Gamma probe-directed lymphatic mapping and sentinel lymphadenectomy in primary melanoma: Reliability of the procedure and analysis of failures after long-term follow-up.

BACKGROUND AND OBJECTIVES: Some patients presenting with cutaneous malignant melanoma without palpable adenopathy have regional metastatic disease. The results of a prospective clinical study of gamma probe-directed sentinel lymph node (SLN) biopsy are presented. METHODS: Over a 3-year period, 103 patients with a diagnosis of invasive primary cutaneous malignant melanoma (Breslow > 0.12 mm or > Clark level II) underwent preoperative lymphoscintigraphy with technetium sulfur colloid followed by gamma-probe-guided sentinel lymphadenectomy. There were 46 women and 57 men with a mean age of 55.7 years (range, 19-91). RESULTS: Mean Breslow thickness was 2.3 mm (range, 0.12-10 mm). Primary locations were head and neck in 12, trunk 46, upper extremity 19, and lower extremity in 26. One hundred sixteen lymph node basins were mapped in 103 patients. Axillary, inguinal, and cervical nodal basins comprised 55, 34, and 11% of the total basins evaluated, respectively. Sixty-eight patients (66%) underwent lymphatic mapping of one regional nodal basin, 27 patients (26%) underwent synchronous lymphatic mapping of 2 regional nodal basins, 6 patients (6%) underwent synchronous lymphatic mapping of 3 regional nodal basins, and 2 patients (2%) underwent synchronous lymphatic mapping of 4 regional nodal basins. Seroma or infection did not occur in any patients. Micrometastatic disease was identified in 15 sentinel lymph node biopsy sites in 13 (10%) patients. Of 10 patients undergoing lymph node dissection, 9(90%) had no additional pathological lymph node involvement. We achieved 99% success rate, 1% rate of failed sentinel node procedure, and 8% false-negative rate after median follow-up for 2 years. CONCLUSIONS: We concluded that gamma probe-directed sentinel lymph node biopsy is a straightforward procedure which can be done in the outpatient setting and facilitates management of patients with cutaneous malignant melanoma. It allows the surgeon to identify all basins at risk for metastatic disease and the location of the sentinel node(s) in relation to the basin.

Extracorporeal photochemotherapy in a patient with Ki-1-positive anaplastic large-cell lymphoma.

A 57-year-old man with Ki-1 anaplastic large-cell lymphoma treated with extracorporeal photochemotherapy is described.

Silicone granuloma in acral skin in a patient with silicone-gel breast implants and systemic sclerosis.

A 68-year-old white woman was referred to us by her rheumatologist for possible participation in a clinical study of photopheresis for scleroderma. In February 1993, she noticed edema of her distal phalanges, Raynaud's phenomenon in both hands, flu-like symptoms, fatigue, intermittent diarrhea, abdominal pain, tearing in both eyes, dyspnea on exertion, dysphagia, and odynophagia. Bilateral silicone-gel breast implants had been placed 12 years before; 2 months before her present evaluation, they were removed and found to be ruptured. Physical examination revealed edema, limited to the fingers and hands bilaterally, and slight induration of the skin on the dorsum of both hands and distal forearms. The remainder of the physical examination was normal. According to our study protocol, a skin biopsy specimen from the dorsum of the right hand was taken, but all other laboratory investigations were refused. Histopathologic examination revealed multiple clear spaces of varying sizes in the dermis and multinucleated macrophages containing small refractile particles, characteristic of silicone granuloma (Figs. 1 and 2); however, the specimen showed no evidence of scleroderma. X-ray energy dispersive analysis by scanning electron-microscopy confirmed the presence of elemental silicon in the small refractile particles. The patient did not receive any treatment after her diagnosis and shortly thereafter, she was lost to follow-up.

Treating nevoid basal cell carcinoma syndrome.

More than 100 anomalies are associated with this syndrome. In this case, a cyst removed from a 15-year-old male was diagnosed as an odontogenic keratocyst. The long history of this syndrome with its associated problems is described.

Change in presentation of breast cancer in a community hospital.

An aggressive mammographic screening program under the auspices of a community hospital resulted in a significantly earlier detection of breast cancer at presentation in 1990 as compared to 1980. It is anticipated that further followup will show a reduction in cancer mortality as a result of this earlier detection.

Granulomatous prostatitis: a hypoechoic lesion of the prostate.

Numerous benign and malignant entities can disrupt the normal prostatic parenchymal architecture producing hypoechoic lesions in the peripheral zone. We report two cases of granulomatous prostatitis mimicking carcinoma. The differential diagnosis of hypoechoic lesions and the etiologies of granulomatous prostatitis are discussed. All hypoechoic lesions in the peripheral zones of the prostate require biopsy for histologic diagnosis.

Bilateral temporal bone involvement with eosinophilic granuloma.

We present an unusual case of bilateral temporal bone destruction due to eosinophilic granuloma in a young child. The patient initially presented with otitis media, with subsequent rapidly developing bilaterally symmetric masses in the mastoid region. Computed tomography demonstrated extensive bony destruction which, after a course of vinblastine chemotherapy, improved dramatically on follow-up scans.

