Patients with lymphatic metastasis of cutaneous malignant melanoma benefit from sentinel lymphonodectomy and early excision of their nodal disease

Early versus delayed excision of lymph node metastases is still being assessed in malignant melanoma. In the present retrospective, multicentre study, the outcome of 314 patients with positive sentinel lymphonodectomy (SLNE) was compared with the outcome of 623 patients with delayed lymph node dissection (DLND) of clinically enlarged lymph node metastases. In order to avoid the lead-time bias, survival was generally calculated from the excision of the primary tumour. Survival curves were constructed using the Kaplan-Meier product-limit estimate. Cox's proportional hazards model was used to perform a multivariate analysis of factors related to overall survival. Compared with SLNE and early performed complete lymph node dissection, DLND yielded a significantly higher number of lymph node metastases. Median and mean tumour thickness were nearly identical in the two therapy groups. The estimated 3-year overall survival rate was 80.1+/-2.8% (+/-standard error of the mean (SEM)) in patients with positive SLNs, and 67.6+/-1.9% in patients with DLND (5-year survival rates 62.5+/-5.5 and 50.2+/-5.4%, respectively). The difference between the two survival curves was statistically significant (P=0.002). Using multifactorial analysis, SLNE (P=0.000052), American Joint Committee on Cancer (AJCC) Breslow thickness category (P<0.000001), age (P=0.01) and gender (P=0.028) were independent predictors of overall survival. The location of the primary tumour (P=0.59) was non-significant. Considering only those centres with sufficient data for epidermal ulceration, this risk factor was also significant. In cutaneous malignant melanoma, early excision of lymphatic metastases, directed by the sentinel node procedure, provides a highly significant overall survival benefit.

The Augsburg experience: histological aspects and patient outcomes

In Augsburg, sentinel lymphonodectomy (SLNE) was introduced into melanoma treatment in 1994. Diagnostic accuracy has been improved by early identification of sentinel lymph node (SLN) micrometastases and even more by their histomorphometric assessment. The S classification defines three categories of SLN metastases, S1 to S3, supplemented by S0 in the absence of metastasis. It is the leading predictor for the status of the remaining regional lymph nodes and an independent prognosticator for distant metastasis and survival. This should find consideration in adjuvant therapy trials. The pivotal question of whether SLN-guided surgery itself achieves survival benefit has been approached by a follow-up study that compared 387 SLNE-treated patients with 473 patients from the pre-SLNE era. In contrast to nonsignificant differences in patients with thin and very thick primary tumors, death from intermediate-thickness melanoma (1.51 to 4 mm) occurred significantly more often in the watch-and-wait group versus the SLNE group. These results must be validated by prospective randomized trials (e.g., NCI 29605).

Prognostic and therapeutic implications of sentinel lymphonodectomy and S-staging in Merkel cell carcinoma

BACKGROUND

Merkel cell carcinoma (MCC) is a rare but very aggressive neuroendocrine neoplasm of the skin with a high propensity for early lymph node metastasis and subsequent distant spread. Optimal treatment and prognostic factors are poorly defined.

OBJECTIVE

The purpose of this study is to assess the prognostic and therapeutic relevance of sentinel lymphonodectomy in MCC.

METHODS

Five patients with biopsy-proven MCC underwent gamma-probe-guided sentinel lymphonodectomy assisted by lymphatic mapping. From each sentinel lymph node (SLN), a series of paraffin sections was histologically and immunohistochemically examined for the presence of micrometastases, which were then staged according to the recently published S classification.

RESULTS

Four of the 5 patients showed metastatic disease in the SLNs, 3 of which were classified as S(2), 1 as S(3). Only 1 of the S(2) patients demonstrated additional positive nodes at completion lymphonodectomy. The patient staged as S(3) refused a radical lymph node dissection and died within 1 year due to widespread metastasis.

CONCLUSIONS

Sentinel lymphonodectomy is a low-morbidity procedure which enables an early detection and exact staging of regional lymph node metastases with potentially high prognostic and therapeutic relevance in MCC.

