Is sentinel lymph node mapping indicated for isolated local and in-transit recurrent melanoma?

The Evolution of the Sentinel Node Biopsy in Melanoma

The growing repertoire of approved immune-checkpoint inhibitors and targeted therapy has revolutionized the adjuvant treatment of melanoma. While the treatment of primary cutaneous melanoma remains wide local excision (WLE), the management of regional lymph nodes continues to evolve in light of practice-changing clinical trials and dramatically improved adjuvant therapy. With large multicenter studies reporting no benefit in overall survival for completion lymph node dissection (CLND) after a positive sentinel node biopsy (SLNB), controversy remains regarding patient selection and clinical decision-making. This review explores the evolution of the SLNB in cutaneous melanoma in the context of a rapidly changing adjuvant treatment landscape, summarizing the key clinical trials which shaped current practice guidelines.

Late Metastatic Melanoma after 25 Years: A Case Report and a Brief Literature Review

The incidence of cutaneous malignant melanoma has shown a drastic increase over recent decades, and approximately 70% of newly diagnosed melanoma are tumors with a Breslow thickness less or equal to 1 mm. In the literature, there are well-documented rare cases of late metastasis of thin melanoma, and given their growing incidence, it is expected in the future to see more cases of late recurrence. We present a case report of a metastatic cutaneous melanoma 25 years from diagnosis and a review of the literature. A 61-year-old female patient presented with a newly discovered asymptomatic nodule on her thigh. Her relevant past medical history included a completely excided lesion with Breslow 1.4 mm thickness in 1989 for which she was followed up according to the guidelines and subsequently declared cured after 10 years of surveillance. Fine-needle aspiration and cytological analysis of the lesion proved to be a subcutaneous localization of malignant melanoma. The lesion was completely excised, and the patient has remained disease free since her surgery. The aim of this case report is to emphasize that late metastasis remains uncommon but a definitive cure from melanoma cannot always be considered a disease-free interval of 10 years. Physicians should always be aware of previous melanoma diagnosis with newly discovered suspicious lesions. Better patient education could improve the detection of recurrence and secondary melanomas without any need for more frequent follow-up visits and a prolonged follow-up time.

Surgical Management of Lymph Nodes in Melanoma

This article provides a comprehensive evaluation of surgical management of the lymph node basin in melanoma, with historical, anatomic, and evidence-based recommendations for practice.

Surgical Considerations and Systemic Therapy of Melanoma

Recent advances in effective medical therapies have markedly improved the prognosis for patients with advanced melanoma. This article aims to highlight the current era of integrated multidisciplinary care of patients with advanced melanoma by outlining current approved therapies, including immunotherapy, targeted therapy, radiation therapy, and other strategies used in both the adjuvant and the neoadjuvant setting as well as the evolving role of surgical intervention in the changing landscape of advanced melanoma.

Current management of regional lymph nodes in patients with melanoma

The publication of recent randomized trials has prompted a significant shift in both our understanding and the management of patients with melanoma. Here, the current management of the regional lymph nodes in patients with melanoma is discussed. This review focuses on selection for sentinel lymph node biopsy, management of the positive sentinel node, management of the clinically positive node, and the controversy over the therapeutic value of early nodal intervention.

Do you know your guidelines? Diagnosis and management of cutaneous head and neck melanoma

The following article is the next installment of the series "Do You Know Your Guidelines?" presented by the Education Committee of the American Head and Neck Society. Guidelines for the prevention, diagnosis, workup, and management of cutaneous melanoma are reviewed in an evidence-based fashion.

Sentinel Lymph Node Biopsy for Recurrent Melanoma: A Multicenter Study

BACKGROUND

Sentinel lymph node biopsy (SLNB) is routinely performed for primary cutaneous melanomas; however, limited data exist for SLNB after locally recurrent (LR) or in-transit (IT) melanoma.

METHODS

Data from three centers performing SLNB for LR/IT melanoma (1997 to the present) were reviewed, with the aim of assessing (1) success rate; (2) SLNB positivity; and (3) prognostic value of SLNB in this population.

