The discrimination of the nomogram was assessed by calculating the area under the receiver operating characteristics (ROC) curve, and to assess the accuracy of the nomogram actual probabilities were plotted against the nomogram-calculated predicted probability.

RESULTS

The overall predictive accuracy of the nomogram was 0.869 (95% confidence interval 0.813-0.925). Mean predicted probability of sentinel node metastasis was highly correlated to the observed risk (r = 0.953; P < 0.012).

CONCLUSION

The nomogram is a useful diagnostic tool that provides an adequate accurate prediction of the probability of sentinel lymph node metastases in patients with cutaneous melanoma.

Impact of False-Negative Sentinel Lymph Node Biopsy on Survival in Patients with Cutaneous Melanoma

BACKGROUND AND OBJECTIVES

Sentinel lymph node biopsy is widely accepted as standard care in melanoma despite lack of pertinent randomized trials results. A possible pitfall of this procedure is the inaccurate identification of the sentinel lymph node leading to biopsy and analysis of a nonsentinel node. Such a technical failure may yield a different prognosis. The purpose of this study is to analyze the incidence of false negativity and its impact on clinical outcome and to try to understand its causes.

METHODS

The Melanoma Data Base at National Cancer Institute of Naples was analyzed comparing results between false-negative and tumor-positive sentinel node patients focusing on overall survival and prognostic factors influencing the clinical outcome.

RESULTS

One hundred fifty-one cases were diagnosed to be tumor-positive after sentinel lymph node biopsy and were subjected to complete lymph node dissection. Thirty-four (18.4%)patients with tumor-negative sentinel node subsequently developed lymph node metastases in the basin site of the sentinel procedure. With a median follow-up of 42.8 months the 5-year overall survival was 48.4% and 66.3% for false-negative and tumor-positive group respectively with significant statistical differences (P < .03).

CONCLUSIONS

The sensitivity of sentinel lymph node biopsy was 81.6%, and a regional nodal basin recurrence after negative-sentinel node biopsy means a worse prognosis, compared with patients submitted to complete lymph node dissection after a positive sentinel biopsy. The evidence of higher number of tumor-positive nodes after delayed lymphadenectomy in false-negative group compared with tumor-positive sentinel node cases, confirmed the importance of an early staging of lymph nodal involvement. Further data will better clarify the role of prognostic factors to identify cases with a more aggressive biological behavior of the disease.

[Anatomical location of the primary tumor as a variable to be considered in sentinel node biopsy of cutaneous melanoma]

INTRODUCTION

The anatomical location of cutaneous melanoma has been suggested to be an independent prognostic factor. The aim of the present study was to determine whether the location of the primary tumor influences sentinel node detection in cutaneous melanoma.

PATIENTS AND METHOD

Two hundred twelve patients with primary cutaneous melanoma (96 of the limbs, 89 of the trunk and 27 of the head or neck) who underwent sentinel lymph node biopsy were studied. Adequate lymphoscintigraphic and surgical localization was evaluated and epidemiological and histopathological variables, the number of lymph nodes draining the site of the primary lesion, sentinel nodes per drainage basin, and tumor-positive nodes were compared.

RESULTS

Localization was less successful for tumors of the head and neck (88.8%), both with lymphoscintigraphy (P<.001) and surgery (P<.0005), especially for lymph nodes adjacent to salivary glands (P<.0005). Melanomas of the trunk showed a greater number of nodes per lesion and wider variability in drainage pathways (P<.0005), although there were no differences in the number of sentinel nodes per drainage basin (P=.455).

CONCLUSIONS

Sentinel node detection with less successful in cutaneous melanomas located in the head and neck. Location of the sentinel node adjacent to a salivary gland is a factor that influences its detection. Cutaneous melanomas of the trunk showed a higher number of draining nodes per lesion than those located in the limbs or head and neck.

Indications for lymphatic mapping and sentinel lymphadenectomy in patients with thin melanoma (Breslow thickness < or =1.0 mm)

BACKGROUND

Patients with thin (Breslow thickness < or =1.0 mm) melanoma have a good prognosis (5-year survival >90%). Consequently, the added benefit of lymphatic mapping and sentinel lymphadenectomy (LM/SL) in these patients is controversial. We hypothesize that LM/SL with a focused examination of the sentinel node (SN) will detect a significant number of SN metastases in patients with thin melanoma and that certain clinical or histopathologic factors may serve as predictors of SN tumor involvement.

METHODS

Over 6 years, 349 patients with melanoma underwent LM/SL and were prospectively entered into an institutional review board (IRB)-approved database. LM/SL was performed with a combined radiotracer and blue dye technique. SNs were serially sectioned, and each section was examined by a dermatopathologist at multiple levels with hematoxylin and eosin as well as immunohistochemical stains.

RESULTS

One hundred forty-six patients (42%) had a melanoma with Breslow thickness < or =1.0 mm; six (4%) of these 146 patients had a tumor-involved SN. On multivariate analysis, none of the clinical or histopathologic factors examined were significantly associated with SN tumor involvement in patients with thin melanoma. Completion lymphadenectomy was performed on all patients with a tumor-involved SN. None of the patients had non-SN tumor involvement.

CONCLUSIONS

The incidence of SN tumor involvement in patients with thin melanoma is considerable. Although we were unable to identify predictors of SN tumor involvement in patients with thin melanoma, efforts to identify predictors of SN tumor involvement should continue. Until better predictors are identified, we continue to advocate offering LM/SL to patients with thin melanomas who demonstrate clinical or histopathologic characteristics that have historically been associated with an increased risk of recurrence and mortality.