Unusual presentation of extranodal diffuse large B-cell lymphoma in a solid-organ recipient during long-term immunosuppressive treatment.

INTRODUCTION: Posttransplant lymphoproliferative disorders (PTLDs) refer to a group of diseases, including diffuse large B-cell lymphoma (DLBCL), that develop after solid organ transplantation or hematopoietic stem cell transplantation. Extranodal involvement in PTLDs is common. Reports about exclusive bone marrow involvement are rare. CASE DESCRIPTION: A 70-year-old woman, who had undergone kidney transplantation in 2018, was diagnosed with exclusively extranodal, Epstein-Barr virus-negative DLBCL, with bone marrow and spleen involvement, during long-term immunosuppression. She achieved complete remission with combined immunochemotherapy and temporary hold of immunosuppression. CONCLUSIONS: This case shows an uncommon clinical presentation of DLBCL, which was challenging to diagnose, being entirely extranodal. The favorable clinical course relied on timely diagnosis and a multidisciplinary approach. Long-term consequences of posttransplant immunosuppression require a high level of suspicion for an appropriate management, aimed at preserving the graft while eradicating the lymphoproliferative disorder.

Tonsil metastasis from cutaneous melanoma: first clinical sign of recurrence after complete lymph node dissection.

BACKGROUND: The development of melanoma metastasis to the palatine tonsil is a very rare event, generally associated with advanced-stage disease and poor prognosis. CASE PRESENTATION: A 29-year-old man presented with a melanoma metastasis to the right palatine tonsil 6 months after the surgical excision of an ulcerated nodular melanoma (tumor thickness 1.8 mm, Clark level IV) on the left shoulder. A metastatic sentinel lymph node had been removed from the left axilla, and a subsequent complete lymph node dissection had disclosed no further metastatic lymph nodes. Although staging tests had revealed multiple visceral metastases, a palliative tonsillectomy was performed. The patient died of metastases 5 months later. CONCLUSION: The case presentation suggests that careful examination of the head and neck should be part of the routine follow-up visit in all melanoma patients.

Primary umbilical melanoma.

We report a 72-year-old woman who presented with a primary melanoma of the umbilicus and periumbilical skin of 4 years' duration. Pathological examination of a biopsy specimen showed Clark's level IV, and tumour thickness 2.3 mm. The patient underwent preoperative lymphatic mapping followed by sentinel lymph node biopsy, and wide local excision of the primary tumour, including its attachment to the peritoneum. Because of the variations in vascularity and the residual embryonal connections of the umbilicus with the peritoneum and other intra-abdominal organs, an aggressive surgical approach is recommended in the management of malignant umbilical tumours.

Tumour regression does not increase the risk of sentinel node involvement in thin melanomas.

Few studies have analysed the relationship between tumour regression and risk of nodal metastasis in patients with thin melanomas (Breslow thickness < or = 1 mm), and the conclusions reported have been conflicting. The aim of this study was to evaluate the role of histological regression as a predictor of lymph node metasta- sis in a selected group of patients with thin melanomas, submitted to lymphatic mapping and sentinel lymph node biopsy. From November 1999 to November 2006, 59 patients with thin melanomas (28 females and 31 males; mean age: 58.7 years) underwent lymphatic mapping and sentinel lymph node biopsy. The mean Breslow thickness was 0.60 mm (range: 0.24-1 mm). Tumour ulceration was present in 2 patients (3.4%) and histological regression in 45 (76.3%). Sentinel lymph node metastases were detected in 2 of 59 patients (3.4%), but only one patient with a positive sentinel lymph node exhibited histological regression of his tumour. Therefore, the sentinel lymph node positivity rate in thin regressing melanomas was 2.2%. Literature data and our experience suggest that tumour regression is not a predictor of sentinel lymph node metastasis in patients with thin melanomas, and therefore does not justify the routine use of lymphatic mapping and sentinel lymph node biopsy in this melanoma setting.

Sentinel lymph node biopsy in patients with thin melanomas.

