Single intralesional tracer dose for radio-guided excision of clinically occult breast cancer and sentinel node

BACKGROUND

The purpose of this study was to determine the feasibility of both lymphatic mapping and probe-guided primary tumor excision by use of intralesional tracer administration in clinically occult breast cancer.

METHODS

Sixty patients with a clinically occult breast lesion were prospectively included. Lymphoscintigraphy was performed after intratumoral injection of 99mTc-labeled nanocolloid guided by ultrasound or stereotaxis. A catheter over a localization wire was inserted for intraoperative blue dye administration by using the same imaging techniques. After sentinel node identification, the gamma-ray detection probe was used for radio-guided wide local excision in patients who underwent breast-conserving therapy.

RESULTS

A sentinel node was visualized on the scintigrams in 56 patients (93%) and could be identified intraoperatively in 58 patients (97%). A sentinel node contained tumor in 10 (17%) of these patients. Extra-axillary sentinel nodes were visualized in 43%, were collected in 38%, and contained metastasis in 7% of the patients. Complete excision of the primary tumor could be accomplished in 39 (87%) of 45 patients.

CONCLUSIONS

Both sentinel node biopsy and probe-guided excision of a nonpalpable breast cancer is feasible with the aid of intralesional tracer administration. Sentinel node metastasis was found in 17% of the patients. A remarkably high percentage of extra-axillary drainage (43%) was observed.

The European Society of Surgical Oncology

Surgery is the key to local tumor control and survival in the vast majority of cancer patients. Optimally performed oncological operations, based both on a profound knowledge of the disease and on organ-based technical expertise are therefore essential. In this field the multinational European Society of Surgical Oncology (ESSO) wants to play a pivotal role, improving surgical treatment and encouraging and promoting education and training in surgical oncology at all levels. To achieve this goal the ESSO is of the opinion that recognition of surgical oncology as a separate subspecialty has to pursued.

Isolated limb perfusion: the European experience

Isolated limb perfusion (ILP) is a method of cancer treatment allowing the administration of high doses of anticancer agents in a limb surgically isolated from systemic circulation. By using continuous leakage monitoring and using the drug melphalan, a high complete remission rate is obtained in patients with melanoma. In patients with sarcomas, ILP with tumor necrosis factor and melphalan represents a neoadjuvant treatment for limb-sparing surgery. This treatment is the first demonstration of an active anti-angiogenic regimen in the clinic.

Regional toxicity after isolated limb perfusion with melphalan and tumour necrosis factor- alpha versus toxicity after melphalan alone

AIMS

To determine whether the addition of high-dose tumour necrosis factor-alpha (TNF alpha) to isolated limb perfusion (ILP) with melphalan increases acute regional tissue toxicity compared to ILP with melphalan alone.

METHODS

A retrospective, multivariate analysis of toxicity after normothermic (37--38 degrees C) and 'mild' hyperthermic (38--40 degrees C) ILPs for melanoma was undertaken. Normothermic ILP with melphalan was performed in 294 patients (70.8%), 'mild' hyperthermic ILP with melphalan in 71 patients (17.1%) and 'mild' hyperthermic ILP with melphalan combined with TNF alpha in 50 patients (12.0%). Toxicity was nil or mild (grades I--II according to Wieberdink et al.) in 339 patients (81.7%), and more severe acute regional toxicity (grades III--V) developed in 76 patients (18.3%). A stepwise logistic regression procedure was performed for the multivariate analysis of prognostic factors for more severe toxicity.

RESULTS

On univariate analysis, 'mild' hyperthermic ILP with melphalan plus TNF alpha significantly increased the incidence of more severe acute regional toxicity compared to normothermic and 'mild' hyperthermic ILP with melphalan alone (36% vs 16% and 17%; P=0.0038). However, after ILP using TNF alpha no grade IV (compartment compression syndrome) or grade V (toxicity necessitating amputation) reactions were seen. Significantly more severe toxicity was seen after ILPs performed between 1991 and 1994 compared with earlier ILPs (33%vs 14%P=0.0001). Also, women had a higher risk of more severe toxicity than men (22% vs 7%; P=0.0007). After multivariate analysis, prognostic factors which remained significant were: sex (P=0.0013) and either ILP schedule (P=0.013) or treatment period (P=0.0003).

CONCLUSIONS

Regional toxicity after 'mild' hyperthermic ILP with melphalan and TNF alpha was significantly increased compared to ILP with melphalan alone. This may be caused by increased thermal enhancement of melphalan due to the higher tissue temperatures (39--40 degrees C) at which the melphalan in the TNF alpha-ILPs was administered or by an interaction between high-dose TNF alpha and melphalan.

Is lymphatic mapping in breast cancer adequate and safe?

Lymphatic mapping with selective lymphadenectomy requires a concerted effort from the nuclear medicine physician, surgeon, and pathologist. Application of preoperative lymphoscintigraphy, and intraoperative use of both a gamma detection probe and a vital dye are recommended. This combined approach increases the likelihood of finding all sentinel nodes without removing nonsentinel nodes. A literature review of current experience reveals that the sentinel node can be found in more than 90% of the patients. When confirmatory lymphadenectomy follows, the false-negative rate can be kept down to about 5% after a certain learning phase. The sensitivity of this novel approach to detect lymphatic dissemination is currently overestimated because lymph node metastases in patients with a tumor-free sentinel node are probably overlooked. This shortcoming will be compensated by the more accurate pathologic evaluation of a sentinel node and the finding of sentinel nodes outside the axilla. Therefore the procedure is probably adequate and safe in patients at low risk of having disseminated disease. Lymphatic mapping with sentinel node biopsy is rapidly becoming the standard of care.

Improved sentinel node visualization in breast cancer by optimizing the colloid particle concentration and tracer dosage

Faint lymph uptake may hamper sentinel node (SN) identification by scintigraphy and subsequent gamma probe localization. The aim of the present study was to evaluate an adjustment in the colloid particle concentration and tracer dosage to optimize mammary lymphoscintigraphy. Scintigraphy was performed in 151 patients with a palpable breast carcinoma and clinically negative axilla: for the first 75 patients (group A) a standard labelling of 0.5 mg nanocolloid with 99Tcm was performed, for the subsequent 76 patients (group B) the labelling dilution volume was reduced from 4 to 2 ml. For both groups the volume of injection was 0.2 ml. Lymph node uptake was evaluated by a 4-step visual score (from 0 = absent to 3+ = very intense), and by count quantification of at 4 h in the first draining SN. The SN visualization rate increased from 93% (70/75) in group A (mean dosage 93.4 MBq, range 57-130 MBq) to 99% (75/76) in group B (mean dosage 106.5 MBq, range 74-139 MBq). The percentage of patients with uptake 3+ was significantly higher (P = 0.001) in group B (51% vs 35% in group A). SN counts were significantly higher for group B (P<0.001). The percentage of patients with less than 2000 counts/node diminished from 45% in group A to 9% in group B (P = 0.001). In group B (P = 0.033) more lymph channels (53% vs 35% in group A) were visualized and for a longer time (26% vs 4% at 4 h). Axillary drainage was seen in 96% in group A and 98% in group B whereas non-axillary drainage was observed in 19% and 25%, respectively. Intraoperative SN identification rate was 97% in group A and 100% in group B. SN metastases were found in 41% of group A and 47% of group B. It is concluded that enhancement of colloid particle concentration and adjustment of tracer dosage led to improved SN identification by substantial increase in lymph node uptake and lymph vessel depiction. A significant reduction of cases with faint SN uptake enables better surgical efficacy.

