Sentinel lymph node biopsy in patients with primary cutaneous melanoma: study of 455 cases

Macrocyclic-Albumin Conjugates for Precise Delivery of Radionuclides and Anticancer Drugs to Tumors

Precise delivery of radionuclides and anticancer drugs to tumor tissue is crucial to ensuring drug synergism and optimal therapeutic effects in radionuclide-based combination radio-chemotherapy. However, current codelivery vectors often rely on physical embedment/adsorption to load anticancer drugs, which lacks precise mechanisms for drug loading and release, resulting in unpredictable combination effects. Herein, a macrocyclic-albumin conjugate (MAC) that enables precise loading and controlled release of anticancer drugs is presented. By conjugating multiple macrocyclic hosts (sulfonate azocalix[4]arenes, SAC4A) to albumin molecules, the MAC facilitates the precise loading of anticancer drugs through host-guest interactions and site-specific labeling of radionuclides. Furthermore, the MAC degrades under hypoxic conditions, enabling the release of loaded drugs upon reaching tumor tissues. Through precise loading and targeted delivery of radionuclides and anticancer drugs, MAC achieves efficient cancer diagnosis and combined radio-chemotherapy in breast cancer cell (4T1)-bearing mice. Considering that SAC4A can load many anticancer drugs, MAC may provide a promising platform for effective combination radio-chemotherapy.

Sentinel lymph node identification in early stage ovarian cancer: is it still possible after prior tumor resection?

Objective

Sentinel lymph node (SLN) detection in ovarian cancer is feasible when tracers are injected before the pathological ovary is resected. This study aims to investigate whether the SLN identification is also feasible in patients whose ovarian tumor has already been resected with injection of the tracer into the ovarian ligaments stumps, i.e. in the event that a frozen section confirms malignancy.

Methods

Patients who underwent laparotomy with frozen section confirming an ovarian malignancy, and those who underwent a second staging laparotomy after prior resection of a malignant ovarian mass, were included. Blue dye and a radioactive isotope were injected in the stumps of the ligamentum ovarium proprium and the ligamentum infundibulo-pelvicum. After an interval of at least 15-min, the sentinel node(s) were identified using either the gamma-probe and / or blue dye.

Results

A total of 11 patients were included in the study, the sentinel node (SLN) procedure was completed in all 11 patients. At least one SLN was identified in 3 patients, resulting in a rather low detection rate of 27,3%.

Conclusion

In this study we showed that SLN procedure after (previous) resection of the tumor seems inferior to detect sentinel nodes when compared to injection of the tracer in the ovarian ligaments before tumor resection.

Trial registration

NCT02540551

Lymphatic Mapping and Sentinel Lymph Node Biopsy in the Management of Primary Cutaneous Melanoma: Report of a Single-centre Experience

Aims and Background

Lymphatic mapping and sentinel lymph node biopsy provide important prognostic data in patients with early stage melanoma and are crucial in guiding the management of the tumor. We report our experience with lymphatic mapping and sentinel lymph node biopsy in a group of patients with primary cutaneous melanoma and discuss recent concepts and controversies on its use.

Patients and Methods

A total of 111 patients with stage I-II AJCC primary cutaneous melanoma underwent lymphatic mapping and sentinel lymph node biopsy from December 1999 through December 2004 using a standardized technique of preoperative lymphoscintigraphy and biopsy guided by blue dye injection in addition to a hand-held gamma probe. After removal, sentinel lymph nodes were submitted to serial sectioning and permanent preparations for histological and immunohistochemical examination. Complete lymph node dissection was performed only in patients with tumor-positive sentinel lymph nodes.

Results

Sentinel lymph nodes were identified and removed in all patients (detection rate of 100%), and metastases were found in 17 cases (15.3%). The incidence of metastasis in sentinel lymph nodes was 2.1%, 15.9%, 35.2%, and 41.6% for melanomas < or 1.0, 1.01-2.0, 2.01-4.0, and > 4.0 mm in thickness, respectively. Complete lymph node dissection was performed in 15 of 17 patients with positive sentinel lymph nodes, and metastases in non-sentinel lymph nodes were detected in only 2 cases (11.7%). Recurrences were more frequently observed in patients with a positive than in those with negative sentinel lymph node (41.1% vs 5.3% at a median follow-up of 31.5 months, P<0.001). The false-negative rate was 2.1%.

Conclusions

Our study confirms that lymphatic mapping and sentinel lymph node biopsy allow accurate staging and yield relevant prognostic information in patients with early stage melanoma.

Patent Blue V as an Alternative Stain for DMEK Grafts: Safety, Stain Retention, and Feasibility

PURPOSE

To determine whether Patent Blue V (PB) can be used as an alternative dye for staining Descemet membrane endothelial keratoplasty (DMEK) grafts.

METHODS

DMEK grafts from donor corneas were stained with 2.5% PB for 4 minutes (n = 2), 2.5% PB for 10 minutes (n = 2), or 0.06% trypan blue (TB) for 4 minutes (n = 1). The stain intensity of the grafts was compared initially and at different time points over a 15-minute period of balanced salt solution wash using a grading scale based on a serial dilution series of PB. Three additional grafts were stained with 2.5% PB for 10 minutes and used in mock surgeries to assess stain retention after injection and manipulation in a donor eye model for 25 minutes. To assess the safety of PB, DMEK grafts were prepared from 10 pairs of corneas where one cornea was stained with 0.06% TB for 4 minutes and the mate cornea was stained with 2.5% PB for 10 minutes. The grafts were preloaded and stored for 5 days in Optisol-GS at 2°C to 8°C, and endothelial cell loss was quantified using Calcein-AM staining and FIJI segmentation by 2 masked readers.

RESULTS

PB stain intensities were lighter than TB-stained grafts. Grafts stained with 2.5% PB for 10 minutes retained sufficient color for the 25-minute duration of mock surgery. The average endothelial cell loss for PB versus TB grafts was 21.6% ± 5.3% versus 20.2% ± 5.4% (P = 0.202) as determined by reader 1 and 23.6% ± 4.8% versus 21.2% ± 5.8% (P = 0.092) as determined by reader 2.

