Long-term clinical impact of sentinel lymph node biopsy in breast cancer and cutaneous melanoma

Sentinel lymph node biopsy (SLNB) is based on the hypothesis that the sentinel lymph node (SLN) reflects the lymph-node status and a negative SLN might allow complete axillary lymph node dissection (ALND) to be avoided. Past and current sentinel lymph node clinical trials for breast carcinoma and melanoma address the prognostic and therapeutic utility of SLN dissection (SLND). This technique has already become a standard of care for breast cancer patients and select patients with melanoma. However, it is still important to discuss current techniques and some controversies. This article reviews these issues as well as current guidelines for treatment and management of patients with various findings on SLNB.

Interaction of an Overexpressed gamma-Tubulin with Microtubules In Vivo and In Vitro

gamma-Tubulin is an ubiquitous MTOC (microtubule-organizing center) component essential for the regulation of microtubule functions. A 1.8 kb cDNA coding for gamma-tubulin was isolated from CHO cells. Analysis of nucleotide sequence predicts a protein of 451 amino acids, which is over 97% identical to human and Xenopus gamma-tubulin. When CHO cells were transiently transfected with the gamma-tubulin clone, epitope-tagged full-length, as well as truncated polypeptides (amino acids 1-398 and 1-340), resulted in the formation of cytoplasmic foci of various sizes. Although one of the foci was identified as the centrosome, the rest of the dots were not associated with any other centrosomal components tested so far. The pattern of microtubule organization was not affected by induction of such gamma-tubulin-containing dots in transfected cells. In addition, the cytoplasmic foci were unable to serve as the site for microtubule regrowth in nocodazole-treated cells upon removal of the drug, suggesting that gamma-tubulin-containing foci were not involved in the activity for microtubule formation and organization. Using the monomeric form of Chlamydomonas gamma-tubulin purified from insect Sf9 cells (), interaction between gamma-tubulin and microtubules was further investigated by immunoelectron microscopy. Microtubules incubated with gamma-tubulin monomers in vitro were associated with more gold particles conjugated with gamma-tubulin than in controls where no exogenous gamma-tubulin was added. However, binding of gamma-tubulin to microtubules was not extensive and was easily lost during sample preparation. Although gamma-tubulin was detected at the minus end of microtubules several times more frequently than the plus end, the majority of gold particles were seen along the microtubule length. These results contradict the previous reports (; ), which might be ascribed to the difference in the level of protein expression in transfected cells.

A new paradigm in the management of anorectal melanoma: Trans-anal excision with sphincter preservation and sentinel node biopsy

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Background: Anorectal melanoma is rare and highly lethal. Historically this disease has often been treated with abdominoperineal (APR) resection and delayed groin dissection for nodal relapse. As an alternative we have investigated trans-anal excision (TAE) with sphincter preservation and lymphatic mapping with sentinel node biopsy (SNB). We compared the outcomes of this more conservative treatment plan between our institutional data (JWCI) and the Surveillance, Epidemiology and End Results (SEER) data. Methods: JWCI prospective melanoma database (1974–2006) and the SEER database (1973–2003) were searched for pts diagnosed with anorectal melanoma (n=60 vs. n=183, respectively). Treatment, types of recurrence, and survival were recorded. Survival was estimated by the Kaplan-Meier method. Results: Lymphoscintography revealed lymphatic drainage to superficial inguinal nodal basin(s) in all cases. Among JWCI pts, the proportion of pts requiring delayed lymphadenectomy was significantly lower when TAE was performed with SNB versus without SNB (10.0% vs. 58.8%; p=0.018). Among JWCI lymphadenectomy specimens, immediate lymphadenectomy for a positive SNB was associated with fewer metastatic lymph nodes than delayed lymphadenectomy for palpable nodal recurrences (1.6 vs. 2.9; p=0.029), suggesting disease progression during observation. Over the past decade, APR rates were 11.5% for JWCI pts and 43.2% for and SEER pts, (p=0.004). JWCI pts and the SEER pts had median survivals of 33 and 17 months, respectively (p=0.009). TAE versus APR did not adversely affect the survival of JWCI pts (39 vs. 23 months; p=0.010) or SEER pts (18 vs. 16 months; p=0.875). Conclusion: Lymphatic mapping with SNB accurately identified the inguinal nodal basin as the most frequently involved basin and reduced the rate of recurrence and extent of nodal involvement. In this study, the largest to analyze surgical treatment and outcomes for pts with anorectal melanoma in the United States, national TAE rates differed from those at a tertiary melanoma center. TAE did not adversely affect survival in either dataset. Therefore, TAE plus SNB is preferred when negative margins can be obtained; APR should be reserved for locally advanced tumors that cannot be removed by TAE.

No significant financial relationships to disclose.

Improved long-term survival in patients with intermediate thickness primary melanoma managed by sentinel node biopsy

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Background: Although improved disease-free survival (DFS) with sentinel node biopsy (SNB) for clinically localized melanoma was observed at the interim analysis from the first Multicenter Selective Lymphadenectomy Trial (MSLT-I) there was not yet an improvement in overall survival (OS). We hypothesize this was due to the few observed early deaths. To investigate this we simulated the MSLT-1 protocol using our institutional database. Methods: 3,800 patients undergoing wide excision with or without SNB were matched by primary stage/ulceration/site and patient demographics. Patients with positive sentinel nodes (SN) underwent immediate completion lymphadenectomy (CLND) whereas non-SNB patients managed by nodal observation underwent delayed CLND at nodal recurrence. Survival was determined by the Kaplan-Meier method. Significance was determined using log-rank and Cox regression analysis. Results: Among matched pairs of SNB and non-SNB patients with 1.2–3.5 mm primaries, projected 10-year OS was 76% with SNB versus 63% without SNB (p=0.0008). There was no corresponding statistically significant difference between all 2001 SNB patients and 1799 non-SNB patients, or within the thin primary and thicker primary groups. By multivariate analysis, only SN status (p<0.0001), Breslow thickness (p<0.0001) and ulceration (p=0.0001) were independently predictive of OS. Conclusions: Our long-term data suggest that performing SNB will improve OS in patients with intermediate thickness melanoma but not with thicker or thinner melanomas as compared to observation and delayed CLND.

No significant financial relationships to disclose.

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Chemokine receptor 5 (CCR5) Δ32 base pair somatic gene deletions from PBM predict survival of patients with advanced stage (IV) melanoma

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Background: Chemokines are a family of secreted chemotactic cytokines that function in leukocyte trafficking and activation. Chemokine receptor 5 (CCR5) is involved in CD4+ T-cell mediated immunity and dendritic cell (DC) activation. A 32 base pair (bp) deletion mutation on chromosome 3p21 result in a non-functional CCR5 with defective immunity. We hypothesized that CCR5Δ32 bp mutations would result in a diminished immune response to melanoma and maybe predictive of outcome of patients with advanced-stage disease. Methods: We identified 160 AJCC stage IV melanoma patients from our database whom had been made NED (no evidence of disease) by surgical resection. 105 (66%) had received active specific immunotherapy in phase I/II trials. Genomic DNA was extracted from peripheral blood mononuclear cells (PBM) and screened by PCR for the presence of CCR5Δ32 bp deletions. PCR products were sequenced to verify the result. Statistical analysis was performed by using Log-rank, Chi-square & Student’s t-test. Results: Of 160 patients, 100 (63%) were men. Ages ranged from 19–82 (median 47 yrs.). 46 (29%) patients had M1a, 48 (30%) Mlb and 66 (41%) Mlc stage of metastases prior to surgical resection. Median follow-up was 47.5 mos. 135 (84%) patients had wild-type (Wt)CCR5 gene; 21 (13%) had heterozygous (HtM) and 4(3%) had homozygous mutations (HoM). 5-yr survival was significantly higher for patients with CCR5 Wt than those with HtM or HoM deletions (55.6%±6.1% vs. 21.4%±10.8%, p=0.031). None of the 21 patients with HtM survived 10yrs. Multivariate analyses demonstrated only CCR5 gene status (Wt vs. HtM/HoM) as predictive of survival (p=0.007). Age (p=0.23), gender (p=0.38), and M stage (M1a vs. M1b/c) (p=0.31) were not important in the statistical model. When immunotherapy responses (+ vs. -) were included in the model both responses and CCR5 mutation status were significant (p=0.0021, p=0.0063 respectively). Conclusions: Our results suggest CCR5Δ32bp somatic mutations from PBM are present in advanced-stage melanoma patients and are highly predictive of survival. Functional CCR5 may be used as a selection factor for surgery but more importantly essential for either active immunotherapy or the natural immune response to be effective for these patients.