Frozen section investigation of the sentinel node in malignant melanoma and breast cancer

BACKGROUND

Intraoperative frozen section investigation allows immediate regional lymph node dissection when the sentinel node contains tumor. The purpose of this study was to determine the sensitivity of frozen section diagnosis of the sentinel node in melanoma and breast cancer patients.

METHODS

A total of 177 sentinel nodes from 99 melanoma patients and 444 lymph nodes from 262 breast cancer patients were assessed by frozen section investigation. Nodes were bisected, and a complete cross-section was obtained for frozen section. Step sections at three levels were made of the remaining lymphatic tissue and were stained with hematoxylin and eosin and S100/HMB45 (melanoma) or CAM5.2 (breast cancer) to obtain a final pathological diagnosis.

RESULTS

Frozen section investigation revealed metastases in 8 of 17 node-positive melanoma patients (47%). Seventy-one of 96 breast cancer patients (74%) with lymph node metastases were identified with frozen section. The specificity was 100% and 99%, respectively.

CONCLUSION

The sensitivity of intraoperative frozen section investigation of sentinel nodes was 47% in melanoma patients and 74% in breast cancer patients. Frozen section examination allows immediate axillary lymph node dissection in the majority of node-positive breast cancer patients. Frozen section analysis is not recommended in patients with melanoma.

The value of Cloquet's node in predicting melanoma nodal metastases in the pelvic lymph node basin

BACKGROUND

A selection of melanoma patients with groin metastases can benefit from a pelvic (iliac/obturator) lymph node dissection in addition to the infrainguinal dissection. However, there are no reliable criteria to determine which patients may benefit from such an inguinal-pelvic lymphadenectomy.

METHODS

In 142 patients (group A) out of a review of 214 groin dissections performed between 1980 and 1994, the tumor status of Cloquet's node was traced retrospectively. In 52 additional patients (group B), the status of Cloquet's node was registered prospectively. The number of positive lymph nodes and the total numbers of retrieved nodes were recorded as well. All patients underwent a combined therapeutic inguinal-pelvic lymph node dissection between January 1995 and June 1999 in a tertiary referral center.

RESULTS

Cloquet's node was free of disease in 18 of 39 patients with involved pelvic nodes in the retrospective study (sensitivity, 54%; negative predictive value, 83%). In the prospective study, 9 of the 20 patients with involved pelvic nodes had a tumor-free Cloquet's node (sensitivity, 55%; negative predictive value, 78%). Additional immunohistochemical staining of Cloquet's node resulted in a sensitivity of 65%. In the combined group A&B, the number of positive nodes in the inguinal region (cutoff point more than three nodes) had a sensitivity of 41% and a negative predictive value of 78% to determine the pelvic nodal status. When we combined the number of positive inguinal nodes and Cloquet's node in group A&B, the best sensitivity was 56% and the best negative predictive value was 82%.

CONCLUSIONS

Cloquet's node has a low sensitivity to predict the pelvic nodal tumor status. This was barely improved when we accounted for the number of positive inguinal nodes. Groin lymph node dissections should encompass the iliac and obturator compartments in patients with palpable inguinal node metastases.

Management of malignant melanoma

The following guidelines are recommended in the management of malignant melanoma. An excisional biopsy is the appropriate diagnostic procedure for a skin lesion suspected of being a melanoma. The advised margin for diagnostic excision is 2 mm of macroscopically normal skin around the lesion; the margins for therapeutic excision are 1 cm of normal skin for a lesion with a Breslow thickness of < 2 mm and 2 cm when the Breslow thickness is > 2 and < or = 4 mm. A margin of at least 2 cm also appears to be justified for thicker melanomas. Elective lymph node dissection is not recommended. Sentinel node biopsy appears to be a promising method to detect occult metastases in the regional lymph nodes. If regional lymph node metastases are present, therapeutic regional lymph node dissection must be conducted. Isolated regional perfusion is indicated for inoperable tumour growth in an extremity. Radiotherapy can be applied palliatively or postoperatively (if non-radical resection is suspected). Adjuvant systemic therapy is still experimental. There is no standard treatment for patients with haematogenic metastasis and they should be entered in trials whenever possible. A follow-up period of 5 years is sufficient for patients with a melanoma of < or = 1.5 mm Breslow thickness and of 10 years when the Breslow thickness is > 1.5 mm. The patients should be actively involved in the follow-up (inspection, palpation). Regular routine blood tests and radiological examinations are not considered to be worthwhile. There is no evidence that the growth of micro-metastases is stimulated by hormonal changes during pregnancy or contraceptive pill use. Excessive exposure to ultraviolet radiation should be discouraged.

Anatomy and physiology of lymphatic drainage of the breast from the perspective of sentinel node biopsy

Knowledge of the anatomy and physiology of the lymphatic system is helpful when considering a particular sentinel node biopsy technique. The delicate balance between internal and external pressures in a lymphatic channel can be influenced by the injection volume and by massage in a negative or positive way. The narrow openings in the interendothelial junctions determine the speed of clearance of particles with a certain size, and this has implications for the timing of lymphoscintigraphy and surgery. Tracer uptake and lymph flow are highly variable and depend on a number of factors, some of which are beyond our control. The lymphatic anatomy is not completely understood despite numerous studies since the end of the 18th century. Several topics have been elucidated in more recent studies and through experience with sentinel node biopsy. First, although axillary drainage is the principal lymphatic path of the breast, any drainage pattern from any quadrant of the breast can occur. Second, most lymph from the breast flows to the nodal basins with a direct course, not passing through the subareolar plexus. Another relevant point is that gentle massage encourages lymph flow and facilitates sentinel node detection. What problems do we still face in clinical practice? The optimum size and number of labeled colloid particles remain to be established. The optimum volume of the tracer also remains to be determined. But the main controversy concerns the injection site. Although the intradermal injection technique has attractive practical features, there is currently insufficient certainty that drainage of tracer injected anywhere in or underneath the skin of the breast reflects drainage from the cancer. Connections between collecting lymphatic vessels from the tumor site and the collecting vessels from the skin and subdermal lymphatics can explain the concordance between intraparenchymal and superficial injections in most patients. To determine the technique that yields the best sentinel node identification rate with the lowest possible false-negative rate would require a large randomized trial with all patients undergoing a complete lymph node dissection and evaluation of all other axillary lymph nodes with serial sections and immunohistochemistry. Current knowledge about sensitivity is based on examination of the other axillary nodes with hematoxylin and eosin staining and not with immunohistochemistry, with the exception of two studies. (33,76) In addition, a complete level I to III dissection may not have been done in all patients, and it is not certain that pathologists removed and examined all the nodes from the specimens. The proposed study seems impossible now that routine axillary node dissection has been abandoned by the larger centers around the world. Choosing the most attractive approach requires determining the aim of lymphatic mapping. A superficial injection technique may be adequate when the purpose is to spare patients without lymph node metastases in the axilla an unnecessary axillary node dissection. An intraparenchymal injection technique should be used when the additional purpose is to determine the stage as accurately as possible and to identify sentinel nodes elsewhere.