RESULTS

The study cohort included 107 patients. Management of the primary melanoma included prior SLNB for 56 patients (52%), of whom 10 (18%) were positive and 12 had complete lymph node dissections (CLNDs). In the present study, SLNB was performed for IT disease (48/107, 45%) or LR melanoma (59/107, 55%). A sentinel lymph node (SLN) was removed in 96% (103/107) of cases. Nodes were not removed for four patients due to lymphoscintigraphy failures (2) or nodes not found during surgery (2). SLNB was positive in 41 patients (40%, 95% confidence interval (CI) 31.5-50.5), of whom 35 (88%) had CLND, with 13 (37%) having positive nonsentinel nodes. Median time to disease progression after LR/IT metastasis was 1.4 years (95% CI 0.75-2.0) for patients with a positive SLNB, and 5.9 years (95% CI 1.7-10.2) in SLNB-negative patients (p = 0.18). There was a trend towards improved overall survival for patients with a negative SLNB (p = 0.06).

CONCLUSION

SLNB can be successful in patients with LR/IT melanoma, even if prior SLNB was performed. In this population, the rates of SLNB positivity and nonsentinel node metastases were 40% and 37%, respectively. SLNB may guide management and prognosis after LR/IT disease.

A surgical perspective report on melanoma management

Management of melanoma includes wide excision with adequate margins and lymph node biopsy depending on the depth of the lesion, with subsequent completion lymphadenectomy for positive sentinel node. Locally advanced disease can be approached in several different ways depending on a variety of patient and disease-specific factors. These include surgical resection, isolated limb perfusion and infusion and intralesional injection therapy such as talimogene laherparepvec, IL-2 and Bacille Calmette-Guerin. Ongoing controversy exists regarding the utility of completion lymphadenectomy, and trials such as MSLT-2 will attempt to shed light on this issue. The future of melanoma management will likely focus on expanding the use of immunotherapy, allowing for narrower surgical margins, particularly in sensitive anatomic areas, and limiting the number of completion lymphadenectomies.

Predictors and Survival Impact of False-Negative Sentinel Nodes in Melanoma

BACKGROUND

The status of the sentinel lymph node in melanoma is an important prognostic factor. The clinical predictors and implications of false-negative (FN) biopsy remain debatable.

METHODS

We compared patients with positive sentinel lymph node biopsy (SNB) [true positive (TP)] and negative SNB with and without regional recurrence [FN, true negative (TN)] from our prospective institutional database.

RESULTS

Among 2986 patients (84 FN, 494 TP, and 2408 TN; median follow-up 93 months), the incidence of FN-SNB was 2.8%. While calculated FN rate was 14.5% [84 FN/(494 TP + 84 FN) × 100], when we accounted for local/in-transit recurrence (LITR) this rate was 8.5% [46 FN/(494 TP + 46 FN) × 100 %]. On multivariate analysis, male gender (OR 2.0, 95% CI 1.1-3.6, p = 0.018), head/neck primaries (OR 2.5, 95% CI 1.3-4.8, p < 0.006), and LITR (OR 3.5, 95% CI 2.1-5.8, p < 0.001) were associated with FN-SNB. Melanoma-specific survival (MSS) for the FN group was similar to the TP group at 5 years (68 vs. 73%, p = 0.539). However, MSS declined more for the FN group with a longer follow up and was significantly worse at 10 years (44 vs. 64%, p < 0.001). On multivariate analysis, FN-SNB was a significant predictor of worse MSS in melanomas <4 mm in Breslow thickness (HR 1.6; 95% CI 1.1-2.5, p = 0.021).

CONCLUSIONS

Male gender, LITR, and head and neck tumors were associated with FN-SNB. FN-SNB was an independent predictor of worse MSS in melanomas <4 mm in thickness, but this survival difference did not become apparent until after 5 years of follow-up.

