[Sentinel node biopsy in breast cancer]. / Wächterlymphknotenbiopsie beim Mammakarzinom.

The international consensus conference from St. Gallen concerning the treatment of early breast cancer concluded in 2003, that sentinel node biopsy was now accepted as method allowing axillary staging in breast cancer. This procedure may avoid complete lymph node dissection in appropriate cases. Since numerous questions associated with the technique are still not defined and the procedure itself is not yet standardized, the German Society of Senology defined the conditions for the routine clinical use of sentinel node biopsy in an interdisciplinary consensus meeting.

A micromorphometry-based concept for routine classification of sentinel lymph node metastases and its clinical relevance for patients with melanoma.

BACKGROUND: The sentinel lymph nodes (SLNs) as the primary targets for lymphatic metastases can be removed selectively by gamma probe-guided sentinel lymph nodectomy (SLNE) in nearly all patients with cutaneous melanoma. Correspondingly high standards in terms of specificity, sensitivity, and microstaging are required for the evaluation of SLNs. METHODS: Since 1995, the authors have performed SLNE in 389 lymph node regions (LNRs) on 342 patients with melanoma. The harvested 636 SLNs and a further 1394 nonsentinel lymph nodes (non-SLNs) were evaluated by standardized, semiserial section histology, including immunohistochemistry. For each LNR, this technique permitted routine S classification using two simple morphometric parameters: the number of tumor-involved, 1-mm slices of the SLNs (n) and the centripetal depth of metastatic cell invasion (d). S1 was defined by 1 < or = n < or = 2 and d < or = 1 mm, equivalent to localized peripheral tumor cell deposits; S2 was defined by n > 2 and d < or = 1 mm, indicating more extended peripheral metastases; S3 was defined by d > 1 mm in SNLs with deeper metastatic infiltration; and S0 meant no detectable tumor cells (n = 0). RESULTS: The authors diagnosed 325 SLNs as S0, 24 SLNs as S1, 22 SLNs as S2, and 18 SLNs as S3. The occurrence of at least one melanoma-positive non-SLN subsequent regional completion lymph node dissection (RCLND) significantly increased from 0 of 12 in S1 SLNs to 2 of 13 in S2 SLNs and 9 of 15 in S3 SLNs (P = 0.001; chi-square test). Like the T classification of the primary melanoma, the S classification proved to be a highly significant predictor for distant metastasis (P < 0.001). It turned out to be an independent factor of influence on distant metastasis and survival in multivariate Cox analyses, which included tumor thickness, primary tumor site, patient gender, and patient age as covariates. CONCLUSIONS: The data presented recommend the S-staging concept as a promising option to fill a gap between the T and conventional N component of the pTNM classification. If its predictive capacity can be confirmed in multicenter studies, then the S classification may become the decisive criterion for or against RCLND, and a combined T plus S staging system will help to improve prognostically relevant stratification of melanoma patients in adjuvant therapy trials.

The predictive value of the sentinel lymph node in malignant melanomas.

At the beginning of a lymphogenous metastasizing process in malignant melanomas, the first tumor cells are found in the so-called sentinel lymph node (SLN), defined as the first tumor-draining lymph node. Its removal and histopathological examination enable us to discover metastases of malignant melanomas long before their possibility of detection by any other method. Since the beginning of 1995, we have performed more than 350 gamma-probe-guided sentinel lymphonodectomies (gamma-SLNE), without any clinical evidence of metastases as determined by lymphoscintigraphy. Using gamma-SLNE, the detection and excision of the SLN succeeded in nearly all patients. The SLNs were fixed in formalin, completely cut into 1-mm thin slices and stained for routine H&E histology and with S-100 and HMB-45. In persons with melanomas thinner than 0.75 mm, we never found micrometastases. However, the SLNs were positive in melanomas from 0.76 to 1.50 mm in about 7% of patients, in melanomas from 1.51 to 4.00 mm in about 21% and in tumors thicker than 4 mm in about 44%. In primary melanomas with satellite or in-transit metastases, the SLNs contained metastases in 75% of patients. Normally, a radical lymph node dissection (RLND) follows, as it is considered to be the necessary consequence following detection of tumor cells. The lymph nodes of the RLNDs contained further metastases in about 30% of patients. The probability of the involvement of lymph nodes other than the SLN correlates with the extension of tumor cells in the SLN. During our 4-year-follow-up, we observed only a single lymph node recurrence in a patient with a negative SLN (false negative rate of about 0.4%). The development of systemic metastasis correlates not only with the Breslow tumor thickness, but also with the extent of the involvement of the melanoma metastasis in the SLN. Summarizing, it can be said that gamma-SLNE has revolutionized melanoma surgery. Based on our data, it is absolutely necessary in the staging of malignant melanoma. In our opinion, the existing classification systems for staging lymph node involvement have to be revised in light of the results of SLNE.