CONCLUSIONS

PB is a viable alternative dye in DMEK grafts for applications where TB may not be available or approved for use.

Reliability and Accuracy of Sentinel Node Biopsy in Cutaneous Malignant Melanoma

Aims and Background

The aims of this study were 1) to investigate whether sentinel lymph node (SLN) biopsy could become the method of choice for the early detection of metastatic disease in patients with malignant melanoma and 2) to identify those patients with lymph node metastases who could benefit from regional lymphadenectomy.

Methods and Study Design

Our study started in March 1998 and involved 110 patients with primary cutaneous malignant melanoma stage I or II (AJCC) in whom the primary lesion had been surgically removed no more than 90 days previously. On the day of lymph node dissection patients were given an intradermal injection of colloid particles of human serum albumin labeled with technetium-99m and an injection of isosulfan blue. The surgical procedure was usually performed with local anesthesia but in some cases locoregional or general anesthesia was preferred. Contralateral and ipsilateral lymphatic areas were scanned with a hand-held gamma camera (Scintiprobe MR 100) to measure the background and identify the hot point indicating the location of the sentinel node to direct the incision.

Results

The combined use of lymphoscintigraphy, isosulfan blue and gamma probe allowed us to identify sentinel nodes in 108 of 110 patients (98.18%) while the SLN was blue in only 90 cases (81.81%). The SLN was positive for metastases in 13 of the 108 patients (12.03%) and regional and distal lymphadenectomy was performed in all of them. The distribution of positive SLNs by primary lesion thickness was as follows: 0.76-1.5 mm: one positive SLN/44 patients (2.27%); 1.51-4 mm: six positive SLNs/51 patients (11.7%); >4 mm: six positive SLNs/15 patients (40%). Only four of 12 patients with ulcerated cutaneous melanoma had positive SLNs. The patients in our study underwent follow-up visits every four months. The median follow-up was 481 days (range, 97-1271 days).

Conclusions

In patients with primary cutaneous melanoma the histological status of the SLN accurately reflects the presence or absence of metastatic disease in the relevant regional lymph node basin. Complete lymph node dissection should only be performed in patients with positive SLNs. Patients with lesions >4 mm are likely to develop recurrences and to die of systemic disease, so in these patients the usefulness of SLN biopsy is questionable. In conclusion, sentinel node mapping is a rational approach for the selection of patients who might benefit from early lymph node dissection of the affected basin.

Dynamic 18F-FDG PET Lymphography for In Vivo Identification of Lymph Node Metastases in Murine Melanoma

Positron lymphography using ¹⁸F-FDG followed by Cerenkov-guided resection of lymph nodes in healthy mice has previously been introduced by our group. Our aim in this study was to further assess the technique's potential beyond merely localizing sentinel lymph nodes. We now aimed to evaluate the potential of positron lymphography to characterize the nodes with respect to their tumor status in order to identify metastatic lymph nodes. We explored whether metastatic nodes could be distinguished from normal nodes via dynamic ¹⁸F-FDG lymphography, to then be resected under Cerenkov imaging guidance. Methods: A murine melanoma cell line highly metastatic to lymph nodes (B16F10) was implanted subcutaneously on the dorsal hind paw of C57 mice while the tumor-free contralateral leg served as an intraindividual control. A model of reactive lymph nodes after concanavalin A challenge served as an additional control to provide nonmalignant inflammatory lymphadenopathy. Dynamic PET/CT imaging was performed immediately after injection of ¹⁸F-FDG around the tumor or intracutaneously in the contralateral footpad. Furthermore, PET/CT and Cerenkov studies were performed repeatedly over time to follow the course of metastatic spread. In selected mice, popliteal lymph nodes underwent Cerenkov luminescence imaging. Hematoxylin and eosin staining was done to verify the presence of lymphatic melanoma infiltration. Results: Positron lymphography using ¹⁸F-FDG was successfully performed on tumor-bearing and non-tumor-bearing mice, as well as on controls bearing sites of inflammation; the results clearly identified the sentinel lymph node basin and delineated the lymphatic drainage. Significantly prolonged retention of activity was evident in metastatic nodes as compared with controls without tumor. On the basis of these results, the contrast in detection and identification of metastatic lymph nodes was distinct and could be used for guided lymph node resection, such as by using Cerenkov luminescence imaging. However, retention after ¹⁸F-FDG lymphography was also seen in acute inflammatory lymphadenopathy. Conclusion: In a tumor model, significantly longer retention of the radiotracer during ¹⁸F-FDG lymphography was seen in metastatic than nonmetastatic lymph nodes, allowing for differentiation between the two and for selective resection of tumor-bearing nodes using Cerenkov imaging. Inflammation can be better differentiated in a subacute state.

Dominant lymph drainage patterns in the occipital and parietal regions: evaluation of lymph nodes in patients with skin cancer of the head

BACKGROUND

The purpose of this study was to evaluate the superficial lymph drainage patterns of primary skin cancers of the head arising from the occipital or parietal region.

METHODS

The dominant patterns of lymph drainage were retrospectively reviewed in eight patients aged 36-85 years with skin cancers in the occipital or parietal region in whom sentinel lymph node biopsy or lymph node dissection had been performed at Hokkaido University Hospital between January 1981 and December 2015.

RESULTS

Lymph drainage was mainly to the occipital (6/8, 75%), level II (5/8, 63%), and level V lymph nodes (5/8, 63%). Of the six patients with drainage to the occipital lymph nodes, four (67%) also had drainage to level V nodes.

CONCLUSION

The dominant lymph drainage pattern in patients with skin cancer arising from the occipital or parietal region was to the occipital, level II, and level V lymph nodes. Further, lymph tended to drain directly from the occipital region to the level V lymph nodes.

Assessment of morbidity following regional nodal dissection in the axilla and groin for metastatic melanoma

BACKGROUND

This study assessed and compared the morbidity of nodal dissection in the axilla and groin including sentinel lymph node biopsy (SLNB), completion lymph node dissection for a positive SLNB (CLND) and therapeutic lymph node dissection (TLND) with and without adjuvant radiotherapy (RT).

