Management of regional lymph nodes in patients with malignant melanoma: questionnaire survey of UK current practice

Neuronal Circuits Modulate Antigen Flow Through Lymph Nodes

When pathogens and toxins breech the epithelial barrier, antigens are transported by the lymphatic system to lymph nodes. In previously immunized animals, antigens become trapped in the draining lymph nodes, but the underlying mechanism that controls antigen restriction is poorly understood. Here we describe the role of neurons in sensing and restricting antigen flow in lymph nodes. The antigen keyhole-limpet hemocyanin (KLH) injected into the mouse hind paw flows from the popliteal lymph node to the sciatic lymph node, continuing through the upper lymphatics to reach the systemic circulation. Re-exposure to KLH in previously immunized mice leads to decreased flow from the popliteal to the sciatic lymph node as compared with naïve mice. Administering bupivacaine into the lymph node region restores antigen flow in immunized animals. In contrast, neural activation using magnetic stimulation significantly decreases antigen trafficking in naïve animals as compared with sham controls. Ablating Na_V1.8 + sensory neurons significantly reduces antigen restriction in immunized mice. Genetic deletion of FcγRI/FcεRI also reverses the antigen restriction. Colocalization of PGP9.5-expressing neurons, FcγRI receptors and labeled antigen occurs at the antigen challenge site. Together, these studies reveal that neuronal circuits modulate antigen trafficking through a pathway that requires Na_V1.8 and FcγR.

Diagnosis and management of melanoma with regional lymph node metastases: a population-based study in France

BACKGROUND

Stage III melanoma represents a borderline situation regarding the potential curability of this potentially aggressive cancer and consequently, regional lymph node metastases (RLNM) are a major challenge for melanoma management.

OBJECTIVE

To describe the management of melanoma with RLNM as practised in France in 2008 and compare results with previous data from 2004, considering that new French recommendations were published in 2005.

METHODS

Retrospective population-based study in five regions of France totalling 8.3 million inhabitants, targeting all incident cases of RLNM diagnosed in 2008. Questionnaires were mailed to physicians to identify cases and collect data, with verification by cancer registries for cases diagnosed concomitantly with the primary tumour using sentinel lymph node biopsies (SLNB).

RESULTS

Data were collected for 101 patients in 2008, and compared to 89 cases treated in 2004. Palpation by a dermatologist was the most common circumstance of diagnosis of RLNM in 2008 (36%), followed by SLNB (29%), self-palpation by the patient (16%) and lymph node ultrasonography (6%), without significant modification from 2004. After lymphadenectomy an adjuvant therapy was proposed in 62% of cases, mainly consisting in high-dose interferon (HD-IFN) (80%). Overall, HD-IFN was proposed in 49% of cases, but effectively started in only 40% of cases after being proposed, and prematurely withdrawn in 28%, showing major changes as compared with 2004 (33%, 77% and 67%, respectively, P < 0.05). Adjuvant chemotherapy was not proposed to any patients in 2008, compared to 29% in 2004. Surveillance procedures included medical imaging less often in 2008 (76%) than in 2004 (92%) (P = 0.004), but more often included FDG-PET (23% vs. 12%, P = 0.09).

CONCLUSION

Overall, actual practice was in accordance with French recommendations. The main developments from 2004 to 2008 were the disappearance of adjuvant chemotherapies and a more accurate selection of patients for adjuvant interferon.

[Sentinel node procedure in head and neck cutaneous melanoma]

INTRODUCTION

Sentinel lymph node (SLN) biopsy is frequently discussed in the management of cutaneous melanoma, especially in head and neck localizations where SLN biopsy is much more demanding. The benefits of SLN protocol are not proved yet. The aim of our study was to present our experience of SLN biopsy in head and neck cutaneous melanoma.

PATIENTS AND METHODS

This retrospective study included all patients managed for head and neck malignant melanoma from 2002 to 2006. We reviewed the technique, implementation and difficulties of the procedure, postoperative outcome, and complications.

RESULTS

Nineteen patients were included. An average of 2.2 lymph nodes were localized per patient using lymphoscintigraphy. Biopsy was impossible for one patient because the deep spinal node was not found. An average of 1.2 nodes was biopsied per patient. One patient presented with micrometastases. Another presented with lymphorrhea.

DISCUSSION

Sentinel node biopsy is widely performed in the management of cutaneous melanoma but remains an option for these indications in the last update of the French Society of Dermatology. SLN biopsy is difficult to implement because of the complexity of head and neck lymphatic system.