No significant financial relationships to disclose.

Lessons learned from two decades of sentinel node biopsies for melanoma

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Background: The long term prognosis for patients with melanoma staged by sentinel node biopsy (SNB) remains unclear, largely due to limited follow-up from a variety of small single institution studies. We evaluated our extensive 20-year experience to evaluate the long term prognostic significance of SNB. Methods: We retrospectively reviewed the records of 2001 successive patients who underwent LM/SNB at our center from 1985 until 2004. After preoperative lymphoscintigraphy, blue dye and a hand-held gamma probe were used for intraoperative identification of sentinel nodes (SN). SN were evaluated for metastases by hemotoxylin and eosin and immunohistochemical staining with HMB45, S-100, and more recently with antibodies to melanA. Patients with tumor-positive SN underwent completion dissection (SCLND). Clinicopathological features of the patients, primaries and SN status were evaluated for their influence on survival using multivariate Cox regression analysis. Results: After median follow-up of 49 months (range 1–237). Median age for our patients was 51 years (range 10–91). Of the 2,001 patients, 1584 (79%) had tumor-negative and 417 (21%) had tumor-positive SN. Survival rates were higher in patients with tumor-negative vs. tumor-positive SN (91 + 2% vs. 72 + 5% at 5 years, log-rank p<0.0001; and 84 + 3% vs. 64 + 7% at 10 years, log-rank p<0.0001). Of the 417 patients with SN metastases, 293 (70%) had a single tumor-positive node, 101 (24%) had 2–3 positive nodes, and 25 (6%) had at least 4 positive nodes (sentinel plus nonsentinel). Overall survival was significantly better when metastases were confined to single vs. multiple nodes (77 + 3% vs. 63 + 5%; p=0.0017). Multivariate analysis with Cox regression identified SN status (p<0.0001) as the most important prognostic factor, Hazard Ratio 3.44 (2.47–4.79). Breslow thickness (p<0.0001) and ulceration (p=0.0001) are also independently significant for survival. Gender and primary site were not significant. Conclusions: Our results demonstrate the long term prognostic significance of SN status. LM/SNB should become standard of care for primary melanoma because it is the most accurate factor for the quantification of the risk for recurrence and death available.

No significant financial relationships to disclose.

Prognostic significance of children with cutaneous melanoma: Implications for treatment

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Background: The incidence of melanoma in pediatric patients, particularly teenagers, is increasing. Treatment strategies employed for adult patients with melanoma have been applied to pediatric populations with minimal data to support similar efficacy. We performed a matched-paired analysis to compare the prognosis of pediatric (≤19 yrs old) and adult melanoma patients. Methods: Single institution, prospectively obtained melanoma database containing >14,000 records was queried for children ages 1–19 years treated for cutaneous melanoma. We identified 197 pediatric patients seen at our institute over the last 35 years. After excluding patients not seen within 4 months of initial diagnosis, 115 pediatric patients were matched to adults (age 20–70 years) chosen from the database by gender, stage, primary site and tumor characteristics (Clark level, Breslow thickness, and ulceration). Overall survival was compared between cohorts by the Kaplan-Meier method. Results: For the pediatric patients, median age at diagnosis was 17.7 years (range 7–19 years). Patients were almost equally distributed between girls (47%) and boys. AJCC stage I and II disease at presentation was most common (73%), with stage III and IV occurring much less frequently (25% and 2%). Most pediatric patients had Clark level IV (37%) lesions; Clark level II (25%), III (25%), V (4%), and I (2%) lesions were less common. Breslow thickness ranged between <1.0mm (38%), 1.1–2.0mm (20%), 2.1–4.0mm (17%), and >4.1mm (12%). The two predominant histologic types were superficial spreading (52%) and nodular (22%) melanoma. 14% of the primary lesions were ulcerated. Rates of disease-free and overall survival were 75%± 4% and 84%± 4% at 5 years and 74%± 4% and 77%± 5% at 10 years, respectively, with a median follow up of 5.1 years (range 1–30 years). Matched pediatric and adult patients showed no difference in survival from time of initial diagnosis and stage of presentation (log rank p=0.24). Conclusions: Stage-specific survival in pediatric and adult melanoma patients is similar. In the absence of specific pediatric trials, standard treatment for children with melanoma should be consistent with that for adults.

No significant financial relationships to disclose.

Surgical and molecular approaches to the sentinel lymph nodes

Intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL) provides a unique opportunity for assessing potential immunologic interactions between the primary tumor and regional lymph node basin. We performed LM/SL in 24 patients with early-stage melanoma and resected an additional nonsentinel node (non-SN) in each case. Sentinel nodes (SNs) and non-SNs were evaluated by routine pathologic analysis, and a portion of each node was processed for expression of three dendritic markers of activation (CD80, CD86, CD40) and their corresponding T-cell receptors (CTLA-4 and CD28). Twenty (83%) patients had matched SNs and non-SNs. A total of 26 nodal pairs were obtained because one patient had three pairs and two other patients each had two pairs. Reverse transcriptase-polymerase chain reaction (RT-PCR) analyses of paired SNs and non-SNs demonstrated a marked reduction in semiquantitative expression of CD80 (77%), CD86 (77%), and CD40 (85%), as well as CTLA-4 (88%) and CD28 (85%) in SNs. The diminished expression appeared to be unrelated to B-cell (CD20) and T-cell (CD2) expression. A quantitative reduction in dendritic cell markers in SNs may be important in the immunologic interaction between the primary site and regional lymph node basin and may also provide useful criteria for identifying SNs.

Does complete resection of melanoma metastatic to solid intra-abdominal organs improve survival?

BACKGROUND

Patients with distant melanoma metastases have median survivals of 4 to 8 months. Previous studies have demonstrated improved survival after complete resection of pulmonary and hollow viscus gastrointestinal metastases. We hypothesized that patients with metastatic disease to intra-abdominal solid organs might also benefit from complete surgical resection.

METHODS

A prospectively acquired database identified patients treated for melanoma metastatic to the liver, pancreas, spleen, adrenal glands, or a combination of these from 1971 to 2000. The primary intervention was complete or incomplete surgical resection of intra-abdominal solid-organ metastases, and the main outcome measure was postoperative overall survival (OS). Disease-free survival (DFS) was a secondary outcome measure.

RESULTS

Sixty patients underwent adrenalectomy, hepatectomy, splenectomy, or pancreatectomy. Median OS was significantly improved after complete versus incomplete resections, but median OS after complete resection was not significantly different for single-site versus synchronous multisite metastases. The 5-year survival in the group after complete resection was 24%, whereas in the incomplete resection group, there were no 5-year survivors. Median DFS after complete resection was 15 months. Of note, the 2-year DFS after complete resection was 53% for synchronous multi-site metastases versus 26% for single-site metastases.

CONCLUSIONS

In highly selected patients with melanoma metastatic to intra-abdominal solid organs, aggressive attempts at complete surgical resection may improve OS. It is important that the number of metastatic sites does not seem to affect the OS after complete resection.

Surgical resection for metastatic melanoma to the liver: the John Wayne Cancer Institute and Sydney Melanoma Unit experience

HYPOTHESIS

Metastatic melanoma to the liver is not incurable; complete surgical resection can achieve long-term survival in selected patients.

BACKGROUND

Metastases to the liver are diagnosed in 10% to 20% of patients with American Joint Committee on Cancer stage IV melanoma. Surgical resection has not been generally accepted as a therapeutic option, as most patients will have other sites of disease that limit their survival to a median of only 4 to 6 months. However, there is little information on outcomes following resection in those patients with disease limited to the liver.

PATIENTS AND METHODS

Review of the prospective melanoma databases at the John Wayne Cancer Institute, Santa Monica, Calif, and the Sydney Melanoma Unit, Sydney, Australia, identified 1750 patients with hepatic metastases, of whom 34 (2%) underwent exploration with intent to resect the metastases. Prognostic factors within the group of patients who underwent resection were examined by univariate and multivariate analysis, and median disease-free survival (DFS) and overall survival (OS) were calculated.

