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Mellemgaard C, Christensen IJ, Salkus G, Wirenfeldt Staun P, Korsgaard N, Hein Lindahl K, Skaarup Larsen M, Klausen S, Lade-Keller J. Reducing workload in malignant melanoma sentinel node examination: a national study of pathology reports from 507 melanoma patients. J Clin Pathol 2024; 77:312-317. [PMID: 36737244 DOI: 10.1136/jcp-2022-208743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/21/2023] [Indexed: 02/05/2023]
Abstract
AIMS Even though extensive melanoma sentinel node (SN) pathology protocols increase metastasis detection, there is a need for balancing high detection rates with reasonable workload. A newly tested Danish protocol recommended examining nodes at six levels 150 µm apart (six-level model) and using SOX10 and Melan-A immunohistochemistry (IHC). We explored if a protocol examining 3 levels 300 µm apart (three-level model) combined with IHC would compromise metastasis detection. The study aim was to optimise the protocol to reduce workload without compromising detection rate. METHODS 8 months after protocol implementation, we reviewed the pathology reports of SNs from 507 melanoma patients nationwide, including 117 SN-positive patients. Each report was reviewed to determine histopathological features, including detection of metastasis, exact levels with metastasis, exact levels with metastasis >1 mm in diameter and IHC results. RESULTS The six-level model detected metastases in 23% of patients, whereas the three-level model would have detected metastases in 22% of patients. The three-level model would have missed a few small metastases (n=4), measuring <0.1 mm, 0.1 mm, 0.4 mm and 0.1 mm, respectively. The six-level model detected metastases >1 mm in 7% of patients. One of these metastases (measuring 1.1 mm) would have been detected by the three-level model, but not as >1 mm. SOX10 and Melan-A had equal sensitivity. CONCLUSIONS Reducing the number of levels examined to three levels 300 µm apart combined with IHC does not have significant impact on metastasis detection rate, and we will therefore recommend that the future melanoma SN guideline takes this into consideration to reduce overall workload.
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Affiliation(s)
- Carina Mellemgaard
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
- Aarhus University, Aarhus, Denmark
| | - Ib Jarle Christensen
- Department of Pathology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Giedrius Salkus
- Department of Pathology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Niels Korsgaard
- Department of Pathology, Hospital South West Jutland, Esbjerg, Denmark
| | | | | | - Siri Klausen
- Department of Pathology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
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Ulmer A, Pfefferle V, Walter V, Granai M, Keim U, Fend F, Sulyok M, Bösmüller H. Reporting of melanoma cell densities in the sentinel node refines outcome prediction. Eur J Cancer 2022; 174:121-130. [PMID: 35994792 DOI: 10.1016/j.ejca.2022.06.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Sentinel node biopsy is a key procedure to predict prognosis in melanoma. In a prospective study we compare reporting on melanoma cell densities in cytospin preparations with semiquantitative histopathology for predicting outcome. PATIENTS AND METHODS Sentinel nodes from 900 melanoma patients were bisected. One half of each node was disaggregated mechanically. The melanoma cell density (number of HMB45 positive cells per million lymphocytes with at least one cell showing morphological features of a melanoma cell) was recorded after examining two cytospins. For the second half the maximum diameter of metastasis was determined after haematoxylin and eosin (H&E) and immunohistological staining of three slides. RESULTS Cytospins were positive for melanoma in 218 of 900 patients (24%). Routine pathology was positive in 111 of 900 (12%) patients. A more extensive pathological workup in cytospin-only positive patients led to a revised diagnosis (from negative to positive) in 23 of 101 patients (22.7%). We found a moderate but significant correlation between melanoma cell densities (determined in cytospins) and the maximum diameter of metastasis (determined by pathology) (rho = 0.6284, p < 0.001). At a median follow-up of 37 months (IQR 25-53 months) melanoma cell density (cytospins) (p < 0.001), thickness of melanoma (p = 0.008) and ulceration status (p = 0.026) were significant predictors for melanoma specific survival by multivariable testing and were all confirmed as key predictive factors by the random forest model. Maximum diameter of metastases, age and sex were not significant by multivariable testing (all p > 0.05). CONCLUSION Recording melanoma cell densities by examining two cytospins accurately predicts melanoma outcome and outperforms semiquantitative histopathology.