A micromorphometry-based concept for routine classification of sentinel lymph node metastases and its clinical relevance for patients with melanoma

BACKGROUND

The sentinel lymph nodes (SLNs) as the primary targets for lymphatic metastases can be removed selectively by gamma probe-guided sentinel lymph nodectomy (SLNE) in nearly all patients with cutaneous melanoma. Correspondingly high standards in terms of specificity, sensitivity, and microstaging are required for the evaluation of SLNs.

METHODS

Since 1995, the authors have performed SLNE in 389 lymph node regions (LNRs) on 342 patients with melanoma. The harvested 636 SLNs and a further 1394 nonsentinel lymph nodes (non-SLNs) were evaluated by standardized, semiserial section histology, including immunohistochemistry. For each LNR, this technique permitted routine S classification using two simple morphometric parameters: the number of tumor-involved, 1-mm slices of the SLNs (n) and the centripetal depth of metastatic cell invasion (d). S1 was defined by 1 < or = n < or = 2 and d < or = 1 mm, equivalent to localized peripheral tumor cell deposits; S2 was defined by n > 2 and d < or = 1 mm, indicating more extended peripheral metastases; S3 was defined by d > 1 mm in SNLs with deeper metastatic infiltration; and S0 meant no detectable tumor cells (n = 0).

RESULTS

The authors diagnosed 325 SLNs as S0, 24 SLNs as S1, 22 SLNs as S2, and 18 SLNs as S3. The occurrence of at least one melanoma-positive non-SLN subsequent regional completion lymph node dissection (RCLND) significantly increased from 0 of 12 in S1 SLNs to 2 of 13 in S2 SLNs and 9 of 15 in S3 SLNs (P = 0.001; chi-square test). Like the T classification of the primary melanoma, the S classification proved to be a highly significant predictor for distant metastasis (P < 0.001). It turned out to be an independent factor of influence on distant metastasis and survival in multivariate Cox analyses, which included tumor thickness, primary tumor site, patient gender, and patient age as covariates.

CONCLUSIONS

The data presented recommend the S-staging concept as a promising option to fill a gap between the T and conventional N component of the pTNM classification. If its predictive capacity can be confirmed in multicenter studies, then the S classification may become the decisive criterion for or against RCLND, and a combined T plus S staging system will help to improve prognostically relevant stratification of melanoma patients in adjuvant therapy trials.

The predictive value of the sentinel lymph node in malignant melanomas

At the beginning of a lymphogenous metastasizing process in malignant melanomas, the first tumor cells are found in the so-called sentinel lymph node (SLN), defined as the first tumor-draining lymph node. Its removal and histopathological examination enable us to discover metastases of malignant melanomas long before their possibility of detection by any other method. Since the beginning of 1995, we have performed more than 350 gamma-probe-guided sentinel lymphonodectomies (gamma-SLNE), without any clinical evidence of metastases as determined by lymphoscintigraphy. Using gamma-SLNE, the detection and excision of the SLN succeeded in nearly all patients. The SLNs were fixed in formalin, completely cut into 1-mm thin slices and stained for routine H&E histology and with S-100 and HMB-45. In persons with melanomas thinner than 0.75 mm, we never found micrometastases. However, the SLNs were positive in melanomas from 0.76 to 1.50 mm in about 7% of patients, in melanomas from 1.51 to 4.00 mm in about 21% and in tumors thicker than 4 mm in about 44%. In primary melanomas with satellite or in-transit metastases, the SLNs contained metastases in 75% of patients. Normally, a radical lymph node dissection (RLND) follows, as it is considered to be the necessary consequence following detection of tumor cells. The lymph nodes of the RLNDs contained further metastases in about 30% of patients. The probability of the involvement of lymph nodes other than the SLN correlates with the extension of tumor cells in the SLN. During our 4-year-follow-up, we observed only a single lymph node recurrence in a patient with a negative SLN (false negative rate of about 0.4%). The development of systemic metastasis correlates not only with the Breslow tumor thickness, but also with the extent of the involvement of the melanoma metastasis in the SLN. Summarizing, it can be said that gamma-SLNE has revolutionized melanoma surgery. Based on our data, it is absolutely necessary in the staging of malignant melanoma. In our opinion, the existing classification systems for staging lymph node involvement have to be revised in light of the results of SLNE.

