Gamma-detecting probe used intraoperatively to locate the sentinel lymph node in patients with malignant melanoma

OBJECTIVE

To assess the usefulness of lymphoscintigraphy and intraoperative gamma probe in the detection of sentinel lymph nodes.

DESIGN

Prospective open study.

SETTING

University hospital, Spain.

SUBJECTS

40 patients with malignant melanoma (24 stage I/II, 16 stage III).

INTERVENTION

The day before operation a lymphoscintigram with 99mTc-nanocolloid was taken and the first lymph node identified was considered to be the sentinel node. A hand-held gamma probe was used for intraoperative mapping.

MAIN OUTCOME MEASURE

Identification of the sentinel node.

RESULTS

Sentinel nodes were identified in 39/40 patients (98%). In 24 patients with stage I/II disease, 34 sentinel nodes were found (6 invaded and 28 clear of melanoma). A total number of 161 regional lymph nodes were harvested, none of them invaded by melanoma. In 16 patients with stage III disease, 22 sentinel nodes were located (14 invaded and 8 clear of melanoma). A total of 89 regional lymph nodes were excised in patients with invaded sentinel nodes (44 of which were invaded and 45 clear of disease). 41 lymph nodes were excised from patients with clear sentinel nodes, and all were also clear of melanoma.

CONCLUSIONS

We conclude that this is a useful technique for the selection of patients with melanoma who may require lymphadenectomy.

Effect of spleen size on splenectomy outcome. A comparison of open and laparoscopic surgery

BACKGROUND

Laparoscopic splenectomy (LS) is gaining acceptance as an alternative to open splenectomy (OS). However, splenomegaly presents an obstacle to LS, and massive splenomegaly has been considered a contraindication. Analyses comparing the procedure with the open approach are lacking. The purpose of this study was to analyze the effect of spleen size on operative and immediate clinical outcome in a series of 105 LS compared with a series of 81 cases surgically treated by an open approach.

METHODS

Between January 1990 and November 1998, 186 patients underwent a splenectomy for a wide range of splenic disorders. Of these patients, 105 were treated by laparoscopy (group I, LS; data prospectively recorded) and 81 were treated by an open approach (group II, OS analyzed retrospectively). Patients also were classified into three groups according to spleen weight: group A, <400 g; group B, 400-1000 g; and group C, >1000 g. Age, gender, operative time, perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia, length of stay, and morbidity were recorded in both main groups.

RESULTS

Operative time was significantly longer for LS than for OS. However, LS morbidity, mortality, and postoperative stay were all lower at similar spleen weights. Spleens weighing more than 3,200 g required conversion to open surgery in all cases. When LS outcome for hematologic malignant diagnosis was compared with LS outcome for a benign diagnosis, malignancy did not increase conversion rate, morbidity, and transfusion, even though malignant spleens were larger and accessory incisions were required more frequently. Postoperative hospital stay was significantly longer in malignant than in benign diagnosis (5 +/- 2.4 days vs. 4 +/- 2.3 days; p < 0. 05).

CONCLUSIONS

In patients with enlarged spleens, LS is feasible and followed by lower morbidity, transfusion rate, and shorter hospital stay than when the open approach is used. For the treatment of this subset of patients, who usually present with more severe hematologic diseases related to greater morbidity, LS presents potential advantages.

[Sentinel lymph node detection with lymphoscintigraphy and intraoperative probe in malignant melanoma patients]

BACKGROUND

The sentinel lymph node is the first node in a lymphatic basin to receive lymphatic drainage from a tumor site. If this node is free of tumor, then radical lymphadenectomy may be avoided. The goal of this study was to assess the usefulness of lymphoscintigraphy and intraoperative gamma probe in the sentinel node detection in patients with malignant melanoma.

METHOD

We prospectively studied 40 patients with malignant melanoma (24 in I/II stages and 16 in III stage). The day before surgery a lymphoscintigraphy with 99mTc-nanocolloid was performed and the first lymph node identified was considered as sentinel node. For intra-operative mapping a hand-held gamma probe was used.

RESULTS

Sentinel nodes were identified in 39/40 (97.5%) patients. In 24 patients with I/II stages 34 sentinel nodes were demonstrated (six positive and 28 negative for malignant melanoma). A total amount of 161 regional lymph nodes was harvested, all of them being negative for malignant melanoma. In 16 patients with III stage, 22 sentinel nodes were located (14 positive and eight negative for malignant melanoma). A total of 89 regional lymph nodes were excised in sentinel nodes positive patients (44 positive and 45 negative for malignant melanoma) and 36 lymph nodes in sentinel node negative, all of them negative for malignant melanoma.

