Evolution of sentinel lymph node biopsy for melanoma at a National Cancer Institute-designated cancer center

Sentinel Lymph Node Identification in Cutaneous Head & Neck Cancer - Lymphoscintigraphy Late Phase

OBJECTIVE

Sentinel node (SN) biopsy following lymphoscintography is recommended for high-risk cutaneous malignancies. Herein, we investigate different lymphoscintography phases, focusing on the importance of the late static phase and the resultant discovery of distal echelon solitary positive sentinel nodes that would otherwise have been overlooked.

METHODS

In this retrospective cohort study, conducted in a tertiary referral medical center, we assessed SN localization and time from tracer injection to SN identification on lymphoscintigraphy. Findings on scan were compared with SN found in the surgical field, and with the final pathological investigation.

RESULTS

Seventy-three patients, undergoing SN biopsy for head and neck skin malignancies, were investigated. Most patients were male (n = 50). The average age was 65.7 (±15.7) years and the average follow-up time was 29.1 (±22.4) months. Overall, 101 SNs were histologically investigated, demonstrating 7 positive SN. Eleven patients (15%) benefited from the late lymphoscintigraphy phase. In four studies, an SN was identified only in the late static phase, one of which was positive for the disease. In seven patients, SN was identified in the early phase with additional, different, SN on the late phase, one of which was positive for the disease. Comparing the yield (positive SNs) of early versus late phases, demonstrated the same importance (p = 0.275).

CONCLUSIONS

The late lymphoscintigraphy phase has a crucial role in high-risk HN cutaneous cancer.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:2164-2168, 2022.

Intraoperative Sentinel Node Mapping in the Colon: Potential and Pitfalls

Sentinel lymph node mapping (SLNM) may play a significant role in future delivery of colon cancer surgery because of an increase in early-stage, node-negative disease due to national bowel cancer screening programmes. Traditionally, colon lymphatic drainage has not been thought relevant as the operative approach cannot be tailored. Recent advances in local and endoscopic risk-reducing interventions for colonic malignancy have caused a rethink in approach. SLNM was initially attempted with blue dye techniques with limited success. Technological improvement has allowed surgeons to use near-infrared (NIR) light and NIR active tracers such as indocyanine green. This review provides an overview of the current status of intraoperative lymph node mapping in the colon, identifies challenges to the delivery of the techniques, and discusses potential solutions that may help SLNM play a role in improving the delivery of surgical care for patients with colon cancer.

A pilot study to assess near infrared laparoscopy with indocyanine green (ICG) for intraoperative sentinel lymph node mapping in early colon cancer

BACKGROUND

Previous attempts at sentinel lymph node (SLN) mapping in colon cancer have been compromised by ineffective tracers and the inclusion of advanced disease. This study evaluated the feasibility of fluorescence detection of SLNs with indocyanine green (ICG) for lymphatic mapping in T1/T2 clinically staged colonic malignancy.

METHODS

Consecutive patients with clinical T1/T2 stage colon cancer underwent endoscopic peritumoral submucosal injection of indocyanine green (ICG) for fluorescence detection of SLN using a near-infrared (NIR) camera. All patients underwent laparoscopic complete mesocolic excision surgery. Detection rate and sensitivity of the NIR-ICG technique were the study endpoints.

RESULTS

Thirty patients mean age = 68 years [range = 38-80], mean BMI = 26.2 (IQR = 24.7-28.6) were studied. Mesocolic sentinel nodes (median = 3/patient) were detected by fluorescence within the standard resection field in 27/30 patients. Overall, ten patients had lymph node metastases, with one of these patients having a failed SLN procedure. Of the 27 patients with completed SLN mapping, nine patients had histologically positive lymph nodes containing malignancy. 3/9 had positive SLNs with 6 false negatives. In five of these false negative patients, tumours were larger than 35 mm with four also being T3/T4.

CONCLUSION

ICG mapping with NIR fluorescence allowed mesenteric detection of SLNs in clinical T1/T2 stage colonic cancer. CLINICALTRIALS.GOV: ID: NCT01662752.

Selective Sentinel Lymph Node Dissection in Lower Extremity Melanoma

BACKGROUND

There is debate as to whether deep inguinal lymph nodes should be removed with the superficial or femoral lymph nodes during sentinel lymph node biopsy for lower extremity melanoma, when both superficial and deep inguinal lymph nodes are identified by preoperative lymphoscintigraphy. This study evaluated the lymphatic drainage patterns in lower extremity melanoma to determine whether certain patterns could be used to limit the level of node removal and define the extent of dissection.