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Affiliation(s)
- Anja Ulmer
- Department of Dermatology, University of Tübingen, 72072 Tübingen, Germany.
| | - Vanessa Pfefferle
- Department of Dermatology, University of Tübingen, 72072 Tübingen, Germany.
| | - Vincent Walter
- Department of Dermatology, University of Tübingen, 72072 Tübingen, Germany.
| | - Massimo Granai
- Department of Pathology, University of Tübingen, 72072 Tübingen, Germany.
| | - Ulrike Keim
- Department of Dermatology, University of Tübingen, 72072 Tübingen, Germany.
| | - Falko Fend
- Department of Pathology, University of Tübingen, 72072 Tübingen, Germany.
| | - Mihály Sulyok
- Department of Pathology, University of Tübingen, 72072 Tübingen, Germany.
| | - Hans Bösmüller
- Department of Pathology, University of Tübingen, 72072 Tübingen, Germany.
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Hellmich L, Witte KE, Ebinger M, Ulmer A. Flow Cytometry for Detection and Quantification of Micrometastases in Sentinel Lymph Nodes from Patients with Primary Melanoma. J Surg Res 2020; 257:477-485. [PMID: 32911437 DOI: 10.1016/j.jss.2020.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 05/01/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Detection of micrometastases in the regional lymph nodes is one of the most important prognostic factors for melanoma patients. Our aim was to evaluate the suitability of flow cytometry for rapid quantification of disseminated melanoma cells in sentinel lymph nodes (SLN). METHODS 132 SLNs from 104 patients diagnosed with melanoma were analyzed by flow cytometry, utilizing the extracellular marker melanoma-associated chondroitin sulfate proteoglycan, in addition to quantitative immunocytology and conventional histopathology, including immunohistochemistry. For quantification, the number of melanoma-positive cells per million lymph node cells (disseminated cancer cell density, DCCD) detected by flow cytometry was compared to the DCCD obtained by immunocytology. RESULTS Compared to histopathology and immunocytology, flow cytometry exhibited a sensitivity of 50% and a specificity of 85%. DCCDs of immunocytology and flow cytometry of the 37 immunocytologically positive SLNs showed a positive correlation (Spearman's ρ = 0.7, P < 0.0001). In 10 SLNs from 9 patients with high tumor load, the flow cytometric DCCD was 8-fold higher on average than the immunocytologic DCCD. CONCLUSIONS Although flow cytometry is not yet suitable for early detection of metastatic melanoma, it promises to become a valuable tool for rapidly quantifying tumor load in high-risk patients.
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Affiliation(s)
- Luisa Hellmich
- Department of Dermatology, University of Tuebingen, Tuebingen, Germany; Department of Dermatology, University of Cologne, Cologne, Germany.
| | - Kai-Erik Witte
- Department of General Pediatrics, Hematology/Oncology, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Martin Ebinger
- Department of General Pediatrics, Hematology/Oncology, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Anja Ulmer
- Department of Dermatology, University of Tuebingen, Tuebingen, Germany
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[Sentinel node biopsy and lymph node dissection in the era of new systemic therapies for malignant melanoma]. Hautarzt 2019; 70:864-869. [PMID: 31605168 DOI: 10.1007/s00105-019-04491-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Recently, adjuvant therapies with checkpoint inhibitors and BRAF/MEK inhibitors have become available for patients with malignant melanoma and microscopic nodal disease. Meanwhile the number of complete nodal dissections for a melanoma-positive sentinel node (SN) have decreased significantly. OBJECTIVE The authors discuss the significance of sentinel node biopsy (SNB) and early lymph node dissection in the era of adjuvant systemic therapy for stage III melanoma. MATERIALS AND METHODS Current publications and recommendations were evaluated. RESULTS Complete nodal dissection for a positive SN significantly reduces the risk of regional nodal relapse. However, neither SNB nor complete nodal dissection following a positive SN are associated with a benefit in survival. With the availability of novel adjuvant systemic treatment strategies for stage III melanoma, SNB has become an even more important part of modern staging diagnostics. Thus, detection of early dissemination of melanoma cells into the SN as well as the quantification of the tumor load are decisive for further therapy planning. CONCLUSION Accurate assessment of the regional lymph node status by SNB is becoming even more important in the era of novel effective adjuvant therapies for microscopic nodal disease. Whether complete lymph node dissection is performed in patients with a positive SN needs to be assessed individually. In the case of "active nodal surveillance" instead of surgery, long-term close follow-up in specialized centers, including ultrasonographic controls, is required.