METHODS

Patients who had nodal dissection in the axilla or groin for cutaneous melanoma over an 18-year period (1995-2013) were prospectively documented on a database. The median follow-up was nearly 3 years. Early complications and clinically relevant lymphoedema were retrospectively analysed to assess the incidence and differences between the region and type of nodal surgery.

RESULTS

Included were 1521 patients following nodal dissection in the axilla (916 patients) and groin (605 patients). Less early complications occurred following SLNB in the axilla compared with the groin (5% versus 14%, P = 0.0001). Early complications were similar for CLND and TLND in the groin (49% versus 43%, P = 0.879) and axilla (28% versus 33%, P = 0.607). Moderate to severe lymphoedema rates were similar following axillary SLNB and CLND (6% versus 8%, P = 0.407). The lymphoedema rate for groin SLNB was lower than CLND (10% versus 20%, P = 0.063). No significant difference in lymphoedema rates followed CLND and TLND in each region. Following TLND, RT increased lymphoedema rates.

CONCLUSIONS

Morbidity may occur following SLNB with the groin having a higher rate of early complications and lymphoedema compared with the axilla. The morbidity following CLND and TLND were similar. Lymphoedema rates were increased following RT.

Localization of the Sentinel Lymph Node in Melanoma Without Blue Dye

OBJECTIVE

The purpose of this study was to assess regional recurrence rates of patients who underwent sentinel lymph node biopsy (SLNB) using radiocolloid guidance alone.

BACKGROUND

Isosulfan blue dye is commonly used along with Tc99-labeled radiocolloid localization in SLNB for melanoma. Blue dye has, however, been associated with allergic reactions, long-term staining of skin, and increased cost. We hypothesized that the rate of regional recurrence when SLNB is performed with radiocolloid alone would be comparable to established reports using both radiocolloid and blue dye.

METHODS

A prospectively collected database was retrospectively queried for patients who underwent SLNB for melanoma during the years 2005 through 2008. Data collected included patient demographics, primary lesion characteristics, operative details, and recurrence. The primary outcome was the rate of recurrence within the biopsied basin after negative SLNB's performed without isosulfan blue dye.

RESULTS

In 215 patients, 279 nodal basins were identified. All patients underwent successful radiocolloid localization, and positive sentinel nodes were found in 40 patients (18.6%). Six of 175 patients with a negative SLNB developed a regional node recurrence as the first site of metastasis (3.4%). Among all 215 patients, 44 experienced recurrence of any kind (20.5%). Higher mitotic rate and Breslow depth were significantly associated with likelihood of recurrence.

CONCLUSIONS

Success rates, node positivity rates, and rates of regional recurrence after SLNB for melanoma using radiocolloid alone are acceptable and similar to those of prior reports using blue dye plus radiocolloid.

Probabilistic issues with sentinel lymph nodes in malignant melanoma

OBJECTIVES

To address issues of probability for sentinel lymph node results in melanoma and provide details about the probabilistic nature of the numbers of sentinel nodes as well as to address how these issues relate to tumor thickness and patient outcomes.

METHODS

Analysis of the probability of observing sentinel node metastases uses the discrete exponential probability distribution to address the number of observed positive sentinel nodes. In addition, mathematical functions derived from survival analysis are used. Data are then chosen from the literature to illustrate the approach and to derive results.

RESULTS

Observations about the numbers of positive and negative sentinel nodes closely follow discrete exponential probability distributions, and the relationship between the probability of a positive sentinel node and tumor thickness follows closely a function derived from survival analysis. Sentinel node results relate to tumor thickness as well as to the total number of nodes harvested but fall short of identifying all those who eventually develop metastatic melanoma.

CONCLUSIONS

Probability analyses provide useful insight into the success and failure of the sentinel node biopsy procedure in patients with melanoma.

Portable gamma camera guidance in sentinel lymph node biopsy: prospective observational study of consecutive cases

INTRODUCTION

Sentinel lymph node biopsy is the most important tool available for node staging in patients with melanoma.

OBJECTIVES

To analyze sentinel lymph node detection and dissection with radio guidance from a portable gamma camera. To assess the number of complications attributable to this biopsy technique.

METHODS

Prospective observational study of a consecutive series of patients undergoing radioguided sentinel lymph node biopsy. We analyzed agreement between nodes detected by presurgical lymphography, those detected by the gamma camera, and those finally dissected.

RESULTS

A total of 29 patients (17 women [62.5%] and 12 men [37.5%]) were enrolled. The mean age was 52.6 years (range, 26-82 years). The sentinel node was dissected from all patients; secondary nodes were dissected from some. In 16 cases (55.2%), there was agreement between the number of nodes detected by lymphography, those detected by the gamma camera, and those finally dissected. The only complications observed were seromas (3.64%). No cases of wound dehiscence, infection, hematoma, or hemorrhage were observed.

CONCLUSIONS

Portable gamma-camera radio guidance may be of use in improving the detection and dissection of sentinel lymph nodes and may also reduce complications. These goals are essential in a procedure whose purpose is melanoma staging.

Saphenous vein sparing superficial inguinal dissection in lower extremity melanoma

Aim. The classic inguinal lymph node dissection is the main step for the regional control of the lower extremity melanoma, but this surgical procedure is associated with significant postoperative morbidity. The permanent lymphedema is the most devastating long-term complication leading to a significant decrease in the patient's quality of life. In this study we present our experience with modified, saphenous vein sparing, inguinal lymph node dissections for patients with melanoma of the lower extremity. Methods. Twenty one patients (10 women, 11 men) who underwent saphenous vein sparing superficial inguinal lymph node dissection for the melanoma of lower extremity were included in this study. The effects of saphenous vein sparing on postoperative complications were evaluated. Results. We have observed the decreased rate of long-term lymphedema in patients undergoing inguinal lymphadenectomy for the lower extremity melanoma. Conclusion. The inguinal lymphadenectomy with saphenous vein preservation in lower extremity melanoma patients seems to be an oncologically safe procedure and it may offer reduced long-term morbidity.