Immunoperoxidase study of lymphomas. Comparison of a one-step frozen section technic with indirect methods on paraffin sections.

Fifty cases of non-Hodgkin's lymphoma (15 nodular and 35 diffuse) were studied to determine the sensitivity, specificity, and ease of several different immunoperoxidase methods. The methods included a rapid, simple one-step immunoperoxidase procedure on frozen sections compared with indirect immunoperoxidase technics on paraffin sections. The frozen-section immunoperoxidase technic stained 15 of 15 nodular lymphomas and 24 of 35 diffuse lymphomas for monoclonal light chain. The majority of the diffuse lymphomas that did not stain for light chains were morphologically and immunohistochemically consistent with T-cell lymphomas. The indirect method on B-5 and formalin-fixed tissues only rarely displayed monoclonal staining for nonplasmacytoid small cell lymphomas but did stain some large cell lymphomas and a majority of plasmacytoid lymphomas for monoclonal light chain. The frozen section technic presented in this report is sufficiently sensitive and reliable to detect immunoglobulins in any morphologic subtype of B-cell lymphoma, whereas paraffin-embedded tissues have only limited application.

Gastrointestinal lymphomas. Immunohistochemical studies on the cell of origin.

The classification of primary malignant lymphomas of the gastrointestinal tract by their cell of origin has been a subject of great controversy in recent years, with the proportion of histologic subtypes varying substantially in different published series. Much of this controversy was initially due to the widely recognized inherent difficulty of classifying lymphomas based on routine histologic sections alone. However, the advent of immunohistochemical techniques has also yielded disparate results. Particularly contentious has been the notion of true histiocytic lymphomas, which some investigators have claimed to be relatively frequent in the gastrointestinal tract, whereas others doubt whether they exist at all. We present here a classification of 25 gastrointestinal lymphomas seen in the surgical pathology services of UCLA Hospital and Stanford University Medical Center. Unlike all previously reported series, we have utilized frozen tissue sections for the performance of immunohistochemical studies, which we and others have found to be far more reliable than the use of formalin-fixed, paraffin-embedded tissues, particularly in detecting monoclonal surface staining of immunoglobulin light- and heavy-chain markers. We find that this technique lessens the likelihood of overinterpreting the stains for histiocyte markers (alpha 1-antitrypsin and lysozyme), which are often difficult to read owing to strong positive staining of benign reactive histiocytes within the tumor. Utilizing these techniques, we have been able to classify definitely 21 of our 25 lymphomas (84%) as of B-cell origin, whereas none appeared to be histiocytic. We conclude that true histiocytic lymphomas of the gastrointestinal tract must be very rare, and we recommend the routine use of frozen tissue sections for more accurate classification of these interesting lesions.

Teratomas of the head and neck in childhood.

Teratomas are tumors consisting of tissue arising from all three embryonic germ layers. Their occurrence in the head and neck region is rare. Three patients with this lesion are presented. Although exhibiting progressive uncoordinated growth, histologic evidence of malignancy in the head and neck form of this tumor is distinctly uncommon. Mortality associated with teratomas is most often secondary to respiratory compromise. Complete surgical extirpation is the treatment of choice to lower mortality and recurrences. The use of fine needle aspiration in the management of neck masses in children is discussed.

Pulmonary nodular amyloidosis presenting as Sjögren's syndrome.

A case of nodular pulmonary amyloidosis with Sjögren's syndrome is presented. A search of the literature failed to reveal any such case in which pulmonary nodules progressively calcify.

Diffuse colitis cystica profunda. Report of a case.

A 20-year-old man had a 2-year history of ulcerative colitis with multiple exacerbations and failure of medical management. In addition to evidence of ulcerative colitis involving the descending colon and rectum, the remainder of the total proctocolectomy specimen demonstrated prominent, circumferential, polypoid elevations of mucosa and epithelial-lined, submucosal mucous cysts diagnostic of colitis cystica profunda. The involvement of the ascending and transverse colon was diffuse. Colitis cystica profunda is an uncommon condition, usually localized to the rectum and which can be misdiagnosed both clinically and pathologically as invasive carcinoma. Diffuse involvement of the proximal colon as noted in this case, is exceedingly rare.

Fatal veno-occlusive disease of the liver following high-dose 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) and autologous bone marrow transplantation.

Veno-occlusive disease of the liver has recently been reported to occur in patients receiving multiagent chemotherapy together with total-body irradiation and bone marrow transplantation for malignancies. Reported is a case of a 22-year-old woman with disseminated diffuse histiocytic lymphoma in whom fatal hepatic veno-occlusive disease developed two and one-half weeks following high-dose 1,3-bis(2-chloroethyl)-1-nitrosourea) (BCNU) therapy and autologous bone marrow transplantation. This appears to be the first report of this entity in association with high-dose BCNU employed as a single chemotherapeutic agent.