Feasibility and technical problems of sentinel node analysis in melanoma

BACKGROUND: Development of the sentinel lymph node (SLN) biopsy the last 10 years has changed surgical approach of solid tumor treatment and particularly of melanoma. The aim of our study was to analyze in our hospital, the feasibility of the SLN biopsy technique in order to define a better prognostic classification of melanomas. PATIENTS AND METHODS: Between July 1999 and October 2003, 97 patients were included in this study in our center. Criteria for inclusion were cutaneo-mucosal melanoma of Breslow >or=1,5 mm, and/or Clarck >or=IV, and/or ulceration, and/or signs of regression, before any surgical margins. RESULTS: Lymphoscintigraphy (LS) identified at least 1 SLN in 94 cases/97 (97%), thus permitting intraoperative SLN mapping and sentinel node biopsy of at least 1 lymph node in 88 cases/94 (94%). Failure of the SLN procedure was noted in 9 cases: in 3 cases, no lymph node was individualized by LS, in 1 patient, intraoperative SLN mapping failed to find the previously identified SLN and in 5 cases, a SLN was identified by LS and intraoperative mapping but could not be removed because of its deep location and difficulty of dissection. In 17 patients, removal of one or two "non sentinel lymph node(s)" was (were) made by the surgeon because of its (their) suspected aspect (black or large). Among the 88 patients who had dissection of at least 1 SLN, a micrometastasis was detected by standard histological evaluation and/or immunohistochemical stains in 14 cases (16%) and into a "non SLN" in 2 cases (2,3%). The median follow up of patients was 16 months (1- 48 months). Among the 14 patients with positive SLN, 6 (43%) relapsed. The other eight were in complete remission of their melanoma with a mean follow up of 11,44 months . Among the 74 patients with negative SLN, 7 (9,5%) developed a recurrence. Among the 9 patients in whom any sentinel lymph node have been removed, 3 had a relapse (one in transit than on lymph nodes, and two on lymph nodes). CONCLUSION: Our results are in accordance with the literature, and confirm the feasibility of SLN mapping and of SLN histological analysis in our center. We described in this study technical problems we encountered. Our study also show the prognostic value of this technique. However, advantage in global survey of sentinel node dissection and regional lymph node dissection in cases of micrometastases has still to be demonstrated.     

Evaluation of a method to reduce the number of sentinel nodes removed in melanoma patients: prospective study

INTRODUCTION: Since 1992, sentinel node (SLN) biopsy was generally applied to melanoma for carcinologic staging. Literature points out an increase of nodes removed for each procedure. It means to a high cost for this procedure and it wanders from the defining concept of SLN. The aim of our study was to evaluate whether, we can minimize number of SLN removed, without influencing the reliability of carcinologic staging. MATERIAL AND METHODS: We conducted a prospective study about 50 patients with stage one melanoma. For each patient, the SLN was identified with hand-held gamma probe technique. We removed only the hottest and all nodes greater than 70% of the hottest. We analysed the characteristics of melanoma, the success rate of this procedure, how many nodes have been removed and how many have had micro-metastases. This result was compared to two main studies with chi(2) test. RESULTS: The success rate of this technique was 100%. We dissected 1,3 SLN for each patient, with 22% positive SLN. Statistical analyse pointed out a better selectivity of our study, rate of pathological positivity and recurrence was alike. DISCUSSION: Our technique decreasing number of removed SLN is reliable. A minimal number of nodes doesn't distort sensitivity of carcinologic staging, and reduce cost of the procedure.     

Influence of the size and the localization of metastases in melanoma sentinel lymph nodes on the results of lymphadenectomy

AIM: Thirty-five cases of lymphadenectomy carried out in the context of positive sentinel lymph node for malignant melanoma have been reviewed to assess the prognostic value of certain metastatic charachteristics. We have checked wether the type (macro or micrometastasis) and localisation (subcapsular or intraparenchymal) in the sentinel lymph node had predictive value for the lymphadenectomy outcome and evolution of the case. MATERIAL AND METHODS: The retrospective study relates to 35 cases (with an average 2 years history) taken from a total of 87 sentinel lymph node protocols; average age 46.5 years, Breslow 2.5 mm with an history of 25 months. RESULTS: Among the 35 positive sentinel lymph nodes we have 19 cases (54.2%) of micrometastasis. Among the 35 lymphadenectomy 5 cases (14.28%) turned out positive, 3 of which concerned micrometastatic sentinel lymph nodes. In our cohort the micrometastatic nature of sentinel lymph nodes did not have statistically significant impact upon the lymphadenectomy result but showed more favourable short-term evolution with 68.42% metastatic free evolution as against 43.75% in case of initial macrometastasis. The subcapsular localisation of micrometastasis equally represents a factor of improved prognosis (69.2% of metastatic free evolution against of 30.8% in the case of intraparenchymal localistion). CONCLUSION: Unfortunately, none of the studied criteria justifies a modification of our present clinical attitude whereby a systematic lymphadenectomy in cases of positive sentinel lymph nodes is performed, whatever the type or localisation of the relevant metastases.     