Update and Review on the Surgical Management of Primary Cutaneous Melanoma

The surgical management of malignant melanoma historically called for wide excision of skin and subcutaneous tissue for any given lesion, but has evolved to be rationally-based on pathological staging. Breslow and Clark independently described level and thickness as determinant in prognosis and margin of excision. The American Joint Committee of Cancer (AJCC) in 1988 combined features from each of these histologic classifications, generating a new system, which is continuously updated and improved. The National Comprehensive Cancer Network (NCCN) has also combined several large randomized prospective trials to generate current guidelines for melanoma excision as well. In this article, we reviewed: (1) Breslow and Clark classifications, AJCC and NCCN guidelines, the World Health Organization's 1988 study, and the Intergroup Melanoma Surgical Trial; (2) Experimental use of Mohs surgery for in situ melanoma; and (3) Surgical margins and utility and indications for sentinel lymph node biopsy (SLNB) and lymphadenectomy. Current guidelines for the surgical management of a primary melanoma of the skin is based on Breslow microstaging and call for cutaneous margins of resection of 0.5 cm for MIS, 1.0 cm for melanomas ≤1.0 mm thick, 1-2 cm for melanoma thickness of 1.01-2 mm, 2 cm margins for melanoma thickness of 2.01-4 mm, and 2 cm margins for melanomas >4 mm thick. Although the role of SLNB, CLND, and TLND continue to be studied, current recommendations include SLNB for Stage IB (includes T1b lesions ≤1.0 with the adverse features of ulceration or ≥1 mitoses/mm²) and Stage II melanomas. CLND is recommended when sentinel nodes contain metastatic deposits.

Sentinel lymph node biopsy in melanoma: controversies and current guidelines

ABSTRACT: 

Melanoma is a global health problem and the incidence of this disease is rising. While localized melanoma has an excellent prognosis, regional and distant disease is associated with much poorer outcomes. Optimal treatment for clinically localized melanoma requires surgical control of the primary site and accurate staging of the regional nodal basin with sentinel lymph node biopsy (SLNB). While further data are required to determine if SLNB is associated with a survival advantage, currently available data supports the use of SLNB for staging of appropriate patients and the procedure may offer benefits beyond staging. This article reviews current data that shapes guidelines regarding patient selection for SLNB in melanoma and highlights areas where performing this procedure remains controversial.

Clinical relevance of novel imaging technologies for sentinel lymph node identification and staging

The sentinel lymph node (SLN) concept has become a standard of care for patients with breast cancer and melanoma, yet its clinical application to other cancer types has been somewhat limited. This is mainly due to the reduced accuracy of conventional SLN mapping techniques (using blue dye and/or radiocolloids as lymphatic tracers) in cancer types where lymphatic drainage is more complex, and SLNs are within close proximity to other nodes or the tumour site. In recent years, many novel techniques for SLN mapping have been developed including fluorescence, x-ray, and magnetic resonant detection. Whilst each technique has its own advantages/disadvantages, the role of targeted contrast agents (for enhanced retention in the SLN, or for immunostaging) is increasing, and may represent the new standard for mapping the SLN in many solid organ tumours. This review article discusses current limitations of conventional techniques, limiting factors of nanoparticulate based contrast agents, and efforts to circumvent these limitations with modern tracer architecture.

Lymphatic mapping and sentinel lymph node biopsy in patients with melanoma: a meta-analysis

PURPOSE

To perform a meta-analysis of all published studies of sentinel lymph node (SLN) biopsy for staging patients with melanoma.

METHODS

Published literature in all languages between 1990 and 2009 was critically appraised. Primary outcomes evaluated included the proportion successfully mapped (PSM) and test performance including false-negative rate (FNR), post-test probability negative (PTPN), and positive predictive value in the same nodal basin recurrence.

RESULTS

A total of 71 studies including 25,240 patients met full eligibility criteria. The average PSM was 98.1% (95% CI, 97.3% to 98.6%) and increased with the year of publication, female sex, ulceration, age, and the quality score of the studies. The FNR ranged from 0.0% to 34.0%, averaging 12.5% overall (95% CI, 11% to 14.2%). FNR increased with the length of follow-up (P = .002) but decreased with greater PSM (P = .001). PTPN averaged 3.4% (95% CI, 3.0% to 3.8%), which also increased in studies with longer follow-up, younger age, female sex, deeper Breslow thickness, and with tumor ulceration while decreasing with greater PSM (P < .001). Approximately 20% of the patients with a positive SLN had additional lymph nodes in the complete lymph node dissection and 7.5% of the patients with positive SLN developed recurrence in the same nodal basin which was greater in studies that also reported higher FNR (P = .01).

CONCLUSION

The estimated risk of nodal recurrence after a negative SLN biopsy was ≤ 5% supporting the use of this technology for staging patients with melanoma.

Inflammation and tumor microenvironment in lymph node metastasis

In nearly all human cancers, the presence of lymph node (LN) metastasis increases clinical staging and portends worse prognosis (compared to patients without LN metastasis). Herein, principally reviewing experimental and clinical data related to malignant melanoma, we discuss diverse factors that are mechanistically involved in LN metastasis. We highlight recent data that link tumor microenvironment, including inflammation (at the cellular and cytokine levels) and tumor-induced lymphangiogenesis, with nodal metastasis. Many of the newly identified genes that appear to influence LN metastasis facilitate general motility, chemotactic, or invasive properties that also increase the ability of cancer cells to disseminate and survive at distant organ sites. These new biomarkers will help predict clinical outcome and point to novel future therapies in metastatic melanoma as well as other cancers.

