Surgery: an ideal profession.

Numerous concepts from the social sciences shed light on the experience and goals of surgeons. We are motivated to strive for self-fulfillment and meet our potential. Meeting our potential can best be achieved when there is the correct balance between challenge and skill, which permits us to achieve flow and reach our goals. Achieving flow requires commitment, concentration, and confidence. As we work with patients, it is also important to consider I-Thou and I-It relationships. The former relates to having authentic relationships, involving dialogue and compassion. The latter involves attending to the careful anticipation and planning needed to operate. The challenges faced in the profession have decreased some external rewards. Our response to these challenges defines who we are. By serving patients, we can achieve our own fulfillment and our growth in relationship with others.

Patterns of drainage and recurrence following sentinel lymph node biopsy for cutaneous melanoma of the head and neck.

OBJECTIVES: To analyze lymphatic drainage patterns and recurrence patterns in patients undergoing sentinel lymph node biopsy (SLNB) for cutaneous head and neck melanoma. DESIGN: Retrospective review of a consecutive series with a mean follow-up of 35 months. SETTING: Tertiary cancer care center. PATIENTS: Fifty-one patients with clinically node-negative cutaneous melanoma of the head and neck region staged by means of SLNB. INTERVENTIONS: Sentinel lymph nodes (SLNs) were identified using preoperative lymphatic mapping along with intraoperative gamma probe evaluation and isosulfan blue dye injection. Patients with a positive SLNB finding by hematoxylin-eosin or immunohistochemical evaluation underwent completion lymphadenectomy of the affected lymphatic basin and were considered for further adjuvant treatment. Patients with a negative SLNB finding were observed clinically. MAIN OUTCOME MEASURES: Location characteristics of SLNs, incidence of positive SLNs, same-basin recurrence, and disease-free survival. RESULTS: The mean number of SLNs per patients was 2.75. The extent of SLNB included removal of 1 node (n = 11), multiple nodes from 1 basin (n = 18), 1 node in multiple basins (n = 7), and multiple nodes in multiple basins (n = 15). Drainage to unexpected basins was found in 13 of 51 patients. Parotid region drainage was identified in 18 patients. There were no same-basin recurrences in patients with a negative SLNB finding. Thirty-six-month disease-free survival was 88.9% for patients with a negative SLN and 72.9% for patients with a positive SLN (P=.17). CONCLUSIONS: The number and location of SLNs is variable and difficult to predict for head and neck cutaneous melanoma. Preoperative lymphoscintigraphy is an important planning instrument to guide complete removal of all SLNs. Based on 3-year follow-up, this procedure can be expected to provide low same-basin recurrence rates for patients with a negative SLN.

Patterns of recurrence after sentinel lymph node biopsy for cutaneous melanoma.

BACKGROUND: Previous sentinel lymph node (SLN) studies for cutaneous melanoma have shown that the SLN accurately reflects the nodal status of the corresponding nodal basin. However, there are few long-term studies that describe recurrence site patterns, predictors for recurrence, and overall survival and disease-free survival after SLN biopsy. METHODS: A retrospective review of patients over a 6-year period was performed to determine patient outcomes and the patterns of recurrence. In all cases, Tc-99 sulfur colloid along with isosulfan blue dye was injected at the primary melanoma site. After resection, the SLN was serially sectioned and evaluated by hematoxylin and eosin staining and immunohistochemistry. RESULTS: One hundred ninety-eight patients were identified who underwent SLN biopsy for cutaneous melanoma including T1 (n = 21), T2 (n = 88), T3 (n = 75), and T4 (n = 14) primary tumors. Of these patients, 38 had a positive SLN. Of the 38 patients with a positive SLN (mean follow-up 38 months), recurrent disease was identified in 10 (26.3%) at a mean interval of 14.2 months. The site of first recurrence was distant (n = 4) and local (n = 6). Regional lymphatic basin recurrence was not identified. Of the 160 patients with a negative SLN (mean follow-up 50 months), recurrent disease was identified in 16 (10.0%) at a mean interval of 31.3 months. The site of first recurrence was systemic (n = 11), local (n = 4), and nodal (n = 1). Overall survival and disease-free survival for patients with a positive SLN at 55 months was 53.3% and 47.7% respectively, while overall survival and disease-free survival for patients with a negative SLN at 53 months was 92.2% and 87.7% respectively (P <0.01). Univariate and multivariate analysis of the entire cohort (n = 198) identified primary tumor depth and positive SLN status as significant predictors of recurrence. CONCLUSIONS: The incidence of nodal basin recurrence after SLN biopsy was found to be 0.6%. Primary tumor depth and pathological status of the SLN are significant predictors of local and systemic recurrence. Long-term follow-up indicates that patients with a positive SLN clearly recur sooner and have decreased overall survival than those with a negative SLN.

Giant adrenal myelolipoma.

Myelolipoma of the adrenal gland is a benign tumor comprising adipose cells and mature hematopoietic elements. Most of these lesions are small and asymptomatic. Giant myelolipomas weighing greater than 4 kg are quite rare with three other cases reported in the literature. A case is presented of a giant myelolipoma that was resected surgically. The literature is reviewed regarding this topic with emphasis on diagnostic and therapeutic implications.