METHODS

A retrospective outcomes review was performed of lower extremity melanoma patients with excision and sentinel lymph node biopsy from 1995 to 2010. Outcomes included location of sentinel lymph node drainage basins, sentinel lymph node-positivity, and disease-free and overall survival, with drainage patterns compared between above- and below-knee melanomas.

RESULTS

Of 499 patients with lower extremity melanoma having sentinel lymph node biopsy, 356 had below-the-knee and 143 had above-the-knee melanoma. For below-knee melanoma, the node-positivity rate was 23 percent (63 of 271) for superficial inguinal, 0 percent (zero of three) for deep inguinal, and 50 percent (one of two) for popliteal basins. For above-knee melanoma, the positivity rate was 21 percent (24 of 113) for superficial inguinal, 33 percent (one of three) for deep inguinal basins, and 0 percent (zero of zero) for popliteal basins. Importantly, no patients with a negative superficial inguinal sentinel lymph node had a positive deep inguinal sentinel lymph node on final pathologic evaluation [corrected].

CONCLUSIONS

A difference was noted in patterns of sentinel lymph node drainage from lower extremity melanoma below and above the knee. Biopsy for deep inguinal basins may be deferred if there is simultaneous drainage to the superficial inguinal basin by preoperative lymphoscintigraphy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Pelvic sentinel lymph node biopsy in melanoma patients: is it worthwhile?

The original procedure of intraoperative lymphatic mapping by using vital blue dye initially described by Morton and colleagues in 1992 was implemented in subsequent years by the introduction of preoperative lymphoscintigraphy (LS) and intraoperative gamma detection probe to allow a better identification of sentinel nodes (SNs). However, it is common, in practice, to detect more than one radioactive node with the gamma detection probe. Whether these additional lymph nodes represent true SNs is not yet clear. The aims of this study are: to investigate the role of pelvic sentinel node biopsy in recurrent pelvic disease in those patients with negative inguinal SN, having one or more deep hot spots identified by preoperative LS (follow-up group). One hundred and four stage I/II melanoma patients with primary tumor of the lower limb and lower trunk were enrolled in a restrospective study at the European Institute of Oncology, Milan, Italy, between 2000 and 2007. All patients presented hot spots both in superficial (groin) and deep (iliac-obturator) areas during dynamic LS. The study population consisted of 35 men and 69 women with a median age of 57 years at the time of diagnosis. The median follow-up period was 49 months (SD 22.4; range, 10-98 months). Of the 104 patients, 83 had a negative SN (80%). All sentinel-lymph-node-positive patients underwent superficial and deep inguinal dissection. Two patients (2.4%; 95% confidence interval: 1.5-8.8%) with negative SNs had pelvic recurrence. Among patients who underwent ilioinguinal dissection, three (14%; 95% confidence interval: 4-35%) had positive pelvic lymph nodes. After a 60-month follow-up, 79% of patients were alive and 66% were disease free. In SN-negative patients, disease-free survival was 69% and in SN-positive patients 53%. No significant difference was found by SN status (log-rank P values 0.15). Even if the sample size of our study cannot bring to conclusive results, and further studies are needed, it might be possible that harvesting pelvic SN in those patients with pelvic hot spots at LS could modify the natural history of melanoma patients in terms of pelvic recurrence and disease free survival. We recommend to improve our knowledge in the role of pelvic sentinel node in the natural history of melanoma.

Predictive role of preoperative lymphoscintigraphy on the status of the sentinel lymph node in clinically node-negative patients with cutaneous melanoma

We reviewed our experience to assess the predictive role of preoperative lymphoscintigraphy with regard to the pathological status of sentinel lymph node (sN) in patients with cutaneous melanoma, to optimize the surgical treatment planning with regard to the use of intraoperative frozen section examination of sN. Eighty-eight patients with clinically node-negative cutaneous melanoma pT1b-T4 stage underwent preoperative lymphoscintigraphy for the lymphatic mapping of sN. A lymphoscintigraphic 'score' (from L1 to L5) was developed based on the ratio of radiotracer concentration within sN nodes as compared with the injection site. Our score allowed us to foresee that sN of patients with thick melanomas (T3 and T4) and a low preoperative score (L1-L2-L3) had a 90% expected likelihood (P<0.001) of harboring metastasis, whereas sN in patients with thin melanomas (T1b-T2) and high preoperative score (from L4 to L5) showed a 100% likelihood of being metastasis free. In conclusion, the sN is a reliable predictor of regional lymph node status in patients with cutaneous malignant melanoma. Moreover, we suggest that a low score (L1-L2-L3) associated with a thick melanoma is a good predictive factor of the positive sN involvement. This information could be useful in scheduling the intraoperative frozen-section examination with an expected benefit of a positive test in almost 90% of patients. Such patients might be selected for a 'one-stage' procedure with a more effective cost/benefit ratio and decreased hospitalization costs.

