Nachweis des Sentinel-Lymphknotens mittels präoperativer Lymphszintigraphie und intraoperativer Gammasondenmessung bei malignem Melanom

Ziel der vorliegenden Arbeit ist die Überprüfung der Wertigkeit nuklearmedizinischer Verfahren in der prä- und intraoperativen Diagnostik des Sentinel-Lymphknotens (SLN). Methoden: Bei 214 Patienten führten wir während der vergangenen vier Jahre die präoperative Lymphszintigraphie und bei 150 Patienten die intraoperative Gammasondenmessung zur Lokalisationsdiagnostik des SLN durch. Ergebnisse: Es fanden sich bei 214 Patienten 247 Abflußgebiete. Bei drei Patienten konnte kein Lymphabfluß nachgewiesen werden. Es handelte sich um Melanome der Wange, zwei dieser Patienten waren voroperiert. 14 Patienten zeigten Intervall-Lymphknoten. Bei 150 Patienten erfolgte eine operative Entfernung des SLN (Sentinel-Lymphonodektomie, SLNE) mit intraoperativer Gammasondenmessung. Bei zwei Patienten mit supraklavikulärem Primärtumor waren vier SLN präoperativ festgelegt worden, von denen intraoperativ nur zwei gefunden wurden. In allen anderen Fällen konnte der SLN intraoperativ entdeckt und entfernt werden. Bei 19 der 150 Patienten (12,7%) wurden Metastasen in einem SLN nachgewiesen. Die Häufigkeit der Metastasierung nahm von 0% im Stadium pT1 kontinuierlich bis 44% im Stadium pT4 zu. Schlußfolgerung: Die Lymphszintigraphie und Gammasondenmessung sind geeignete Verfahren für die Lokalisation des SLN. Die SLNE ist eine zuverlässige Methode, um eine Lymphknotenbeteiligung bei malignem Melanom nachzuweisen. Sie minimiert den operativen Eingriff.

[Phlebology in German departments of dermatology. An analysis on behalf of the German Society of Phlebology]

BACKGROUND

Phlebologic diseases have become extremely common and have major socio-economic impact. However, the percentage of dermatologists working in phlebology appears to be decreasing according to the data of the German Society of Phlebology (DGP).

METHODS

To investigate the reasons for this development, we--on behalf of the DGP--sent a questionnaire to 120 German Departments of Dermatology in autumn 2012.

RESULTS

In 76 returned questionnaires, the number of physicians with additional fellowship training in phlebology averaged 1.5; the average number of those who fulfill the criteria for training fellows in phlebology was 0.9. In 71.1 % of the departments there was a phlebologist. A special phlebologic outpatient clinic existed in 73.7 % of the departments. Sonography with Doppler (89.5 %) and duplex (86.8 %) was used as the most frequent diagnostic tool. For therapy, compression (94.7 %), sclerotherapy (liquid 78.9 %, foam 63.2 %, catheter 18.4 %), endoluminal thermic procedures (radio wave 28.9 %, laser 17.1 %) and surgery (especially crossectomy and stripping 67.1 %, phlebectomy of tributaries 75 %) were used. The average number of treatments was very heterogenous in the different departments.

CONCLUSIONS

Phlebology definitely plays an important role in dermatology. Most departments fulfill the formal criteria for the license to conduct advanced training in phlebology. A wide spectrum of phlebological diagnostic and therapeutic procedures is available.

Sentinel lymphonodectomy in nonmelanoma skin malignancies

BACKGROUND

Whereas the value of sentinel lymphonodectomy (SLNE) in malignant melanoma is established, experience with SLNE in nonmelanoma skin cancers is limited.

OBJECTIVES

The feasibility of SLNE in nonmelanoma skin tumours is evaluated.

METHODS

Thirty-seven patients with high-risk nonmelanoma skin tumours underwent SLNE: 11 squamous cell carcinomas (SCCs), seven Merkel cell carcinomas (MCCs), five cutaneous lymphomas, eight adnexal carcinomas and six other skin cancers, all clinical stage N0.

RESULTS

In nine patients (four MCCs, two SCCs, three lymphomas) the sentinel lymph nodes (SLNs) showed histological evidence of microinvolvement. In five of these nine patients, radical lymph node dissection (RLND) was performed, revealing further micrometastases in three patients (two SCCs, one MCC). No patient with negative SLN showed tumour dissemination during the follow-up over a mean of 2.5 years (range 2 months to 4.5 years, median 2.4 years).

CONCLUSIONS

Our data provide evidence that SLNE is a minimally invasive and highly sensitive staging tool in selected patients with high-risk nonmelanoma skin cancers.

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.

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.

[Melanoma. Results with "sentinel node" sampling]

Since June 1995 we have practised a gamma probe guided sentinel lymphadenectomy (SLNE) in 274 patients after injecting a colloidal 99 m-Tc labelled solution around the tumor. By this technique the detection and excision of the SLN succeeded in 99.3% of all cases. We found micrometastases in about 53.1% of patients with pT3 and pT4 melanomas. The specimen of the radical lymph node dissection contained in 30% further metastases. A regional recurrence after SLNE occurred only in one case, a SLN-negative patient.