Slow dynamic lymphoscintigraphy is not a reliable predictor of sentinel-node negativity in cutaneous melanoma

We reviewed data from 160 consecutive patients (89 M/71 F; 53.5 [range, 9-88] years) who had under-gone lymphoscintigraphy and sentinel lymph node biopsy (SNB) in our hospital for histologically proven cutaneous malignant melanoma (CMM) (located on the upper limb: 33; lower limb: 57; trunk: 44; and head and neck: 26 patients), with a Breslow index > 1 mm and without clinical or radiologic evidence of metastatic spread. Colloidal (99m)Tc-rhenium sulfide (36-76 MBq) was injected intradermally in the four quadrants around the tumorectomy scar, followed by dynamic acquisition and static imaging. SN(s) were identified in 157 patients (overall identification rate, 98%). Fast (< 20 minutes), intermediate (20-30 minutes), or slow (> 30 minutes) lymphatic drainage was observed, respectively, in 122 (78%), 24 (15%), or 11 (7%) cases. Overall malignancy rate was 15%, respectively found in 19 (16%), 2 (8%), and 2 (18 %) patients with fast, intermediate, or slow drainage. No statistical difference between SN-positivity rates of patients with fast (19/122 = 16%) versus intermediate or slow drainage (4/35 = 11.4%) was observed (p = 0.69). Therefore, lymphoscintigraphic SN appearance time in CMM patients is unable both to predict SN metastasis and spare them from undergoing SN excision.

La recherche du ganglion sentinelle dans le mélanome malin cutané de bas stade est-elle réellement peu invasive ?

AIM

The aim of this study was to analyze outcome in patients enrolled in sentinel node biopsy procedure in early-staged cutaneous melanoma.

MATERIAL AND METHODS

Therefore a prospective study was conducted enrolling patients presenting with early-staged cutaneous melanoma. Our study focused on age and sex, duration from diagnosis to treatment, duration of hospitalization, dressing care and work inability in current follows. Duration from scintigraphy to surgery was analyzed and compared to sensibility of the procedure. What is more we observed rate and kind of complications and economical consequences, increasing duration of dressing care and work inability. The authors aimed at evaluating costs of SLN procedure including hospitalization, lymphoscintigraphy, general anaesthesia, costs of dressings, inability and overcosts of complications.

RESULTS

Forty-five patients were enrolled in our study (sex-ratio 1/2) mean aged 60 years old. Duration from diagnosis to treatment was mean 36 days. Sensibility of the procedure was excellent in trunk and limbs cases, lower in head and neck. In current cases patients were mean hospitalized three days, underwent 20 days of dressings and work inability depended on further interferon treatment. Complications occurred in 25% as seroma or local infections requiring antibiotherapy. Duration to healing was then 45 days increasing inability. Global costs of SLN procedure were significantly higher than previous wait and watch policy.

CONCLUSION

SLN biopsy is an expensive and invasive procedure with a high rate of complications. It defers melanoma treatment, only way to gain survival.

Ganglion sentinelle dans le mélanome malin de bas stade : état des lieux en France en 2003

AIM

The aim of this study was to establish the status of sentinel lymph node (SLN) biopsy procedure in cutaneous melanoma in France in 2002.

MATERIAL AND METHODS

This study was based upon the statistics of the main French melanoma centers. A short questionnary was sent to Head Physician by email. The authors asked for the global attitude as far as SLN was concerned, number of cutaneous melanoma diagnosed during year 2002 and of SLN procedures performed, critters of inclusion and postoperative management in each case. Abstension could be argued in a free item. Answers were sent back by email.

RESULTS

The authors collected 22 answers coming from overall territory; 64% performed SLN procedure (14 centers), 36% applied "wait and watch" policy. Staffs performing SLN diagnosed a mean of 101 (8-400) melanoma and biopsied a mean of 21 (0-53) sentinel nodes. The others diagnosed a mean of 151 (15-250) melanoma. Patients were enrolled for Breslow thickness upper to 1.5 mm in 71%, to 1 mm in 29%. Ulceration was a critter of inclusion in 93% (21 staffs), 100% enrolled patients whose tumor presented signs of regression. SLN was performed for primary sites located overall body in 71%, only in limbs and trunk in 29%. Positive node lead to regional lymph node clearance, then observation or interferon protocol. Negative node lead to "wait and watch policy" in 14%, different interferon protocols according to Breslow thickness in 86%.

CONCLUSION

SLN procedure is not homogenous in France. France is divided as far as SLN is concerned. If 64% are performing SLN, more than 50% of the new melanoma are not included in the trial.

Sentinel lymph node biopsy progress in surgical treatment of cancer

BACKGROUND

Forty-three years after the first description of the sentinel lymph node technique in malignant tumours of the parotid by Gould, sentinel lymph node biopsy (SNLB) has become a precious tool in the treatment of solid tumours.

METHODS

In the following review we give a synopsis of the fundamentals of the sentinel lymph node concept and then proceed to an overview of recent advances of SNLB in gastrointestinal cancers.

RESULTS

In some tumour entities, SNLB has been shown to reflect reliably the lymph node status of the tumour-draining lymph node basin. In melanoma and breast cancer, it became a widely accepted element of the routine surgical management of these malignant diseases. In gastrointestinal tumours, the technique is currently under intense investigation. First reports on its application in other solid tumours, such as non-small cell lung cancer, thyroid carcinoma, oropharyngeal carcinoma, vulvar carcinoma, and Merckel cell carcinoma of the skin, were published more recently.

CONCLUSION

SNLB has become an important component of diagnosis and treatment of solid tumours. A growing number of publications on SNLB in gastrointestinal cancer documents the interest of many investigators in the application of this technique in this tumour entity. As long as imaging techniques like 18FDG PET or other molecular imaging techniques are limited by their spatial resolution, SNLB remains the technique of choice for lympho-nodal staging.