Is completion lymph node dissection needed in case of minimal melanoma metastasis in the sentinel node?

OBJECTIVE

The purpose of this study was to evaluate the micromorphometric Starz-classification in melanoma patients.

SUMMARY BACKGROUND DATA

The micromorphometric Starz-classification suggests that melanoma patients with a sentinel node metastasis invading no more than 0.3 mm (S-I) or 0.31 to 1.0 mm (S-II) below the capsular level can be spared further surgery, while invasion of the metastasis of more than 1.0 mm (S-III) implies a need for completion dissection.

METHODS

Seventy patients with sentinel node metastases were studied. Twenty patients with an S-I or S-II classification were spared further surgery and 50 S-III patients underwent completion dissection. The median follow-up time was 33 months.

RESULTS

No lymph node recurrences were detected in the 20 S-I, II patients. Six of the 50 S-III patients (12%) had additional involved nodes in the dissection specimen. In these patients no recurrences developed in the cleared regional basins. Overall 3-year survival was 100% in the S-I, II patients and 80% in the S-III patients (P = 0.04). Three-year disease-free survival rates were 83% and 60%, respectively (P = 0.40).

CONCLUSIONS

: This study suggests that further surgery is unnecessary in S-I and S-II patients, while it does seem prudent to carry out completion dissection in S-III patients. The distinct survival difference between the 2 groups of patients suggests that the S-classification also has prognostic implications.

Microscopic tumor burden in sentinel lymph nodes predicts synchronous nonsentinel lymph node involvement in patients with melanoma

PURPOSE

We and others have demonstrated that additional positive lymph nodes (LNs) are identified in only 8% to 33% of patients with melanoma who have positive sentinel LNs (SLNs) and undergo complete therapeutic LN dissection (cTLND). We sought to determine predictors of additional regional LN involvement in patients with positive SLNs.

PATIENTS AND METHODS

Patients with clinically node-negative melanoma who underwent SLN biopsy (1991 to 2003) and had positive SLNs were identified. Clinicopathologic factors, including extent of microscopic disease within SLNs, were evaluated as potential predictors of positive non-SLNs.

RESULTS

Overall, 359 (16.3%) of the 2,203 patients identified had a positive SLN. Positive non-SLNs were identified in 48 (14.0%) of the 343 patients with positive SLNs who underwent cTLND. On univariate analysis, several measures of SLN microscopic tumor burden, one versus three or more SLNs harvested, tumor thickness more than 2 mm, age older than 50 years, and Clark level higher than III were predictive of positive non-SLNs; primary tumor ulceration and number of positive SLNs had no apparent impact. On multivariable logistic regression analysis, measures of SLN microscopic tumor burden were the most significant independent predictors of positive non-SLNs; tumor thickness more than 2 mm and number of SLNs harvested also predicted additional disease. A model was developed that stratified patients according to their risk for non-SLN involvement.

CONCLUSION

In melanoma patients with positive SLNs, SLN tumor burden, primary tumor thickness, and number of SLNs harvested may be useful in identifying a group at low risk for positive non-SLNs and be spared the potential morbidity of a cTLND.

Intraoperative evaluation of sentinel lymph nodes for metastatic melanoma by imprint cytology

BACKGROUND

Sentinel lymph node biopsy (SLN) has revolutionized nodal staging. Accurate intraoperative evaluation of SLN permits a single procedure, with lymphadenectomy being performed during the initial operative procedure when the SLN is positive. There is a paucity of literature on intraoperative imprint cytology (IIC) evaluation of the SLN in melanoma. The purpose of this article is to present an update to our experience with IIC for SLN in melanoma.

METHODS

Melanoma patients had SLNs examined by IIC. SLNs were bisected, and imprints were made from each half. Imprints were stained with hematoxylin and eosin and with Diff-Quik. Paraffin-embedded sections were examined with multiple hematoxylin and eosin-stained sections from the SLNs in conjunction with immunohistochemical staining for S-100, Melan-A, and HMB-45 proteins.

RESULTS

Metastases were identified in 40 (17%) of 229 patients. Of these, 13 patients were detected by IIC (sensitivity, 33%). The negative predictive value was 88%. No false-positive results were identified (specificity, 100%). The positive predictive value was 100%. The accuracy of IIC was 78%. The sensitivity for detecting macrometastases (>2 mm) was better than that for detecting micrometastases (< or =2 mm): 62% vs. 16% (P < .01). Patients with positive SLNs by IIC had lymphadenectomy under the same anesthetic. A total of 533 nonsentinel lymph nodes were identified in 42 patients. Only two patients (8%) had positive nonsentinel lymph nodes after a negative IIC.