EANM practice guidelines for lymphoscintigraphy and sentinel lymph node biopsy in melanoma

PURPOSE

Sentinel lymph node biopsy is an essential staging tool in patients with clinically localized melanoma. The harvesting of a sentinel lymph node entails a sequence of procedures with participation of specialists in nuclear medicine, radiology, surgery and pathology. The aim of this document is to provide guidelines for nuclear medicine physicians performing lymphoscintigraphy for sentinel lymph node detection in patients with melanoma.

METHODS

These practice guidelines were written and have been approved by the European Association of Nuclear Medicine (EANM) to promote high-quality lymphoscintigraphy. The final result has been discussed by distinguished experts from the EANM Oncology Committee, national nuclear medicine societies, the European Society of Surgical Oncology (ESSO) and the European Association for Research and Treatment of Cancer (EORTC) melanoma group. The document has been endorsed by the Society of Nuclear Medicine and Molecular Imaging (SNMMI).

CONCLUSION

The present practice guidelines will help nuclear medicine practitioners play their essential role in providing high-quality lymphatic mapping for the care of melanoma patients.

The Role of Regional Therapies for in-Transit Melanoma in the Era of Improved Systemic Options

The incidence of melanoma has been increasing at a rapid rate, with 4%–11% of all melanoma recurrences presenting as in-transit disease. Treatments for in-transit melanoma of the extremity are varied and include surgical excision, lesional injection, regional techniques and systemic therapies. Excision to clear margins is preferred; however, in cases of widespread disease, this may not be practical. Historically, intralesional therapies were generally not curative and were often used for palliation or as adjuncts to other therapies, but recent advances in oncolytic viruses may change this paradigm. Radiation as a regional therapy can be quite locally toxic and is typically relegated to disease control and symptom relief in patients with limited treatment options. Regional therapies such as isolated limb perfusion and isolated limb infusion are older therapies, but offer the ability to treat bulky disease for curative intent with a high response rate. These techniques have their associated toxicities and can be technically challenging. Historically, systemic therapy with chemotherapies and biochemotherapies were relatively ineffective and highly toxic. With the advent of novel immunotherapeutic and targeted small molecule agents for the treatment of metastatic melanoma, the armamentarium against in-transit disease has expanded. Given the multitude of options, many different combinations and sequences of therapies can be offered to patients with in-transit extremity melanoma in the contemporary era. Reported response and survival rates of the varied treatments may offer valuable information regarding treatment decisions for patients with in-transit melanoma and provide rationale for these decisions.

Surgical management of primary and recurrent melanoma

Melanoma accounts for less than 2% of skin cancer cases but causes most skin cancer-related deaths. Surgery continues to be the cornerstone of treatment of melanoma and surgical principles are guided by data derived from clinical research. This article examines the evolution of surgical techniques for the diagnosis and treatment of primary and locally recurrent melanoma.

Locoregional therapies in melanoma

In-transit disease is defined as any dermal or subcutaneous metastases that arise between the primary melanoma but not beyond the draining regional nodal basin. Patients who develop in-transit disease are at further risk to develop additional locoregional and distant disease. Treatment must be individualized and take into consideration the extent of disease, tumor characteristics, and patient characteristics including age, comorbidities, previous therapies, and site of recurrence. Surgery, regional perfusions and intralesional injections all play a role in management options. These patients should be discussed and managed by a multidisciplinary team whenever possible.

Subcutaneous metastases from melanoma: a discussion of clinical experience

SUMMARY 

The majority of locoregional relapses of cutaneous melanoma occur as subcutaneous local recurrences/in-transit metastases; subcutaneous metastases (SMs) are also common in distant metastases. SM therapy is challenging and depends on the number, site, depth, size, clinical behavior and presence of other metastases. Isolated, resectable SMs should be treated surgically. In multiple/unresectable lesions, several local modalities are used: carbon dioxide laser ablation, radiotherapy, cryotherapy, intralesional injections and electrochemotherapy. Hyperthermic isolated limb perfusion is the preferred method of treating multiple, bulky in-transit metastases in extremities, allowing for high response rates and long-lasting remission. Electrochemotherapy is a simple method for the fast ablation of SMs that are not feasible for hyperthermic isolated limb perfusion. Recent advances in systemic therapy of melanoma, including immunotherapy (anti-CTLA4/anti-PD-1) and targeted therapy (BRAF/MEK inhibitors), have significantly impacted on SM treatment. We present our own SM cases treated with different modalities. The future of SM therapy will rely on a combination of different local, locoregional and systemic modalities, and we can expect major improvements in long-term outcomes.