Sentinel nodes outside lymph node basins in patients with melanoma

BACKGROUND

Lymphoscintigraphy occasionally reveals hot spots outside lymph node basins in patients with melanoma. The aim of this study was to evaluate such abnormally located hot spots.

METHODS

Sentinel node biopsy was studied prospectively in 379 patients with clinically localized cutaneous melanoma. One day after lymphoscintigraphy, sentinel node biopsy was performed guided by vital blue dye and a gamma ray detection probe.

RESULTS

Persisting hot spots outside the regional node basins were seen in 25 patients (6.6 per cent). Several specific drainage patterns were discerned. In five patients, aberrant sentinel nodes were not explored. The hot spot represented a lymphangioma in two patients. Radioactive lymph nodes were identified in the remaining 18 patients (4.7 per cent). Four patients had metastasis in one of these aberrant lymph nodes.

CONCLUSION

Sentinel nodes were found outside a lymph node basin in 5 per cent of patients. Particular drainage patterns exist. It is recommended to incorporate such sites in the late scintigraphy images and to pursue aberrant sentinel nodes, as they may be the only sites of metastasis.

History of sentinel node and validation of the technique

Sentinel node biopsy is a minimally invasive technique to select patients with occult lymph node metastases who may benefit from further regional or systemic therapy. The sentinel node is the first lymph node reached by metastasising cells from a primary tumour. Attempts to remove this node with a procedure based on standard anatomical patterns did not become popular. The development of the dynamic technique of intraoperative lymphatic mapping in the 1990s resulted in general acceptance of the sentinel node concept. This hypothesis of sequential tumour dissemination seems to be valid according to numerous studies of sentinel node biopsy with confirmatory regional lymph node dissection. This report describes the history and the validation of the technique, with particular reference to breast cancer.

False negative sentinel node procedure established through palpation of the biopsy wound

We describe our first false negative sentinel node biopsy after ceasing confirmatory axillary lymph node dissection in breast cancer. Palpation of the axilla through the biopsy wound prevented understaging.

High tPA-expression in primary melanoma of the limb correlates with good prognosis

To investigate whether the course of primary melanoma disease correlates with expression of the various components of the proteolytic plasminogen activation (PA) system, immunohistochemical stainings for activators of plasminogen (tissue type (tPA) and urokinase type (uPA)), inhibitors of plasminogen activation (type 1 (PAI-1) and type 2 (PAI-2)) and the receptor for uPA (uPAR) were performed on 214 routinely processed melanoma lesions. All lesions were primary cutaneous melanomas, minimally 1.5 mm thick, and derived from patients with only local disease at the moment of diagnosis (clinically stage II (T(3-4)N(0)M(0)), American Joint Committee on Cancer). Median patient follow-up was 6.1 years. Single variables as immunohistochemical staining results (extent of tumour cell staining, pattern of tumour cell staining and for some components also staining of stromal cells), histopathological and clinical parameters as well as treatment variables were analysed in order to assess their prognostic importance, in terms of time to recurrence, time to distant metastasis and duration of survival. The extent of tPA tumour cell positivity, categorized as 0-5%, 6-50% and 51-100%, appeared to be of importance for these end-points. Lesions with 51-100% tPA-positive tumour cells were found to have the best prognosis, whereas lesions with 6-50% tPA-positive tumour cells had the worst. Moreover, the prognostic significance of Breslow thickness, microscopic ulceration and sex was confirmed in this study. Multivariate analyses, incorporating these relevant factors, showed that the extent of tPA tumour cell positivity was an independent prognostic factor for distant metastasis-free interval (P = 0.012) and for the duration of survival (P = 0.043).

Evaluation of mammary lymphoscintigraphy by a single intratumoral injection for sentinel node identification

The aim of this study was to evaluate the findings of mammary lymphoscintigraphy by a single intratumoral injection in 150 patients with breast carcinoma: 100 patients (group A) investigated in the validation phase of the study and 50 (group B) studied after the tracer dose was optimized.

METHODS

Immediately after injection of 99mTc-nanocolloid using a 25-gauge needle and a 0.2-mL volume, simultaneous anterior and lateral images were acquired with a dual-head gamma camera during 20 min followed by sequential static anterior and prone lateral breast images after 30 min and after 2 and 4 h. 57Co-assisted skin marking defined the sentinel node location for subsequent gamma probe, blue dye-guided sentinel node biopsy.

RESULTS

In group A (mean dose, 61.6 MBq; range, 42-88 MBq) scintigraphy revealed lymph nodes in 83 patients (83%), with an increase in the rate of visualization from 72% for the first 40 patients to 90% for the last 60; patient age (P = 0.01) and administered tracer dose (P = 0.04) were found to be significant factors for visualization, with optimal results obtained from doses higher than 65 MBq. Lymph nodes were visible in 34 patients (41%) during the first 30 min after injection, whereas in 49 patients appearance occurred at 2-4 h. A total of 97 lymphatic basins were visualized (80 axillary, 3 clavicular, 14 internal mammary). In group B (mean dose, 90.8 MBq; range, 68-124 MBq), the visualization rate was 94%, with early lymph node appearance in 27 patients (57%) and a total of 53 basins (45 axillary, 8 internal mammary). In combination with intraoperative blue dye mapping and y probing, the identification rate increased to 90% in group A and 98% in group B. Prone lateral images contributed to identification of intramammary lymph nodes in a total of 14 patients and axillary nodes close to the injection site in 8 other patients.

CONCLUSION

Mammary lymphoscintigraphy by single intratumoral injection is a valid method for lymphatic mapping and identification of both axillary and nonaxillary sentinel nodes. Lymph node visualization appears to be improved with higher tracer doses. The compactness of the injection site enables high-quality additional lateral images that can depict intramammary or axillary lymph nodes adjacent to the injection site.

