Analysis of predictive factors for the outcome of complete lymph node dissection in melanoma patients with metastatic sentinel lymph nodes.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is a widely accepted procedure to accurately stage patients with melanoma. However, there is no consensus concerning the practical consequences of a positive SLN, since a survival benefit of a complete lymph node dissection (CLND) has not yet been demonstrated. OBJECTIVE: We wondered whether we could identify a subgroup of patients with metastatic involvement of the SLN who could be excluded from the recommendation to undergo CLND. METHODS: At the Department of Dermatology at the University of Munich, a total of 213 patients with metastatic SLNs (24.9%) were identified among 854 patients who had undergone SLNB between 1996 and 2007. All SLN-positive patients had been advised to have CLND. Survival analyses were performed by using the Kaplan-Meier approach. RESULTS: A total of 176 (82.6%) of 213 SLN-positive patients underwent CLND. In this group, 26 patients (14.8%) showed metastatic disease in non-sentinel lymph nodes (NSLN). The 5-year overall survival (OS) was 26.1% in NSLN-positive patients and 74% in NSLN-negative patients. SLN-positive patients who refused CLND had a better prognosis than patients with CLND. Breslow tumor thickness was significantly associated with positive CLND status with higher median values in CLND-positive than CLND-negative patients (3.03 vs 2.22 mm). LIMITATIONS: The subgroup of patients with metastatic disease in CLND may have been too small to reach statistical significance for other tumor- or patient-related parameters. Mitotic indices of the primary melanomas had not been determined in this retrospective study; thus a possible correlation with lymph node status could not be tested. CONCLUSION: Among SLN-positive patients, the presence of metastatic NSLN is a highly significant poor prognostic factor. Tumor thickness is a significant prognostic parameter for positive CLND status and might be considered in the decision to perform CLND in case of metastatic SLN.

Prognostic factors associated with sentinel lymph node positivity and effect of sentinel status on survival: an analysis of 1049 patients with cutaneous melanoma.

Sentinel lymph node biopsy (SLNB) is a widely accepted staging procedure in patients with melanoma. However, it is unclear which factors predict the occurrence of micrometastasis and overall prognosis and whether SLNB should also be performed in patients with thin primary tumors. At our Department of Dermatology, University of Munich (Germany), 1049 consecutive melanoma patients were identified for SLNB between 1996 and 2007, and were followed-up to assess disease-free and overall survival. Of those, a total of 854 patients were analyzed prospectively. Patients with positive SLN were subjected to selective lymphadenectomy. The association of patient characteristics with SLN was assessed by multivariate logistic regression. Survival curves were performed using the Kaplan-Meier method. Cox proportional hazard regression with different adjustments was used to estimate the effect of SLN on survival. The detection rate of SLN was 97.24%, of which 24.9% were metastatic. Significant parameters upon SLN positivity were tumor thickness and nodular type of melanoma. The 5-year overall survival was 90.1 and 58.1% in SLN-negative and SLN-positive patients, respectively. Upon multivariate analysis tumor thickness and SLN status were significant factors influencing both disease-free survival and overall survival. In conclusion, our data confirm that SLNB is relevant as a diagnostic and staging procedure and that tumor thickness is of predictive importance. SLN status should be taken into account when designing clinical trials and informing patients about the probable course of their disease. Our data suggest that in case of a nodular melanoma subtype SLNB should also be considered at a tumor thickness below 1 mm.

Microscopically controlled surgery (MCS).

To confirm a local R0 resection of tumors with infiltrative growth at problem sites and for sparing of tissue, microscopically controlled surgery represents a safe and proven method, particularly when there are no gaps between the tissue taken at the incision margins.

The use of high-resolution ultrasonography for preoperative detection of metastases in sentinel lymph nodes of patients with cutaneous melanoma.

