A Meta-analysis of the Prognostic Significance of Sentinel Lymph Node Status in Merkel Cell Carcinoma

BACKGROUND: Merkel cell carcinoma is an aggressive cutaneous neoplasm with a high propensity to metastasize to lymph nodes. OBJECTIVE: The objective of this study was to determine the prognostic significance of sentinel lymph node status in patients with Merkel cell carcinoma. METHODS: A meta-analysis of case series of patients with Merkel cell carcinoma managed with sentinel lymph node biopsy was performed. RESULTS: Forty of 60 patients (67%) had a biopsy-negative sentinel lymph node; 97% of this group had no recurrence at 7.3 months median follow-up. Twenty patients (33%) had a biopsy-positive sentinel lymph node; 33% of this group experienced local, regional, or systemic recurrence at 12 months median follow-up. Risk of recurrence or metastasis was 19-fold greater in biopsy-positive patients (odds ratio, 18.9; p = 0.005). None of 15 biopsy-positive patients who underwent therapeutic lymph node dissection experienced a regional recurrence; 3 of 4 who did not receive therapeutic lymphadenectomy experienced regional recurrence. CONCLUSION: Sentinel lymph node positivity is strongly predictive of a high short-term risk of recurrence or metastasis in patients with Merkel cell carcinoma. Therapeutic lymph node dissection appears effective in preventing short-term regional nodal recurrence. Aggressive adjuvant treatment should be considered for patients with positive sentinel lymph nodes.     

Lymphocytic Infiltrates and Subclinical Epithelial Tumor Extension in Patients With Chronic Leukemia and Solid-Organ Transplantation

BACKGROUND: Dense infiltrates in association with squamous cell carcinoma (SCC) or basal cell carcinoma (BCC) in patients with underlying chronic lymphocytic leukemia (CLL) may complicate pathologic interpretation of histologic margins. OBJECTIVE: The study was conducted to determine the frequency of identifying dense inflammatory infiltrates in frozen histologic sections during Mohs operation for BCC or SCC in patients with CLL and organ-transplant recipients, to characterize the infiltrate (reactive versus leukemic) in CLL, and to estimate the subclinical tumor extension in patients with CLL, transplant recipients, and control subjects undergoing Mohs procedure. METHODS: Frozen sections of head and neck BCC and SCC obtained during Mohs procedures in patients with CLL, organ transplant recipients, and a control group were reviewed retrospectively. Biopsy specimens of CLL with dense infiltrates were assessed with immunohistochemical stains. Subclinical tumor extension (postoperative defect size minus preoperative tumor size) was evaluated in each group. RESULTS: Dense infiltrates were found in tumors of 20 of 55 patients with CLL (36%), 1 of 8 transplant recipients (13%), and 1 of 105 controls (1%). In patients with CLL, 75% of the dense infiltrates were B-cell leukemic. Compared with controls, the mean subclinical tumor extension was larger in patients with CLL (P=0.029) and in transplant recipients (P=0.55). CONCLUSION: Dense leukemic infiltrates associated with BCC or SCC in CLL may complicate pathologic interpretation of Mohs surgical histologic margins and may be associated with larger postoperative defects relative to preoperative clinical tumor appearance. In patients with CLL, as in transplant recipients, SCC seems more likely to develop than BCC.     

Pediatric-specific reference intervals in a nationally representative sample of Iranian children and adolescents: the CASPIAN-III study

Background

This study aimed to determine for the first time the age- and gender-specific reference intervals for biomarkers of bone, metabolism, nutrition, and obesity in a nationally representative sample of the Iranian children and adolescents.

Methods

We assessed the data of blood samples obtained from healthy Iranian children and adolescents, aged 7 to 19 years. The reference intervals of glucose, lipid profile, liver enzymes, zinc, copper, chromium, magnesium, and 25-hydroxy vitamin D [25(OH)D] were determined according to the Clinical & Laboratory Standards Institute C28-A3 guidelines. The reference intervals were partitioned using the Harris–Boyd method according to age and gender.

Results

The study population consisted of 4800 school students (50% boys, mean age of 13.8 years). Twelve chemistry analyses were partitioned by age and gender, displaying the range of results between the 2.5th to 97.5th percentiles. Significant differences existed only between boys and girls at 18 to 19 years of age for low density lipoprotein-cholesterol. 25(OH)D had the only reference interval that was similar to all age groups and both sexes.

Conclusions

This study presented the first national database of reference intervals for a number of biochemical markers in Iranian children and adolescents. It is the first report of its kind from the Middle East and North Africa. The findings underscore the importance of providing reference intervals in different ethnicities and in various regions.