Reliability of lymphoscintigraphy in indicating the number of sentinel nodes in melanoma patients

BACKGROUND

This study was undertaken to establish the reliability of lymphoscintigraphy in indicating the number of sentinel nodes in patients with melanoma.

METHODS

Lymphoscintigraphy was performed with dynamic imaging after injection of 60 MBq 99mTc-nanocolloid (1.6 mCi) and static imaging after 2 hours in 200 patients with clinically localized primary melanoma of the skin. The following day, sentinel nodes were retrieved with the blue dye technique and a gamma detection probe (Neoprobe 1000/1500). The discrepancies between the number of sentinel nodes indicated by lymphoscintigraphy and the actual number of sentinel nodes as established by the surgeon were evaluated.

RESULTS

Lymphoscintigraphy showed drainage to 393 sentinel nodes in 255 lymphatic fields in 199 patients. In 48 lymphatic fields (19%) in 46 patients (23%), the number of sentinel nodes was different from the number that was visualized with scintigraphy. Additional sentinel nodes were found by the surgeon because a lymphatic vessel was not seen on the lymphoscintigraphy (43%), because a sentinel node was not visualized separately from other hot nodes or vessels or the injection site (36%), or because a sentinel node was blue and not hot (4%). Fewer sentinel nodes were found than suggested by scintigraphy because a lymphangioma was mistaken for a sentinel node (4%) or because a single elongated node was depicted as two hot spots (6%).

CONCLUSIONS

Although lymphoscintigraphy is indispensable for lymphatic mapping, the predicted number of sentinel nodes is accurate in only 81% of lymph node fields. The limited discriminating power of the gamma camera is an important cause of discrepancies.

Lymphatic mapping with intralesional tracer administration in breast carcinoma patients

BACKGROUND

The objectives of the study were to determine how often a sentinel lymph node is visualized by lymphoscintigraphy in breast carcinoma patients, how often the sentinel lymph node is identified during surgery, and the sensitivity of these procedures to identify the presence of axillary lymph node metastasis.

METHODS

A total of 136 patients were enrolled in 2 hospitals. Preoperative dynamic and static lymphoscintigraphy were performed; in addition, both a vital dye and a gamma detection probe were used intraoperatively. The tracers were injected into the primary lesion. Sentinel lymph node biopsy was followed by completion axillary lymph node dissection. The sentinel lymph nodes and other axillary lymph nodes were examined routinely and by immunohistochemical staining.

RESULTS

A sentinel lymph node was visualized by lymphoscintigraphy in 118 patients (87%). During the operation a sentinel lymph node was localized in 126 patients (93%). A total of 224 sentinel lymph nodes were harvested (average of 1.7 and range of 1-4 sentinel lymph nodes per patient). Of all the sentinel lymph nodes, 37 were blue (17%), 68 were radioactive (30%), and 119 were both blue and radioactive (53%). The sentinel lymph nodes contained metastatic disease in 56 patients (44%). Three sentinel lymph node biopsies were false-negative (sensitivity 95%).

CONCLUSIONS

Sentinel lymph node biopsy with preoperative lymphoscintigraphy after intralesional tracer administration and intraoperative use of both a gamma detection probe and a vital dye is a reliable technique for staging the axilla of breast carcinoma patients.

Reliability of sentinel lymph node biopsy for staging melanoma

BACKGROUND

The aim of this study was to evaluate the reliability of sentinel lymph node biopsy for staging melanoma.

METHODS

Two hundred consecutive patients with a cutaneous melanoma of at least 1. 0 mm Breslow thickness, without palpable regional lymph nodes, were included from 1993 in a prospective cohort study in a single tertiary care hospital. One day after lymphoscintigraphy, sentinel node biopsy was performed, guided by a gamma probe and patent blue dye. Lymph node dissection was performed only if metastasis was found in a sentinel node. Median follow-up was 32 (range 3-61) months. No patient was lost to follow-up.

RESULTS

A sentinel node was removed in 199 of 200 patients (mean 2.2 nodes per patient). Forty-eight patients (24 per cent) had metastasis in a sentinel node. Fifteen patients developed recurrence after removal of a tumour-negative sentinel node; six relapsed in the previously mapped basin (false-negative rate 11 per cent (six of 54)). The overall survival at 3 years was 93 per cent if the sentinel node was negative and 67 per cent if it was positive. Sentinel node status and Breslow thickness were strong predictors of recurrence and survival. Minor complications were seen in 18 patients.

CONCLUSION

The sentinel node status was a strong prognostic factor, even with a false-negative rate of 11 per cent. Published in abstract form as Eur J Nucl Med 1999; 26(Suppl): S57

Sentinel node biopsy for melanoma in the head and neck region

BACKGROUND

Lymphatic drainage in the head and neck region is known to be particularly complex. This study explores the value of sentinel node biopsy for melanoma in the head and neck region.

METHODS

Thirty consecutive patients with clinically localized cutaneous melanoma in the head and neck region were included. Sentinel node biopsy was performed with blue dye and a gamma probe after preoperative lymphoscintigraphy. Average follow-up was 23 months (range, 1-48).

RESULTS

In 27 of 30 patients, a sentinel node was identified (90%). Only 53% of sentinel nodes were both blue and radioactive. A sentinel node was tumor-positive in 8 patients. The sentinel node was false-negative in two cases. Sensitivity of the procedure was 80% (8 of 10).

CONCLUSIONS

Sentinel node biopsy in the head and neck region is a technically demanding procedure. Although it may help determine whether a neck dissection is necessary in certain patients, further investigation is required before this technique can be recommended for the standard management of cutaneous head and neck melanoma.

Long-term functional morbidity after mild hyperthermic isolated limb perfusion with melphalan

AIMS

To assess long-term functional morbidity in patients entered in the prospective randomized EORTC trial investigating the role of adjuvant isolated limb perfusion (ILP) with melphalan for high-risk primary melanoma.

METHODS

In 65 patients (ILP 36, wide excision only 29), limb circumference and joint mobility measurements were performed on the treated and the contralateral limb after a mean interval of 48 months after primary treatment. The two treatment groups were comparable regarding age, sex distribution, percentage of skin grafts or regional lymph-node dissections, and interval between primary treatment and physical measurements.

RESULTS

None of the patients had severe complaints of the treated limb at the time of analysis. The ankle suffered most from ILP, with a statistical significant restricted extension in approximately 40% of the perfused patients. Abduction of the shoulder was minimally affected in treated upper limbs, probably as a result from the formation of scar tissue after axillary lymph-node dissection. Although no significant differences could be demonstrated in the circumference of upper or lower limbs, atrophy was seen in 24% of perfused lower limbs. Of the five perfused patients who developed oedema, four had also undergone a regional lymph-node dissection.

CONCLUSION

This risk of long-term functional morbidity should be weighed against the possible advantages of ILP in patients with limb melanoma or sarcoma.