[Melanoma. Results with "sentinel node" sampling]. / Melanom. Ergebnisse mit dem "Sentinel node".

Since June 1995 we have practised a gamma probe guided sentinel lymphadenectomy (SLNE) in 274 patients after injecting a colloidal 99 m-Tc labelled solution around the tumor. By this technique the detection and excision of the SLN succeeded in 99.3% of all cases. We found micrometastases in about 53.1% of patients with pT3 and pT4 melanomas. The specimen of the radical lymph node dissection contained in 30% further metastases. A regional recurrence after SLNE occurred only in one case, a SLN-negative patient.

[Sentinel lymph node detection by preoperative lymphoscintigraphy and intraoperative gamma probe guidance in malignant melanoma]. / Nachweis des Sentinel-Lymphknotens mittels präoperativer Lymphszintigraphie und intraoperativer Gammasondenmessung bei malignem Melanom.

AIM: The purpose of this work was to prove the clinical significance of nuclear medical procedures in pre- and intraoperative detection of the SLN. METHODS: In the past 4 years, we did preoperative lymphoscintigraphy in 214 patients (pts.). Intraoperative localisation of the SLN with a hand-held gamma probe followed in 150 pts. RESULTS: In 214 pts. 247 lymphatic draining regions were found by preoperative scintigraphy. In 3 pts. with melanoma of the cheek no lymphatics/lymph nodes could be detected. 14 pts. showed interval lymph nodes. In 150 pts. gamma probe guided SLNE was done. In 2 pts. with supraclavicular primary tumor 4 SLN had been defined by preoperative scintigraphy but only 2 could be found intraoperatively. In all other cases (98.7%) the sentinel node was detected correctly by the gamma probe and then removed. In 19 of 150 pts. (12.7%) metastases were detected in the pathologic specimen. The incidence of lymph node metastases showed a continuous increase from 0% at tumor stage pT1 to 44% at stage pT4. CONCLUSION: SLNE is an accurate method to determine nodal involvement in melanoma and minimizes operative invasiveness in melanoma surgery.

Secondary lymph node involvement from primary cutaneous large B-cell lymphoma of the leg: sentinel lymph nodectomy as a new strategy for staging circumscribed cutaneous lymphomas.

BACKGROUND: Primary cutaneous large B-cell lymphoma of the leg (LBCLL) is a recently defined type of non-Hodgkin's lymphoma. It forms a separate category in the new classification of primary cutaneous lymphomas elaborated by the European Organization for Research and Treatment of Cancer. It is associated with a less favorable prognosis than the most frequently occurring types of primary cutaneous B-cell lymphoma. METHODS: The authors present four patients with the typical clinicopathologic constellation of LBCLL. Three of them died during the years 1993-1996. The authors reviewed their courses. The fourth patient was staged by sentinel lymph nodectomy (SLNE), i.e., the selective surgical removal and histologic examination of the first draining lymph node associated with the cutaneous tumor. RESULTS: The courses of the three previous patients were characterized by secondary involvement of regional lymph nodes followed by systemic dissemination of the lymphoma in a third step. Although the conventional staging of the fourth patient had been negative for any extracutaneous lymphoma manifestation, the SLNE revealed initial regional lymph node involvement, which had decisive implications for the choice of therapy. CONCLUSIONS: SLNE may gain a prominent role in the staging of circumscribed cutaneous lymphomas, in addition to its already established position in melanoma management. Further positive effects of SLNE are 1) better distinction of primary cutaneous lymphomas with secondary lymph node involvement from primary lymph node lymphomas with skin manifestation, and 2) better insight into the biology of different primary cutaneous lymphoma types.