RESULTS

Of 34 patients undergoing exploratory celiotomy, 24 (71%) underwent hepatic resection and 10 (29%) underwent exploration but not resection. Eighteen patients (75%) underwent complete surgical resection, while the remaining 6 underwent palliative or debulking procedures with incomplete resection. The operative resections included lobectomy (n=14), segmentectomy (4), nonanatomic resection (5), and extended lobectomy (1). The median number of resected lesions was 1, and median lesion size was 5 cm (range, 0.7-22 cm). The median disease-free interval between initial diagnosis of melanoma and development of hepatic metastases was 58 months (range, 0-264 months). Median DFS and OS estimates in the 24 patients who underwent surgical resection were 12 months (range, 0-147 months) and 28 months (range, 2-147 months), respectively. Five-year DFS and OS in this group were 12% and 29%. Macroscopically, complete resection of disease (P =.001) and histologically negative resection margins (P =.03) significantly improved DFS by univariate analysis. Patients rendered surgically free of disease also tended to have improved OS (P =.06). Median OS was 28 months for patients who underwent surgical resection compared with 4 months for patients who underwent exploration only (P<.001).

CONCLUSIONS

Resection of metastatic melanoma to the liver may improve DFS and OS in selected patients, similar to resection of other metastatic sites. Therefore, patients with limited metastatic sites, including the liver, who can be rendered free of disease should be considered for complete surgical resection, as their prognosis is otherwise dismal.

Sentinel lymph nodes show profound downregulation of antigen-presenting cells of the paracortex: implications for tumor biology and treatment

The sentinel lymph node (SN) is the first node on the direct lymphatic drainage pathway from a tumor. Melanoma-associated SNs are the most likely site of early metastases and their immune functions are strikingly down-modulated. We evaluated histologic and cytologic characteristics of 21 SNs and 21 nonsentinel nodes (NSNs) from melanoma patients who had clinically localized (AJCC Stage I--II) primary cutaneous melanoma. SNs showed highly significant reductions in total paracortical area and in the area of the paracortical subsector occupied by dendritic cells. The frequency of paracortical interdigitating dendritic cells (IDCs) was dramatically reduced in SNs, and most IDCs (approximately 99%) lacked the complex dendrites associated with active antigen presentation. The release of immunosuppressive factors from the primary melanoma may induce a localized and specific paralysis in the SN, which prevents the recognition of otherwise immunogenic melanoma antigens by IDCs. This immune paralysis may facilitate the implantation and growth of melanoma cells in the SN. Cytokine therapy may be able to reverse this immune paralysis. These findings have an important practical application in the histopathologic confirmation that a node is truly sentinel. They also offer an hypothesis to explain the failure of the immune surveillance mechanisms to identify and respond to a small primary melanoma that expresses immunogenic tumor antigens.

Serum TA90 antigen-antibody complex as a surrogate marker for the efficacy of a polyvalent allogeneic whole-cell vaccine (CancerVax) in melanoma

INTRODUCTION

TA90 is a tumor-associated 90-kD glycoprotein antigen expressed on most melanoma cells, including those of CancerVax, a polyvalent allogeneic whole-cell vaccine. Previous studies have shown that a TA90 antigen-antibody immune complex (IC) in the serum of patients with melanoma is a marker of subclinical tumor burden and a strong prognostic factor. We hypothesized that the induction of TA90-IC during postoperative adjuvant CancerVax therapy might indicate vaccine-mediated immune destruction of subclinical melanoma cells with release of TA90, and thereby serve as a surrogate marker of vaccine efficacy.

METHODS

From 1993 to 1997, 219 melanoma patients were enrolled in a prospective phase II trial of CancerVax plus bacille Calmette-Guerin (BCG) after complete tumor resection. Coded serum samples were prospectively collected and analyzed for TA90-IC before and 2, 4, 8, 12, and 16 weeks after initiation of CancerVax therapy. TA90-IC seroconverters were those patients whose negative TA90-IC values (< .410) became positive (> or = .410) after initiation of CancerVax treatment.

RESULTS

Before CancerVax therapy, 51 patients had positive TA90-IC values and 168 patients had negative TA90-IC values. During CancerVax treatment, all 51 positive patients remained positive, 79 (47%) negative patients seroconverted to positive, and 89 (53%) negative patients remained negative. Seroconverters had higher 2-year rates of disease-free survival (59% vs. 32%; P < .006) and overall survival (78% vs. 63%; P < .02) than did patients whose TA90-IC values remained positive.

CONCLUSIONS

CancerVax induces TA90-IC in melanoma patients with subclinical disease. TA90-IC seroconverted patients have significantly improved disease-free and overall survival compared with TA90-IC positive patients. TA90-IC is an important prognostic factor that can serve as a surrogate marker for the clinical efficacy of CancerVax.

Application of an [(18)F]fluorodeoxyglucose-sensitive probe for the intraoperative detection of malignancy

BACKGROUND

Whole-body positron emission tomography (PET) has been shown to be a highly sensitive method for detecting malignancy not imaged by conventional modalities. We have adapted a hand-held gamma-ray-sensitive probe to detect the radiation emission from the [(18)F]fluorodeoxyglucose (FDG) used in PET imaging. This pilot study was devised to examine the feasibility of using a hand-held probe to intraoperatively differentiate normal from tumor-bearing tissue.

MATERIALS AND METHODS

A commercially available gamma probe was adapted to detect the radioactivity released from FDG and examined to determine the in vitro sensitivity for localization of a FDG point source. Eight consecutive patients underwent resection of metastatic colon cancer or melanoma; each received a preoperative injection of 7--10 mCi of FDG. The gamma probe was used to determine radioactive counts per second from tumor and normal tissue, and ratios of tumor to adjacent normal background were calculated.

RESULTS

In vitro studies with a FDG point source demonstrated the probe could identify the source with a 50% reduction in maximum counts 1.7 +/- 0.1 cm from the source (full-width half-maximum measurement). Based on the results of their preoperative PET scans 17 tumors were identified from the 8 patients. Of the 17 tumors assessed the in vivo tumor-to-background ratios varied from 1.16:1 to 4.67:1 for the melanoma patients (13 tumors) and from 1.19:1 to 7.92:1 for colon cancer patients (4 tumors). Thirteen tumors were resected; four (2 patients) were unresectable.

CONCLUSIONS

This study demonstrates the use of a hand-held gamma-ray-sensitive probe to intraoperatively differentiate the radioactivity released from FDG from tumor-bearing and adjacent normal tissue. While further studies are necessary for us to optimize the use of this probe, the intraoperative detection of FDG-avid malignancies may ultimately improve our ability to completely resect patients with metastatic disease.

Functional interleukin-4 receptor and interleukin-2 receptor common gamma chain in human gastric carcinoma: a possible mechanism for cytokine-based therapy

Interleukin (IL)-2 and IL-4 play a critical role in the regulation of the immune response. Yet both of the receptors for these cytokines have been found on nonhematopoietic cells, including human gastric carcinoma cell lines and tissue specimens. IL-4 causes G1 phase cell cycle arrest of gastric carcinoma; the effect directly correlates with the expression of IL-4 receptor (IL-4R) and is seen within 48 hours after treatment. Cells lacking IL-4R are unaffected by IL-4. We examined signal transduction pathways employed by IL-4 that may account for cell cycle arrest of an established human gastric carcinoma cell line, CRL 1739. Western blot analysis was performed on CRL 1739 cultured in the presence of IL-4 (500 U/ml). Cells were lysed, protein extracted, and electroblotted; blots were then probed with murine mono-clonal antibodies to specific intracellular proteins. Western blotting of CRL 1739 with antiphosphotyrosine antibody (4G10) demonstrated multiple (140 kDa and 65 kDa) phosphoproteins seen only in IL-4-treated CRL 1739. Immunoprecipitation and blotting of CRL 1739 with specific secondary antibodies demonstrated that the 140 kDa phosphoprotein was IL-4R", the 65kDa phosphoprotein was IL-2Rgc, the 130 kDa phosphoprotein was Janus kinase (JAK1), and the 116 kDa phosphoprotein was JAK3. Reverse transcription-polymerase chain reaction with specific primers demonstrated that multiple human gastric tumor specimens expressed IL-4R" and IL-2Rgc but did not express the leukocyte marker CD45. These results suggest that human gastric carcinomas may express functional cytokine receptors, including the IL-2Rgc commonly found in association with the lymphocyte IL-2R. These receptors may represent novel targets for directing cytokine-based therapy.

Accuracy of gamma probes in localizing radioactivity: in-vitro assessment and clinical implications

BACKGROUND

Radioguided surgery (RGS) uses gamma probes to localize radioactive targets. We examined the in-vitro localizing properties of commercially available gamma probes for three common RGS radioisotopes: technetium-99m (99mTc), indium-111 (111In), and iodine-125 (125I).