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.

Efficacy of repeat sentinel lymph node biopsy in patients who develop recurrent melanoma

BACKGROUND

Even after negative sentinel lymph node biopsy (SLNB) for primary melanoma, patients who develop in-transit (IT) melanoma or local recurrences (LR) can have subclinical regional lymph node involvement.

STUDY DESIGN

A prospective database identified 33 patients with IT melanoma/LR who underwent technetium 99m sulfur colloid lymphoscintigraphy alone (n = 15) or in conjunction with lymphazurin dye (n = 18) administered only if the IT melanoma/LR was concurrently excised.

RESULTS

Seventy-nine percent (26 of 33) of patients undergoing SLNB in this study had earlier removal of lymph nodes in the same lymph node basin as the expected drainage of the IT melanoma or LR at the time of diagnosis of their primary melanoma. Lymphoscintography at time of presentation with IT melanoma/LR was successful in 94% (31 of 33) cases, and at least 1 sentinel lymph node was found intraoperatively in 97% (30 of 31) cases. The SLNB was positive in 33% (10 of 30) of these cases. Completion lymph node dissection was performed in 90% (9 of 10) of patients. Nine patients with negative SLNB and IT melanoma underwent regional chemotherapy. Patients in this study with a positive sentinel lymph node at the time the IT/LR was mapped had a considerably shorter time to development of distant metastatic disease compared with those with negative sentinel lymph nodes.

CONCLUSIONS

In this study, we demonstrate the technical feasibility and clinical use of repeat SLNB for recurrent melanoma. Performing SLNB cannot only optimize local, regional, and systemic treatment strategies for patients with LR or IT melanoma, but also appears to provide important prognostic information.

Plasma cytokine analysis in patients with advanced extremity melanoma undergoing isolated limb infusion

BACKGROUND

Preprocedure clinical and pathologic factors have failed to consistently differentiate complete response (CR) from progressive disease (PD) in patients after isolated limb infusion (ILI) with melphalan for unresectable in-transit extremity melanoma.

METHODS

Multiplex immunobead assay technology (Milliplex MAP Human Cytokine/Chemokine Magnetic Bead Panel, Millipore Corp., Billerica, MA; and Magpix analytical test instrument, Luminex Corp., Austin, TX) was performed on pre-ILI plasma to determine concentrations of selected cytokines (MIP-1α, IL-1Rα, IP-10, IL-1β, IL-1α, MCP-1, IL-6, IL-17, EGF, IL-12p40, VEGF, GM-CSF, and MIP-1β) on a subset of patients (n = 180) who experienced CR (n = 23) or PD (n = 24) after ILI. Plasma from normal donors (n = 12) was also evaluated.

RESULTS

Of 180 ILIs performed, 28 % (95 % confidence interval 22-35, n = 50) experienced a CR, 14 % (n = 25) experienced a partial response, 11 % (n = 21) had stable disease, 34 % (n = 61) had PD, and 13 % (n = 23) were not evaluable for response. Tumor characteristics and pharmacokinetics appeared similar between CR (n = 23) and PD (n = 24) patients who underwent cytokine analysis. Although there were no differences in cytokine levels between CR and PD patients, there were differences between the melanoma patients and controls. MIP-1α, IL-1Rα, IL-1β, IL-1α, IL-17, EGF, IL-12p40, VEGF, GM-CSF, and MIP-1β were significantly higher in normal controls compared to melanoma patients, while IP-10 was lower (p < 0.001) in controls compared to melanoma patients.

CONCLUSIONS

Patients with unresectable in-transit melanoma appear to have markedly decreased levels of immune activating cytokines compared to normal healthy controls. This further supports a potential role for immune-targeted therapies and immune monitoring in patients with regionally advanced melanoma.