Prognostic factors associated with sentinel lymph node positivity and effect of sentinel status on survival: an analysis of 1049 patients with cutaneous melanoma

Sentinel lymph node biopsy (SLNB) is a widely accepted staging procedure in patients with melanoma. However, it is unclear which factors predict the occurrence of micrometastasis and overall prognosis and whether SLNB should also be performed in patients with thin primary tumors. At our Department of Dermatology, University of Munich (Germany), 1049 consecutive melanoma patients were identified for SLNB between 1996 and 2007, and were followed-up to assess disease-free and overall survival. Of those, a total of 854 patients were analyzed prospectively. Patients with positive SLN were subjected to selective lymphadenectomy. The association of patient characteristics with SLN was assessed by multivariate logistic regression. Survival curves were performed using the Kaplan-Meier method. Cox proportional hazard regression with different adjustments was used to estimate the effect of SLN on survival. The detection rate of SLN was 97.24%, of which 24.9% were metastatic. Significant parameters upon SLN positivity were tumor thickness and nodular type of melanoma. The 5-year overall survival was 90.1 and 58.1% in SLN-negative and SLN-positive patients, respectively. Upon multivariate analysis tumor thickness and SLN status were significant factors influencing both disease-free survival and overall survival. In conclusion, our data confirm that SLNB is relevant as a diagnostic and staging procedure and that tumor thickness is of predictive importance. SLN status should be taken into account when designing clinical trials and informing patients about the probable course of their disease. Our data suggest that in case of a nodular melanoma subtype SLNB should also be considered at a tumor thickness below 1 mm.

"The malignant wart": a review of primary nodular melanoma of the foot and report of two cases

The reported incidence of melanoma is rapidly rising and second only to lung cancer. Primary melanoma of the lower extremity accounts for approximately 30% of all cases reported, with half of these cases localized to the foot itself. Unfortunately, melanoma can be misdiagnosed and treatment delayed, as they are usually not painful. The overall 5- and 10-year survival rates improve with early diagnosis and aggressive treatment. This is a report of 2 cases of primary nodular melanoma of the foot initially misdiagnosed as a "wart." Following confirmation with biopsy, definitive surgical intervention in both cases consisted of resection of the primary malignancy and ipsilateral superficial inguinal lymph node basin resection using a multidisciplinary approach to patient care. Given the rapid increase in incidence of melanoma in the general population, one must have a high index of suspicion and low threshold for excisional biopsy of concerning dermatopathology on the foot and lower extremity. Early detection and combined appropriate surgical resection and adjunctive chemotherapeutic treatment of melanoma in a multidisciplinary setting are paramount in decreasing mortality rates.

Clinical and histopathological risk factors to predict sentinel lymph node positivity, disease-free and overall survival in clinical stages I-II AJCC skin melanoma: outcome analysis from a single-institution prospectively collected database

BACKGROUND

To investigate if the tumour infiltrating lymphocytes (TILs) are able to predict the sentinel lymph node (SLN) positivity, the disease-free survival (DFS) and overall survival (OS) in clinical stages I-II AJCC primary cutaneous melanoma (PCM).

METHODS

The study included consecutive patients with PCM, all diagnosed, treated and followed up prospectively. Logistic regression was used to investigate the association between DFS, OS, SLN positivity and Breslow thickness, Clark level, TIL, ulceration, lesion site, gender, regression and age.

RESULTS

From November 1998 to October 2008, 1251 consecutive patients with PCM were evaluated. Median age was 51 (range 15-96) with 32.2% (N=393) of them older than 60; 44.8% of them were males. Of the whole series, a total of 404 patients with primary vertical growth phase (VGP) melanoma and no clinical evidence of metastatic disease underwent SLN biopsy. Of these, 74 (18.8%) had a positive SLN. In a multivariate analysis, primary melanoma on the extremities versus that on the axial locations (truncal and head/neck) (OR 0.49, 95% CI 0.25-0.98, p 0.04) and TILs (TILs versus no TILs) (OR 0.47, 95%CI 0.25-0.90, p 0.02) were predictive for lower probability of SLN involvement, while thickness (>4mm versus 0-1mm) (OR 24, 19, 95% CI 4.91-119.13, p<.001) was predictive for higher risk of SLN positivity. A multivariate stepwise analysis confirmed these results. The histological status of the SLN was the most significant predictor of DFS and OS. Patients with a negative SLN had a 5-year DFS of 75.9%, compared with 35.2% in patients with a positive SLN (p<.0001) and a 5-year OS of 88.7% versus 42.9%, respectively (p<.0001).

CONCLUSIONS

Our study demonstrates that the absence of TILs predicts SLN metastasis, in multivariate analysis the SLN positivity predicts DFS and OS.

A comprehensive overview of radioguided surgery using gamma detection probe technology

The concept of radioguided surgery, which was first developed some 60 years ago, involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. The use of gamma detection probe technology in radioguided surgery has tremendously expanded and has evolved into what is now considered an established discipline within the practice of surgery, revolutionizing the surgical management of many malignancies, including breast cancer, melanoma, and colorectal cancer, as well as the surgical management of parathyroid disease. The impact of radioguided surgery on the surgical management of cancer patients includes providing vital and real-time information to the surgeon regarding the location and extent of disease, as well as regarding the assessment of surgical resection margins. Additionally, it has allowed the surgeon to minimize the surgical invasiveness of many diagnostic and therapeutic procedures, while still maintaining maximum benefit to the cancer patient. In the current review, we have attempted to comprehensively evaluate the history, technical aspects, and clinical applications of radioguided surgery using gamma detection probe technology.

The role of VEGF-C staining in predicting regional metastasis in melanoma

Sentinel lymph node status is the most important prognostic factor in primary melanoma. The number of melanoma-associated lymphatic vessels has been associated with sentinel lymph node status and survival. Vascular endothelial growth factor-C (VEGF-C) is found to promote tumour-associated lymphatic vessel growth. In many human neoplasms, VEGF-C expression in neoplastic cells or tumour-associated macrophages (TAMs) has been linked to lymphatic dissemination of tumour cells. Recent studies have suggested a correlation between VEGF-C expression in primary melanoma and the presence of lymph node metastasis. We performed VEGF-C immunohistochemical staining on melanoma tissues of 113 patients with known sentinel lymph node status. We showed that both high VEGF-C expression in melanoma cells and TAMs are positively associated with the presence of a positive sentinel lymph node. No correlation with Breslow thickness, Clark invasion level or ulceration could be detected. VEGF-C expression in melanoma cells was predictive of a shorter overall and disease-free survival, without being an independent predictor of survival. Our results confirm that VEGF-C expression in primary cutaneous melanoma plays a role in the lymphatic spread of the tumour.