METHODS

The linear and angular localizing properties of five gamma probes were assessed. Radioactive counts in air were obtained at multiple energy threshold settings for each radioisotope. The full width half maximum (FWHM) and angular half maximum (AHM) were calculated to determine localizing accuracy.

RESULTS

The FWHM of the five probes ranged from 1.2 to 3.4 cm for 99mTc, 1.8 to 2.7 cm for 111In and 1.6 to 2.8 cm for 125I. AHM of the probes ranged from 20 to 49 degrees for 99mTc, 14 to 35 degrees for 111In, and 18 to 47 degrees for 125I. The ranking of probe accuracy depended on the radioisotope studied. Absolute count rates varied with energy threshold settings for each probe and radioisotope. Probes required individualized energy threshold settings for optimal performance.

CONCLUSIONS

The five probes varied in their characteristics for localizing the three radioisotopes. Each probe has particular detection characteristics that may change with different radioisotopes. Differences in radioisotope detection may explain intraoperative variation in localization during lymphatic mapping and sentinel lymph node dissection (LM/SL). Surgeons should be aware of probe performance characteristics before intraoperative use.

Stereotactic radiosurgery in the treatment of metastatic disease to the brain

We review 190 consecutive patients with 434 metastatic tumors treated by gamma knife stereotactic radiosurgery, from August 1994 to February 1999. Median actuarial survival for all patients was 34 weeks. Factors correlated with significantly improved survival included controlled systemic disease and nonmelanoma histology. We found that no significant survival benefit could be discerned from adjuvant whole brain radiotherapy in this patient group. Survival was not statistically different for patients initially presenting with 1-4 metastases at initial treatment.

Stereotactic radiosurgery in the treatment of metastatic disease to the brain

OBJECTIVE

In recent years, stereotactic radiosurgery has been growing in popularity as a treatment modality for metastatic disease to the brain. The technique has advantages of reduced cost and low morbidity compared with open surgical treatment. Furthermore, it avoids the potential cognitive side effects of fractionated whole-brain radiotherapy. We undertook this study to determine the usefulness of adjuvant radiation therapy and to determine prognostic factors in patients treated with stereotactic radiosurgery.

METHODS

We reviewed our series of patients with metastatic tumors treated using gamma knife stereotactic radiosurgery from August 1994 to February 1999. Nonparametric methods were used to compare treatment subgroups by demographic features including age, Karnofsky Performance Scale score, diagnosis, and systemic disease status. Univariate and multivariate analyses of survival and freedom from progression were performed using Kaplan-Meier and Cox proportional hazards regression techniques.

RESULTS

This study included 190 patients harboring 431 lesions who were treated in 263 treatment sessions. The median follow-up after radiosurgery was 36 weeks for all patients. The median actuarial survival from the time of radiosurgery in all patients was 34 weeks. When patients were stratified according to tumor histology, those without melanoma had a median survival of 39 weeks, and those with melanoma had a median survival of 28 weeks. The cause of death could be determined in 122 (92%) of the patients known to have died during the data capture period. For patients harboring melanoma, death was attributable to systemic disease in 31 (47%), to central nervous system-related processes in 29 (44%), and to unknown causes in 6 (9%). For non-melanoma patients, death was attributable to systemic disease in 45 (68%), to central nervous system-related processes in 17 (26%), and to unknown causes in 4 (6%). Significantly improved survival (P = 0.002) was observed in patients with controlled systemic disease. No significant difference in survival could be ascertained for patients presenting with up to four lesions, although patients with a total tumor volume greater than 9 cc had shortened survival. No survival benefit could be demonstrated for whole-brain radiotherapy administered either concomitantly or after radiosurgery.

CONCLUSION

Factors correlated with significantly improved survival included controlled systemic disease and non-melanoma histology. We found no significant survival benefit that could be discerned from adjuvant whole-brain radiotherapy in this patient group.

Principles of sentinel lymph node identification: background and clinical implications

The management of clinically negative regional lymph nodes in early-stage melanoma has been controversial for many years. While some advocate wide excision of the primary with elective node dissection (ELND), others recommend excision of the primary alone and therapeutic node dissection (TLND) for recurrences in the nodal basin. ELND is based on the concept that metastases occur by passage of the tumor from the primary to the regional nodes and distant sites, in which case early dissection of regional nodes will disrupt metastatic progression and prevent the spread of disease. Advocates of the "wait and watch" approach suggest that regional node metastases are markers for disease progression and that distant disease can occur without node metastases. Four randomized prospective studies comparing ELND and TLND have not demonstrated overall survival advantage for ELND, but suggest that patients with early regional metastases may benefit from ELND. As an alternative, Morton et al., from UCLA and the John Wayne Cancer Institute, devised intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL). These minimally invasive operative procedures allow identification of the first and key (sentinel) lymph node (SN). The technique accurately maps the lymphatics by lymphoscintigraphy, and vital blue dye leads the surgeon to the SN. The pathologist then concentrates on seeking metastases in the nodes most likely to contain metastases. Patients with tumor-positive SN undergo completion lymph node dissection (CLND), while those without SN metastases avoid the complications and costs associated with this procedure. Morton et al., in a report on their initial experience of LM/SL, performed CLND in all cases regardless of SN tumor status and demonstrated the precise staging capacity of the procedure. Since this initial report, numerous studies have validated the accuracy and low morbidity of the procedure. Each center must master a learning phase. The procedure is dependent on the close cooperation of nuclear medicine physicians, surgeons, and pathologists. While LM/SL is now almost standard practice in the US, the results of clinical trials are awaited to determine whether LM/SL can replace ELND and TLND in the management of early-stage melanoma.

Judging the therapeutic value of lymph node dissections for melanoma

BACKGROUND

The management of the regional lymph nodes remains controversial for early-stage melanoma and for those patients with lymph node metastases; American Joint Committee on Cancer stage III. This study examines the importance of quality of the surgical resection measured by the extent of lymph node dissection (quartile of the total number of lymph nodes removed) to determine if this factor is an important prognostic factor for survival.

STUDY DESIGN

We reviewed our computer-assisted database of more than 8,700 melanoma patients prospectively collected from 1971 through the present to identify patients who underwent lymph node dissection for stage III melanoma. We included only patients who had their nodal dissections performed at our institute. Patients who underwent sentinel lymph node dissection were excluded. These patients were then analyzed as a group and by individual lymphatic basins: cervical, axillary, and inguinal basins. Univariate and multivariate analyses were used to examine the model that included tumor burden, thickness of the primary melanoma, gender, age, clinical status of the lymph nodes (palpable versus not palpable), and the primary site. The survival and recurrence rates were analyzed using the Cox proportional hazards model.

RESULTS

Five hundred forty-eight patients underwent regional lymph node dissections. Of these patients, 214 underwent axillary dissections, 181 inguinal dissections, and 153 cervical dissections. The extent of the nodal dissections was based on the quartile of nodes excised, ranging from 1 to 98 (mean +/- SD = 25.8 +/- 15.8). Patients were stratified by tumor burden and quartile of number of lymph nodes removed. The overall 5-year survival of patients with four or more lymph nodes having tumor and the highest quartile of lymph nodes removed was 44% and was 23% for the lowest quartile of total lymph nodes excised (p = 0.05). By univariate analysis, tumor burden (p = 0.0001), quartile of total lymph nodes removed (p = 0.043), and primary site (p = 0.047) were statistically significant for predicting overall survival. Gender, clinical status of the nodes, primary tumor thickness, age, and dissected basin were not significant (p > 0.05). By multivariate analysis only the tumor burden (p = 0.0001) and quartile of lymph nodes resected (p = 0.044) were statistically significant.

CONCLUSIONS

The extent of lymph node dissection for melanoma when analyzed by quartiles is an independent factor in overall survival. This factor appears to be more important with increasing tumor burden in the lymphatic basin. The extent of lymph node dissection should be considered as a prognostic factor in the design of clinical trials that involve stage III melanoma.