A multicenter prospective evaluation of the clinical utility of F-18 FDG-PET/CT in patients with AJCC stage IIIB or IIIC extremity melanoma

OBJECTIVE/BACKGROUND

There is a high risk of relapse in stage IIIB/IIIC melanoma. The utility of 2-[fluorine-18]-fluoro-2-deoxy-D-glucose positron emission tomography integrated with computed tomography (FDG-PET/CT) in these patients to evaluate response to treatment or for surveillance after treatment is currently not well defined.

METHODS

Prospective data from 2 centers identified 97 patients with stage IIIB/IIIC extremity melanoma undergoing isolated limb infusion (ILI) who had whole body FDG-PET/CT scans before and every 3 months after treatment. Clinical response was determined at 3 months by Response Evaluation Criteria In Solid Tumors.

RESULTS

Complete response (CR) after ILI occurred in 33% (32/97) of patients. FDG-PET/CT accurately identified 59% of patients who were CRs (19/32), whereas 41% (13/32) had residual metabolic activity in the extremity that was histologically negative for melanoma. The 3-year disease-free rate was 62.2% (95% CI: 40.1%-96.4%) for those patients who were CRs by both clinical/pathologic examination and FDG-PET/CT (n = 19) compared to only 29.4% (95% CI: 9.9%-87.2%) of those CRs who still had residual FDG-PET/CT activity (n = 13). FDG-PET/CT was utilized for surveillance of disease recurrence outside the regional field of treatment. Fifty-two percent (51/97) of patients developed disease outside the extremity at a median time of 212 days from pre-ILI FDG-PET/CT. In 47% (29/62) of these cases, the recurrence was resected.

CONCLUSIONS

Although FDG-PET/CT does not appear to accurately identify patients who appear to be CRs to ILI, it does appear to identify a subgroup of patients whose regional progression-free survival is markedly worse. However, FDG-PET/CT appears to be an excellent method for surveillance in stage IIIB/IIIC patients after ILI with ability to identify surgically resectable recurrent disease in these high-risk patients.

Rationale for complete metastasectomy in patients with stage IV metastatic melanoma

Patients with stage IV melanoma have usually been treated with systemic therapies; however, the overall survival for patients with this approach is disappointing. A complete surgical resection of metastatic disease to stage IV sites offers the best chance to maximize survival. This review article will present data supporting the position that if a complete metastasectomy is technically feasible, then surgery should be strongly considered the first option for properly selected patients with stage IV melanoma.

Regional treatment strategies for in-transit melanoma metastasis

For in-transit melanoma confined to the extremities, regional chemotherapy in the form of hyperthermic isolated limb perfusion and isolated limb infusion are effective treatment modalities carrying superior response rates to current standard systemic therapy. Despite high response rates, most patients will eventually recur, supporting the role for novel research aimed at improving durable responses and minimizing toxicity. Although the standard cytotoxic agent for regional chemotherapy is melphalan, alternative agents such as temozolomide are currently being tested, with promising preliminary results. Current strategies for improving chemosensitivity to regional chemotherapy are aimed at overcoming classic resistance mechanisms such as drug metabolism and DNA repair, increasing drug delivery, inhibiting tumor-specific angiogenesis, and decreasing the apoptotic threshold of melanoma cells. Concurrent with development and testing of these agents, genomic profiling and biomolecular analysis of acquired tumor tissue may define patterns of tumor resistance and sensitivity from which personalized treatment may be tailored to optimize efficacy. In this article rational strategies for treatment of in-transit melanoma are outlined, with special emphasis on current translational and clinical research efforts.

Management of popliteal sentinel nodes in melanoma

BACKGROUND

Although most melanomas on the distal lower extremity drain exclusively to inguinal lymph nodes, a small percentage (<5%) drain to interval nodes in the popliteal basin. We investigated a possible relationship between tumor-draining popliteal and inguinal nodes in patients with lower-extremity melanoma.