     

Chimeric thoracodorsal lymph node flap with a perforator-based fasciocutaneous skin island for treatment of lower extremity lymphedema: A case report

Free vascularized lymph node transfer (VLNT) is applied more and more in the treatment of lymphedema. A random-pattern skin island with VLNT is of use but can have its limitations in flap inset. We describe an option for free VLNT in the treatment of lower extremity lymphedema. We present the case of a chimeric thoracodorsal lymph node flap (TAP-VLNT) with a thoracodorsal artery perforator (TAP) flap (5 × 9 cm) to the lower leg in a 22-year old female patient with stage 2 lower leg lymphedema caused by severe traumatic skin decollement and postoperative scarring after a car accident. TAP flap enabled tailored and tension-free wound closure at the recipient site after scar release and lymph node flap inset. The anastomosis was performed to the anterior tibial artery. The postoperative course was uneventful with no complications or secondary donor-site lymphedema. Follow-up at 6 months showed reasonable cosmetic and functional outcomes. The circumference reduction rate was up to 11% and the patient reported improved quality of life. The purpose of this report is to describe a case of a more flexible lymph node flap inset and tension-free wound closure by harvesting a thin thoracodorsal artery perforator (TAP) skin island together with a thoracodorsal VLNT as a chimeric flap (TAP-VLNT) for treatment of lower extremity lymphedema. Larger series with longer follow-up data are needed to justify its widespread use and demonstrate long-term results.     

Cancer prevention: a new era beyond cyclooxygenase-2

The seminal epidemiological observation that nonsteroidal anti-inflammatory drugs (NSAIDs) prevent colon and possibly other cancers has spurred novel approaches to cancer prevention. The known inhibitory effect of NSAIDs on the eicosanoid pathway prompted studies focusing on cyclooxygenase (COX) and its products. The increased prostaglandin E2 levels and the overexpression of COX-2 in colon and many other cancers provided the rationale for clinical trials with COX-2 inhibitors for cancer prevention or treatment. Their efficacy in the prevention of sporadic colon and other cancers remains unknown; one COX-2 inhibitor has been withdrawn because of side effects, and there are concerns about whether these effects are class-specific. There is evidence to suggest that COX-2 may not be the only or ideal eicosanoid pathway target for cancer prevention. Six sets of observations support this notion: the relatively late induction of COX-2 during carcinogenesis; the finding that NSAIDs may not require inhibition of COX-2 for their effect; the modest effect of coxibs in cancer prevention; that currently available coxibs have multiple non-COX-2 effects that may account for at least some of their efficacy; the possibility that concurrent inhibition of COX-2 in non-neoplastic cells may be harmful; and the possibility that COX-2 inhibition may modulate alternative eicosanoid pathways in a way that promotes carcinogenesis. Given the limitations of COX-2-specific inhibitors and the biological evidence mentioned above, we suggest that targets other than COX-2 should be pursued as alternative or complementary approaches to cancer prevention.     

Challenges of implementing point-of-care testing (POCT) glucose meters in a pediatric acute care setting

OBJECTIVES: To investigate factors contributing to analytical bias in POCT glucose values generated by the NICU versus the core laboratory. METHODS: The LifeScan Flexx hospital system glucose meters (SureStep) were used in precision and comparison studies between the NICU and laboratory (ABL715 and Vitros 950). RESULTS: Analysis of 40 neonatal blood samples revealed a positive bias between the NICU glucose meters versus either the laboratory glucose meter or instrument (mean difference of 0.28 and 0.21 mmol/L, respectively). Linear regression analysis (R2 = 0.0584) of the difference in glucose results versus time elapsed between measurements indicated that the bias observed between the NICU and laboratory glucose meters was not due to in vitro glycolysis for samples transported on ice. Further analysis indicated that the bias appeared to be mostly operator driven, with different NICU operators exhibiting different mean biases. Increasing the amount of blood applied to the SureStep Pro test strip (e.g., 60 vs. 20 microL), led to higher values for glucose concentration for the same blood. Nearly 50% of all glucose values reported for the NICU were obtained by the SureStep Flexx glucose meters in a 3-month period following the introduction of POCT, yet the number of laboratory-reported glucose results for the same period increased by 21% as compared to the previous year. CONCLUSIONS: Operator error appears to be a source of bias present between the NICU and laboratory, and despite glucose meter utilization in the NICU, the number of glucose measurements by the central laboratory increased after POCT introduction.