Secondary lymph node involvement from primary cutaneous large B-cell lymphoma of the leg: sentinel lymph nodectomy as a new strategy for staging circumscribed cutaneous lymphomas

BACKGROUND

Primary cutaneous large B-cell lymphoma of the leg (LBCLL) is a recently defined type of non-Hodgkin's lymphoma. It forms a separate category in the new classification of primary cutaneous lymphomas elaborated by the European Organization for Research and Treatment of Cancer. It is associated with a less favorable prognosis than the most frequently occurring types of primary cutaneous B-cell lymphoma.

METHODS

The authors present four patients with the typical clinicopathologic constellation of LBCLL. Three of them died during the years 1993-1996. The authors reviewed their courses. The fourth patient was staged by sentinel lymph nodectomy (SLNE), i.e., the selective surgical removal and histologic examination of the first draining lymph node associated with the cutaneous tumor.

RESULTS

The courses of the three previous patients were characterized by secondary involvement of regional lymph nodes followed by systemic dissemination of the lymphoma in a third step. Although the conventional staging of the fourth patient had been negative for any extracutaneous lymphoma manifestation, the SLNE revealed initial regional lymph node involvement, which had decisive implications for the choice of therapy.

CONCLUSIONS

SLNE may gain a prominent role in the staging of circumscribed cutaneous lymphomas, in addition to its already established position in melanoma management. Further positive effects of SLNE are 1) better distinction of primary cutaneous lymphomas with secondary lymph node involvement from primary lymph node lymphomas with skin manifestation, and 2) better insight into the biology of different primary cutaneous lymphoma types.

[Finger tip necroses after dihydroergotamine medication in limited systemic scleroderma]

A 78 year old women developed acute fingertip necrosis just a few days after starting dihydroergotamine. The lesions healed in 3 weeks after the medication was stopped. The patient had suffered from Raynaud syndrome for 5 years and limited systemic sclerosis was diagnosed during the necrotic episode. Advanced age and microangiopathies are contraindications to the use of ergot-containing preparations.

Tree-pollen allergy is efficiently treated by short-term immunotherapy (STI) with seven preseasonal injections of molecular standardized allergens

The efficacy and tolerance of short-term immunotherapy (STI) by seven preseasonal injections of tree-pollen allergens (ALK7 Frühblühermischung) was investigated in a double-blind, placebo-controlled, multicenter study with 111 rhinoconjunctivitis patients. Nasal and bronchial symptoms simultaneously analyzed, and nasal symptoms as a single end point, but not the overall score of nasal, bronchial, and conjunctival symptoms, showed a significantly lower increase with STI during birch-pollen exposure (both P=0.033, n=105, Mann-Whitney U-test). However, a selective analysis with patients from centers with high recruitment figures (n> or =10 patients, n=29 STI, n=32 placebo) showed a significantly lower increase of nasal, bronchial, and overall symptom score (STI 11.0 vs placebo 18.0, P=0.001, U-test). STI had equidirected effects on conjunctival, nasal, and bronchial symptoms analyzed as multiple end points, although conjunctival symptoms were not significantly different as a single end point. The seasonal increase in drug use was reduced by 62% in the STI group compared with placebo (P=0.032, t-test). Specific IgG4 increased only after STI (P<0.001); IgE was not significantly different. Eosinophil cationic protein remained unchanged with STI, but significantly increased with placebo in the pollen season (P=0.003). STI was well tolerated. In conclusion, STI was shown to be efficacious and safe for the treatment of patients with tree-pollen rhinoconjunctivitis.