STUDY DESIGN

We queried our melanoma database to identify patients who underwent sentinel node biopsy (SNB) for an infrapopliteal melanoma. Patterns of nodal drainage and nodal metastasis were analyzed.

RESULTS

Of 461 patients who underwent SNB for a primary infrapopliteal melanoma, 15 (3.2%) had drainage to the popliteal basin. Thirteen melanomas were on the posterior leg and foot, and 2 were on the anterior lower leg. Mean Breslow thickness was 2.4 mm. All 15 patients with popliteal drainage also had inguinal drainage and therefore underwent concurrent inguinal and popliteal SNB. The average number of popliteal sentinel nodes was 1.4 (range 1 to 3). Eight patients (53%) had a tumor-positive popliteal sentinel node, and 6 of the 8 underwent completion popliteal lymphadenectomy. Four of the 8 patients (50%) also had tumor-positive inguinal sentinel nodes; all underwent complete inguinal lymphadenectomy. We also identified 9 additional patients who underwent SNB for locoregional recurrent melanomas of the infrapopliteal leg. Three (33%) of these patients had concurrent inguinal and popliteal SNB, with 1 isolated tumor-positive popliteal node found.

CONCLUSIONS

In our series, a high percentage of popliteal sentinel lymph nodes contained metastases, and these patients frequently also had inguinal metastases. In our patients, all inguinal metastases were associated with concomitant popliteal metastases. Although it is anatomically separate, the inguinal basin appears to be a functional extension of the popliteal basin.

Solitary dermal melanoma: beginning or end of the metastatic process?

BACKGROUND

Solitary dermal melanoma (SDM) is confined to the dermal and/or subcutaneous tissue without an epidermal component. It is unclear whether this lesion is a subtype of primary melanoma or distant cutaneous metastasis from an unknown primary. We evaluated our large experience to determine the prognosis and optimal management of SDM.

METHODS

Our melanoma referral center's database of prospectively acquired records was used for identification and clinicopathologic analysis of patients presenting with SDM between 1971 and 2005.

RESULTS

Of 12,817 database patients seen during a 34-year period, 101 (0.8%) had SDM. Of 92 patients free of distant metastasis on initial presentation, 55 (60%) were observed and 37 (40%) underwent surgical nodal staging: regional metastases were identified in 7 (19%). Nodal recurrence occurred in 1 of 30 patients (3.3%) with histopathology-negative nodes compared with 13 of 55 patients (24%) who underwent nodal observation instead of nodal staging. Thus, 21 of 92 patients (23%) had nodal metastasis identified during surgical nodal staging or postoperative nodal observation. At a median follow-up of 68 months, estimated 5-year overall survival rate was 73% for 71 patients with localized disease versus 67% for 21 patients with regional disease (P=0.25) versus 22% for 9 patients with distant disease (P=0.009, regional versus distant disease).

CONCLUSIONS

SDM resembles intermediate-thickness primary cutaneous melanoma with respect to prognostic characteristics and clinical evolution, but its rate of distant metastasis justifies radiographic staging and its high rate of regional node metastasis justifies wide excision and sentinel node biopsy.

The European approach to in-transit melanoma lesions

The biological behavior of melanoma is unpredictable. Three to five per cent of melanoma patients will develop in-transit lesions and the median time to recurrence ranges between 13-16 months. At the time of recurrence the risk of occult nodal metastasis, with clinically negative regional lymph nodes, is as high as 50%. The risk of in-transit lesions depends on the tumor biology and not on the surgical approach to the regional lymph nodes. The high incidence of in-transit lesions at the lower limb may be caused by the gravity and delayed lymphatic drainage. The treatment of limited disease is local excision, laser ablation, cryosurgery, while multiple in-transit lesions or bulky disease located in a limb can be successfully treated with regional chemotherapy, a therapeutic isolated limb perfusion or infusion with melphalan or a combination of melphalan and tumor necrosis factor (TNF) alpha. If local regional treatment or systemic dacarbazine based systemic treatment fails, novel systemic treatment strategies with vaccines, antibodies and gene therapy are currently investigated.