BACKGROUND: Sentinel lymph node biopsy (SLNB) reliably assesses the status of the regional lymph node basins and provides prognostic information in patients with cutaneous melanoma, but is logistically demanding and expensive. OBJECTIVE: The aim of this study was to evaluate the ability of high resolution B-mode ultrasonography (US) for pre-operative identification and characterization of sentinel lymph nodes (SLN) in patients with cutaneous melanoma. PATIENTS AND METHODS: In a prospective trial, the use of high resolution US was assessed in 25 consecutive patients with cutaneous melanoma identified for SLNB, first, for its value in primary detection of SLN, and, second, for its value in the correct assessment of SLN after lymphoscintigraphic mapping. RESULTS: High resolution B-mode US correctly identified two of 6 positive SLN. The sensitivity, specificity, positive predictive value, and negative predictive value of US were 33.3% (95% CI 43.3-77.7), 100.0% (95% CI 88.1-100.0), 100.0% (95%CI 15.8-100.0) and 87.9% (95% CI 71.8-96.6), respectively. CONCLUSION: High resolution B-mode US cannot replace SLNB, especially in the detection of micrometastases, but it remains the most important method to assess the lymph node status for macrometastases presurgically.

Dermatology - a surgical discipline - as exemplified by surgical procedures at the Hospital of Munich Thalkirchner Strasse.

BACKGROUND: Despite the enormous progress in dermatosurgery during the last 35 years,this achievement is not always appropriately acknowledged by other surgical specialties. We outline the significance of dermatosurgery by looking at the development of dermatological operations at the Department of Dermatology,University of Munich/Hospital of Munich Thalkirchner Strasse. PATIENTS AND METHODS: Data were collected and analyzed from surgery records, tables and from the SAP ISH-Med.The survey covered the time frame from 1971 to 2006. RESULTS: There were 101,103 inpatient operations. The number of operations per year increased steadily,especially the number of medium-sized and large operations. A special domain of dermatosurgery is the sentinel lymph node biopsy in patients with malignant melanoma. In the last years, there was a continuous increase of patients in whom more than one tumor had to be excised. The percentage of patients undergoing dermatosurgery was constant at 46% of all inpatients. CONCLUSIONS: The surgical therapy of skin tumors is the most important part of inpatient treatment of dermatology patients. The development of dermatosurgery shows that due to the increase of skin tumors and the opening of new fields of activity (for example the removal of sentinel lymph nodes) there is a growing demand for dermatological surgeons. Solid training and competent representation in dermatology and attention to our interactions with other surgical specialties will help guarantee optimal patient care in the future.

[Intraoperative labeling of sentinel lymph nodes with a combination of vital dye and radionuclide tracer--results in sentinel lymph node-positive patients]. / Intraoperative Markierung von Sentinel-Lymphknoten bei kombinierter Anwendung von Vitalfärbung und Radiotracer--Ergebnisse bei Sentinel-Lymphknoten-positiven Patienten.

BACKGROUND: Sentinel lymph node biopsy enhances the accuracy of tumor staging in patients with malignant melanoma and can help select candidates for regional lymphadenectomy. There are two techniques for identifying the sentinel lymph node: intradermal injection of a radionuclide tracer or of a blue dye. We evaluated both methods to determine how they can be best utilized to locate a sentinel lymph node. PATIENTS AND METHODS: In a retrospective study, 323 patients with melanoma (tumor thickness > or = 0.75 mm) who underwent sentinel lymph node biopsy after both radionuclide and blue dye injection were evaluated. The labeling of lymph nodes showing micrometastasis by histopathological examination was determined. RESULTS: 63 patients showed sentinel lymph nodes with micrometastasis. All of these nodes (100 %) were labeled with radionuclide tracer, but only 90 % with blue dye. In 5 patients, only radionuclide labeling identified the histopathologically-positive lymph node. In 36 patients, several sentinel lymph nodes were identified, with the histopathologically-positive nodes usually showing a higher radioactive signal intensity than the negative ones. CONCLUSION: Since in some patients histopathologically-positive lymph nodes are only labeled by radionuclide tracer, radionuclide labeling is indispensable for locating sentinel lymph nodes. In contrast, labeling with blue dye represents a supplementary method, which can simplify the recognition of the sentinel lymph node during surgery.

Sentinel node mapping in patients with malignant melanoma using melanoma Tc-99m colloidal rhenium sulfide.

