Should the Hunt for Internal Mammary Chain Sentinel Nodes Begin? An Evaluation of 150 Breast Cancer Patients

Background: The aim of this study was to determine the visualization rate, identification rate, and clinical implications of biopsy of sentinel nodes in the internal mammary chain (IMC) in patients with breast cancer.Methods: From January 1999 to December 2002, 691 sentinel node procedures were performed. Preoperative lymphoscintigraphy was performed after injection of ^99mTc-labeled nanocolloid into the tumor (.2 mL; 115 MBq; 3.1 mCi). The sentinel node was surgically identified with the aid of patent blue dye and a gamma ray detection probe.Results: The sentinel node in the IMC could be harvested in 130 (87%) of the 150 patients in whom it was visualized on the images and contained metastases in 22 (17%) of these 130 cases. In nine patients (7%), the IMC sentinel node was tumor positive, whereas the axilla was tumor-free. Stage migration was seen in all patients with a tumor-positive IMC sentinel node (17%). There was a change of management in 38 (29%) of the 130 patients: institution or omission of radiotherapy to the IMC, adjuvant systemic therapy, or omission of an axillary lymph node dissection.Conclusions: Pursuit of IMC sentinel nodes improves the staging of patients with breast cancer and enables treatment to be better adjusted to the needs of the individual patient.     

Safety and efficacy of isolated limb perfusion in elderly melanoma patients

Background Older patients are assumed to have a higher risk of complications from isolated limb perfusion (ILP). A study was performed evaluating the safety and efficacy of ILP in patients older than 75 years with advanced melanoma of the limbs. Methods A total of 218 therapeutic ILPs with melphalan with or without tumor necrosis factor α were performed in 202 patients with advanced measurable melanoma and were analyzed retrospectively. Fifty-three patients (28%) were 75 years or older. Results Complete response rates were 56% for those older than 75 years and 58% for the younger group (P=.79). Locoregional relapse occurred in 56% of the older group versus 51% in the younger group (P=.61). Limb toxicity, systemic toxicity, local complications, and long-term morbidity were similar in both age groups. Perioperative mortality was low, with one procedure-related death in the older group. Older patients stayed in the hospital for a median of 23 days (younger patients, 19 days;P<.01). Conclusions ILP results in similar response rates in the elderly with recurrent melanoma, without increased toxicity, complications, or long-term morbidity compared with younger patients. Older age in itself is not a contraindication for ILP.     

Dynamic sentinel node biopsy for penile cancer: reliability of a staging technique

PURPOSE: We determine the value of dynamic sentinel node biopsy for staging squamous cell carcinoma of the penis. MATERIALS AND METHODS: A total of 90 patients with clinically node negative penile cancer were prospectively entered in this study. Preoperative lymphoscintigraphy was performed after intradermal injection of 99mtechnetium nanocolloid around the primary tumor. The sentinel node was intraoperatively identified with the aid of intradermal administered patent blue dye and a gamma ray detection probe. Histopathological examination of sentinel nodes included serial sectioning and immunohistochemical staining. Regional lymph node dissection was performed only if metastasis was found in a sentinel node. Median followup was 36 months (range 5 to 95). RESULTS: Lymphoscintigraphy visualized 217 sentinel nodes in 159 inguinal regions of 88 patients. A total of 208 sentinel nodes were intraoperatively identified in 149 inguinal regions of 88 patients. Sentinel node metastasis was found in 19 inguinal regions of 18 patients. Four of 8 patients with unilateral clinical stage N1 disease had a tumor positive sentinel node on the opposite site. Regional recurrence after excision of a tumor negative sentinel node or after nonvisualization was seen in 5 patients, resulting in a false-negative rate of 22% (5 of 23). The 3-year disease specific survival was 98% and 71% for patients with a tumor negative or tumor positive sentinel node, respectively (p = 0.0018). CONCLUSIONS: Occult lymph node metastases in penile cancer can be detected with a sensitivity of about 80% by dynamic sentinel node biopsy, including preoperative lymphoscintigraphy, vital dye and a gamma ray detection probe.     