CONCLUSIONS

IIC is a viable alternative to frozen sectioning when intraoperative evaluation is desired. IIC is significantly more sensitive for macrometastases. IIC evaluation of SLNs in melanoma makes a single operative procedure possible for a significant proportion of patients with regional nodal metastases.

What is a sentinel node? Re-evaluating the 10% rule for sentinel lymph node biopsy in melanoma

INTRODUCTION

Many surgeons use the "10% rule" to define whether a lymph node is a sentinel node (SLN) when staging malignant melanoma. However, this increases the number of SLN removed and the time and cost of the procedure. We examined the impact of raising this threshold on the accuracy of the procedure.

METHODS

We reviewed the records of 561 patients with melanoma (624 basins) who underwent SLN with technetium Tc99 labeled sulfur colloid using a definition of a SLN as 10% of that of the node with the highest counts per minute (CPM).

RESULTS

Of the 624 basins, 154 (25%) were positive for metastases. An average of 1.9 nodes per basin were removed (range 1-6). Metastases were found in the hottest node in 137 cases (89% of positive basins, 97% of basins overall). Increasing the threshold above 10% decreased the number of nodes excised and the costs involved, but incrementally raised the number of false negative cases above baseline (a 4% increase for a "20% rule," 5% for a "30% rule," 6% for a "40% rule," and 7% for a "50% rule"). Taking only the hottest node would raise the false negative rate by 11%.

CONCLUSIONS

Although using thresholds higher than 10% for the definition of a SLN will minimize the extent of surgery and decrease the costs associated with the procedure, it will compromise the accuracy of the procedure and is not recommended.

The impact of factors beyond Breslow depth on predicting sentinel lymph node positivity in melanoma

BACKGROUND

In addition to Breslow depth, the authors previously described how increasing mitotic rate and decreasing age predicted sentinel lymph node (SLN) metastases in patients with melanoma. The objectives of the current study were to verify those previous results and to create a prediction model for the better selection of which patients with melanoma should undergo SLN biopsy.

METHODS

The authors reviewed 1130 consecutive patients with melanoma in a prospective database who underwent successful SLN biopsy. After eliminating patients aged <16 years and patients who had melanomas that measured <1 mm, 910 remaining patients were reviewed for clinical and pathologic features and positive SLN status. Univariate association of patient and tumor characteristics with positive SLN status was explored by using standard logistic regression techniques, and the best multivariate model that predicted lymph node metastases was constructed by using a backward stepwise-elimination technique.

RESULTS

The characteristics that were associated significantly with lymph node metastasis were angiolymphatic invasion, the absence of regression, increasing mitotic rate, satellitosis, ulceration, increasing Breslow depth, decreasing age, and location (trunk or lower extremity compared with upper extremity or head/neck). Previously reported interactions between mitotic rate and age and between Breslow depth and age were confirmed. The best multivariate model included patient age (linear), angiolymphatic invasion, the number of mitoses (linear), the interaction between patient age and the number of mitoses, Breslow depth (linear), the interaction between patient age and Breslow depth, and primary tumor location.

CONCLUSIONS

Younger age, increasing mitotic rate (especially in younger patients), increasing Breslow depth (especially in older patients), angiolymphatic invasion, and trunk or lower extremity location of the primary tumor were associated with a greater likelihood of positive SLN status. The current results support the use of factors beyond Breslow depth to determine the risk of positive SLN status in patients with cutaneous melanoma.

Melanoma patients with positive sentinel nodes who did not undergo completion lymphadenectomy: a multi-institutional study

BACKGROUND

Completion lymph node dissection (CLND) is considered the standard of care in melanoma patients found to have sentinel lymph node (SLN) metastasis. However, the therapeutic utility of CLND is not known. The natural history of patients with positive SLNs who do not undergo CLND is undefined. This multi-institutional study was undertaken to characterize patterns of failure and survival rates in these patients and to compare results with those of positive-SLN patients who underwent CLND.

METHODS

Surgeons from 16 centers contributed data on 134 positive-SLN patients who did not undergo CLND. SLN biopsy was performed by using each institution's established protocols. Patients were followed up for recurrence and survival.