Filamentous polymers induced by overexpression of a novel centrosomal protein, Cep135

A novel 135 kDa centrosomal component (Cep135) was identified by immunoscreening of a mammalian expression library with monoclonal antibodies raised against clam centrosomes. It is predicted to be a highly coiled-coil protein with an extensive alpha-helix, suggesting that Cep135 is a structural component of the centrosome. To evaluate how the protein is arranged in the centrosomal structure, we overexpressed Cep135 polypeptides in CHO cells by transient transfection. HA- or GFP-tagged full (amino acids 1-1144) as well as truncated (#10, 29-1144; Delta3, 29-812) polypeptides become localized at the centrosome and induce cytoplasmic dots of various size and number in CHO cells. Centrosomes are associated with massive approximately 7 nm filaments and dense particles organized in a whorl-like arrangement in which parallel-oriented dense lines appear with a regular approximately 7 nm periodicity. The same filamentous aggregates are also detected in cytoplasmic dots, indicating that overexpressed Cep135 can assemble into elaborate higher-ordered structures in and outside the centrosome. Sf9 cells infected with baculovirus containing Cep135 sequences induce filamentous polymers which are distinctive from the whorl seen in CHO cells; #10 forms highly packed spheroids, but the Delta3-containing structure looks loose. Both structures show an internal repeating unit of dense and less dense stripes. Although the distance between the outer end of two adjacent dense lines is similar between two types of polymers ( approximately 120 nm), the dense stripe of Delta3 polymers ( approximately 40 nm) is wider than #10 ( approximately 30 nm). The light band of Delta3 ( approximately 40 nm) is thus narrower than #10 ( approximately 60 nm). Since thin fibers are frequently seen to extend from one dense line to the next, the coiled-coil rod of Cep135 may span the light band. These results suggest that overexpressed Cep135 assemble into distinctive polymers in a domain-specific manner.

A review of the literature for whole-body FDG PET in the management of patients with melanoma

BACKGROUND

A review and meta-analysis of the literature on the use of 2-[18F]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) in the detection of recurrent melanoma was conducted. The goals were to evaluate the quality of data reporting and to determine the overall values for the sensitivity and specificity of whole body FDG PET and management changes.

METHODS

Guidelines to evaluate reporting within articles were formulated based on the United States medical payer source criteria for assessing studies reporting information on the utilization of new medical technology. A meta-analysis was conducted using methodology described in the peer reviewed literature.

RESULTS

Our MEDLINE PLUS search resulted in a universe of 89 total articles. Within these 89, 19 were categorized in our targeted content area of which 13 were selected for analysis in our targeted subset, with the remaining 70 covering 24 different related content areas. Five of 13 (38%) articles in the target subset reported data which was adequate for incorporation into modeling objectives based on PET sensitivity and specificity values, with 1 of 13 (8%) in the same target subset reporting data adequate for modeling based on change-in-management data. Through a meta-analysis of the 13 target articles we determined, within a 95% confidence level, an overall sensitivity of 92% (95% confidence level 88.41%-95.82%) and an overall specificity of 90% (95% confidence level 83.26%-96.05%) as calculated by number of lesions, for FDG PET detecting recurrent melanoma throughout the whole body. Furthermore, limited data available for change-in-management suggests an overall FDG PET directed change-in-management value of 22%.

CONCLUSIONS

Our review suggests that improvements can be made to more effectively report the results of these FDG PET studies. The overall values determined through the meta-analysis indicate the potential benefits of using FDG PET as a diagnostic/management tool. Furthermore, these values should prove useful to assessing the cost effectiveness of utilizing FDG PET in the management of recurrent melanoma.

Is the node of Cloquet the sentinel node for the iliac/obturator node group?

PURPOSE

Some surgeons question the survival advantage of ilioinguinal lymphadenectomy for metastatic melanoma because they believe that deep nodal involvement signifies a poor prognosis that is unchanged by surgery. However, several series, including our own, have reported 5-year survival rates reaching 30%. New adjuvant therapies may further improve survival after ilioinguinal lymphadenectomy, but this applies only to nodal basins with metastatic disease. We hypothesized that the node of Cloquet accurately reflects the pathologic status of the iliac/obturator nodes, allowing deep pelvic lymphadenectomy to be selectively performed.

PATIENTS AND METHODS

Between 1972 and 1998, 691 patients with primary cutaneous melanoma underwent both elective and therapeutic complete (superficial and deep) ilioinguinal lymphadenectomy. Of the 204 (30%) patients with tumor-positive inguinal and/or iliac/obturator nodes, 68 had a node of Cloquet identified during pathologic review of the lymphadenectomy specimen. Chart and computer database review of these 68 patients was undertaken to determine the association between the tumor status of Cloquet's node and that of deep pelvic nodes. Immunohistochemical analysis was performed on eight of 11 negative Cloquet's nodes in patients with positive iliac/obturator nodes. Paraffin blocks of the other three negative nodes of Cloquet were unavailable for immunohistochemistry, and they were excluded from analysis.

RESULTS

Tumor-positive deep nodes were identified in the lymphadenectomy specimen from 20 of 30 (67%) patients with a positive Cloquet's node and from eight of 35 (23%) patients with a negative Cloquet's node (P = 0.0019). Re-examination of these eight tumor-negative Cloquet's nodes using immunostaining with S-100 and HMB45 identified tumor in 3 nodes, increasing the sensitivity of Cloquet's node for predicting deep nodal metastases from 71% to 82%. The 6.8 odds ratio of positive iliac/obturator nodes given a positive node of Cloquet increased to 12.4 after immunohistochemical analysis. The positive and negative predictive values were also enhanced from 67% to 70% and 77% to 84%, respectively.

DISCUSSION

The tumor status of the node of Cloquet significantly reflects the tumor status of the iliac/obturator nodes, particularly when Cloquet's node is examined by immunohistochemical analysis. The node of Cloquet assumes the role of the sentinel node in patients whose superficial inguinal lymph nodes drain through Cloquet's node to the iliac/obturator nodes.

Functional interleukin 4 receptor and interleukin 2 receptor common gamma-chain on human non-small cell lung cancers: novel targets for immune therapy

OBJECTIVE

The interleukin 4 receptor has been demonstrated on the surface of human non-small cell lung carcinoma cell lines and tumor specimens. Interleukin 4 causes G1-phase cell-cycle arrest of non-small cell lung cancer cell lines expressing the interleukin 4 receptor; the effect directly correlates with the expression of the interleukin 4 receptor and is seen within 48 hours after treatment. We examined signal transduction pathways used by the interleukin 4 receptor that may account for growth arrest of the cell line LUst but had no effect on another non-small cell lung cancer cell line, SK-MES-1.

METHODS

Western blot analysis was performed on both LUst and SK-MES-1 cell lines cultured in the presence of interleukin 4 (500 U/mL). Cells were lysed, protein extracted, and electroblotted; blots were then probed with murine monoclonal antibodies to specific intracellular proteins.

RESULTS

Western blotting of the cell lines with antiphosphotyrosine antibody (4G10) demonstrated multiple (140 kd, 100-130 kd, and 65 kd) phosphoproteins seen only in the interleukin 4-treated LUst cell line and not observed in the SK-MES-1 cell lines. Immunoprecipitation and blotting of the LUst cell line with specific secondary antibodies demonstrated that the 140-kd phosphoprotein was the interleukin 4 receptor, the 130-kd phosphoprotein was Janus kinase 1, the 116-kd phosphoprotein was Janus kinase 3, and the 65-kd phosphoprotein was the interleukin 2 receptor gamma-chain. Specific binding was not observed in the non-small cell lung cancer cell line SK-MES-1, suggesting that a functional interleukin receptor gamma-chain was not present. Southern blotting with complementary DNA probes to interleukin 2 receptor gamma-chain confirmed the absence of this receptor on cell line SK-MES-1.

CONCLUSIONS

These results suggest that non-small cell lung cancer cells may express functional cytokine receptors, including the interleukin 2 receptor gamma-chain commonly found in association with the lymphocyte interleukin 2 receptor. These receptors may be novel targets for directing cytokine-based immune therapy.

Standardized probe-directed sentinel node dissection in melanoma

BACKGROUND

Radiopharmaceutical agents appear to improve the accuracy of sentinel node (SN) identification in patients with early-stage melanoma, but the optimal radiopharmaceutical agent and its timing from injection to surgery remain controversial. We undertook this investigation to examine the utility of 3 methods of intraoperative lymphatic mapping with radiopharmaceutical-directed sentinel lymphadenectomy (LM/SL). We suspected that concurrent injection of radiopharmaceutical and blue-dye would lead to the greatest success of SN identification.

METHODS

The study was composed of 247 consecutive patients who had American Joint Committee on Cancer stage I or II melanoma. Before LM/SL, all patients underwent cutaneous lymphoscintigraphy by 1 of 3 techniques: technetium 99m (Tc 99m) human serum albumin (HSA) injected at least 24 hours before LM/SL (124 patients), Tc 99m filtered sulfur colloid (SC) injected no more than 4 hours before LM/SL (same-day SC, 95 patients), or Tc 99m SC injected at least 18 hours before LM/SL (prior-day SC, 28 patients). At the time of LM/SL, isosulfan blue dye was injected alone (SC groups) or with a second dose of HSA (HSA group). A hand-held gamma probe was used to determine the radioactive (hot) counts of blue-stained and nonstained nodes, and the in vivo and ex vivo node-to-background count ratios of the nodes were compared.