Sentinel node biopsy site used as full thickness skin graft donor for cutaneous melanoma

BACKGROUND: Wound defects after wide local excision (WLE) for cutaneous melanoma can occasionally require the use of skin grafts for closure. Harvesting the skin graft can result in an additional wound. METHODS: The increasing use of sentinel lymph node (SLN) biopsy in cutaneous melanoma at our institution has facilitated the development of an alternative technique for obtaining donor skin. The proposed method utilizes the skin overlying the SLN as the skin graft donor site. Sixteen patients underwent WLE of intermediate to thick melanomas with SLN biopsy and full thickness skin graft harvested from the SLN biopsy site. RESULTS: After a median follow-up of 12 months, there were no graft failures. There were 2 partial graft losses. There were no wound complications. There were no melanoma recurrences. CONCLUSIONS: In cases where primary closure is not technically feasible or cosmetically favorable, the use of the SLN incision site as a skin graft donor provides the surgeon with an effective repair and spares the patient an additional skin graft donor site defect.     

Recurrence of a basal cell carcinoma in a skin graft in spite of total excision. A case report

The authors report an original case of a recurrence of basal cell carcinoma in a skin graft recipient site. The skin graft was used to resurface the defect following complete excision of basal cell carcinoma in the mandibular angle area. Three answers can be given to the question of the origin of that new carcinoma: recurrence of the primary carcinoma, metastasis to a lymph node or a transfer of a basal cell carcinoma located into the skin graft which grew further. This last hypothesis remains the most probable because the histology of the two carcinomas was different and that the patient presented many others locations of basal cell carcinomas. Skin grafted areas must be checked for recurrence of basal cell carcinoma in such patients because invisible basal cell carcinoma can be transferred within the graft where they can grow for their own.     

Sentinel lymph node procedure in uterine cancers: review of the literature

In cancer research, regional lymph node status is a major prognostic factor and a decision criterion for adjuvant therapy warranting the lymphadenectomy. The sentinel node procedure, which has emerged to reduce morbidity of extensive lymphadenectomy, remains a major step in the surgical management of various cancers. Sentinel node procedure has become a standard technique for the determination of the nodal stage of the disease in patients with melanoma, vulvar cancer and recently in breast cancer. In cervical and endometrial cancers, the sentinel node biopsy is still at the stage of feasibility. In this article, we review the technical aspects, results and clinical implications of sentinel node procedure in cervical and endometrial cancers.     

Patterns of recurrence after sentinel lymph node biopsy for cutaneous melanoma

BACKGROUND: Previous sentinel lymph node (SLN) studies for cutaneous melanoma have shown that the SLN accurately reflects the nodal status of the corresponding nodal basin. However, there are few long-term studies that describe recurrence site patterns, predictors for recurrence, and overall survival and disease-free survival after SLN biopsy. METHODS: A retrospective review of patients over a 6-year period was performed to determine patient outcomes and the patterns of recurrence. In all cases, Tc-99 sulfur colloid along with isosulfan blue dye was injected at the primary melanoma site. After resection, the SLN was serially sectioned and evaluated by hematoxylin and eosin staining and immunohistochemistry. RESULTS: One hundred ninety-eight patients were identified who underwent SLN biopsy for cutaneous melanoma including T1 (n = 21), T2 (n = 88), T3 (n = 75), and T4 (n = 14) primary tumors. Of these patients, 38 had a positive SLN. Of the 38 patients with a positive SLN (mean follow-up 38 months), recurrent disease was identified in 10 (26.3%) at a mean interval of 14.2 months. The site of first recurrence was distant (n = 4) and local (n = 6). Regional lymphatic basin recurrence was not identified. Of the 160 patients with a negative SLN (mean follow-up 50 months), recurrent disease was identified in 16 (10.0%) at a mean interval of 31.3 months. The site of first recurrence was systemic (n = 11), local (n = 4), and nodal (n = 1). Overall survival and disease-free survival for patients with a positive SLN at 55 months was 53.3% and 47.7% respectively, while overall survival and disease-free survival for patients with a negative SLN at 53 months was 92.2% and 87.7% respectively (P <0.01). Univariate and multivariate analysis of the entire cohort (n = 198) identified primary tumor depth and positive SLN status as significant predictors of recurrence. CONCLUSIONS: The incidence of nodal basin recurrence after SLN biopsy was found to be 0.6%. Primary tumor depth and pathological status of the SLN are significant predictors of local and systemic recurrence. Long-term follow-up indicates that patients with a positive SLN clearly recur sooner and have decreased overall survival than those with a negative SLN.     