The aim of the present study is to report our experience with lymphatic mapping (LM) and sentinel lymph node biopsy (SLNB) in a selected group of patients with thin primary cutaneous melanomas. Fifty patients (22 females and 28 males; mean age, 57.8 years; range, 30-77 years) with a mean tumor thickness of 0.63 mm (range, 0.24-1.00 mm) underwent LM/SLNB. Twenty-eight (56%) of them had Clark level II, 20 (40%) had Clark level III, and two (4%) had Clark level IV. Tumor ulceration was present in two patients (4%) and histological regression in 35 patients (70%). Sentinel lymph node (SLN) metastases occurred in two of 50 patients (4%). The first case was a 0.88-mm thick, Clark level III, non-ulcerated superficial spreading melanoma of the trunk, without any regression. The second case was a 0.95-mm thick, Clark level IV, non-ulcerated superficial spreading melanoma of the neck, with regression. Both patients were disease-free 76 and 50 months after the SLNB procedure and followed complete lymph node dissection, respectively. The patients with negative SLN were disease-free after a median follow up of 44 months (mean, 43.2; range, 15-84 months). Published data and our experience suggest that LM/SLNB is not routinely indicated for melanomas less than 0.75 mm. Our results confirmed the accuracy of the new American Joint Committee on Cancer/International Union Against Cancer criteria, in which SLNB is required for thin melanomas less than 1.0 mm when they have ulceration or Clark level IV and V invasion.

Lymphatic mapping and sentinel lymph node biopsy in the management of primary cutaneous melanoma: report of a single-centre experience.

AIMS AND BACKGROUND: Lymphatic mapping and sentinel lymph node biopsy provide important prognostic data in patients with early stage melanoma and are crucial in guiding the management of the tumor. We report our experience with lymphatic mapping and sentinel lymph node biopsy in a group of patients with primary cutaneous melanoma and discuss recent concepts and controversies on its use. PATIENTS AND METHODS: A total of 111 patients with stage I-II AJCC primary cutaneous melanoma underwent lymphatic mapping and sentinel lymph node biopsy from December 1999 through December 2004 using a standardized technique of preoperative lymphoscintigraphy and biopsy guided by blue dye injection in addition to a hand-held gamma probe. After removal, sentinel lymph nodes were submitted to serial sectioning and permanent preparations for histological and immunohistochemical examination. Complete lymph node dissection was performed only in patients with tumor-positive sentinel lymph nodes. RESULTS: Sentinel lymph nodes were identified and removed in all patients (detection rate of 100%), and metastases were found in 17 cases (15.3%). The incidence of metastasis in sentinel lymph nodes was 2.1%, 15.9%, 35.2%, and 41.6% for melanomas < or 1.0, 1.01-2.0, 2.01-4.0, and > 4.0 mm in thickness, respectively. Complete lymph node dissection was performed in 15 of 17 patients with positive sentinel lymph nodes, and metastases in non-sentinel lymph nodes were detected in only 2 cases (11.7%). Recurrences were more frequently observed in patients with a positive than in those with negative sentinel lymph node (41.1% vs. 5.3% at a median follow-up of 31.5 months, P < 0.001). The false-negative rate was 2.1%. CONCLUSIONS: Our study confirms that lymphatic mapping and sentinel lymph node biopsy allow accurate staging and yield relevant prognostic information in patients with early stage melanoma.

Lymphatic mapping and sentinel lymphonodectomy in recurrent cutaneous squamous cell carcinomas.

There are subsets of cutaneous squamous cell carcinoma (SCC), including recurrent tumours, that have a high-risk for both local recurrence and metastasis. Since the presence of regional lymph node metastases carries a poor prognosis, the early evaluation of the nodal status is crucial for staging and treatment planning. Recent trials have shown that the lymphatic mapping (LM) and sentinel lymphonodectomy (SLNE) may be successfully employed to screen nodal basins in patients with high-risk cutaneous SCCs at clinical stage N0. We report our experience with this procedure in five selected patients affected with recurrent cutaneous SCCs. A metastatic sentinel lymph node (SLN) was found in 1 of the 5 cases. No false negative result was observed. SLNE is a feasible and minimally invasive staging procedure in patients with high-risk cutaneous SCCs. It may select patients with clinically occult metastases in the regional nodal basins, who can be submitted to therapeutic lymph node dissection (LND), avoiding the morbidity of a prophylactic LND in patients without metastases in SLNs.