RESULTS

Preoperative LS identified 299 drainage basins; LM/SL identified at least 1 SN in 119 (98%) of 121 basins using same-day SC, 142 (97%) of 146 basins using HSA, and 32 (100%) of 32 basins using prior-day SC. There was no difference (P = .62) in the accuracy rate between the 3 techniques. The total number of SNs was 463. Same-day SC yielded higher intraoperative node-to-background count ratios than did either of the other techniques (P < .0001). Same-day SC also had the greatest relative change in radioactivity between the blue sentinel node and the post-excision basin (P < .0001), and the highest rate of SNs that were both blue and hot (in vivo or ex vivo ratio > or = 2, P = .05).

CONCLUSIONS

LS and LM/SL performed on the same day with a single injection of filtered Tc 99m SC serves as the most useful method for probe-directed LM/SL. This technique demonstrated the highest in vivo and ex vivo count ratios, fall-off of radioactivity between the excised nodes and post-excision basin, and concordance between blue dye and hot nodes. It should be recommended as the method of choice for probe-directed LM/SL.

Function of a minus-end-directed kinesin-like motor protein in mammalian cells

CHO2 is a mammalian minus-end-directed kinesin-like motor protein present in interphase centrosomes/nuclei and mitotic spindle fibers/poles. Expression of HA- or GFP-tagged subfragments in transfected CHO cells revealed the presence of the nuclear localization site at the N-terminal tail. This domain becomes associated with spindle fibers during mitosis, indicating that the tail is capable of interaction with microtubules in vivo. While the central stalk diffusely distributes in the entire cytoplasm of cells, the motor domain co-localizes with microtubules throughout the cell cycle, which is eliminated by mutation of the ATP-binding consensus motif from GKT to AAA. Overexpression of the full-length CHO2 causes mitotic arrest and spindle abnormality. The effect of protein expression was first seen around the polar region where microtubule tended to be bundled together. A higher level of protein expression induces more elongated spindles which eventually become disorganized by loosing the structural integrity between microtubule bundles. Live cell observation demonstrated that GFP-labeled microtubule bundles underwent continuous changes in their relative position to one another through repeated attachment and detachment at one end; this results in the formation of irregular number of microtubule focal points in mitotic arrested cells. Thus the primary action of CHO2 appears to cross-link microtubules and move toward the minus-end direction to maintain association of the microtubule end at the pole. In contrast to the full-length of CHO2, overexpression of neither truncated nor mutant polypeptides resulted in significant effects on mitosis and mitotic spindles, suggesting that the function of CHO2 in mammalian cells may be redundant with other motor molecules during cell division.

Long-term survival after complete resection of melanoma metastatic to the adrenal gland

BACKGROUND

Survival of patients with American Joint Committee on Cancer stage IV melanoma is generally poor, although there are occasional long-term survivors who have undergone surgical resection of a limited number of metastases. In the study, we examined the outcome of patients with adrenal gland metastases.

METHODS

Eighty-three patients with adrenal metastases were identified from our computerized melanoma database of 8250 patients. Univariate and multivariate analyses for overall survival differences were performed by using proportional hazards modeling.

RESULTS

Median survival for the 83 patients was 9.3 months (1-67 months). Of the 27 patients who underwent surgical exploration, 18 (66%) were rendered clinically free of disease by adrenalectomy alone (12 cases) or by adrenalectomy and resection of additional disease (6 cases). Nine patients underwent palliative adrenal resection. Median survival was 25.7 months after complete resection compared with 9.2 months after palliative resection (P = .02).

CONCLUSIONS

Patients with adrenal metastases from melanoma, either isolated or with a limited number of additional metastases, may benefit from surgical resection if all visible disease can be removed. Patients with unresectable extra-adrenal disease achieve no survival benefit from adrenalectomy.

Prognostic significance of occult metastases detected by sentinel lymphadenectomy and reverse transcriptase-polymerase chain reaction in early-stage melanoma patients

PURPOSE

Detection of micrometastases in the regional tumor-draining lymph nodes is critical for accurate staging and prognosis in melanoma patients. We hypothesized that a multiple-mRNA marker (MM) reverse transcriptase-polymerase chain reaction (RT-PCR) assay would improve the detection of occult metastases in the sentinel node (SN), compared with hematoxylin and eosin (H&E) staining and immunohistochemistry (IHC), and that MM expression is predictive of disease relapse.

PATIENTS AND METHODS

Seventy-two consecutive patients with clinical early-stage melanoma underwent sentinel lymphadenectomy (SLND). Their SNs were serially sectioned and assessed for MAGE-3, MART-1, and tyrosinase mRNA expression by RT-PCR, in parallel with H&E staining and IHC, for melanoma metastases. MM expression in the SNs was correlated with H&E and IHC assay results, standard prognostic factors, and disease-free survival.

RESULTS

In 17 patients with H&E- and/or IHC-positive SNs, 16 (94%) expressed two or more mRNA markers. Twenty (36%) of 55 patients with histopathologically negative SNs expressed two or more mRNA markers. By multivariate analysis, patients at increased risk of metastases to the SN had thicker lesions (P =.03), were 60 years of age or younger (P <.05), and/or were MM-positive (P <.001). Patients with histopathologically melanoma-free SNs who were MM-positive, compared with those who were positive for one or fewer mRNA markers, were at increased risk of recurrence (P =.02). Patients who were MM-positive with histopathologically proven metastases in the SN were at greatest risk of disease relapse (P =. 01).

CONCLUSION

H&E staining and IHC underestimate the true incidence of melanoma metastases. MM expression in the SN more accurately reflects melanoma micrometastases and is also a more powerful predictor of disease relapse than are H&E staining and IHC alone.

Validation of the accuracy of intraoperative lymphatic mapping and sentinel lymphadenectomy for early-stage melanoma: a multicenter trial. Multicenter Selective Lymphadenectomy Trial Group

OBJECTIVE

To evaluate the multicenter application of intraoperative lymphatic mapping, sentinel lymphadenectomy, and selective complete lymph node dissection (LM/SL/SCLND) for the management of early-stage melanoma.

SUMMARY BACKGROUND DATA

The multidisciplinary technique of LM/SL/SCLND has been widely adopted, but not validated in a multicenter trial. The authors began the international Multicenter Selective Lymphadenectomy Trial (MSLT) 5 years ago to evaluate the survival of patients with early-stage primary melanoma after wide excision alone versus wide excision plus LM/SL/SCLND. This study examined the accuracy of LM/SL/SCLND in the MSLT, using the experience of the organizing center (John Wayne Cancer Institute [JWCI]) as a standard for comparison.

METHODS

Before entering patients into the randomization phase, each center in the MSLT was required to finish a 30-case learning phase with complete nuclear medicine, pathology, and surgical review. Selection of MSLT patients in the LM/SL/SCLND treatment arm was based on complete pathologic and surgical data. The comparison group of JWCI patients was selected using these criteria: primary cutaneous melanoma having a thickness > or =1 mm with a Clark level > or =III, or a thickness <1 mm with a Clark level > or =IV (MSLT criterion); LM/SL performed between June 1, 1985, and December 30, 1998; and patient not entered in the MSLT. The accuracy of LM/SL/SCLND was determined by comparing the rates of sentinel node (SN) identification and the incidence of SN metastases in the MSLT and JWCI groups.

RESULTS

There were 551 patients in the MSLT group and 584 patients in the JWCI group. In both groups, LM performed with blue dye plus a radiocolloid was more successful (99.1 %) than LM performed with blue dye alone (95.2%) (p = 0.014). After a center had completed the 30-case learning phase, the success of SN identification in the MSLT group was independent of the center's case volume or experience in the MSLT.

CONCLUSIONS

Lymphatic mapping and sentinel lymphadenectomy can be successfully learned and applied in a standardized fashion with high accuracy by centers worldwide. Successful SN identification rates of 97% can be achieved, and the incidence of nodal metastases approaches that of the organizing center. A multidisciplinary approach (surgery, nuclear medicine, and pathology) and a learning phase of > or =30 consecutive cases per center are sufficient for mastery of LM/SL in cutaneous melanoma. Lymphatic mapping performed using blue dye plus radiocolloid is superior to LM using blue dye alone.