Multivariate prognostic model for patients with thick cutaneous melanoma: importance of sentinel lymph node status

Background The overall prognosis of patients with thick cutaneous melanoma (TCM) is generally thought to be poor. Surgically staging these patients with sentinel lymph node (SLN) biopsy remains controversial. This study was performed to determine whether SLN status improved our ability to predict outcome over other known prognostic factors and to develop a model incorporating independent prognostic factors to estimate the risk of recurrence for an individual patient. Methods A prospective database identified patients with TCM (>4.0 mm or Clark level V) and clinically negative nodes who underwent SLN biopsy. Univariate and multivariate analyses were performed. Results From 1991 to 2001, 126 patients were identified; 75 (60%) were male. The median age was 60 years. The median tumor thickness was 5.5 mm, and 43% were ulcerated. Thirty percent of patients had a positive SLN. Recurrence was seen in 50 patients (40%). Median follow-up, relapse-free survival, and overall survival were 25, 50, and 68 months, respectively. Factors independently predictive of recurrence were age ≥60 years, depth >5.5 mm, ulceration, and SLN positivity. SLN status was the most significant prognostic factor (P< .001). The relative risk of recurrence for an individual patient ranged from 1 in patients for whom no adverse factors were present to 29.4 when all factors were present. Conclusions SLN status was the strongest independent predictor of outcome in patients with TCM. However, patients with TCM are prognostically heterogeneous, and all independently predictive factors should be considered when an individual patient’s risk of recurrence is assessed.     

One-stage versus two-stage lymph node dissection after investigation of sentinel lymph node in cutaneous melanoma: a comparison of complications, costs, hospitalization times, and operation times

The aim of the study was to evaluate whether complication rate, costs, operation times, and hospitalization times differed in two different patient groups: in group 1, frozen section analysis of the sentinel lymph node and lymph node dissection were carried out in the same operation. In group 2, normal investigation of the sentinel lymph node and lymph node dissection were done in a second operation. One hundred thirty-five patients with cutaneous melanoma were included. Hospitalization times, costs, complication rates, and operation times of two-stage and one-stage lymph node dissection of the draining area after detection of metastases in the sentinel lymph node were retrospectively compared. Lymph node metastasis in the sentinel lymph node was found in 23 patients. In 11 patients, removal of the sentinel lymph node and dissection of the lymph node basin was performed in the same operation. In 12 patients, a two-stage procedure was the treatment of choice. Operation times were not different in the two groups (p=0.87) while two-stage operation patients were hospitalized significantly longer (14.2 ± 9.7 vs 23.9 ± 24 days; p=0.01) and costs were significantly higher (7,836.90 ± 2,397.95 Swiss francs vs 5,279.40 ± 1,994.90 Swiss francs). In addition, more complications were found in the two-stage group.     

Regional differences in the use of sentinel lymph node biopsy for melanoma: a potential quality measure

Sentinel lymph node biopsy (SLNB) provides accurate nodal staging in patients with melanoma. However, its prevalence across geographic regions is unknown. Our aim was to determine if SLNB for melanoma has been widely adopted throughout the United States. All patients in the Surveillance, Epidemiology and End Results (SEER) cancer registry for 2004 with melanoma were evaluated. Data were collected for demographics, depth of melanoma, and type of nodal evaluation (regional lymph node dissection vs SLNB). Registry sites were categorized into West, Midwest, Northeast, and Southeast. Chi2 analysis was performed to identify regional differences in receipt of SLNB. Overall, the West region (n = 2352) had a higher use of SLNB compared with the Midwest (n = 497), Northeast (n = 630), and Southeast (n = 268) regions (82.1% vs 77.9%, 65.4%, and 60.1%, respectively; P < 0.001). Intermediate-thickness (1 to 4 mm) melanomas had differences in SLNB use between the West and Midwest (83.6% and 81.4%) versus the Northeast and Southeast (66.3% and 60.2%) (P < 0.05). This population-based analysis shows low use of SLNB for melanoma in some U.S. regions. Further studies need to address the reasons for these differences and target ways to improve rates. Results suggest that SLNB may be considered as a potential quality measure.