RESULTS

In this study population, the median age was 59 years, and 62% were male. The median tumor thickness was 2.6 mm, 77% of tumors had invasion to Clark level IV/V, and 33% of lesions were ulcerated. The primary melanoma was located on the extremities, trunk, and head/neck in 45%, 43%, and 12%, respectively. The median follow-up was 20 months. The median time to recurrence was 11 months. Nodal recurrence was a component of the first site of recurrence in 20 patients (15%). Nodal recurrence-free survival was statistically insignificantly worse than that seen in a contemporary cohort of patients who underwent CLND. Disease-specific survival for positive-SLN patients who did not undergo CLND was 80% at 36 months, which was not significantly different from that of patients who underwent CLND.

CONCLUSIONS

This study underscores the importance of ongoing prospective randomized trials in determining the therapeutic value of CLND after positive SLN biopsy in melanoma patients.

Treatment strategy for cutaneous malignant melanoma

The incidence of cutaneous malignant melanoma has been rising in Japan. With education, recent advances in accurate diagnosis and establishment of the concept, more lesions are being diagnosed as early melanomas, for which there is a high cure rate. However, many patients will still present with thicker lesions or nodal involvement, which carries a significantly worse prognosis. Recently there have been advances in the management and treatment of cutaneous melanoma. This article reviews the clinical evidence behind the current treatment recommendations for primary and recurrent cutaneous melanoma in Japan.

American Joint Committee on Cancer Clinical Stage as a Selection Criterion for Sentinel Lymph Node Biopsy in Thin Melanoma

BACKGROUND

A significant proportion of newly diagnosed melanomas are thin lesions (< or = 1.00 mm). Because tumor thickness correlates with the risk for nodal metastases, sentinel lymph node (SLN) biopsy in this subset is controversial. Incorporating other prognostic factors (Clark level and ulceration), we evaluated the 6th edition American Joint Committee on Cancer (AJCC) clinical stage as a simple and widely applicable guideline for offering SLN biopsy for thin melanoma.

METHODS

This study was a review of a prospective melanoma SLN database from 1993 to 2003 with emphasis on SLN positivity rates based on the 6th edition AJCC primary tumor thickness intervals and clinical stage.

RESULTS

Three hundred five patients underwent SLN biopsy, with an overall positivity rate of 17.7%. By the 6th edition AJCC, lesions < or = 1.00 mm had an SLN positivity rate of 6.6%. By 6th edition clinical stage, SLN positivity rates were 4.9% for stage IA and 10.4% for stage IB. By using stage IA as the criterion for not offering SLN biopsy, this procedure would have been avoided in 46% (39 of 85) of < or = 1.00-mm melanoma patients with a negative SLN.

CONCLUSIONS

Sixth edition AJCC clinical stage IB as a selection criterion for performing SLN biopsy in thin melanoma identifies most patients with a positive SLN while also avoiding a negative SLN biopsy in many patients. Until additional widely accepted and validated selection criteria are available, SLN biopsy for clinical stage IB, but not stage IA, thin melanomas is a reasonable approach.

The prognostic role of the sentinel lymph node in clinically node-negative patients with cutaneous melanoma: experience of the Genoa group

AIM

To define the benefit of intraoperative frozen section examination of the sentinel lymph node (sN), and to assess its prognostic value in clinically node-negative melanoma patients.

MATERIALS AND METHODS

Between July 1993 and December 2001, 214 patients with Stage I-II cutaneous melanoma underwent sN biopsy; complete follow-up data are available in 169 of 175 patients who underwent preoperative lymphoscintigraphy, lymphatic mapping with Patent Blue-V and radio-guided surgery (RGS).

RESULTS

In an initial subset, the sN was identified in 35 out of 39 patients; in the principal group of 169 patients, the sN was detected in all patients. The benefit of frozen section examination, that is the proportion of all patients having intraoperative histologic examination who tested positive, was 17.2% (29/169); notably, in patients with pT(1-2) vs pT(3-4) melanoma the corresponding values were 2.3 and 33.3%, respectively, (P=0.000). Cox regression analysis for overall survival indicated that sN-positive patients had a two-fold increased risk of death; the most significant predictors of relapse-free survival were sN status (P=0.004), age (P=0.015), and T stage grouping (P=0.033).

CONCLUSIONS

The sN is a reliable predictor of regional lymph node status in patients with cutaneous melanoma. Frozen section examination can be useful in avoiding a 'two-stage' operative procedure in patients with tumour-positive sN, but its greatest benefit seems to be restricted to patients with pT(3)-pT(4) primary melanoma.

Training and mentoring surgeons in lymphatic mapping

Intraoperative lymphatic mapping and selective lymphadenectomy for solid malignancies is a novel technique, having been introduced into surgical practice in the last 12 years. Dissemination of this technique among surgeons has followed a course similar to that found with the introduction of new laparoscopic techniques. A case series from a leading institution forms the core of the surgical literature for the new operation and is followed by additional case series, which offer technical refinements. Distinct from the laparoscopic techniques, however, sentinel node methodology offers a proficiency assessment through completion lymphadenectomy. Several completed clinical trials using sentinel lymph node technology have afforded a means for training and mentoring surgeons to perform the procedure. These multi-institutional studies and mentoring programs represent an initial step towards development of a more structured framework to evaluate new surgical procedures.