PURPOSE: The aim of the study was to localize the sentinel lymph node using lymphoscintigraphy aided by Tc-99m colloidal rhenium sulfide. MATERIALS AND METHODS: Thirty consecutive patients with histologically proved melanoma, but no clinical evidence of metastases, were examined before operation by injecting 20 to 40 MBq (0.5 to 1.1 mCi) Tc-99m colloidal rhenium sulfide with a mean particle size of 100 nm (range, 50 to 200 nm) intradermally around the lesion. Lymphoscintigraphy was performed immediately after injection. In addition, blue dye was injected before operation. A hand-held gamma probe guided the sentinel node biopsy. RESULTS: Lymphoscintigraphy revealed hot spots in all patients. During surgery, the sentinel node was identified in all 30 patients. The number of sentinel nodes per patient ranged from 1 to 4 (mean, 1.9). Histologic examination confirmed the metastatic involvement of the sentinel lymph node in 11 of 30 patients. The sentinel lymph node-positive rate was 22.4%, which was comparable to findings using Tc-99m-labeled nanocolloids. CONCLUSION: The findings indicate that Tc-99m-bound colloidal rhenium sulfide is suitable for sentinel node mapping.

Frequency of facial basal cell carcinoma does not correlate with site-specific UV exposure.

BACKGROUND: Basal cell carcinoma (BCC) is the most common type of skin cancer in whites. Long-term exposure to UV radiation is considered a major risk factor. We decided to investigate whether maximally exposed areas of the body are also the most frequent sites where BCCs develop. DESIGN: Retrospective analysis of distribution and histopathologic features of 3065 facial BCCs. SETTING: University hospital. PATIENTS: Patients with primary or recurrent BCC of the face. INTERVENTION: Exact topographic documentation followed by removal of BCC with Mohs prcedure and analysis of tumor extension. MAIN OUTCOME MEASURE: To test the hypothesis that site-specific UV exposure correlates with site-specific BCC frequency. RESULTS: The most frequent sites of BCC were the nose (n = 1373), orbital area (n = 386), and ears (n = 269). Subdivision of these anatomical units showed that most nasal BCCs are located at the base of the nose (n = 851), while the apex (n = 292) and the dorsum of the nose (n = 230) were less frequent sites despite their prominent sun exposure. The shaded retroauricular fold (n = 99) and the sun-exposed preauricular crest (n = 105) were similar in frequency of BCCs; fewer BCCs were located on the helix of the ears (n = 65). Finally, almost 10 times more BCCs were found in the medial quadrant of the orbit (n = 225) than in the lateral quadrant (n=24). No correlation between prominent UV-exposed facial contours and particular histologic features, such as solid, morpheaform, or adenoid-cystic, could be established. CONCLUSIONS: Site-specific cumulative UV exposure alone is a poor predictor of frequency or histologic features of BCC. Additional site-specific textural qualities of facial skin may be considered as potential cofactors for the development of BCC.

Micrographic surgery of basal cell carcinomas of the head.

Basal cell carcinoma (BCC) is a locally invasive malignant cutaneous tumour with a rising incidence. This tumour can be treated successfully by a variety of techniques, including local excision, radiation, cryotherapy, curettage, electrodessication and laser obliteration. Micrographic surgery is a specialised type of minimal marginal surgery that offers higher cure rates than do other options in the treatment of contiguous skin cancers in selected settings. The horizontal frozen histological sections of the excised tumour permit complete microscopic examination of the surgical margin. Maximum sparing of tumour-free adjacent tissue is achieved with histological mapping of the tumour boundaries, and subsequent wound reconstruction is optimised. Data on topographical distribution, histopathological subtype, subclinical tumour extension, therapeutic procedures required for complete eradication, and recurrence rates were recorded in 3065 BCC of the head. Micrographic surgery is the treatment of choice for large or invasive primary BCC with uncertain clinical boundaries, especially in difficult anatomical regions, for recurrent or re-recurrent BCC, and for tumours with an aggressive histopathological pattern.

As diferenças fundamentais entre as variaçöes da cirurgia micrográfica / The fundamental diference among the variations of micrografic surgery

Qualquer que seja a técnica escolhida para a realizaçäo da cirurgia micrográfica, esta é mais eficaz do que o método convencional de cirurgia excisional para garantir melhor índice de cura do tumor. Apesar de terem os mesmos princípios básicos de poupar ao máximo o tecido sadio peritumoral, as três variaçöes mais importantes da cirurgia micrográfica têm diferenças fundamentais entre sí. O objetivo deste trabalho é descrever essas diferenças, comparando os métodos entre si. Dessa forma, acredita-se estar contribuindo para ampliar o conceito de cirurgia micrográfica, melhorando a interpretaçäo e compreensäo do controle histológico das margens cirúrgicas