[Sentinel lymphadenectomy in malignant melanoma]. / Sentinel-Lymphadenektomie beim malignen Melanom.

The sentinel lymph node dissection (SLND) is one of the most striking developments in the treatment of melanoma. Since the first report by Morton et al. in 1992, the method has been refined, and its use has increased. Introduced as an alternative to elective lymph node dissection (ELND), it has rapidly made its way into clinical practice. SLND allows precise pathologic staging through removal and analysis of a limited number of nodes (false-negative rate < 2%). It distinguishes patients with clinically occult nodal disease from those with tumor-free regional basin who would not benefit from radical dissection. However, the SLND is still an experimental procedure with yet unproven utility.

Primary therapy of malignant melanomas: sentinel lymphadenectomy.

BACKGROUND: Each melanoma is drained by one or, occasionally, several individual lymph nodes within the nearest lymph node region (sentinel lymph node). OBJECTIVE: By histopathologic examination of the removed sentinel lymph node (SLN), it is possible to select patients clinically according to stage I or II (UICC classification), but who, microscopically, represent stage III. METHODS: Sentinel lymphadenectomies (SLNEs) were performed initially by the vital blue dye technique, and later by gamma-probe guidance only. The removed SLNs were examined by hematoxylin and eosin as well as immunohistochemical stains (S100, and HMB 45). RESULTS: We have performed 115 gamma-probe-guided SLNEs in 100 patients. The SLN could be found in all cases. In pT3 + 4 melanomas, 27.5% of the SLNs were positive; in only one patient with a pT2 tumor were micrometastases found. CONCLUSIONS: gamma-Probe-guided SLNE is a reliable procedure with minimal complications that should be performed in all pT3 + 4 (intraoperative frozen section histology) melanomas without clinically evident metastases.

[Sentinel lymph nodes in breast carcinoma]. / Sentinel Lymphknoten beim Mammakarzinom.

Aim of the experiment is to select patients with positive axillary lymph nodes by means of the sentinel lymph node concept. In this way all other patients who would not benefit from a lymph node dissection are spared from this procedure and its morbidity. Till now the sentinel lymphadenectomy is, however, still an experimental technic with yet unproven utility.

[Surgical procedures in therapy of breast carcinoma with reference to the value of axillary endoscopy techniques]. / Chirurgische Strategien zur Therapie des Mammakarzinoms unter Berücksichtigung des Stellenwertes axilloskopischer Techniken.

During the last decades the surgical treatment of breast cancer has been dramatically changed. Today breast conservative treatment represents a therapeutic option applicable to nearly 70% of the women. In contrast to this, the technic of axillary dissection remained unchanged. Suzanne et al. proposed an axilloscopic technic to reduce this morbidity. The sometimes unacceptable low lymph node count in the specimen induced us to modify this procedure. In the future the sentinel lymph node concept perhaps offers the possibility to select NO-patients and to spare the axillary dissection completely to this sub-group.

[Scintillation probe guided sentinel lymphadenectomy in malignant melanoma]. / Szintillationssondengesteuerte Sentinel-Lymphadenektomie beim malignen Melanom.

In cutaneous melanoma, biopsy of the first tumor-draining lymph node (Sentinel node, SLN) may replace routine elective lymph node dissection (ELND). The SLN has been shown to contain the first micrometastasis in early lymphatic tumor dissemination. As micrometastases were identified in 10-30% of stage I (AJCC/UICC) patients, sentinel lymphonodectomy (SLND) should enable us to select patients clinically in stages I and II, but histopathologically in stage III. This optimization of patient selection is mandatory as only this subgroup profits from ELND. Since the beginning of 1995 we was scintillation detector (gamma probe)-guided sentinel biopsy in patients with a melanoma > 1.0 mm and clinically negative lymph nodes. After injecting colloidal 99m-Tc-labelled tin(II)-sulfide solution around the tumor (or the biopsy scar), the SLN can be localized exactly. The technique is minimally invasive and easy to handle. If the SLN contains tumor, a standard en bloc lymphonodectomy is performed. Long-term follow-up, however, is needed to delineate the role of this procedure in melanoma treatment.

[Surgical therapy of primary breast carcinoma--options and perspectives]. / Chirurgische Therapie des primären Mamma-Karzinoms--Optionen und Perspektiven.