CONCLUSIONS

In patients with malignant melanoma, lymphoscintigraphy with 99Tc-nanocolloid is useful for the detection of sentinel lymph node. Biopsy of this node is useful for the selection of patients to undertake a lymphadenectomy.

Splenomegaly should not be considered a contraindication for laparoscopic splenectomy

OBJECTIVE

To analyze the impact of spleen size on operative and immediate clinical outcome in a series of 74 laparoscopic splenectomies (LS).

SUMMARY BACKGROUND DATA

LS is gaining acceptance as an alternative to open splenectomy. However, splenomegaly hinders LS, and massive splenomegaly has been considered a contraindication.

METHODS

Between February 1993 and September 1997, 74 patients with a wide range of splenic disorders were treated by laparoscopy and prospectively recorded. They were classified into three groups according to spleen weight: group I, <400 g (n = 52); group II, 400 to 1000 g (n = 9); and group III, >1000 g (n = 13). Age, operative time, number of trocars required, need for perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia requirements, length of hospital stay, and morbidity rates were recorded.

RESULTS

LS was completed in 69 patients, and the conversion rate was thus 6.7%. Operative time was significantly longer in patients with larger spleens, and an accessory incision was more frequently required. However, there were no significant differences in transfusion rate, length of stay, severe morbidity, or conversion rate.

CONCLUSIONS

Preliminary evaluation of LS for patients with large spleens suggests that it requires a longer operative time, but it is feasible and may potentially offer the same advantages (shorter stay and faster recovery) as it does to those with smaller spleens.

[Detection of sentinel lymph nodes by lymphatic gammagraphy and intraoperative gamma-ray probe in patients with malignant melanoma. Initial results]

In the last years there has been an arising concern in the sentinel lymph node identification, the first lymph node to receive direct draining from the primary tumour, specially in malignant melanoma (MM). We studied 20 patients with MM: 10 with palpable regional lymph nodes and 10 without palpable LN by performing a lymphoscintigraphy using 99mTc-nanocolloid and a gamma-ray detecting probe during the surgery to locate the sentinel lymph node. In patients with palpable LN, 13 sentinel lymph nodes were identified. Ten of them were MM involved. Furthermore, 82 LN were harvested from involved lymph basins and 30 of them were positive for MM. In patients without palpable LN, 14 sentinel lymph nodes were identified (3 positives and 11 negatives for MM) and other 76 LN were resected (all of them negative). There were not <<skip metastases>> in any patient. These preliminary results support the utility of the technique for the diagnosis and lymphadenectomy selection in patients without palpable LN but which could be involved by micrometastases.

Mid-arm sentinel lymph nodes showing surprising drainage from a malignant melanoma in the forearm

A 51-year-old man with a malignant melanoma in his left forearm was studied to detect the sentinel lymph node and to assess the possibility of micrometastases in regional lymph nodes. Lymphoscintigraphy demonstrated two sentinel lymph nodes in the midarm. Two other nodes in the same location as well as in the left axilla were also observed. The exact location of the sentinel lymph nodes was identified with a gamma-ray detector. At the time of surgery, blue dye was injected around the primary lesion and the two sentinel lymph nodes on the inner side of the left arm were resected. Both lymph nodes were pigmented black. The histopathologic study demonstrated metastases from malignant melanoma in both nodes. This case reflects the main role of lymphoscintigraphy in identifying draining lymph nodes in unusual locations as observed in this patient.

Extraperitoneal laparoscopically assisted ilioinguinal lymphadenectomy for treatment of malignant melanoma

BACKGROUND

Current treatment of malignant melanoma of the leg includes ilioinguinal lymphadenectomy (IIL). Standard open IIL (open IIL) includes sectioning of the inguinal ligament to gain access to the iliac nodes. Extraperitoneal laparoscopic IIL (lap IIL) is a feasible, less aggressive approach. It can be combined with standard superficial lymphadenectomy for treatment of malignant melanoma.

DESIGN

Comparative, prospective, nonrandomized series.

SETTING

Tertiary care center.

PATIENTS

Twelve consecutive, unselected patients with malignant melanoma treated with lap IIL (group 1) were compared with 10 consecutive, unselected patients with malignant melanoma on whom open IIL was performed (group 2).

INTERVENTIONS

Standard open IIL and laparoscopic extraperitoneal iliac lymphadenectomy (lap IIL) plus superficial groin lymphadenectomy.

MAIN OUTCOME MEASURES

Operative time, intraoperative complications, requirements of analgesia, total volume of lymphatic drainage, number of lymph nodes retrieved, immediate morbidity, hospital stay, and long-term morbidity were evaluated.