Clear cell sarcoma (malignant melanoma) of soft parts: A clinicopathologic study of 30 cases

BACKGROUND

Clear cell sarcoma, or malignant melanoma of soft parts, is a rare tumor that occurs predominantly in the extremities of young adults. The importance of surgery has been well established. However, the role of adjuvant radiotherapy has yet to be determined.

METHODS

Thirty cases of clear cell sarcoma that occurred in The Netherlands between 1978 and 1992 were studied retrospectively. Follow-up information on 29 patients was obtained; the follow-up period ranged from 4 to 241 months, with a median of 30 months. All tumors occurred in the extremities, mostly of young adults.

RESULTS

The 5-year survival rate of the 29 patients was 54%. For the 23 patients who presented with localized disease, the 5-year survival and 5-year disease free survival were 65%. Eleven of these patients remained disease free after resection of the primary tumor. Patients with a tumor 2 cm or smaller had better survival than patients with a larger but still-localized tumor (P = 0.009). Adjuvant radiotherapy to the primary tumor site also seemed to have a beneficial effect on survival (P = 0.036). All patients with a local recurrence (8 patients) or regional lymph node metastasis (13 patients) developed distant metastasis. Fourteen of 18 patients with distant spread died of their disease; 2 patients were still alive with disease and 2 patients were disease free, 7 and 32 months after resection of solitary distant metastases.

CONCLUSIONS

Early diagnosis and initial radical surgery are essential for a favorable outcome. Once regional lymph node metastasis or hematogenous dissemination has occurred, the prognosis is dismal.

Absence of severe systemic toxicity after leakage-controlled isolated limb perfusion with tumor necrosis factor-alpha and melphalan

BACKGROUND

Severe systemic toxicity and hemodynamic changes after isolated limb perfusion (ILP) with tumor necrosis factor-alpha (TNF-alpha) and melphalan, with or without interferon-gamma, have been reported in several series. We studied whether these side effects could be precluded by preventing leakage from the isolated circuit into the systemic circulation.

METHODS

Clinical and pharmacokinetic data for 20 consecutive patients with recurrent melanoma of the limbs who were treated by ILP with TNF-alpha (3-4 mg) and melphalan, with or without interferon-gamma, were studied. Leakage rates and TNF-alpha levels were determined during and after ILP and were correlated with systemic toxicity and hemodynamic changes.

RESULTS

Only two patients experienced leaks (2% and 13%) during ILP. For 18 patients without leakage, the mean peak systemic TNF-alpha level was 2.8 ng/ml at 10 minutes after ILP. After leakage, the peak systemic TNF-alpha levels were 31.9 and 88.3 ng/ml at 5 minutes. Toxicity was mild and consisted mainly of fever (n = 17) and nausea/vomiting (n = 19) during the first day after ILP. Some patients developed tachycardia (n = 6), hypotension (n = 3; responding immediately to fluid challenge), a decrease in the WBC count (n = 3; grade I) or thrombocyte count (n = 11; grade I/II, no hemorrhage or therapeutic intervention), or hepatotoxicity [cytolysis (n = 15; 14 grade I/II and 1 grade IV) or hyperbilirubinemia (n = 7; grade I/II, all resolving spontaneously)]. Patients with tachycardia or hepatotoxicity exhibited significantly higher TNF-alpha levels after ILP, compared with other patients.

CONCLUSIONS

Systemic toxicity after ILP with TNF-alpha is minimal and does not differ from that after ILP with melphalan alone when leakage is adequately controlled.

Consensus on the management of malignant melanoma of the skin in The Netherlands. Dutch Melanoma Working Party

In 1996 the Dutch Melanoma Working Party, in co-operation with the National Organization for Quality Assurance in Hospitals in the Netherlands and the Dutch Association of Comprehensive Cancer Centres, organized the third consensus conference on the management of melanoma of the skin. The following guidelines were approved. The recommended margin for diagnostic excision is 2 mm of macroscopically normal skin around the lesion; the margins for therapeutic excision are 1 cm of normal skin for a Breslow thickness of < or = 2 mm and 2 cm for a Breslow thickness of > 2 and < or = 4 mm. A margin of at least 2 cm also appears to be justified for thicker melanomas. Elective lymph node dissection is not recommended. Sentinel node biopsy appears to be a promising method to detect occult metastases in the regional lymph nodes. If regional lymph node metastases are present, therapeutic regional lymph node dissection must be conducted. Isolated regional perfusion is indicated for inoperable tumour growth in an extremity. Radiotherapy can be applied curatively (for example, if surgery is not possible), palliatively (if desired in combination with hyperthermia) or postoperatively (if non-radical resection is suspected). Adjuvant systemic therapy for melanoma patients is still experimental. Atypical (dysplastic) naevi and congenital naevi are major risk factors for melanoma. No consensus has been reached about the prophylactic excision of all congenital naevi. A follow-up period of 5 years is sufficient for patients with a melanoma of < or = 1.5 mm Breslow thickness (provided there are no histological signs of regression) and of 10 years when the Breslow thickness is > 1.5 mm. The patient should be actively involved in the follow-up (inspection, palpation). Regular routine blood tests, radiological examination and ultrasound scanning are not considered to be worthwhile. There is no evidence that the growth of micro-metastases is stimulated by hormonal changes during pregnancy or contraceptive pill use. Excessive exposure to ultraviolet radiation should be discouraged. Regular population screening for melanoma is not considered to be worthwhile, owing to the relatively low frequency and the predominantly favourable stage at the time of diagnosis, particularly in young people.

Relation between limb toxicity and treatment outcomes after isolated limb perfusion for recurrent melanoma

BACKGROUND

The optimal toxic reaction of the normal tissues in perfused limbs after isolated limb perfusion (ILP) is unknown. Theoretically, more severe limb toxicity could reflect a concomitant increased toxic effect to the tumor and improved outcomes. We determined whether there is a relation between limb toxicity and treatment outcomes after ILP for recurrent limb melanoma.

STUDY DESIGN

Among 252 patients with recurrent melanoma of the limbs, treatment outcomes in 192 patients (76%) with no or mild acute limb toxicity were compared with those in 60 (24%) with more severe reactions. Multivariate analysis was used to identify prognostic factors for complete response, limb recurrence-free interval, and survival.

RESULTS

Among 112 patients with measurable disease, 65 patients (58%) had a complete response and 27 (42%) experienced a relapse in the perfused limb. For complete response, uninvolved regional lymph nodes (p = 0.0025) and ILP using tumor necrosis factor-alpha (p = 0.0076) appeared to be favorable prognostic factors in multivariate analysis. There was no evidence of a relation between limb toxicity and complete response either in univariate (p = 0.16) or multivariate analysis (p = 0.46). For limb recurrent-free interval, only the number of lesions was a significant prognostic factor (p = 0.047); limb toxicity was not (p = 0.095). In 140 patients with recurrent melanoma excised before or at the moment of ILP, independent prognostic factors for survival were gender, the number of positive nodes, and stage of disease. There was no relation between limb toxicity and survival in either univariate (p = 0.53) or multivariate analysis (p = 0.94). Forty-eight (34%) of the 140 patients had a relapse in the perfused limb. No prognostic factors for limb recurrent-free interval could be identified; limb toxicity was not related to relapse time in univariate or multivariate analyses (p = 0.16 and p = 0.14, respectively).