The new staging system for cutaneous melanoma in the era of lymphatic mapping

In 2002, the American Joint Committee on Cancer (AJCC) revised the staging system for cutaneous melanoma on the basis of a survival analysis of important melanoma prognostic factors. Features of the revised system include new strata for primary tumor thickness, incorporation of primary tumor ulceration as an important staging criterion in both the tumor (T) and node (N) classifications, revision of the N classification to reflect the prognostic significance of regional nodal tumor burden, and new categories for distant metastatic disease. These changes reflect evolving insight into melanoma arising from the results of numerous clinical investigations and database analyses. One of the most important recent changes in melanoma care is the establishment of lymphatic mapping and sentinel lymph node (SLN) biopsy as a highly accurate and minimally morbid technique for pathologic regional nodal staging. In this article, the salient features of the revised melanoma staging system are examined, with specific attention paid to its use in this era of lymphatic mapping and SLN biopsy.

Mitotic Rate and Younger Age Are Predictors of Sentinel Lymph Node Positivity: Lessons Learned From the Generation of a Probabilistic Model

BACKGROUND

Sentinel lymph node (SLN) biopsy allows surgeons to identify patients with subclinical nodal involvement who may benefit from lymphadenectomy and, possibly, adjuvant therapy. Several factors have been variably, and sometimes discordantly, reported to have predictive value for SLN metastasis to best select which patients require SLN biopsy.

METHODS

We reviewed 419 patients who underwent SLN biopsy for melanoma from a prospectively collected melanoma database. To derive a probabilistic model for the occurrence of a positive SLN, a multivariate logistic model was fit by using a stepwise variable selection method. The accuracy of each model was evaluated by using receiver operator characteristic curves.

RESULTS

On univariate analysis, the number of mitoses per square millimeter, increasing Breslow depth, decreasing age, ulceration, and melanoma on the trunk showed a significant relationship to a positive SLN. Multivariate analysis revealed that once age, mitotic rate, and Breslow thickness were included, no other factor, including ulceration, was significantly associated with a positive SLN. The data suggest that younger patients with tumors <1 mm may still have a substantial risk for a positive SLN, especially if the mitotic rate is high.

CONCLUSIONS

In addition to Breslow depth, mitoses per square millimeter and younger age were factors identified as independent predictors of a positive SLN. This model may identify patients with thin melanoma at sufficient risk for metastases to justify SLN biopsy.

Sentinel lymph node biopsy in patients with Stage I/II melanoma: Clinical experience and literature review

BACKGROUND

The sentinel lymph node (sN) represents one of the most powerful predictors of the outcome of patients with Stages I and II cutaneous melanoma, and may be relevant for the therapeutic planning of early-stage melanoma patients. Since adopting the technique of lymphatic mapping with vital blue dye (Patent Blue-V) in July 1993, we have periodically up-dated the methodology and revised our results in order to define the contribution of radio-guided surgery (RGS) to the detection of the sN as well as the role of intraoperative frozen section examination of the sN.

MATERIALS AND METHODS

Between July 1993 and December 1997, 180 patients with clinically node-negative primary cutaneous melanoma (Stages I-II) underwent sN biopsy followed by "selective lymph node dissection" (SLND) whenever sN metastasis was detected. Presently, complete data are available in 165 patients who were divided into two consecutive subsets of 39 and 126 patients, based on the technique for the identification of the sN: Patent Blue-V only or Patent Blue-V associated to RGS. Moreover, in this second subset of patients intraoperative frozen section findings were compared with definitive pathologic examination.

RESULTS

As regards the first subset of 39 patients (17 males and 22 females; mean age 51.3 years), the sN was identified in 35 patients (89.7%); 8 patients (22.8%) were found to have metastatic melanoma cells in their sN, and they all underwent SLND of the affected basin. As regards the second set of 126 patients (54 males and 72 females; mean age 53.5 years), the sN was detected in every case by means of the combined technique (Patent Blue-V and RGS): in 4 of 126 patients (3.2%), the sN was detected by means of RGS only whereas in no patient was the sN detected by Patent Blue-V only. Frozen section examination was performed in 123 of 126 patients who had sN detection by Patent Blue-V and RGS, and the intraoperative examination had a sensitivity of 66.6% (22 of 33), specificity of 100% (90 of 90), negative predictive value of 89.1% (90 of 101), and accuracy of 91% (112 of 123). The benefit of frozen section examination in avoiding a two-stage procedure was 17.9% (22 of 123 patients). In patients with thicker lesions (pT(3)-pT(4)), the sensitivity and the benefit of intraoperative examination were 76% (19 of 25) and 32% (19 of 59 patients), respectively.