[Erythema necrolyticum migrans after rectal adenocarcinoma]

Necrolytic migratory erythema (NME) is mostly associated with a pancreatic-A-cell-glucagonoma and is considered to be a well-defined cutaneous paraneoplastic syndrome. We report on a 74-year old female who atypically developed a NME after surgical treatment of a rectal adenocarcinoma. Continuous staging and laboratory investigation over four years gave no evidence of any metastasis or further neoplasia.

Primary therapy of malignant melanomas: sentinel lymphadenectomy

BACKGROUND

Each melanoma is drained by one or, occasionally, several individual lymph nodes within the nearest lymph node region (sentinel lymph node).

OBJECTIVE

By histopathologic examination of the removed sentinel lymph node (SLN), it is possible to select patients clinically according to stage I or II (UICC classification), but who, microscopically, represent stage III.

METHODS

Sentinel lymphadenectomies (SLNEs) were performed initially by the vital blue dye technique, and later by gamma-probe guidance only. The removed SLNs were examined by hematoxylin and eosin as well as immunohistochemical stains (S100, and HMB 45).

RESULTS

We have performed 115 gamma-probe-guided SLNEs in 100 patients. The SLN could be found in all cases. In pT3 + 4 melanomas, 27.5% of the SLNs were positive; in only one patient with a pT2 tumor were micrometastases found.

CONCLUSIONS

gamma-Probe-guided SLNE is a reliable procedure with minimal complications that should be performed in all pT3 + 4 (intraoperative frozen section histology) melanomas without clinically evident metastases.

[Lung edema and erosive gastroduodenitis as a sequela of inappropriate use of an adrenaline dose aerosol after wasp sting]

Epinephrine (adrenaline) is an important drug in the treatment of severe anaphylactic reactions. Along with other drugs such as H1-antihistamines and glucocorticosteroids, it is found in every first aid kit for at-risk individuals, such as those who are allergic to insect stings. Subcutaneous or intramuscular injections if carried out by an untrained individual or the patient himself might give rise to potential problems. Therefore, it is common to prescribe epinephrine pressure aerosol as a safer alternative. If epinephrine aerosol is overused, it can cause serious problems. A patient developed by self-medication following a wasp sting lung edema as well as an erosive gastroduodenitis. She consumed two aerosol vials each of which contained about 73 mg of adrenaline. In order to avoid such incidents it is crucial that every doctor provides his or her patient with sufficient oral and written information regarding the correct use fo epinephrine inhalers.

["Sentinel" lymphonodectomy with scintillation detector. A new strategy in treatment of malignant melanoma]

For decades the results of elective lymph node dissection (ELND) are differently discussed, so that it is not definitely recommended at present the less so since the morbidity of this operation can't be neglected. Since the beginning of 1995 we practice a gamma-probe guided sentinel lymphonodectomy (SLNE) on patients with melanoma from a Breslow tumor thickness of 1 mm upward, after injecting a colloidal 99m-Tc labelled tin (II) - sulfide solution around the tumor or the scar, if the tumor has been excided before. By this method, that allows a selection of patients who according clinically to a stage I or II (UICC) but even histopathologically to a stage III and who are profiting of a removal of the regional lymph nodes, the sentinel node can be exactly localised, tissue-sparing removed at minimal complication rates and the completeness of the removal can be verified by measurements of the radioactivity. When finding metastases in the histopathological examination of the node a dissection of the whole region follows.

[Behavior and attitude regarding skin cancer prevention and early detection in relation to current knowledge--studies of visitors to an industrial fair]

During the course of the 42nd International Trade Fair 1990 in Munich a total of 1245 visitors were interrogated with regard to their education in the early recognition of skin cancer, and their behaviour in respect of exposure to sunlight. The same persons were also subjected to melanoma screening, both with regard to special assessment of pigment lesions and inspection of the entire skin. The questionnaire showed that women were better informed than men. Approximately 87% of the questioned women had heard of the problems of melanoma, whereas only about 55% of the men belonged to the informed group. The knowledge of cancer education proved to be above average in the age group between 30 and 60 years. Persons with ample knowledge on melanoma education demonstrated more motivation to take part in cancer prevention examinations and also in examinations relating to other organ systems. Thus, the necessity of cancer screening examinations was substantially more often a matter of course among women than among men. The occurrence of skin cancer on the own body as well as its occurrence in members of one's own family does not guarantee essential knowledge on melanoma education, although in the informed group the percentage of persons directly or indirectly affected by melanoma, was higher. With regard to the behaviour towards sunlight, young people dealt more cautiously and consciously with the sun than those aged 45 and over who had exposed themselves to sunlight without exercising any caution, especially in the past.(ABSTRACT TRUNCATED AT 250 WORDS)