CONCLUSIONS

More severe acute limb toxicity is not associated with improved outcomes. One should aim at grade II toxicity (slight erythema or edema, compatible with complete recovery) at the most to increase the therapeutic ratio of ILP.

Low risk of locoregional recurrence of primary breast carcinoma after treatment with a modification of the Halsted radical mastectomy and selective use of radiotherapy

BACKGROUND

The purpose of the current study was to evaluate the locoregional recurrence rate after treatment of patients with operable breast carcinoma with a modification of the Halsted radical mastectomy and the selective use of radiotherapy and to identify risk factors for locoregional recurrence.

METHODS

Between 1979-1987, 691 consecutive patients underwent mastectomy after a negative biopsy of the axillary apical lymph nodes. The median age of the patients was 59 years (range, 26-89 years). The clinical tumor size was < 2 cm in 72 patients, 2-5 cm in 387 patients, and >5 cm in 169 patients; 16 patients had a T4 tumor. Surgery was comprised of a modification of the Halsted radical mastectomy, including at least part of the pectoralis major muscle and the entire pectoralis minor muscle, in 573 patients; 303 patients had positive axillary lymph nodes. Adjuvant radiotherapy to the chest wall and regional lymph nodes was given to 74 patients, whereas an additional 414 patients underwent irradiation to the internal mammary and medial supraclavicular lymph nodes. The median follow-up was 91 months.

RESULTS

The actuarial overall survival rate was 82% at 5 years and 63% at 10 years. The 10-year chest wall and regional lymph node control rates, including patients with prior distant failures, were 95% and 94%, respectively. The only two significant prognostic factors for locoregional recurrence on multivariate analysis were lymph node status and pathologic tumor size.

CONCLUSIONS

Excellent locoregional control can be achieved with a modified technique of radical mastectomy in patients with negative apical biopsy and the selective use of comprehensive radiotherapy. These results may serve as a reference outcome for comparison with other locoregional treatment strategies.

Positive iliac and obturator nodes in melanoma: survival and prognostic factors

BACKGROUND

The need for deep groin dissection when superficial nodes contain metastatic melanoma is controversial.

METHODS

A review of 362 therapeutic groin dissections performed at our tertiary referral center between 1961 and 1995 revealed 71 patients (20%) with positive iliac and/or obturator nodes. This group was analyzed for survival rates, prognostic factors for survival, regional tumor control, and morbidity.

RESULTS

Patients with involved deep nodes exhibited overall 5-year and 10-year survival rates of 24% (SE, 5%) and 20% (SE, 5%), respectively. Independent prognostic factors for survival were the number of positive iliac nodes (P = .0011), the Breslow thickness (P = .0069), and the site of the primary tumor (P = .0075). Patients with an unknown primary tumor seemed to have better prognoses. Seven patients (10%) experienced recurrence in the surgically treated groin. The short- and long-term morbidity rates (infection, 17%; skin flap necrosis, 15%; seroma, 17%; mild/ moderate lymphedema, 19%; severe lymphedema, 6%) compared well with those of other series studying inguinal as well as ilioinguinal dissections.

CONCLUSIONS

From the present study it can be concluded that removal of deep lymph node metastases is worthwhile, because one of every five such patients survives for 10 years. Prognostic factors for survival are the number of involved iliac nodes, the Breslow thickness, and the site of the primary tumor. Long-term regional tumor control can be obtained for 90% of the patients. The morbidity of an additional deep lymph node dissection is acceptable.

Lymphoscintigraphy in oncology: a rediscovered challenge

The validation of the sentinel node concept in oncology has led to the rediscovery of lymphoscintigraphy. By combining preoperative lymphatic mapping with intraoperative probe detection this nuclear medicine procedure is being increasingly used to identify and detect the sentinel node in melanoma, breast cancer, and in other malignancies such as penile cancer and vulvar cancer. In the past lymphoscintigraphy has been widely applied for various indications in oncology, and in the case of the internal mammary lymph-node chain its current use in breast cancer remains essential to adjust irradiation treatment to the individual findings of each patient. In another diagnostic area, lymphoscintigraphy is also useful to document altered drainage patterns after surgery and/or radiotherapy; its use in breast cancer patients with upper limb oedema after axillary lymph-node dissection or in melanoma patients with lower-extremity oedema after groin dissection can provide information for physiotherapy or reconstructive surgery. Finally, the renewed interest in lymphoscintigraphy in oncology has led not only to the rediscovery of findings from old literature reports, but also to a discussion about methodological aspects such as tracer characteristics, image acquisition or administration routes, as well as to discussion on the study of migration patterns of radiolabelled colloid particles in the context of cancer dissemination. All this makes the need for standardized guidelines for lymphoscintigraphy mandatory.

Lymphatic mapping and sentinel lymph node biopsy in breast cancer

Lymphatic mapping with selective lymphadenectomy is an attractive approach in breast-cancer patients. It uses existing technology to exploit logical anatomic and physiological principles to identify occult regional lymph-node metastases. The lymphatic flow is visualized and the first (sentinel) lymph node on a direct drainage pathway from the primary tumour is identified. This is the node at greatest risk of harbouring metastatic deposits. Retrieving this node requires a concerted effort from the nuclear medicine physician, surgeon and pathologist. Lymphoscintigraphy can indicate the number of sentinel nodes and their location. The surgeon can use two techniques to find the node. A vital dye injected at the tumour site will stain the lymphatic duct as well as the sentinel node and allow their visual identification. Alternatively, a lymph-node-seeking radiopharmaceutical will also migrate from the tumour site to the sentinel node and will enable its retrieval with the use of a gamma detection probe. The pathologist has a number of techniques to identify tumour deposits in the lymph node. A review of the literature shows that the sentinel node can be found in more than 90% of the patients. With experience, the false-negative rate can be kept down to about 5%. This novel approach of lymphatic mapping with selective lymphadenectomy may lead to a substantial reduction in the need for axillary node dissection in patients with breast cancer without compromising survival and regional control, and without loss of prognostic and staging information. This development will translate into a great reduction in patient morbidity and medical expenses.

Hyperthermic isolated limb perfusion with tumor necrosis factor alpha, interferon gamma, and melphalan for locally advanced nonmelanoma skin tumors of the extremities: a multicenter study

BACKGROUND

Hyperthermic isolated limb perfusion (HILP) with tumor necrosis factor alpha (TNF-alpha), interferon gamma, and melphalan has proved to be useful in the treatment of recurrent malignant melanoma and of locally advanced soft tissue sarcomas of the extremities.