CONCLUSIONS

Sentinel node lymphadenectomy can be better accomplished when both procedures (lymphatic mapping with Patent Blue-V and RGS) are used because the two methods look quite complementary. In fact, the use of the radiocolloid mapping allows to detect a hot spot in the regional basin prior to making the skin incision in order to perform a minimal invasive access, and it may also more accurately differentiate the true sN from a secondary echelon node (non-sN). The use of frozen section examination should be restricted to patients with pT(3)-pT(4) primary melanoma, due to the higher sensitivity and benefit in terms of avoiding a two-stage operative procedure.

Rapid immunohistochemistry of sentinel lymph nodes for metastatic melanoma

Sentinel lymph node (SLN) biopsy is performed on patients with malignant melanoma (MM) to assess the need for selective complete lymphadenectomy. Melanoma metastasis to regional lymph nodes is an important prognostic indicator in patients with MM. This study assesses the sensitivity and specificity of rapid immunohistochemistry (RIHC) in intraoperative delineation of melanoma metastasis to SLN. RIHC for S-100 protein, HMB45, and a melanoma marker cocktail (melan A, HMB45, and tyrosinase) was performed on 71 SLNs obtained from 28 patients with MM. Frozen sections (6 micro thick) on plus slides were fixed for 2 to 3 minutes in cold acetone and then stored at -70 degrees C. The EnVision kit (Dako, Carpinteria, CA) for rapid immunohistochemistry (RIHC) on frozen tissue sections was used, and the staining technique took 19 minutes. Together with preparation of the frozen sections and fixation in acetone, immunostained slides were available in approximately 25 minutes. Of the 71 SNLs examined, 7 showed melanoma metastasis in permanent sections. RIHC of frozen sections detected metastatic melanoma in 6 SLNs, with a sensitivity of 86% for HMB45 and 71% for S-100 protein and the melanoma cocktail and a specificity of 97% for HMB45 and 100% for S-100 and the melanoma cocktail. We conclude that RIHC for HMB45, S-100 protein, and the melanoma cocktail may help detect melanoma metastasis in SLN intraoperatively, leading to total lymph node dissection and obviating the need for 2 surgical procedures. Section folds and background stain can make interpretation difficult. Intraoperative time constraints require a more rapid technique. A recent consensus group has discouraged frozen-section examination of SLN.

Malignant melanoma: current state of primary and adjuvant treatment

Metastatic malignant melanoma remains a highly lethal disease with an incidence that continues to rise. Management of melanoma includes definitive local, regional and distant control. There is substantial prospective and retrospective data to base the extent of both primary as well as adjuvant therapy. The results of these trials have on occasion been at odds. A critical assessment of the available information pertaining to the adjuvant treatment of cutaneous melanoma is needed. This review provides a critical assessment of the current data that is available to guide both primary resection as well as adjuvant therapy. To date, current trials have shown little promise with nonspecific immunostimulants and cytotoxic chemotherapy. In contrast, dose interferon-alpha2b has been shown to improve relapse-free survival and likely improves melanoma-specific survival as well. Based on the available data, interferon-alpha2b remains the adjuvant therapy of choice for high-risk patients treated outside clinical trials, and the appropriate control arm for clinical trials evaluating new or modified adjuvant regimens.

Prediction of nonsentinel lymph node status in melanoma

BACKGROUND

Most melanoma patients with a positive sentinel lymph node dissection (SLND) undergo a completion lymph node dissection (CLND) that does not yield additional positive nonsentinel lymph nodes (NSLN). This study was designed to determine if NSLN status can be predicted using patient, primary tumor, and sentinel lymph node (SLN) characteristics.

METHODS

The study population includes melanoma patients who had a positive SLND and subsequently underwent CLND retrieved from our prospective institutional melanoma database. The primary tumor and SLN pathologies were prospectively determined. An Size/Ulceration (SU) score was derived by assigning 1 point for primary tumor ulceration and 1 point for SLN tumor size >2 mm.

RESULTS

Ninety-eight patients had a positive SLND and underwent CLND. Sixteen of these patients had a positive NSLN. On univariate analysis, primary tumor characteristics (thickness, ulceration, no regression), SLN metastasis characteristics (size >2 mm, location nonsubcapsular), and SU score were all significantly associated with positive NSLN status. However, on multivariate analysis, only the SU score was a significant independent predictor of NSLN status. No patient with an SU score of 0 had a positive NSLN.