The single-photon emission computed tomography/computed tomography: a new procedure to perform the sentinel node biopsy in patients with head and neck melanoma

The aim of this study was to define and validate a new technique to detect the sentinel node (SN) in patients treated for head and neck melanoma. In a small series of 23 head and neck melanoma patients, lymphatic mapping was followed by SN biopsy, using in 12 patients a new diagnostic imaging technique, single-photon emission computed tomography/computed tomography. The procedure is described and the major problems encountered are discussed. The preliminary data show that identification of SN using single-photon emission computed tomography/computed tomography never failed in 12 patients, and biopsies performed, compared with those in a standard group, took significantly less time (Mann-Whitney test P=0.006). In conclusion, the authors underline the possibility of a wide use for this technique.

Predicting sentinel node status in AJCC stage I/II primary cutaneous melanoma

BACKGROUND

Sentinel lymph node (SLN) status is an important prognostic factor for survival for patients with primary cutaneous melanoma. To address the issue of selecting patients at high and low risk for a positive SLN, prognostic factors were sought that predict SLN involvement by examining characteristics of both the primary tumor and the patient within the context of a biological model of melanoma progression.

METHODS

The study included 682 patients with primary vertical growth phase (VGP) melanoma and no clinical evidence of metastatic disease who underwent SLN biopsy (1995-2003). Logistic regression and classification tree analyses were used to investigate the association between SLN positivity and Breslow thickness, Clark level, tumor infiltrating lymphocytes (TIL), ulceration, mitotic rate (MR), lesion site, gender, and age. RESULTS.: In all, 88 of the 682 patients had > or =1 positive SLN (12.9%). In the multivariate analysis, MR, TIL, and thickness were found to be independent prognostic factors for SLN positivity. In the classification tree, four different risk groups were defined, ranging from minimal risk (2.1%) to high risk (40.4%). In lesions < r =2.0 mm, MR was important in risk-stratifying patients, and in lesions >2.0 mm TIL was important.

CONCLUSIONS

By incorporating biologically based variables such as VGP, TIL, and MR along with thickness into a prognostic model, both patients at high risk and minimal risk for SLN positivity can be identified. If validated, this model can be used in patient management and trial design to select patients to undergo or be spared SLN biopsy.

Single-Institution Experience in the Management of Patients with Clinical Stage I and II Cutaneous Melanoma: Results of Sentinel Lymph Node Biopsy in 240 Cases

BACKGROUND

Lymphatic mapping and sentinel lymph node biopsy (SLNB) has been developed as a minimally invasive technique to determine the pathologic status of regional lymph nodes in patients without clinically palpable disease and incorporated in the latest version of the American Joint Committee on Cancer (AJCC) staging system for cutaneous melanoma.

OBJECTIVE

To analyze the results of SLNB and the prognostic value of the micrometastases and the pattern of early recurrences in patients according to sentinel lymph node (SLN) status.

METHOD

Patients with cutaneous melanoma in stages I and II (AJCC 2002) who underwent lymphatic mapping and SLNB from 1997 to 2003 were included in a prospective database for analysis.

RESULTS

The rate of identification of the SLN was 100%. Micrometastases to SLN were found in 20.8% of patients. The rate of SLN micrometastases increased according to Breslow thickness and clinical stage. Breslow thickness of 0.99 mm was the optimal cutpoint for predicting the SLNB result. Twenty-four patients (12.3%) developed a locoregional or distant recurrence at a median follow-up of 31 months. Recurrences were more frequent in patients with a positive SLN. Among patients who had a recurrence, those with a positive SLN were more likely to have distant metastases than those with negative SLN. Nodal recurrences were more frequent in patients with a negative SLN compared with those with a positive SLN.

CONCLUSIONS

The status of the SLN provides accurate staging for identifying patients who may benefit from further therapy and is the most important prognostic factor of relapse-free survival.

Biopsia selectiva de ganglio centinela en tumores cutáneos no melanoma

PURPOSE

To assess the feasibility of the Sentinel lymph node biopsy (SLNB) technique in cutaneous non-melanoma malignancies.

MATERIALS AND METHODS

Nine patients were retrospectively evaluated performing a scintigraphy with 99mTc-nanocolloid. On the day of the surgery, an initial dynamic study and static images were obtained. The first drainage station visualized was considered the sentinel node (SLN). The SLN position was marked on the skin and after a correct localization in the surgical field with a gamma probe the SLN was obtained. Patients of this study have been followed up for 8 to 48 months.

RESULTS

Lymphoscintigraphy detected the sentinel node in 88,8 % of our studies (the SLN was not observed in a patient with a Merkel's tumour on the back). The SLN was identified intraoperatively in those patients with positive imaging. Those cases without scintigraphic demonstrated migration were also not found intraoperatively. Histopathological analysis of the SLN showed non metastatic disease and none patient developed metastases or local recurrence in the monitoring period.

CONCLUSIONS

Sentinel node biopsy can be applied to certain cutaneous non-melanoma malignancies. In patients with unclear drainage and to avoid unnecessary lymphadenectomy, the technique offers clear advantages. In our study the SLN analysis was related to the clinical progress. A large number of patients should be examined to truly assess the benefit of this technique in this kind of malignancies and to determinate when the technique must be performed.

Results of Sentinel Lymph Node Biopsy in Patients With Thin Melanoma

BACKGROUND

Sentinel lymph node (SLN) biopsy has been shown to be a highly accurate method of staging nodal basins in melanoma patients. Although this technique is widely accepted in patients with intermediate-thickness tumors, it is unclear what the indications are for thin (< or = 1 mm) melanoma.

METHODS

From May 1991 to October 2004, 223 patients with thin melanoma underwent SLN biopsy at Memorial Sloan-Kettering Cancer Center. Most patients with thin melanoma were selected for the procedure because of high-risk clinicopathologic features.

RESULTS

Nodal metastases were found in eight patients (3.6%) who underwent SLN biopsy. All positive SLNs were found in patients with > or = .75 mm-thick and Clark level IV melanoma (8 of 114; 7%). Age, sex, tumor location, thickness, Clark level, ulceration, regression, tumor-infiltrating lymphocytes, mitotic rate, and number of mapped nodal basins were not predictive of positive SLNs (chi(2); P = not significant). With a median follow-up of 25 months, there have been no recurrences or deaths in patients with melanoma < .75 mm. Six patients have had regional and/or systemic recurrences (2.7%), only one of whom had a positive SLN. Three patients have died of melanoma; all had negative SLNs.