OBJECTIVE

To determine whether this modality is also effective in the treatment of locally advanced nonmelanoma skin tumors of the extremities.

PATIENTS AND METHODS

Fifteen patients with locally advanced primary, recurrent, or metastatic skin tumors of the extremities (12 with squamous cell carcinoma and 3 with Merkel cell carcinoma) underwent HILP with TNF-alpha, interferon gamma, and melphalan. Six tumors were localized in the upper extremity (40%), and 9 in the lower extremity (60%). Treatment-related complications, limb salvage rate, local recurrence, and regional and distant metastases were scored during a median follow-up of 20 months.

RESULTS

After HILP, 9 patients (60%) showed a complete response (with histopathological confirmation). Four patients (27%) showed a partial response (with histopathological confirmation in 1 patient), and 2 patients (13%) showed no change (with histopathological confirmation in 1 patient and with clinical evidence in 1 patient). Two patients (13%) showed treatment-related complications. The limb salvage was achieved in 12 patients (80%), and the local recurrences developed in 4 patients (27%). During follow-up, regional lymph node metastases were observed in 2 patients (13%) and distant metastases in 2 patients (13%).

CONCLUSION

Based on our results, HILP with TNF-alpha, interferon gamma, and melphalan should be considered as a limb-saving treatment modality in patients with locally advanced nonmelanoma skin tumors of the extremities who would otherwise be candidates for ablative surgery.

Technique of lymphatic mapping and sentinel node biopsy for melanoma

AIMS

An increasing number of surgeons perform sentinel node biopsy to identify melanoma patients with early lymphatic dissemination who may benefit from regional node dissection or adjuvant therapy. The addition of lymphoscintigraphy and intraoperative gamma-ray detection with a hand-held probe increases the sensitivity of the surgical technique substantially.

METHODS

The value of lymphoscintigraphy is discussed. The operative technique of lymphatic mapping and sentinel node biopsy is described, including the use of a vital dye and a gamma-ray probe.

CONCLUSIONS

Close to 100% of first-tier lymph nodes can be identified with this combined approach without the unnecessary removal of too many higher-echelon nodes.

Improved staging of breast cancer through lymphatic mapping and sentinel node biopsy

Sentinel node biopsy is a less invasive technique for staging breast cancer than complete axillary lymph-node dissection and may be as accurate. In the case of a 71-year-old woman with a T1 breast cancer, sentinel node biopsy improved staging. Metastases were discovered in sentinel nodes outside the axilla while the axillary nodes were tumour-free.

Identification and biopsy of the sentinel lymph node in breast cancer

AIMS

To examine the hypothesis that lymphatic dissemination in breast cancer occurs sequentially.

METHODS

Thirty patients with clinically localized adenocarcinoma were studied. Patent blue dye was administered into the tumour at the beginning of a modified radical mastectomy or segmental mastectomy with en bloc axillary lymph-node dissection (ALND). In the removed specimen, blue-stained lymphatic channels were dissected from the primary tumour to the first draining lymph node(s) (sentinel node(s)).

RESULTS

Identification of a sentinel node (SN) was successful in 26 patients (87%). In 10 patients the SN was tumour-positive. In six of these patients, the SN was the only tumour-positive node. There was no incidence of 'skip' metastasis.

CONCLUSIONS

This study confirms the sequential nature of lymphatic dissemination. When confirmed in vivo, these data may lead to a substantial reduction of the need for ALND without compromising survival and regional control and without loss of prognostic and staging information.

Prophylactic isolated limb perfusion for localized, high-risk limb melanoma: results of a multicenter randomized phase III trial. European Organization for Research and Treatment of Cancer Malignant Melanoma Cooperative Group Protocol 18832, the World Health Organization Melanoma Program Trial 15, and the North American Perfusion Group Southwest Oncology Group-8593

PURPOSE

Patients with primary cutaneous melanoma > or = 1.5 mm in thickness are at high risk of having regional micrometastases at the time of initial surgical treatment. A phase III international study was designed to evaluate whether prophylactic isolated limb perfusion (ILP) could prevent regional recurrence and influence survival.

PATIENTS AND METHODS

A total of 832 assessable patients from 16 centers entered the study; 412 were randomized to wide excision (WE) only and 420 to WE plus ILP with melphalan and mild hyperthermia. Median age was 50 years, 68% of patients were female, 79% of melanomas were located on a lower limb, and 47% had a thickness > or = 3 mm.

RESULTS

Median follow-up duration is 6.4 years. There was a trend for a longer disease-free interval (DFI) after ILP. The difference was significant for patients who did not undergo elective lymph node dissection (ELND). The impact of ILP was clearly on the occurrence-as first site of progression - of in-transit metastases (ITM), which were reduced from 6.6% to 3.3%, and of regional lymph node (RLN) metastases, with a reduction from 16.7% to 12.6%. There was no benefit from ILP in terms of time to distant metastasis or survival. Side effects were higher after ILP, but transient in most patients. There were two amputations for limb toxicity after ILP.

CONCLUSION

Prophylactic ILP with melphalan cannot be recommended as an adjunct to standard surgery in high-risk primary limb melanoma.

Vascular complications of isolated limb perfusion

AIM

Isolated limb perfusion (ILP) is a complex vascular procedure which uses an extracorporeal circuit with high doses of cytostatic drugs and often hyperthermia for the treatment of extremity tumours. Our study investigated the incidence, treatment and subsequent outcome of vascular complications after ILP, about which little is known.

METHODS

A retrospective study was performed, in which we found 10 vascular complications after 466 ILPs (2.1%).

RESULTS

In eight patients, acute arterial obstruction developed in the immediate post-operative period, resulting from a thrombus at the arteriotomy site. Prompt reintervention with thrombectomy restored the circulation in all patients. One patient developed an arterial thrombus in the brachial artery due to compression of the surrounding tumour 12 days after ILP, which was successfully treated with thrombectomy and freeing the artery from the tumour. One patient was treated conservatively for digital micro-emboli. All complications occurred in women, maybe because of their generally smaller vessel size. No limbs were lost and all patients were free of any vascular problem after a median follow-up of 3.6 years.

CONCLUSIONS

We conclude that vascular complications after ILP are rare, consist mainly of thrombosis at the arteriotomy site and can be successfully treated by prompt thrombectomy. Therefore, close observation of the peripheral circulation after ILP is necessary.

Cervical lymph-node metastasis from cutaneous melanoma of the head and neck: a search for prognostic factors

AIMS

To identify prognostic factors determining overall survival in patients with surgically treated neck node metastases of cutaneous melanoma.

METHODS

A retrospective study was carried out in 70 patients who were surgically treated with curative intent for cervical lymph-node metastasis from cutaneous head and neck melanoma at our institution between 1960 and 1986.