Advantages of concurrent biochemotherapy modified by decrescendo interleukin-2, granulocyte colony-stimulating factor, and tamoxifen for patients with metastatic melanoma

PURPOSE

Concurrent biochemotherapy results in high response rates but also significant toxicity in patients with metastatic melanoma. We attempted to improve its efficacy and decrease its toxicity by using decrescendo dosing of interleukin-2 (IL-2), posttreatment granulocyte colony-stimulating factor (G-CSF), and low-dose tamoxifen.

PATIENTS AND METHODS

Forty-five patients with poor prognosis metastatic melanoma were treated at a community hospital inpatient oncology unit affiliated with the John Wayne Cancer Institute (Santa Monica, CA) between July 1995 and September 1997. A 5-day modified concurrent biochemotherapy regimen of dacarbazine, vinblastine, cisplatin, decrescendo IL-2, interferon alfa-2b, and tamoxifen was repeated at 21-day intervals. G-CSF was administered beginning on day 6 for 7 to 10 days.

RESULTS

The overall response rate was 57% (95% confidence interval, 42% to 72%), the complete response rate was 23%, and the partial response rate was 34%. Complete remissions were achieved in an additional 11% of patients by surgical resection of residual disease after biochemotherapy. The median time to progression was 6.3 months and the median duration of survival was 11.4 months. At a maximum follow-up of 36 months (range, 10 to 36 months), 32% of patients are alive and 14% remain free of disease. Decrescendo IL-2 dosing and administration of G-CSF seemed to reduce toxicity, length of hospital stay, and readmission rates. No patient required intensive care unit monitoring, and there were no treatment-related deaths.

CONCLUSION

The data from this study indicate that the modified concurrent biochemotherapy regimen reduces the toxicity of concurrent biochemotherapy with no apparent decrease in response rate in patients with poor prognosis metastatic melanoma.

Lymphatic mapping and sentinel lymphadenectomy after wide local excision of primary melanoma

BACKGROUND

Lymphatic mapping and sentinel lymphadenectomy (LM/SL) are generally avoided in patients who have already undergone wide local excision (WLE) of a primary melanoma, because of concern that disruption of the cutaneous lymphatics might alter lymphatic flow to the sentinel node. We reviewed carefully chosen patients who had undergone LM/SL after WLE to identify circumstances that might make this approach otherwise safe and clinically accurate.

STUDY DESIGN

From our melanoma database of 8,300 patients, of whom 1,015 had undergone LM/SL, we retrospectively identified 47 patients who had previously undergone WLE. Patient and tumor characteristics were collected and compared with followup data from clinic files.

RESULTS

Median WLE surgical margins before LM/SL were 2.0 cm and most patients had extremity lesions. Eleven of the 47 patients (23%) had tumor-involved sentinel nodes, and 8 of these patients (73%) had a solitary nodal metastasis. With a median followup period of 36 months, 3 sentinel node-negative patients developed nodal recurrences. Two of these patients had positive sentinel nodes on pathology re-review and were not considered failures of the lymphatic mapping surgical procedure. The third patient developed in-transit metastases and delayed nodal recurrence. An additional patient, who had a primary tumor on the trunk, developed a nodal recurrence in the basin opposite that identified by lymphoscintigraphy. The overall error rate of the technique was 4 in 36 (11%). This included 2 pathology misdiagnoses (5.6%), 1 nodal recurrence associated with in-transit regional metastases (2.8%), and 1 lymphatic mapping error (2.8%).

CONCLUSIONS

LM/SL can be cautiously performed in patients who have undergone previous WLE if the primary resection margin was no greater than 2.0 cm and the primary was not in a region of ambiguous drainage. Lymphatic mapping may be inaccurate when melanomas have been resected with large margins, especially if the wound was closed with rotation flaps, and when melanomas are on the head and neck or trunk regions.

Efficacy of lymphatic mapping, sentinel lymphadenectomy, and selective complete lymph node dissection as a therapeutic procedure for early-stage melanoma

BACKGROUND

Lymphatic mapping, sentinel lymphadenectomy, and selective complete lymph node dissection (LM/SL/SCLND) is an increasingly popular alternative to elective lymphadenectomy (ELND) for patients with early-stage melanoma. Although several reports have demonstrated the accuracy of the LM/SL technique, there are no data on its therapeutic value.

METHODS

We performed a matched-pair statistical analysis of 534 patients with clinical stage I melanoma; one half of the patients were treated with LM/SL and the other half were treated with ELND. Patients in the two treatment groups were matched for age (54% were < or =50 years of age), gender (63% were male patients), site of the primary melanoma (49% were on the extremities, 36% on the trunk, and 15% on the head and neck), and thickness of the primary melanoma (7% were < 0.75 mm, 42% between 0.75 and 1.5 mm, 43% between 1.51 and 4.0 mm, and 8% > 4 mm). Patients in the LM/SL group underwent complete regional lymphadenectomy (SCLND) only if the LM/SL specimen contained metastatic melanoma.

RESULTS

The overall incidences of nodal metastases were no different (P = .18) between LM/SL (15.7%) and ELND (12%) groups, but the incidence of occult nodal disease was significantly (P = .025) higher among patients with intermediate-thickness (1.51-4.0-mm) primary tumors who underwent LM/SL (23.7%) instead of ELND (12.2%). Survival data were compared by the log-rank score test. LM/SL/SCLND and ELND resulted in equivalent 5-year rates of disease-free survival (79 +/- 3.3% and 84 +/- 2.2%, respectively; P = .25) and overall survival (88 +/- 3.0% and 86 +/- 2.1%, respectively; P = .98). The LM/SL and ELND groups also exhibited similar incidences of same-basin recurrences (4.8% vs. 2.1%, P = .10, respectively) and in-transit metastases (2.6% vs. 3.8%, P = .48) after tumor-negative dissections. Patients who underwent ELND showed a higher incidence of distant recurrences (8.9% vs. 4.0%, P = .03), but this may be related to the longer follow-up period for these patients (median, 169 months), compared with the LM/SL-treated patients (45 months). Among patients with tumor-positive nodal dissections, the 5-year overall survival rates were higher, and approached significance (P = .077) for patients treated by LM/SL/SCLND (64 +/- 12%) compared with ELND (45 +/- 10%).

CONCLUSIONS

These findings suggest that LM/SL/SCLND is therapeutically equivalent to ELND but may be more effective for identifying nodal metastases in patients with intermediate-thickness primary tumors.

Active specific immunotherapy with polyvalent melanoma cell vaccine for patients with in-transit melanoma metastases

BACKGROUND

This study was conducted to document the rate, duration, and type of objective response to active specific immunotherapy with a polyvalent melanoma cell vaccine (PMCV) for patients with in-transit melanoma metastases and to identify any acute or chronic toxic effects of PMCV treatment.

METHODS

An analysis was conducted of all in-transit melanoma patients seen at the John Wayne Cancer Institute in Santa Monica, California, during the period 1985-1997 who were enrolled in prospective PMCV protocols in the absence of other therapies with possible antitumor activity (n = 54). Clinical response to PMCV was assessed by standard criteria. Survival curves were estimated by the Kaplan-Meier method. Toxicity was graded according to the Eastern Cooperative Oncology Group standard.

RESULTS

PMCV produced a 17% (9 of 54 patients) objective response rate with a 13% rate (7 of 54 patients) of complete remission (CR). The median duration of CR was >22 months. Complete response lasting more than 1 year was observed in 4 patients (7.2%); 1 patient remained in remission over 9 years. Median survival was >53 months (i.e., not reached) for responders, 42 months for nonresponders, and 53 months overall. Salvage interventions allowed reinduction with PMCV in 23 of 25 patients, who subsequently remained clinically free of disease for a median of 14 months. Overall toxicity was mild, easily tolerable, and did not significantly change the quality of life. There were no toxic deaths.

CONCLUSIONS

PMCV can cause objective complete regression of measurable intransit metastatic melanoma with minimal toxicity, and may prolong patients' median survival.

Parotid region lymphatic mapping and sentinel lymphadenectomy for cutaneous melanoma

BACKGROUND

Routine elective superficial parotidectomy for patients with primary cutaneous melanomas of the scalp, auricle, or face has been questioned. We evaluated an alternative, i.e., lymphatic mapping and sentinel lymphadenectomy, for patients with primary cutaneous melanomas draining to the region of the parotid gland.