RESULTS

Operative time was significantly longer for the lap IIL group (group 1) than for the open IIL group (group 2) (177+/-44 vs 140+/-18 minutes, respectively; P<.05), but no patients in group 1 needed conversion to open surgery or developed related complications. Overall lymphatic drainage was significantly lower in group 1 than in group 2 (615+/-518 mL vs 1393+/-793 mL, repectively; P<.01). The number of doses of analgesics (13+/-8 vs 31+/-22, P<.03) and length of postoperative stay (7.3+/-3.3 vs 13+/-5 days, P<.006) were also significantly lower in the laparoscopic group. The overall number of lymph nodes retrieved was similar in both groups (10.2+/-4.6 vs 10+/-3, P=.9). One patient developed a groin hernia of 6 m after open IIL.

CONCLUSIONS

Laparoscopically assisted IIL offers a less aggressive approach than open IIL and entails less pain and a shorter hospital stay, as we observed in 2 groups with similar oncological results (mainly, a similar number of lymph nodes retrieved) who were treated with one procedure or the other. Further research should be done to confirm these preliminary advantages in a prospective randomized trial with long-term follow-up.

Immunohistochemical study of alpha, mu and pi class glutathione S transferase expression in malignant melanoma. MMM Group. Multidisciplinary Malignant Melanoma Group

Human pi, mu and alpha class glutathione S transferases (GST) have been localized immunohistologically in normal skin, naevi and melanoma. Pi GSTs were found principally in the stratum basalis and, to a lesser extent, in the superficial layers. Normal melanocytes showed strong nuclear and cytoplasmatic staining. Distribution of GST mu in the epidermis showed that only the stratum basale, where melanocytes are located, stained well but with weak nuclear staining. Normal melanocytes were also well stained. The alpha GSTs were relatively abundant in the upper strata and to a lesser extent, in the basal layers. The absence of nuclear staining gives these cells a target appearance. Normal melanocytes showed strong cytoplasmatic staining. The pi GSTs seem to be most persistently and strongly expressed in malignant melanoma (MM), but mu GSTs are also found, whereas the alpha GSTs were only occasionally present. The finding of the GST mu in the melanocytes of the basal layer raises new questions regarding the role of GST mu in these cells because of the inherent risk of MM in individuals with a congenital deficiency of this isoenzyme. The role of GSTs in the resistance of cells to chemotherapy is also discussed.

Juxta-anastomotic sacciform dilation: an unusual complication of colonic stapled suture

The commonest complications of stapling closure in gastrointestinal surgery are dehiscence, bleeding at the site of anastomosis and stenosis. Juxta-anastomotic sacciform dilation following end-to-side circular stapling anastomosis of the left colon is reported as an unusual complication. The case highlights the need for careful technique in order to obtain all the advantages offered by staplers.

[Entero-urinary fistula. A study of 22 cases]

We performed a retrospective study on 22 patients with entero-urinary fistulas that had been diagnosed and treated at the Hospital Clinico i Provincial in Barcelona during the period spanning 1981-1988. Fistulas were classified according to the organs or parts with which they communicated. Among the important etiogenic conditions were diverticular disease of colon. Crohn's disease, actinic lesions, trauma and xanthogranulomatous pyelonephritis. The clinical manifestations were principally urological in the form of recurrent urinary infection and terminal pneumaturia. The most useful diagnostic techniques were cystoscopy; serial voiding cystourethrography (SVCU), retrograde urethrography and pyelography. Treatment was by surgery in all cases. Diversion procedures or surgical excision of the fistulous tract were performed as warranted by each case. The etiopathogenic, morphological and therapeutical aspects of vesico-enteric fistulas are discussed.

[Pyonephrosis as a cause of acute peritonitis. Review of the literature and report of a case]

We report on a 52-year-old patient with spontaneous intraperitoneal rupture of pyonephrosis. The diagnostic features, preoperative findings and treatment are discussed and the literature reviewed.

Papillary-cystic neoplasm of the pancreas. Report of two cases and review of the literature

Two cases of papillary-cystic neoplasm of the pancreas are reported in women aged 22 and 23 years. The patient in the first case presented with acute abdominal pain and hemoperitoneum. This form of presentation has not been previously reported. This type of pancreatic tumor is very rare, exclusively affecting young women, and has a good prognosis despite its various histologic features, which suggest a malignant appearance. The authors consider this neoplasm as having an acinar origin because in the cells of one of the patients we observed ultrastructurally the presence of abundant rough endoplasmatic reticulum with formation of annulate lamellae and a few prezymogen granules.