During the past quarter of the century the management of breast cancer has been dramatically influenced by new ideas and discoveries which, after being tested in controlled studies, govern current clinical practice. New therapeutic options are discussed, and first results are presented. The following procedures are illustrated: Van Nuys Classification of DCIS, skin-sparing mastectomy, stereotactic biopsy (ABBI), endoscopic axillary dissection, fluorescentic detection of positive lymph nodes, sentinel lymph nodes. Neoadjuvant chemotherapy, and menstrual cycle-dependent timing.

[Breast carcinoma staging with sentinel lymphadenectomy]. / Mammacarcinomstaging mittels Sentinel-Lymphadenektomie.

The objective of our trial was to evaluate the significance and usefulness of sentinel lymphadenectomy (SLNE) for the staging of regional lymph nodes in breast cancer patients. The study presented illustrates the method and our results. As has been documented for melanoma, the first lymph node [sentinel node (SLN)] to receive lymphatic drainage from a primary tumor is the expected first site of lymph-node metastasis. The database presented includes 12 patients with operable breast cancer and clinically negative lymph nodes. In 11 cases the described method was applicable. In only one case was there no correlation between the histology of the SLN and the axillary specimen. Three SLN were tumor-positive. Successful completion of examination of a large number of patients with a long follow-up has the potential of reducing the number of axillary dissections and of significantly reducing morbidity in the majority of breast cancer patients.

["Sentinel" lymphonodectomy with scintillation detector. A new strategy in treatment of malignant melanoma]. / Die "sentinel" Lymphonodektomie mittels Szintillationsdetektor. Eine neue Strategie in der Behandlung maligner Melanome.

For decades the results of elective lymph node dissection (ELND) are differently discussed, so that it is not definitely recommended at present the less so since the morbidity of this operation can't be neglected. Since the beginning of 1995 we practice a gamma-probe guided sentinel lymphonodectomy (SLNE) on patients with melanoma from a Breslow tumor thickness of 1 mm upward, after injecting a colloidal 99m-Tc labelled tin (II) - sulfide solution around the tumor or the scar, if the tumor has been excided before. By this method, that allows a selection of patients who according clinically to a stage I or II (UICC) but even histopathologically to a stage III and who are profiting of a removal of the regional lymph nodes, the sentinel node can be exactly localised, tissue-sparing removed at minimal complication rates and the completeness of the removal can be verified by measurements of the radioactivity. When finding metastases in the histopathological examination of the node a dissection of the whole region follows.

[Arteriovenous fistula of the vertebral artery: a rare complication following central venous catheterization. A case report]. / AV-Fistel der arteria vertebralis: eine seltene Komplikation nach zentralvenöser Katheterisierung. Ein Fallbericht.

Arteriovenous fistulas of the vertebral artery are in most cases caused by penetrating injuries. This report concerns a patient with ankylosing spondylitis, whose fistula most probably was brought about by puncture of the internal jugular vein for aorto-coronary-bypass surgery.

[Stage-III cerebrovascular insufficiency in stenoses and occlusions of the extracranial A. carotis. An indication for surgery?]. / Zerebrovaskuläre Insuffizienz Stadium III bei Stenosen und Verschlüssen der extrakraniellen A. carotis.

Reconstructive surgery was performed on 93 patients with stage III cerebrovascular insufficiency, extracranial stenoses and (or) occlusions of the cerebral blood flow. Compared with the spontaneous course in acute stroke, results of surgery point towards recommending an aggressive procedure provided certain criteria are observed (time limit, absence of haemorrhagia), particularly in view of the potential mortality of the condition. Late prognosis, assessed on the basis of 40 patients subjected to neurological follow-up 4 1/2 years after the operation, can be considered favourable.

[Alterations of blood gases during sleep and consciousness in surgical patients (author's transl)]. / Veränderungen der Blutgase im Schlaf-Wachrhythmus bei frischoperierten Patienten.

Measurements of blood gases and respiratory rate were made in 63 surgical patients during consciousness and sleep. Sleep-induced hypoventilation results in significant alteration of arterial PO2 and PCO2. The therapeutic possibilities to avoid critical postoperative hypoxaemia are intermittent positive pressure ventilation, mobilisation of the patient and O2 insufflation.