RESULTS

Median follow-up of the 14 patients still alive was 10 years. Of the 70 patients, 64 underwent a radical neck dissection, four a modified radical neck dissection and two a postero-lateral neck dissection. In 63 patients, the node dissection was for palpable involved nodes and in seven for microscopic disease. Survivals after 5 and 10 years were 23% (SE 5%) and 20% (SE 5%), respectively. Five-year survival was 62% (SE 17%) for patients with a melanoma less than 1.5 mm thick and 16% for lesions thicker than 1.5 mm. A regional recurrence in the neck occurred in 16 (23%) patients, of whom 14 were found also to have distant metastases. All patients with regional recurrence died from disease.

CONCLUSIONS

Of the 15 patient-, tumour- and treatment-related factors tested, only the Breslow thickness of the primary lesion carried prognostic significance for survival (Bonferroni corrected P-value: 0.026).

Hyperthermic isolated limb perfusion with tumour necrosis factor and melphalan as treatment of locally advanced or recurrent soft tissue sarcomas of the extremities

Hyperthermic isolated limb perfusion (HILP) with various chemotherapeutic agents has been used for the local treatment of high-grade soft tissue sarcomas (STS) of the extremities, but in most cases with a disappointing result. Most regimens should certainly not be considered superior to surgery plus radiotherapy. Although the majority of extremity STS can be resected locally, some have a very large size and are in close proximity to bones, nerves or blood vessels. In these cases, amputation is the only means of resecting the tumour. A new combination of drugs used in the set-up of HILP with tumour necrosis factor-alpha and melphalan has emerged as a very promising option for the limb-saving management of locally advanced STS. In recent studies, complete response rates of approximately 30% and partial remission rates of 50% have been achieved, while the overall limb-salvage rate is more than 80%.

Toxicity and morbidity of isolated limb perfusion

Because a relationship between toxicity and treatment outcome has never been demonstrated for isolated limb perfusion (ILP) with melphalan, it is important to keep the side-effects of the procedure restricted to a minimum. Risk factors for more severe acute regional toxicity have recently been identified with tissue temperature above 40 degrees C and a high melphalan peak concentration being the most important. Acute regional toxicity should be mild taking into account these factors and maintaining the normal physiological conditions in the limb during ILP. This should also decrease the incidence of long-term morbidity, especially ankle stiffness and muscle atrophy, since a relation between the severity of the acute regional tissue reactions and long-term morbidity has been demonstrated. Lymphedema is strongly linked to a concomitant regional lymph node dissection and this operation may be delayed until the acute regional tissue reactions have faded. It is not yet clear whether the addition of tumor necrosis factor-alpha (TNF-alpha) to melphalan increases regional toxicity. In the absence of melphalan leakage to the systemic circulation, systemic toxicity is minimal; this is also true with TNF-alpha. Compared to ILP with melphalan +/- TNF-alpha, ILP with other drugs is less effective and often is associated with increased regional toxicity.

Isolated limb perfusion in primary and recurrent melanoma: indications and results

In advanced melanoma of the limbs with in-transit metastasis, melphalan with isolated limb perfusion (M-ILP) produces around 50% complete remissions (CR). The combination of melphalan with tumour necrosis factor-alpha (TNFalpha) and interferon-gamma (IFNgamma) in isolated limb perfusion (TIM-ILP) gives around 80% CR. A prospective randomised phase II study compared 32 patients who received TIM-ILP with 32 patients who received TM-ILP (without IFNgamma). The overall remission rate (ORR) and the CR rate were superior with TIM-ILP as compared to TM-ILP, 100% vs. 91% and 78% vs. 69% respectively, but the differences are not significant. Given the efficacy of M-ILP on in-transit metastasis, the procedure was tested as an adjunct to surgery in high-risk (Breslow > or = 1.5 mm) primary melanoma of the limbs. Through the combined effort of the melanoma groups of the European Organization for Research and Treatment of Cancer (EORTC), the World Health Organization (WHO), and the North American Perfusion Group, 832 evaluable patients from 16 centres were entered in a phase III study. Median followup is 6.4 years. There was a trend for a longer disease-free interval after M-ILP. The difference is significant if the patients without elective lymph node dissection (ELND) are separately analysed, with a high significance in the 1.5 to 3 mm thickness subgroup. The occurrence of in-transit metastases was reduced from 6.6% to 3.3% by M-ILP. There was, however, no benefit of M-ILP in terms of survival. Prophylactic M-ILP cannot be recommended as a standard adjunct to surgery in high-risk primary limb melanoma. TIM-ILP or TM-ILP is a regional therapy with a very high regional response rate on melanoma in-transit metastasis.

Hyperthermic isolated limb perfusion for the treatment of soft tissue sarcomas

Hyperthermic isolated limb perfusion (HILP) with various chemotherapeutic agents has been used for the local treatment of high-grade soft tissue sarcomas (STS) of the extremities, but in most cases, with a disappointing result. Most such regimens certainly should not be considered superior to surgery plus radiotherapy. Although the majority of extremity STS can be resected locally, some are very large and are in close proximity to bone, nerve or blood vessels. In these cases, amputation is the only means of resecting the tumour. A new combination of drugs used in the set-up of HILP with tumour necrosis factor-alpha and melphalan has emerged as a very promising option for the limb-saving management of locally advanced STS. In recent studies, complete response rates of approximately 30% and partial remission rates of 50% have been achieved, while the overall limb-salvage rate is more than 80%.

Computed tomography for the detection of neck node metastases in melanoma patients

AIMS

To assess the value of CT scanning for detection of lymph node metastases in the neck.

METHODS

The appearance and site of the metastases was studied, as well as the sensitivity and specificity of CT.

RESULTS

Nodal metastases did not always show a high contrast uptake and nodal density therefore cannot be used as a criterion for metastasis. Irregular contrast enhancement was seen in seven of the 21 tumour-positive necks. Frequently, metastases in the parotids, superficial nodes in the neck and in the posterior triangle were seen. The sensitivity and specificity of palpation and CT scanning were 87 and 100%, respectively.

CONCLUSIONS

However, because small, clinically occult, melanoma metastases were frequently overlooked on CT, the role of this imaging modality in assessing occult metastases remains limited. Based on recent data from literature it is reasonable to speculate that ultrasound guided fine needle aspiration cytology (FNAC) will prove to be more effective than a non-invasive staging procedure of the neck in melanoma patients.

Principles and guidelines for surgeons: management of cutaneous malignant melanoma. European Society of Surgical Oncology Brussels

This article outlines and discusses the principles of the guidelines for the management of malignant melanoma by surgeons. The guidelines are based, in large part, on the consensus of the Dutch Melanoma Working Party that was revised in 1997. The article reflects internationally accepted treatment principles that have arisen both from critical assessment of existing evidence and data, and from the outcome of randomized studies.