[PET scanning for malignant melanoma and positive sentinel node diagnostics]. / PET-skanning ved malignt melanom og positiv sentinel node.

INTRODUCTION: To illuminate the value of using positron emission tomography (PET) scan as a clinical routine screening procedure for detecting subclinical metastases in melanoma patients with positive sentinel node biopsy, we carried out a retrospective study which included a total of 80 patients. MATERIAL AND METHODS: 80 patients with cutaneous malignant melanoma and subclinical lymph node metastases diagnosed by sentinel node biopsy (SNB) were submitted to 18F-fluoro-2-deoxy-D-glucose (FDG) whole-body PET-scanning within 100 days after SNB and wide local excision (WLE). Before FDG-PET scanning, patients were screened conventionally and found to be without evidence of further dissemination. The average follow-up was 30 months (range 7-81 months). RESULTS: 13 patients out of totally 80 patients had a suspicious FDG-PET scan. 4 of these patients (5%) were found true positive by verifying examinations. 67 patients had a negative FDG-PET scan - 4 of these patients developed a clinical recurrence within a period of 6 months after SNB (false negative). This resulted in a sensitivity of 50% and a specificity of 31%. CONCLUSION: We conclude that FDG-PET scanning in connection with SNB cannot be recommended as a routine investigation for patients with malignant melanoma and positive SNB.

[Prognosis after sentinel node biopsy in malignant melanoma]. / Prognosen efter sentinel node-biopsi ved malignt melanom.

INTRODUCTION: Sentinel node biopsy (SNB) is used in patients with cutaneous malignant melanoma (MM) to detect subclinical spread to the regional lymph nodes, after which a radical lymph node dissection can be performed. Since 2001, the Department of Plastic Surgery, Roskilde Amts Sygehus, has used SNB routinely in patients with cutaneous MM who have a statistical risk of at least 10% of harbouring subclinical lymph node metastasis. MATERIALS AND METHODS: In the four-year period from 2001 to 2004, 248 consecutive patients with primary MM underwent SNB at the time of radical surgery for their MM. If metastatic spread was found in the removed sentinel node, a radical lymph node dissection was performed shortly afterward. All patients were followed up after their operation in the department's outpatient clinic. RESULTS: Regional lymph node metastatic spread was found by SNB in 32% of the patients. At radical lymph node dissection, further metastatic lymph nodes were found in 24% of the dissected cases. The median follow-up time was 21 months (range 1-51 months). 7% of SN-negative cases developed recurrence during follow-up, in contrast to 23% of the SN-positive cases. The median time to recurrence was 14 months. The two-year and four-year disease-free survival rates were 93% and 85% in the SN-negative group and 73% and 55% in the SN-positive group, respectively. Risk factors for recurrence were: extracapsular SN growth, more than one metastatic SN and further lymph node metastases being found by formal node dissection. 18% of the SN-positive patients died during the follow-up period, in contrast to 3% of the SN-negative cases. The MM-specific two-year and four-year survival rates were 84% and 64% in the SN-positive group and 99% and 97% in the SN-negative group, respectively. CONCLUSION: Sentinel node biopsy is a procedure that detects MM patients who have a very high risk of recurrence and death by MM within a few years after primary treatment. SNB status is a very strong prognostic factor, and SN-positive cases should be followed carefully.

Routine use of FDG-PET scans in melanoma patients with positive sentinel node biopsy.

PURPOSE: Positron emission tomography (PET) scanning is an efficient and well-known diagnostic tool in various malignant disorders. However, the utility of PET as a clinical routine screening procedure for the detection of subclinical metastases in stage III melanoma patients has not yet been established. METHODS: Thirty-three patients with cutaneous malignant melanoma and subclinical lymph node metastases diagnosed by sentinel node biopsy (SNB) were submitted to( 18)F-fluoro-2-deoxy-D: -glucose (FDG) whole-body PET scanning within 100 days after SNB and wide local excision. Before PET scanning, patients were screened conventionally and found to be without evidence of further dissemination. Positive PET scan findings were evaluated by computed tomography scanning, magnetic resonance imaging and ultrasonography. Biopsy was performed whenever possible. The median follow-up was 15 months (range 6-39 months). RESULTS: Nine patients (27%) had a positive PET scan performed after SNB and WLE. On verification, four cases (12%) were found to be true positive for melanoma metastasis and were thus upgraded from stage III to stage IV. Furthermore, one patient (3%) had another primary malignancy (prostate carcinoma), and two (6%) were found to have non-malignant lesions. Two PET-positive patients (6%) refused further investigations. In one case (3%) the PET scan was false negative. Twenty-three (69%) PET scans were true negative. CONCLUSION: In a number of stage III melanoma patients with positive SNB, postoperative whole-body FDG-PET scanning revealed further melanoma dissemination not found by conventional screening methods and thus identified these cases as stage IV. Relevant therapy can accordingly be instituted earlier on the basis of FDG-PET scanning.

Sentinel node biopsy in cutaneous melanoma.

Status of the regional lymph nodes is a strong prognostic factor in patients with cutaneous malignant melanoma (CMM) and can be assessed by sentinel lymph node biopsy (SLNB). We present our technique of preoperative lymphatic mapping and intraoperative vital dye and handheld gamma probe. Our results and three years follow-up of its routine use in 198 patients with verified primary CMM are presented. Median follow-up time was 24 months (range 1-47). Metastatic regional lymph node disease was found by SLNB in 61 patients (31%) and additional metastatic nodes were found by formal node dissection in 30% of these cases. Complications were relatively mild but included one case of lymphoedema in a node negative patient. By follow-up, 13% had developed a recurrence including 26% of node positive patients and 8% of node negative patients. Mortality was also substantially higher in node positive cases with 18% dying in the follow-up period and 3% in the node negative group. The SLNB procedure was associated with a false negative rate of 8%. Using the presented technique, we found that SLNB was a useful procedure for staging patients with CMM and for selecting patients for more extensive metastatic screening and inclusion in trials of adjuvant treatments.

[Screening for skin cancer in organ transplant recipients in Denmark]. / Screening for hudcancer hos organtransplanterede patienter i Danmark.

INTRODUCTION: Non-melanoma skin cancer (NMSC) is a serious cause of morbidity and mortality in organ transplant recipients. The necessary immunosuppressive therapy is linked to an increased number of biologically more aggressive acting skin tumours. Preventing disease and providing early diagnosis and treatment is thus essential. This is done through repetitive patient education and regular examination of the skin performed by a trained specialist, i.e., a dermatologist. We investigated the routine level of monitoring for NMSC in organ transplant recipients in Denmark. MATERIALS AND METHODS: A questionnaire survey was conducted on how hospital departments educate patients in NMSC prevention, the frequency of full-body skin examination and where patients are treated when a tumour is found. The questionnaire was sent to 28 medical departments in Denmark that follow up organ transplant recipients. Twenty-five departments returned the questionnaire. RESULTS: A full-body skin examination was routinely done in six (24%) of the departments. Fifteen (60%) of the departments informed patients about the risk factors for developing skin cancer, but only five (20%) provided written information. DISCUSSION: There appears to be considerable scope for improvement in the follow-up of organ transplant recipients. Providing thorough and repeated information to organ transplant patients, in addition to early diagnosis and treatment carried out by trained specialists according to standard guidelines, can minimize the morbidity and mortality caused by non-melanoma skin cancer in these patients. We suggest that written guidelines be provided in order to improve these patients" treatment and prognosis. A corresponding survey done in the United Kingdom produced almost the same conclusions.