The hidden sentinel node in breast cancer

The purpose of this study was to analyse the occurrence of non-visualisation during preoperative lymphoscintigraphy for sentinel node identification in breast cancer. Preoperative lymphoscintigraphy was performed in 495 clinically node-negative breast cancer patients (501 sentinel node procedures) after injection of technetium-99m nanocolloid. Anterior and prone lateral (hanging breast) planar images were obtained a few minutes and 4 h after injection. The sentinel node was intraoperatively identified with the aid of patent blue dye and a gamma-ray detection probe. A sentinel node was visualised on the 4-h images in 449 of 501 procedures (90%). This visualisation rate improved from 76% to 94% during the study period. Delayed imaging (5-23 h) in 19 patients whose sentinel nodes failed to show, resulted in visualisation in four of them. A repeat injection of radiocolloid in 11 patients revealed a sentinel node in six. In the end, the visualisation rate was 92%. The sentinel node was surgically retrieved in 24 of the remaining 42 patients with non-visualisation (57%). Sentinel nodes that were visualised were tumour-positive in 38% and non-visualised sentinel nodes were involved in 50% (chi2, P=0.17). In a multivariate regression analysis, scintigraphic non-visualisation was independently associated with increased patient age (P<0.001), decreased tracer dose (P<0.001) and increased number of tumour-positive lymph nodes (P=0.013). The use of a sufficient amount of radioactivity (at least 100 MBq) is recommended for lymphatic mapping in breast cancer, especially in elderly women. Delayed imaging and re-injection of the radioactive tracer increase the visualisation rate. The non-visualised sentinel node can be identified intraoperatively in more than half of the patients.     

Repeat dynamic sentinel node biopsy in locally recurrent penile carcinoma

Study Type – Diagnosis (case series)
Level of Evidence 4

OBJECTIVE

To explore the role of repeat dynamic sentinel‐node biopsy (SNB) in clinically node‐negative patients with locally recurrent penile carcinoma after previous penile surgery and SNB.

PATIENTS AND METHODS

Between 1994 and 2008, 12 patients (4% of the 304 in our prospectively maintained dynamic sentinel node database) with clinically node‐negative groins had a repeat SNB for locally recurrent penile carcinoma after previous penile surgery and SNB. Five of these patients had previously had a unilateral inguinal node dissection for groin metastases. The median disease‐free interval was 18 months. The protocol and technique of primary dynamic SNB and the repeat procedure were similar, including preoperative lymphoscintigraphy and blue‐dye injection. Completion inguinal node dissection was only done if there was an involved sentinel node.

RESULTS

No sentinel nodes were seen on preoperative lymphoscintigraphy in the five groins that had previously been dissected. A sentinel node was visualized on lymphoscintigraphy in the remaining 19 undissected groins. In 15 of these groins (79%) the sentinel node was identified during surgery. Histopathological analysis showed involved sentinel nodes in four groins of three patients. Additional metastatic nodes were found in one completion inguinal lymph node dissection specimen. During a median follow‐up of 32 months after the repeat SNB, one patient developed a groin recurrence 14 months after a tumour‐negative sentinel node procedure.

CONCLUSIONS

Repeat dynamic SNB is feasible in clinically node‐negative patients with locally recurrent penile carcinoma despite previous SNB.     

The value of prognostic indices in aplastic anaemia

Summary In 43 patients with aplastic anaemia we assessed the accuracy of different prognostic systems. Patients dying within 6 months after diagnosis were correctly predicted in 60% of cases with the Lynch-index with a sensitivity of 82%. With the Najean-index 40% of these patients are correctly predicted, this index has a sensitivity of 100%. More accurate are the prognostic criteria proposed by Camitta et al [5]. With these criteria, this rapidly fatal group is correctly predicted in 85% of the patients, indicating that 15% Of the patients are incorrectly predicted to have a limited survival. The sensitivity, however, is 100%. The Lohrmann-index, based on reticulocyte count predicts 64% of this group with severe aplasia.None of these prognostic systems do accurately predict long survival. We suggest that the best differentiation between patients with a long-term prognosis (more than 5 years) and patients who die from aplastic anaemia within 5 years, is made by re-evaluating the leucocyte and platelet count 3 months after the initial diagnosis. Decrease in blood counts (over 10%) predicts death from aplastic anaemia within 5 years correctly in all patients; stable or increased blood counts predict long survival in 75% of the patients.