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Cook MG, Massi D, Szumera-Ciećkiewicz A, Van den Oord J, Blokx W, van Kempen LC, Balamurugan T, Bosisio F, Koljenović S, Portelli F, van Akkooi AC. An updated European Organisation for Research and Treatment of Cancer (EORTC) protocol for pathological evaluation of sentinel lymph nodes for melanoma. Eur J Cancer 2019; 114:1-7. [DOI: 10.1016/j.ejca.2019.03.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 02/13/2019] [Accepted: 03/10/2019] [Indexed: 10/27/2022]
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Nogami Y, Banno K, Irie H, Iida M, Kisu I, Masugi Y, Tanaka K, Tominaga E, Okuda S, Murakami K, Aoki D. The efficacy of preoperative positron emission tomography-computed tomography (PET-CT) for detection of lymph node metastasis in cervical and endometrial cancer: clinical and pathological factors influencing it. Jpn J Clin Oncol 2014; 45:26-34. [PMID: 25368102 DOI: 10.1093/jjco/hyu161] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE We studied the diagnostic performance of (18)F-fluoro-2-deoxy-d-glucose-positron emission tomography/computed tomography in cervical and endometrial cancers with particular focus on lymph node metastases. METHODS Seventy patients with cervical cancer and 53 with endometrial cancer were imaged with (18)F-fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography before lymphadenectomy. We evaluated the diagnostic performance of (18)F-fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography using the final pathological diagnoses as the golden standard. RESULTS We calculated the sensitivity, specificity, positive predictive value and negative predictive value of (18)F-fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography. In cervical cancer, the results evaluated by cases were 33.3, 92.7, 55.6 and 83.6%, respectively. When evaluated by the area of lymph nodes, the results were 30.6, 98.9, 55.0 and 97.0%, respectively. As for endometrial cancer, the results evaluated by cases were 50.0, 93.9, 40.0 and 95.8%, and by area of lymph nodes, 45.0, 99.4, 64.3 and 98.5%, respectively. The limitation of the efficacy was found out by analyzing it by the region of the lymph node, the size of metastatic node, the historical type of tumor in cervical cancer and the prevalence of lymph node metastasis. CONCLUSION The efficacy of positron emission tomography/computed tomography regarding the detection of lymph node metastasis in cervical and endometrial cancer is not established and has limitations associated with the region of the lymph node, the size of metastasis lesion in lymph node and the pathological type of primary tumor. The indication for the imaging and the interpretation of the results requires consideration for each case by the pretest probability based on the information obtained preoperatively.
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Affiliation(s)
- Yuya Nogami
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo
| | - Kouji Banno
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo
| | - Haruko Irie
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo
| | - Miho Iida
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo
| | - Iori Kisu
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo
| | - Yohei Masugi
- Department of Pathology, School of Medicine, Keio University, Tokyo
| | - Kyoko Tanaka
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo
| | - Eiichiro Tominaga
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo
| | - Shigeo Okuda
- Department of Radiology, School of Medicine, Keio University, Tokyo, Japan
| | - Koji Murakami
- Department of Radiology, School of Medicine, Keio University, Tokyo, Japan
| | - Daisuke Aoki
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo
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