[Surgical therapy of malignant melanoma of the skin]

Operative treatment is the therapy of choice in malignant melanoma under curative as well as palliative considerations. Today more conservative surgical strategies are preferred, however. Thus, the safety margins for the excision of the primary tumor have been significantly reduced. With the introduction of the minimally invasive sentinel node biopsy the elective lymph node dissection, a high morbidity intervention, has become obsolete. Sentinel node biopsy should be performed in all melanomas thicker than 0.75 mm, as the percentage of lymph nodes harvesting micrometastases increases in correspondence to the clinical tumor stage up to 75%.

First experience with gamma probe guided sentinel lymph node surgery in penile cancer

Because of the curative approach, the detection of lymph node metastases in squamous cell carcinoma (SCC) of the penis is of significant clinical relevance. Sentinel lymph node (SLN) identification by means of lymphangiography has been proven to be insufficiently safe. However, the high morbidity of inguinal lymphadenectomy and the considerable individual variability regarding the location of lymph node metastases justify the necessity of a technique that enables the identification of SLNs. Since 1998, SLNs have been intraoperatively identified and selectively dissected, after peritumoral injection of technetium-99m nanocolloid and using lymphoscintigraphy, in three patients (one with malignant melanoma and two with SCC). At least one SLN could be detected in each patient. The maximum surgical time was 30 min. There were no severe complications. Lymph node metastases did not occur in any patient. Upon a mean follow-up of 10 months, all patients are currently free of tumor. Owing to the long-term results of sentinel lymphadenectomy in malignant melanoma of other locations and our preliminary results with respect to penile carcinoma. we consider the current method appropriate as the only primary operation for lymph node staging in early stages and, in combination with modified inguinal lymphadenectomy, in locally advanced stages.

[Sentinel lymph node detection by preoperative lymphoscintigraphy and intraoperative gamma probe guidance in malignant melanoma]

AIM

The purpose of this work was to prove the clinical significance of nuclear medical procedures in pre- and intraoperative detection of the SLN.

METHODS

In the past 4 years, we did preoperative lymphoscintigraphy in 214 patients (pts.). Intraoperative localisation of the SLN with a hand-held gamma probe followed in 150 pts.

RESULTS

In 214 pts. 247 lymphatic draining regions were found by preoperative scintigraphy. In 3 pts. with melanoma of the cheek no lymphatics/lymph nodes could be detected. 14 pts. showed interval lymph nodes. In 150 pts. gamma probe guided SLNE was done. In 2 pts. with supraclavicular primary tumor 4 SLN had been defined by preoperative scintigraphy but only 2 could be found intraoperatively. In all other cases (98.7%) the sentinel node was detected correctly by the gamma probe and then removed. In 19 of 150 pts. (12.7%) metastases were detected in the pathologic specimen. The incidence of lymph node metastases showed a continuous increase from 0% at tumor stage pT1 to 44% at stage pT4.

CONCLUSION

SLNE is an accurate method to determine nodal involvement in melanoma and minimizes operative invasiveness in melanoma surgery.

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.

[Sentinel lymphadenectomy in malignant melanoma]

The sentinel lymph node dissection (SLND) is one of the most striking developments in the treatment of melanoma. Since the first report by Morton et al. in 1992, the method has been refined, and its use has increased. Introduced as an alternative to elective lymph node dissection (ELND), it has rapidly made its way into clinical practice. SLND allows precise pathologic staging through removal and analysis of a limited number of nodes (false-negative rate < 2%). It distinguishes patients with clinically occult nodal disease from those with tumor-free regional basin who would not benefit from radical dissection. However, the SLND is still an experimental procedure with yet unproven utility.

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.

[Scintillation probe guided sentinel lymphadenectomy in malignant melanoma]

In cutaneous melanoma, biopsy of the first tumor-draining lymph node (Sentinel node, SLN) may replace routine elective lymph node dissection (ELND). The SLN has been shown to contain the first micrometastasis in early lymphatic tumor dissemination. As micrometastases were identified in 10-30% of stage I (AJCC/UICC) patients, sentinel lymphonodectomy (SLND) should enable us to select patients clinically in stages I and II, but histopathologically in stage III. This optimization of patient selection is mandatory as only this subgroup profits from ELND. Since the beginning of 1995 we was scintillation detector (gamma probe)-guided sentinel biopsy in patients with a melanoma > 1.0 mm and clinically negative lymph nodes. After injecting colloidal 99m-Tc-labelled tin(II)-sulfide solution around the tumor (or the biopsy scar), the SLN can be localized exactly. The technique is minimally invasive and easy to handle. If the SLN contains tumor, a standard en bloc lymphonodectomy is performed. Long-term follow-up, however, is needed to delineate the role of this procedure in melanoma treatment.

["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.