Lymphoscintigraphic localization of sentinel node in early colorectal cancer: results of a monocentric study

BACKGROUND AND OBJECTIVES

Evaluation of the feasibility of the sentinel node technique in early colorectal neoplasms and its overall accuracy in predicting nodal metastases.

METHODS

Thirty-five patients with colon or rectal lesions or degenerate polyps not radically excised by endoscopy were included. Lymphatic mapping was performed with 99mTc labeled albumin colloid injected submucosally by an endoscopic route the afternoon before the surgical procedure. The day of the intervention, 2.5% patent blue V dye (S.A.L.F: Italy) was injected circumferentially around the tumor. A hand held gamma detecting probe (Scintiprobe m100, Pol-Hi-Tech, Italy) was employed to detect "hot" nodes, in vivo and ex vivo. All sentinel nodes were embedded separately for haematoxylin and eosin staining. No IHC or PCR techniques were employed.

RESULTS

Sentinel lymph nodes (SLN) were successfully identified in 35 out of 35 patients. Concordance between SLN and nodal status was observed in 32 out of 35 cases (91.4%); four patients (11.4%) were upstaged. Three skip nodal metastases were observed (false-negative rate: 8.5%).

CONCLUSIONS

The sentinel node technique with blue dye and radiotracer seems valuable in early colorectal cancers detected by screening programs: a good organization and a learning curve are needed, as further multicentric studies.

Sentinel Node Mapping for Melanoma: Results of Trials and Current Applications

The value of sentinel node (SN) biopsy as a staging procedure and as a guide to prognosis with patients who have melanoma is now clearly established. As well, there is recent clinical trial evidence suggesting a survival benefit for patients found to be SN positive who have an immediate complete lymph node dissection (CLND), compared with those with nodal disease not treated by CLND until it becomes clinically apparent. Clinical trials are ongoing to determine whether CLND is necessary in all patients who are found to be SN positive.

Sentinel lymph node biopsy for local recurrence of breast cancer after breast-conserving therapy

BACKGROUND

Lymphatic mapping (LM) with sentinel lymph node (SLN) biopsy has revolutionized the surgical staging of primary breast cancer, but its utility and feasibility have not been established in patients with ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery (BCS) and radiation.

METHODS

We reviewed our breast cancer database to identify all patients who underwent preoperative lymphoscintigraphy for IBTR and whose primary tumor had been managed by BCS, SLN biopsy and/or axillary node dissection, and adjuvant breast irradiation.

RESULTS

Preoperative lymphoscintigraphy identified migration to the regional nodal drainage basins in 11 (73%) of 15 patients, as follows: 5 ipsilateral axillary, 1 supraclavicular, 2 internal mammary, 2 interpectoral, and 3 contralateral axillary. Two patients demonstrated drainage to two nodal basins. In four patients, no drainage was observed. Intraoperative LM with radioisotope plus blue dye identified at least 1 SLN in 11 of 14 patients, and histopathologic evaluation revealed metastasis in 3 patients (2 contralateral axillary and 1 ipsilateral axillary). During preoperative lymphoscintigraphy, the radiocolloid migration time tended to be longer and the drainage pathways more variable than those associated with primary tumors.

CONCLUSIONS

LM/SLN biopsy can be successfully performed in patients with IBTR after prior BCS, axillary surgical staging, and adjuvant radiation. This approach illustrates variations in the lymphatic drainage of recurrent breast tumors and may permit the identification of regional metastasis not noted with conventional imaging techniques.

Sentinel lymph node mapping in colon cancer

BACKGROUND

By systematically reviewing the literature on sentinel lymph node mapping of colon cancers, this study aimed to evaluate this technique as it applies to colon cancers.

METHODS

Human studies on lymphatic mapping for colon cancers were reviewed. Multiple publications of the same studies, abstracts, and case reports were excluded. Current Contents, MEDLINE, EMBASE, and Cochrane Library databases were investigated.