CONCLUSIONS

Nodal metastasis in thin melanoma is uncommon, especially in patients with < .75 mm and Clark level II or III melanoma. In our experience, no single clinicopathologic factor was predictive of nodal metastases. The prognostic implications of positive SLNs in thin melanoma remain undefined.

The use of LYVE-1 antibody for detecting lymphatic involvement in patients with malignant melanoma of known sentinel node status

BACKGROUND

Sentinel node (SN) status is the most important prognostic indicator in patients with cutaneous melanoma without clinically evident metastatic spread, but the procedure is associated with considerable morbidity. The LYVE-1 lymphatic marker offers the possibility of studying lymphangiogenesis and tumour metastasis within the primary excision.

AIMS

To establish whether lymphatic vessel numbers/distribution within the primary tumour correlated with SN status. To assess whether tumour cells were easily demonstrable within lymphatics and could be used as a surrogate for SN status.

METHODS

Double immunostaining for LYVE-1 and S100 in cutaneous biopsies from 18 SN+ patients with no lymphatic/vascular involvement on routine histology and 18 SN- patients matched for tumour thickness and ulceration.

RESULTS

Lymphatic vessels were detected in all cases. Vessels within the tumour mass were suggestive of active lymphangiogenesis; those outside were mainly mature vessels with well defined walls. Tumour cells within lymphatics were detected in one of 18 SN- and five of 18 SN+ patients. Lymphatics containing tumour cells were all outside the tumour mass in well formed vessels, suggesting melanoma cell invasion into preformed lymphatics. There was no significant difference in lymphatic counts between SN+ and SN- patients. Although peritumorous lymphatic counts were higher in ulcerated than non-ulcerated melanomas, they did not vary with Breslow thickness.

CONCLUSION

LYVE-1 staining can reliably demonstrate lymphatic vessel distribution, but lymphatic counts cannot predict melanoma metastatic potential and cannot substitute for SN biopsy. LYVE-1 immunostaining can detect melanoma cells within lymphatics, but is unreliable in predicting melanoma metastasis, failing to detect metastatic spread in more than two thirds of patients with regional node metastasis.

Evaluation of extensive initial staging procedure in intermediate/high-risk melanoma patients

INTRODUCTION

Early diagnosis and treatment of metastases have been shown to improve overall survival of melanoma patients. The purpose of this study was to evaluate the impact of extensive initial staging, including positron emission tomography (PET) scan on the management of melanoma patients.

PATIENTS AND METHODS

Forty-three patients with intermediate/poor prognosis primary melanoma benefited from complementary excision and sentinel lymph node biopsy (SLB) after clinical and paraclinical staging (computed tomography, nuclear magnetic resonance and whole body fluorodeoxyglucose PET scan).

RESULTS

No systemic metastases were demonstrated, while the SLB procedure emphasized the presence of regional lymph node metastases in 10 patients as suggested by the PET scan in four patients (sensitivity of the PET scan 40%). These 10 patients with early diagnosed lymph node involvement benefited from early surgery and were included in adjuvant treatment protocols. A secondary primary cancer was fortuitously diagnosed and treated early in two patients.

CONCLUSIONS

The development of new adjuvant therapies and therapeutic procedures (specific and non-specific immunotherapy, gamma-knife radiosurgery, etc.) now raises the relevance of extensive staging in intermediate/poor prognosis melanoma patients. We confirm in our series that PET scan is not useful to detect micrometastasis and cannot replace SLB in initial regional staging. However, we show in our study that 12 of 43 patients were treated early or were included early in treatment protocols thanks to the extensive staging procedure. Nevertheless, it seems important to evaluate through larger prospective trials the real impact of these early diagnoses and new treatments on overall survival before defining new diagnostic and therapeutic guidelines.

J, Lewin S, Marone MMS. Pesquisa do linfonodo sentinela em pacientes com melanoma: experiência com fitato marcado com Tecnécio-99m e revisão da literatura

FUNDAMENTOS: A progressão linfática do melanoma maligno habitualmente se inicia pelo linfonodo sentinela (LNS), cuja análise histopatológica permite predizer o acometimento de toda a cadeia. OBJETIVO: O trabalho tem por objetivo descrever a utilização do 99mTc-Fitato na detecção do LNS em pacientes com melanoma maligno, revisando as indicações e informações fornecidas por sua biópsia. MÉTODO: A pesquisa de LNS foi realizada por meio da linfocintilografia com 99mTc-Fitato em 92 pacientes com melanoma (54,0±14,3 anos). Após 18-24 horas, 88 pacientes foram submetidos à localização intra-operatória com detector portátil, seguida da ressecção e análise histopatológica do LNS. RESULTADOS: A linfocintilografia permitiu a identificação do LNS em todos os estudos, havendo detecção intra-operatória em 98,8% dos casos. O LNS estava acometido em 23 pacientes (26%). O valor preditivo negativo foi de 100% e não se observaram reações adversas pelo uso do 99mTc-Fitato. CONCLUSÃO: A detecção do LNS pode ser realizada com diferentes radiofármacos, incluindo o 99mTc-Fitato, que apresenta vantagens de custo e disponibilidade no Brasil. A pesquisa de LNS resulta em maior acurácia e menor morbidade no estadiamento de pacientes com melanoma maligno

Reassessing the role of lymphatic mapping and sentinel lymphadenectomy in the management of cutaneous malignant melanoma

Lymphatic mapping and sentinel lymphadenectomy was developed as a minimally invasive technique to provide regional lymph node staging information for patients at high risk for metastatic melanoma, but without clinically palpable disease. Only patients who demonstrate micrometastases undergo complete regional lymphadenectomy, sparing approximately 80% of patients the expense and morbidity of an elective lymph node dissection. This technique has been widely accepted as the preferred method to determine the pathologic status of the regional lymph nodes and the staging information gained is incorporated into the latest version of the American Joint Committee on Cancer staging system for cutaneous melanoma. Still, there is much controversy as to the use of this technique as a staging procedure and its overall therapeutic benefit in the treatment of patients with melanoma. Currently ongoing clinical trials will determine if lymphatic mapping and sentinel lymphadenectomy directly influences overall survival for patients with malignant melanoma. We review the latest technical aspects of this procedure and discuss the controversies surrounding its use.