CONCLUSIONS

The SU score is predictive of NSLN status in patients with a positive SLND. Patients with an SU score of 0 are very unlikely to have positive NSLNs at CLND.

The learning curve for sentinel node biopsy in malignant melanoma

Sentinel node biopsy (SNB) has emerged as an accurate means of identifying nodal micrometastasis in cutaneous melanoma. In order to assess our learning curve, we compared our first 30 cases with our subsequent 30 cases. A total of 60 patients underwent SNB for cutaneous melanoma, using preoperative lymphoscintigraphy together with the intraoperative use of a Neoprobe and Patent Blue V dye. At least one sentinel node was identified in 93% of patients (90% in our first 30 cases; 97% in our subsequent 30 cases). Sentinel nodes contained tumour in 21% of cases. Of the sentinel nodes that contained tumour in the first 30 cases, 87% were identified by Neoprobe examination and 60% using blue dye. In the second 30 cases, the tumour-containing sentinel nodes were identified in all cases by both the Neoprobe and the blue dye. The sentinel node appeared to be the only involved node in 71% of patients. In the first 30 patients, one patient with a negative sentinel node developed nodal recurrence. These data confirm the feasibility of the sentinel-node technique in cutaneous melanoma. However, there is a learning curve, and the technique should be performed only by limited numbers of people with suitable training.

[Selective sentinel node biopsy in melanoma using preoperative lymphoscintigraphy location and intraoperative detection gamma probe]

BACKGROUND

The experience in detection of sentinel lymph node in melanoma using preoperative scintigraphy and intraoperative gamma probe is referred.

PATIENTS AND METHODS

We studied 60 patients with stage I-II melanoma who underwent sentinel lymph node biopsy performed using 99m-Tc-labelled sulphur colloid as radioactive tracer. A preoperative scintigraphy was performed and intraoperative gamma probe was used to localize the sentinel node in all cases. Scintigraphy results, effectiveness of intraoperative detection (technical efficacy), pathological results, and follow-up have been studied.

RESULTS

Preoperative detection was 98.3% and the mean basin detected was 1.17. There were multiple basins especially when melanomas were on the trunk. Technical efficacy was 98.4% and intraoperative detection was more difficult in parotid gland region. HMB-45 immunohistochemical staining was essential in pathological studies, in whom 10% were positives. Lymphadenectomy could be avoided in 90% of the patients. Recurrences were not detected during follow-up and metastases were found only in non biopsied cases. Sentinel node biopsy morbidity was significative lesser than that of lymphadenectomy.

CONCLUSIONS

Preoperative scintigraphy and intraoperative gamma probe use to localize sentinel node in melanoma have a high efficacy. They can reveal multiple basins and they allow a more selective surgical approach and a minimal dissection.

Anaphylactic reactions to isosulfan blue dye during sentinel lymph node biopsy for breast cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) is an alternative to axillary dissection for many breast cancer patients. Cases of anaphylactic reaction to the isosulfan blue dye used during SLNB have recently been reported. No study on the incidence of serious anaphylactic reactions during SLNB for breast cancer has been reported.

METHODS

We reviewed 639 consecutive SLNBs for breast cancer performed at our institution. Sentinel lymph node biopsy was performed using both isosulfan blue dye and technetium-99m sulfur colloid. Cases of anaphylaxis were reviewed in detail.

RESULTS

Overall, 1.1% of patients had severe anaphylactic reactions to isosulfan blue requiring vigorous resuscitation. No deaths or permanent disability occurred. In patients with anaphylaxis, hospital stay was prolonged by a mean of 1.6 days. In 1 patient, the anaphylactic reaction required termination of the operation.

CONCLUSIONS

Prompt recognition and aggressive treatment of anaphylactic reactions to isosulfan blue are critical to prevent an adverse outcome. Lymphatic mapping with blue dye should be performed in a setting where personnel are trained to recognize and treat anaphylaxis.

Use of adjuvant therapy in cutaneous melanoma

Surgery remains the principal treatment for local, regional and isolated metastatic melanoma. Adjuvant therapy is now available for patients with high risk of recurrence after surgical treatment but is controversial and inconsistently used around the world. In 1995, high-dose interferon-alpha 2b was approved by the FDA, providing clinicians with the first adjuvant therapy for use outside a clinical trial. In this review, we discuss surgical approaches to the management of the primary lesion and regional lymph nodes and the use of high-dose interferon. We will also provide guidelines for the use of interferon and discuss current clinical trials evaluating alternate forms of adjuvant therapy.