RESULTS

Lymphatic mapping appears to be readily applicable to colon cancers, identifying lymph nodes most likely to harbor metastases. Identification of sentinel lymph nodes varied from 58% to 100% and carried a false-negative rate of approximately 10% in larger studies, but potentially rose 4% to 25% among patients representing a range from node-negative to node-positive (micrometastases) conditions. The prognostic implication of these micrometastases requires further evaluation. Lymphatic mapping in 6% to 29% of cases identified aberrant lymphatic drainage that altered the extent of the lymphadenectomy.

CONCLUSIONS

Further follow-up evaluation to assess the prognostic significance of micrometastases for colon cancers is required before the staging benefits of sentinel node mapping can have therapeutic implications. Lymphatic mapping offers the possibility of improving staging by identifying patients with early disseminated disease who should be considered for adjuvant treatment or included in trials of adjuvant treatment to speed up the breakthrough of more effective adjuvant regimens. Large studies are needed to determine whether the sentinel node concept is as valid for colon cancers as studies so far have shown it is for malignant melanoma and breast cancer.

[Sentinel lymph node in melanoma]

The procedure of sentinel node biopsy (SNB) has emerged as an important advance especially with respect to staging of malignant melanoma. Elective (prophylactic) lymph node dissection that had been practiced in primary melanoma with a suspected increased risk of (clinically occult) lymphatic metastasis has been replaced by SNB. Patients with proven metastatic involvement of the sentinel node (12-25%) can be specifically selected for regional lymph node dissection. Metastatic involvement of the sentinel node (SN) is a significant independent prognostic factor. The value of detecting metastasis by highly sensitive diagnostic tools such as RT-PCR is just as uncertain as is the therapeutic benefit of operative or conservative therapies in sentinel node-positive patients with respect to improving prognosis and is currently under study.

The natural course of cutaneous melanoma

The natural course of cutaneous melanoma (CM) is determined by its metastatic spread and depends on tumor thickness, ulceration, gender, localization, and the histologic subtype of the primary tumor. CM metastasis develops via three main metastatic pathways and occurs as satellite or in-transit metastasis, as regional lymph node metastasis or as distant metastasis at the time of primary recurrence. About 50% of all CM patients with tumor progression firstly develop regional lymph node metastases. In the other 50% the first metastases are satellite or in-transit metastases (about 20%), or immediately distant metastases (about 30%). Development of distant metastasis appears to be an early event in metastatic spread and may in the majority of cases originate from the primary tumor, only few cases may develop secondarily to locoregional metastasis. Reporting of organ involvement in distant metastasis greatly differs between the results of imaging techniques and autopsy results in respect to the metastatic patterns detected, pointing out that there is a need of improved imaging systems. Proliferation, neovascularization, lymphangiogenesis, invasion, circulation, and embolism are important steps in the pathogenesis of CM metastasis, with tumor vascularity as an important independent significant prognostic factor. The expression of chemokine receptors in cancer cells associated with the expression of the respective chemokine receptor ligands in the target sites of the metastasis is an interesting observation which may stimulate the development of new therapeutic strategies.

Controversies in the management of metastatic melanoma to regional lymphatic basins

The primary management of lymph nodes involved with metastatic melanoma is regional lymphadenectomy. Many controversies of regional lymph node dissection exist including extent and nature of the lymphadenectomy, treatment of lymphatic metastases in unusual locations and the role of adjuvant radiotherapy. Although radical neck dissection has been the gold standard for cervical disease, modified dissections do not seem to compromise regional control in appropriately selected patients. In the axilla, a Level I, II, and III dissection is most commonly performed. Combined superficial and deep groin dissection is justified for clinically palpable disease although management of patients with histologically positive yet clinically non-palpable disease is more controversial. Burden of disease, imaging, patient co-morbidity, and Cloquet nodal status must be considered. Many technical variations exist in an attempt to improve morbidity rates secondary to lymphadenectomy. Unfortunately, complication rates are difficult to compare secondary to variable study designs, definitions, and patient populations. Adjuvant radiation therapy appears warranted in patients with high risk of regional recurrence including bulky disease, extracapsular extension or cervical location.