[Recombinant leukocyte A interferon in metastasized malignant melanoma]

The efficacy and tolerance of recombinant leukocyte A interferon (interferon alpha-2a) in 30 patients with metastasized malignant melanoma in clinical stages III and IV were tested in a phase II study. During the first 10 weeks, the patients received 18 X 10(6) IU interferon alpha-2a i.m. daily and afterwards the same dose three times a week for a further four months. In 21 patients, the tumor growth was progressive. In six patients in clinical stage IV, there was a standstill for at least two months, and in three patients in clinical stage III, there was complete remission lasting between 12 and 16 months so far. The side effects of therapy differed in the individual patients. Fever, chills, limb pain, tiredness, nausea and lack of appetite were observed most often. All these symptoms as well as the frequently occurring leukopenia and elevation of the transaminases were especially pronounced at the beginning of therapy. They were dose-dependent, but reversible.

[Cyclosporin A in the treatment of pemphigus foliaceus and pemphigus erythematosus]

We present the cases of two female patients with pemphigus foliaceus and pemphigus erythematosus, respectively, who did not respond to long-term azathioprine and prednisone treatment in high dosages. In both patients the skin condition improved nearly completely after therapy with cyclosporine A (3.5-6.5 mg/kg per day) in combination with prednisone (7.5-10 mg every 2 days). We did not observe any side-effects during 1 year of this therapy.

[Steroid receptors in malignant melanomas]

Epidemiological and experimental investigations have led to the hypothesis that the growth of malignant melanoma is induced by hormones. The demonstration of free-hormone binding sites in melanoma tissue may help to determine the validity of this hypothesis, as receptors are necessary for the transformation of hormonal action. The DCC assay with subsequent saturation analysis was used for the demonstration of specific cytoplasmatic binding sites of steroid hormones. The presence of free-cytosolic estrogen-, progesterone- and glucocorticosteroid receptors was investigated in 50 melanoma samples from 46 patients. In 20 of the 50 specimens, free estrogen and progesterone receptors were found. Free-glucocorticosteroid receptors we found in 10 cases. The use of four fold-labeled estradiol (2,4,6,7-[3]-17 beta-estradiol) in the DCC assay produced a false-positive demonstration of free-estrogen receptors. Tyrosinase hydroxylates estradiol at the C2 level of the steroid. Using fourfold labeled estradiol, tritium is separated at the C2 position, thus forming radioactive water in the cytosol which mimics high, free-estrogen binding sites. The use of twofold-labeled estradiol or L-dopa in the experiments with fourfold labeled estradiol produced no false-positive determinations of estrogen receptors. The demonstration of receptors in malignant melanomas was unaffected by the sex of the patient. Also, the type of malignant melanoma, the invasion level, and the prognostic index did not show a correlation with the presence of the various hormone receptors. In metastases, free steroid hormone receptors were detected less often than in the primary tumor.

[Malignant melanoma in lupus (tuberculosis cutis luposa)]

We report on a 72 years old man showing a strikingly fast spreading malignant melanoma developing on a lupus vulgaris which had existed since childhood. The coincidence of both diseases is obviously extremely rare. A pathogenetic relationship between melanoma and lupus vulgaris, such as claimed for carcinoma in lupo, especially after X-ray irradiation, is not inferable.