PATIENTS

Retrospective review of our large (>8000 patients) melanoma database identified 39 patients with primary melanomas (American Joint Committee on Cancer stage I or II) of the scalp (n = 19), auricle (n = 11), or face (n = 9) who underwent intraoperative lymphatic mapping to identify a sentinel node (SN) in the region of the parotid gland, between June 1985 and July 1997.

RESULTS

A SN was identified in the parotid region of 37 patients (94.9%), four of whom had SN metastases. The mean number of SN obtained was 2.3/patient (range, 1-4/patient). The two patients (5.1%) for whom a parotid-region SN could not be identified underwent superficial parotidectomy during the same operation. Among the 33 patients with tumor-free SN, with a median follow-up period of 33.2 months (range, 1-121 months), there was one (3.1%) intraparotid recurrence; thus, the false-negative rate was 3.1%. The procedure-related surgical morbidity rate was only 2.6% (one case of temporary facial nerve paresis).

CONCLUSIONS

For patients with primary melanomas of the scalp, auricle, or face, sentinel lymphadenectomy can be performed accurately in the parotid region and offers a low-morbidity alternative to routine elective superficial parotidectomy.

Cytoreductive surgery and adjuvant immunotherapy: a new management paradigm for metastatic melanoma

Although patients with metastatic disease are usually not offered surgery as part of their comprehensive treatment plan, the authors suggest that surgical reduction of the tumor burden may enhance the host immune response and create a favorable setting for the use of active specific immunotherapy.

Comparison of blue dye and probe-assisted intraoperative lymphatic mapping in melanoma to identify sentinel nodes in 100 lymphatic basins

OBJECTIVE

To determine whether combining isosulfan blue dye with a radiopharmaceutical agent will increase intraoperative detection of sentinel nodes (SNs) in patients with early-stage melanoma.

PATIENTS AND DESIGN

Clinical trial with a consecutive sample. Eighty-seven patients with clinical stage I melanoma underwent preoperative lymphoscintigraphy with 1 of 3 radiopharmaceutical agents to identify the lymphatic basin and the site of the SN. All patients subsequently underwent intraoperative lymphatic mapping and selective lymph node dissection (SLND) with isosulfan blue dye and a radiopharmaceutical agent. A handheld gamma probe determined the radioactive counts over the draining lymph node basins and individual blue-stained lymph nodes before (in vivo) and after (ex vivo) their removal. An irrelevant body site was used as the denominator of a count ratio by which absolute counts were standardized for comparison. Completion lymphadenectomy was undertaken in patients whose SLND specimen had histopathologic evidence of tumor cells.

SETTING

Tertiary care cancer center.

INTERVENTION

Lymph node sampling.

MAIN OUTCOME MEASURE

Accuracy of SN detection by blue dye and radiopharmaceutical techniques.

RESULTS

Preoperative lymphoscintigraphic images identified 100 lymph node basins and 135 lymph nodes in 87 patients. All 3 radiopharmaceutical agents were equally effective in imaging the SN before surgery. During SLND, we identified and removed 136 blue-stained and radioactive (hot) SNs and 8 additional non-blue-stained hot nodes from 98 basins (98.0%). Of the 144 excised lymph nodes, 132 nodes (91.7%) from 83 basins had either an in vivo- or an ex vivo-background count ratio of 2:1 or more and 125 nodes (86.8%) from 77 basins had a count ratio of 3:1 or more. Twelve blue-stained SNs had count ratios of less than 2:1. Seventeen SNs (11.8%) from 15 basins contained metastases: 16 were identified with blue dye and probe and 1 was identified with blue dye alone. Four (1.1%) of 377 non-SNs excised during completion lymphadenectomy contained metastases. There have been no lymph node recurrences during mean follow-up of 16.3 months (range, 7-42 months).

CONCLUSIONS

The blue dye technique remains the criterion standard for SLND in melanoma. The addition of a radiopharmaceutical tracer serves as a useful adjunct to the visualization of blue-stained SNs.

Gamma knife radiosurgery for metastatic melanoma: an analysis of survival, outcome, and complications

OBJECTIVE

Although the mainstays for treatment of metastatic brain disease have been surgery and/or external beam radiation therapy, an increasing number of patients are being referred for stereotactic radiosurgery as the primary intervention for their intracranial pathological abnormalities. The lack of efficacy and cognitive and behavioral consequences of whole brain irradiation have prompted clinicians to select patients for alternative therapies. This study analyzes the effectiveness of Leksell gamma unit therapy for metastatic melanoma to the brain.

METHODS

We present our experience with 59 Leksell gamma unit treatment sessions in 45 consecutive patients who presented with metastatic melanoma to the brain. Five of these procedures were performed as salvage therapy for patients who needed second radiosurgical treatment for new lesions that were remote from the previous targets and were not included in the overall analyses.

RESULTS

The population included 78% male patients. The mean patient age was 53 years (age range, 24-80 yr). The mean time from diagnosis of primary melanoma to discovery of brain metastasis was 43 months (median, 27.5 mo; range, 1-180 mo). At the time of diagnosis of brain disease, 35.5% of the patients (16 of 45 patients) had neurological symptoms, 77.7% (35 of 45 patients) had known visceral metastases, and 11.1% (5 of 45 patients) had seizure disorders. Eighty-six percent of the lesions (80 of 93 lesions) were cortical, 12% (11 of 93 lesions) were cerebellar, 1% (1 of 93 lesions) were pontine, and 1% (1 of 93 lesions) were thalamic. Fifty-seven percent of the sessions (31 of 54 sessions) were performed for a single lesion, 24.1% (13 of 54 sessions) for two lesions, 9.2% (5 of 54 sessions) for three lesions, 7.4% (4 of 54 sessions) for four lesions, and 1.8% (1 of 54 sessions) for five lesions. The mean treatment volume was 5.6 cc, with a mean prescription of 21.6 Gy to the 56.0% mean isodose line. The median survival time of the patients in our population, using Kaplan-Meier curves, was 43 months from the time of diagnosis of primary melanoma (range, 3-180 mo) and 8 months (range, 1-20 mo) from the time of gamma knife treatment. Complications included seizures within 24 hours of the procedure in four patients, with transient nausea and vomiting in three patients, transient worsening of preprocedure paresis responsive to steroids in three patients, and increased confusion in one patient. All 45 patients were located for follow-up (mean follow-up duration, 1 yr). After gamma knife treatment, 78% of the patients (35 of 45 patients) experienced either improved or stable neurological symptomatology before death or at the time of the latest follow-up examination. There were 26 deaths (58%). The cause of death was determined to be neurological in only 2 of 45 patients (7.7%). Follow-up magnetic resonance images revealed a 97% local tumor control rate of gamma knife-treated lesions, with 28% radiographic disappearance (9 of 32 cases). Six patients developed new lesions remote from radiosurgical targets and underwent second procedures.

CONCLUSION

Although metastatic melanoma to the brain continues to have a foreboding prognosis for long-term survival, gamma knife radiosurgery seems to be a relatively safe, noninvasive, palliative therapy, halting or reversing neurological progression in 77.8% of treated patients (35 of 45 patients). The survival rate matches or exceeds those previously reported for surgery and other forms of radiotherapy. Only 7.7% of the patients in our study population who died as a result of metastatic melanoma (2 of 26 patients) died as a result of neurological disease. The routine use of therapeutic level antiseizure medication is emphasized, considering the findings of our review.

Sentinel node localization in breast cancer

The status of the axillary nodes is the strongest known prognostic variable in patients with early breast cancer, and is routinely used in planning postoperative therapy. Conventional axillary lymph node dissection is limited by sampling error and potential morbidity. Sentinel node techniques have revolutionized the management of axillary nodes. Accurate identification and focused histologic evaluation of the sentinel node allow accurate prediction of the tumor status of other axillary nodes, thereby avoiding the morbidity and expense of a complete axillary dissection in node-negative patients. Radiotracer techniques play an important role in the preoperative and intraoperative localization of the sentinel nodes. Optimal localization of the sentinel node requires the use of both preoperative lymphoscintigraphy and intraoperative radiosensitive probes. Lymphoscintigraphy also identifies patients with lymphatic drainage to sites other than the axilla, thereby allowing more appropriate treatment and follow-up in this subset of patients. Procedures for localizing sentinel nodes require an understanding of the kinetics of the radiopharmaceuticals or other tracers used and the detection devices employed in each institution. Both surgical and nuclear medicine personnel should understand these principles, and close cooperation between surgeons, nuclear medicine physicians, and pathologists is essential for the application of sentinel node techniques.