Is there a relation between type of primary melanoma treatment and the development of intralymphatic metastasis? A review of the literature.

BACKGROUND: Intralymphatic metastases (ILM) originate from tumor cell emboli entrapped in dermal lymphatics between primary tumor and regional lymph node basin. Because of this origin, sentinel lymph node biopsy (SLNB) might increase ILM by restricting lymph flow. METHODS: Pubmed, Embase, Cochrane and Medline were searched for articles on ILM between 1980 and September 2014. ILM Incidences were calculated after wide local excision (WLE), excision with elective lymph node dissection (ELND) or therapeutic lymph node dissection (TLND), WLE with SLNB with or without completion lymph node dissection (CLND) and delayed lymph node dissection (DLND) for patients developing nodal metastasis during follow-up. RESULTS: In 36 studies, 14,729 patients underwent WLE, 1682 patients WLE/ELND, 362 patients WLE/DLND and 11,201 patients WLE/SLNB. On meta-analysis, ILM occurrence was 3.4% (95% CI 2.8-4.2%). ILM occurred most frequently in the WLE/DLND group (5.5%, 95% CI 3.5-8.7%), followed by WLE/ELND (4.7%, 95% CI 3.1-7.0%), WLE/SLNB (4.5%, 95% CI 3.5-5.7%) and WLE alone (1.9%, 95% CI 1.4-2.7%). 1330 SLNB+ patients were identified and 5783 SLNB- patients. For these groups, on meta-analysis, ILM recurrence was 13.2% (95% CI 10.8-16.2%) and 3.4% (95% CI 2.5-4.5%), respectively (p=0.01). CONCLUSION: In this review SLNB is associated with an increase of ILM with an incidence of 1.9% for WLE vs. 3.4% for SNLB-. Selection bias in this review cannot be excluded. However, ILM occur four times more frequently after SLNB+ than SLNB- procedures and more often after SLNB+/CLND than WLE/DLND or WLE/ELND. ILM should therefore be viewed as a bio-marker of aggressive primary disease. SYNOPSIS: Sentinel lymph node biopsy is thought to increase intralymphatic metastasis by restricting lymph flow. This review demonstrates that there is an increase in metastasis, but this result has to be interpreted with caution due to possible selection bias. Aggressive tumor characteristics are likely the cause of this increase.

Tumor mitotic rate added to the equation: melanoma prognostic factors changed? : a single-institution database study on the prognostic value of tumor mitotic rate for sentinel lymph node status and survival of cutaneous melanoma patients.

BACKGROUND: This study aimed to investigate the predictive value of the tumor mitotic rate per mm(2) (TMR) for sentinel lymph node (SLN) status and survival in intermediate and thick cutaneous melanoma. METHODS: Patients treated for stage I and II melanoma with wide local excision and SLN biopsy between May 1995 and May 2013 were analyzed. In case of insufficient data regarding TMR, pathology slides were reanalyzed. Prognostic factors for SLN status and survival were analyzed with the emphasis on TMR, which was analyzed as a continuous variable, dichotomized (median value) and categorized by two methods. RESULTS: The study analyzed 453 patients with complete TMR data. The median Breslow thickness was 2.20 mm, and 31.8 % of patients had tumor-positive sentinel lymph node biopsies (SLNBs). In the univariate analysis, TMR was associated with tumor-positive SLNB. This association was not significant in the multivariate analysis. Breslow thickness, primary tumor location on trunk and legs, and younger age were associated with tumor-positive SNLB. At a median follow-up of 47 months, 119 patients (26.3 %) had recurrent disease, and 92 (20.3 %) had died of melanoma. In the univariate analysis, TMR could be established as a significant prognostic factor for disease-free and disease-specific survival, but not in the multivariate analyses. Breslow thickness, ulcerated melanoma, and tumor-positive SLNB were significant prognostic factors for survival. CONCLUSION: The study was unable to establish TMR as an independent prognostic factor associated with the presence of SLN metastasis. Regarding survival, increasing TMR showed a strong association with decreased survival in the univariate analysis, but this association was rendered nonsignificant by the importance of Breslow thickness and ulceration status in the multivariate model.

Bilateral catheter-directed thrombolysis in a patient with deep venous thrombosis caused by a hypoplastic inferior vena cava.

INTRODUCTION: Deep venous thrombosis treatment using catheter-directed thrombolysis is advocated over systemic thrombolysis because it reduces bleeding complications. With the development of a catheter that combines ultrasound vibrations and the local delivering of thrombolytics, new and safer treatments appear that are suitable for more complex problems. REPORT: An adolescent male presented with bilateral iliofemoral thrombosis based on a hypoplastic inferior vena cava that had existed for more than two weeks. He was successfully treated by bilateral ultrasound-accelerated catheter-directed thrombolysis using EkoSonic® (Small Vessel) Endovascular System (EKOS) and stenting of the inferior vena cava. After eight months of follow-up, the inferior vena cava is still patent. CONCLUSION: EKOS thrombolysis of longer existing bilateral deep venous thrombosis in the central venous system is a successful treatment modality in congenital inferior vena cava anomalies.

Central blood flow measurements in stable preterm infants after the transitional period.

BACKGROUND: Central blood flow measurements can provide detailed information on the hemodynamic condition of the preterm infant. However, reference values for right and left ventricular output (RVO and LVO) and superior vena cava flow (SVC flow) are only available for infants in the transitional period. The aim of this study was to determine RVO, LVO and SVC after the transitional period in stable preterm infants. METHODS: RVO, LVO and SVC flow were measured with functional echocardiography on days 7 and 14 of life in stable preterm infants less than 32 weeks gestation, with minimal respiratory support and no cardiovascular support. Infants with a clinical suspicion of an infection within 48 h after data collection or a ductal diameter >1.4 mm were excluded from analysis. RESULTS: We performed 111 measurements in 62 preterm infants with a median (range) gestational age of 28 (25-31) weeks and birth weight of 1105 (650-2370) g. 57 measurements were analysed on day 7 and 47 on day 14. The mean (SD) RVO, LVO and SVC flow were 429 (116), 296 (74) and 89 (33) ml/kg/min on day 7 and 433 (81), 300 (79) and 86 (26) ml/kg/min on day 14. There were no significant differences in flows between days 7 and 14 in the paired measurements. CONCLUSION: This study provides central blood flow values in stable preterm infants after the transitional period. The flow variables were shown to remain stable between days 7 and 14.