The risk of regional lymph node metastases in patients with melanoma less than 1.0 mm thick: recommendations for sentinel lymph node biopsy

BACKGROUND

Lymphatic mapping and sentinel lymph node biopsy can upstage patients with intermediate thickness (1.0 to 4.0 mm) melanoma. Currently, there are no strict guidelines for sentinel lymph node biopsy in patients with melanoma <1.0 mm thick.

STUDY DESIGN

A retrospective review of our patient database (598 patients treated at two institutions in Baltimore, MD, between January 1970 and June 2002) was performed to identify patients with primary cutaneous melanoma <1.0 mm thick who developed recurrent disease. This cohort of patients with > or =5 years of followup from the date of diagnosis was compared with patients with primary melanoma of similar thickness and similar followup intervals without recurrent disease.

RESULTS

A total of 114 patients with primary cutaneous melanoma <1.0 mm thick were identified, 17 of whom developed disease recurrence. In 13 patients, the site of first recurrence was the regional lymph nodes and in 4 patients disease recurred with distant metastases. The median time to lymph node recurrence was 55 months (range 2 to 112) months. Patients with regional lymph node recurrences had a significant (p = 0.02) difference in median primary tumor thickness of 0.80 mm versus 0.45 mm in patients without recurrent disease; there was no association of Clark level of invasion to recurrence (p = 0.42). In all, 35% of patients (7 of 20) presenting with melanoma 0.80 to 0.99 mm thick developed lymph node recurrence a median of 41 months (range 8 to 112 months) after surgical treatment.

CONCLUSIONS

Sentinel lymph node biopsy can be justified for patients with melanoma > or =0.8 mm thick provided that the technique would detect metastatic disease years before it becomes clinically evident.

[Marking the route of lymphatic spread of melanoma and sentinel lymph node biopsy]

<zakljucak> Biopsija limfnih zlezda strazara je postupak koji, uz relativno nizak morbiditet, daje precizne podatke o stanju regionalnog limfonodalnog basena bolesnika sa melanomom koze. Stanje regionalnih limfnih zlezda je kljucni prognosticki parametar, veoma bitan za planiranje daljeg lecenja. Za uspesnu identifikaciju i histopatolosku obradu SLN neophodna je saradnja hirurga, nuklearnog radiologa i histopatologa. Dijagnostikovanjem okultnih metastaza u regionalnim limfnim zlezdama identifikuju se bolesnici kojima treba uciniti kompletnu limfonododisekciju, kao i oni koji mogu imati koristi od primene adjuvantne antitumorske terapije. Uvodjenjem ovog postupka dilema izvodjenja ili ne ELND vise ne postoji. Tehnicki i kadrovski zahtevi medjutim, jos uvek je ne svrstavaju u rutinske standardne postupke u lecenju melanoma. Pronalazenje mikrometastaza u regionalnim limfnim zlezdama menja stadijum bolesti u kome je bolesnik do tada bio (migracija stadijuma, Will Rogers fenomen). Novim klasifikacionim sistemom definise se klinicki i patoloski stadijum bolesti (14, 114). Ukoliko su regionalni limfonodusi ispitivani klinickim i/ili radioloskim postupcima, moze se govoriti o klinickom stadijumu bolesti. Za odredjivanje patoloskog stadijuma neophodna je histoloska evaluacija limfnih zlezda dobijenih bilo selektivnom bilo elektivnom limfadenektomijom. SLNB se smatra jednim od najvecih napredaka u terapiji melanoma u zadnjoj deceniji XX veka (4, 111). Ocekuje se da ce postati standard u lecenju bolesnika sa klinicki negativnim limfnim zlezdama (99, 111, 112), posebno sa usvajanjem novog sistema za odredjivanje stadijuma koze (14, 114, 115).

Role of sentinel lymphadenectomy in thin invasive cutaneous melanomas

PURPOSE

Regional lymph node status is the strongest prognostic determinant in early-stage melanoma. Lymphatic mapping and sentinel lymphadenectomy (LM/SL) is standard to stage regional nodes because it is accurate and minimally morbid, yet its role for thin (<or= 1.5 mm) primary melanomas is unknown.

PATIENTS AND METHODS

Our melanoma database of more than 10,000 patients was reviewed for patients with melanomas <or= 1.50 mm thick who underwent LM/SL. All had lymphoscintigrams and LM/SL via dye alone or with radiopharmaceutical. Patients with tumor-positive sentinel nodes (SNs) underwent completion dissections.

RESULTS

Five hundred twelve patients underwent LM/SL. Most were men (57%), and median age was 49 years. Most primary melanomas were on the torso (44%). Twenty-five patients (4.9%) had tumor-positive SNs. The thinnest lesion with a nodal metastasis was 0.35 mm. The SN-negative and SN-positive cohorts were equivalent by sex, but SN+ patients tended to be younger (P =.053), with significantly more SN metastases in those younger than 44 years (P =.005). No consistent pathology among SN-positive primary melanomas was found. Among those with 1.01- to 1.05-mm primaries, 7.1% were SN-positive. Among 272 patients with lesions <or= 1.00 mm, 2.9% had positive SNs and 1.7% with lesions <or= 0.75 mm had SN metastases. All 13 deaths were in SN-negative patients. Median follow-up durations in SN-positive and SN-negative patients were 25 and 45 months, respectively.

CONCLUSION

The high nodal positivity rate associated with primary melanomas 1.01 to 1.50 mm thick suggests that LM/SL is indicated in this group. Younger age may be correlated with nodal metastases in patients with lesions <or= 1.00 mm. Lesions <or= 0.75 mm have minimal metastatic potential, and therefore LM/SL is rarely indicated.