[Combination chemotherapy with cis-dichloro-diammineplatinum (II) and ifosfamide in malignant melanomas (author's transl)]

We report our results on 9 patients with disseminated malignant melanoma, treated with combination of DDP and IF, 3 in addition with VD. In none of them a complete remission was obtained, the median survival was 4.2 months. These disappointing results, in addition to the rather toxic side effects from the chemotherapy, do not present any benefit over less toxic regimens.

[Amiodarone pigmentation. A rare, but typical drug side-effect]

Amiodarone is one of the most effective antiarrhythmic and anti-anginose drugs. A rare but typical side-effect with an incidence of 1:100 is sunburn, and of 1:1,000 a black-violet to slaty pigmentation of the sun-exposed skin areas. According to histochemical and ultrastructural findings the skin pigment deposits are considered to be lipofuscin.

[Circumscribed pseudolymphomas: definition, diagnosis and differential diagnosis]

Pseudolymphomas are benign reactive inflammatory lymphoreticular proliferations in the skin with potency of spontaneously regression. Despite of different etiology the patho- and morphogenesis may be largely uniform. The differential diagnosis includes numerous chronic granulomatous processes, but above all true (malignant) lymphomas. Histologically there are characteristic the kind and pattern of the infiltrate as well as (mostly) the absence of typical signs of malignant proliferations.

[Allergic contact dermatitis due to tromantadin (author's transl)]

37 observations on allergic contact dermatitis due to tromantadine are reported. With the increasing distribution and application of this adamantane derivative, the incidence of this type of clinical picture will probably increase further. The attendant physician should therefore accordingly explain to his patients and inform them of the initial symptoms - presumably striking intensification and local extension of the herpes eruption in spite of intensive treatment.

[Dacarbazine (DTIC) therapy and the Budd-Chiari syndrome]

A case of a 58 years old female is presented, who died because of a Budd-Chiari-syndrome. This complication had developed during treatment with Dacarbazine (DTIC), which was given after surgical removal of a malignant melanoma. The causative relation between the Budd-Chiari-syndrome and this cytostatic drug is discussed, even though the influence of other drugs cannot be excluded.

Loosening of a total hip prosthesis at contact allergy due to benzoyl peroxide

It is reported that a 62-year-old man with total hip prosthesis developed a recurrent sterile fistula and loosening of his prosthesis due to allergy to the bone cement component benzoyl peroxide.

Particles from mouse melanoma B16 containing reverse transcriptase and 70S RNA related to human melanoma cytoplasmic RNA

The mouse melanoma B16 contains particles encapsulating high molecular weight RNA of 60--70S size associated with a reverse transcriptase. The [3H]DNA synthesized by these particles possesses homology with RNA isolated from a hamster melanoma and from three human malignant melanomas.

[Diagnosis of herpes simplex diseases]

The diagnosis of herpes simplex diseases will be made on ground of the typical clinical symptoms in more than 90% of all cases. A very easy additional procedure is the Tzanck test. If possible, immunofluorescent microscopy and electron microscopy of negatively stained virus particles may be helpful. Remaining questions should be solved by further virological examination in special laboratories. Information about sampling and shipment of the diagnostic material (vesicle fluid, swabs from mouth and genital ulcers, blood etc.) should be obtained prior to collection.

[Acryronitril as a contact allergen]

A case of allergic contact dermatitis following the use of a Plexidur finger splint is reported. The allergen was acrylonitrile, one of the original constituents of the polymer Plexidur.

Oncornavirus-like particles in human skin cancers

A high-molecular-weight RNA encapsulated with an RNA-instructed DNA polymerase in particles possessing the density characteristic of the RNA tumor viruses has been detected in 13 out of 14 human malignant melanomas. The [3H]DNA synthesized by these particles in an endogenous reaction hybridizes to RNA extracted from the human melanoma particulate structures, but not to RNA from normal skin. Similar particles containing RNA and enzyme have been found in basal cell and squamous cell carcinomas of the skin. The RNA of the melanoma particles is easily distinguishable by hybridization from the RNAs found in the particles of the basal and squamous cell carcinomas.

Drug effects in melanoma: tumor-specific interactions of proflavine and ethidiumbromide

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