Frozen section investigation of the sentinel node in malignant melanoma and breast cancer.

BACKGROUND: Intraoperative frozen section investigation allows immediate regional lymph node dissection when the sentinel node contains tumor. The purpose of this study was to determine the sensitivity of frozen section diagnosis of the sentinel node in melanoma and breast cancer patients. METHODS: A total of 177 sentinel nodes from 99 melanoma patients and 444 lymph nodes from 262 breast cancer patients were assessed by frozen section investigation. Nodes were bisected, and a complete cross-section was obtained for frozen section. Step sections at three levels were made of the remaining lymphatic tissue and were stained with hematoxylin and eosin and S100/HMB45 (melanoma) or CAM5.2 (breast cancer) to obtain a final pathological diagnosis. RESULTS: Frozen section investigation revealed metastases in 8 of 17 node-positive melanoma patients (47%). Seventy-one of 96 breast cancer patients (74%) with lymph node metastases were identified with frozen section. The specificity was 100% and 99%, respectively. CONCLUSION: The sensitivity of intraoperative frozen section investigation of sentinel nodes was 47% in melanoma patients and 74% in breast cancer patients. Frozen section examination allows immediate axillary lymph node dissection in the majority of node-positive breast cancer patients. Frozen section analysis is not recommended in patients with melanoma.

[Importance of regional surgery networks]. / Het belang van regionale chirurgische netwerken.

The rapid advantages in medicine require large-scale implementation where justified, and concentration where complexity of the care makes this necessary. Cautious initiatives to establish regional surgical networks were taken in many places in the Netherlands. These networks might play an important part in the spreading and concentration of care. New surgical techniques, such as the sentinal node procedure, can be implemented professionally using these networks. Also, within these networks, guest surgeons may in various locations perform relatively rare operations or assist with them, especially if the ultimate result of the treatment is primarily determined peroperatively by specific surgical technical experience. In cases in which the results of the treatment depend not so much on the surgeon himself but rather on the experience of various disciplines with a range of diagnostic and therapeutic interventions, referral to a centre is in general to be preferred.

[Effective intraoperative identification of parathyroid adenomas by means of a gamma probe after injection of technetium 99m-sestamibi in 5 patients]. / Effectieve intraoperatieve detectie van een bijschildklieradenoom met een gammaprobe na injectie van technetium-99m-sestamibi bij 5 patiënten.

Primary hyperparathyroidism is caused by a single adenoma in the majority of patients. In five patients (2 men aged 74 and 78 and 3 women aged 78, 58 an 73 years) a recently introduced approach for intraoperative identification of pathological parathyroid glands was applied using intravenously injected technetium-99m(99mTc)-sestamibi and a gamma probe. For two patients this was a reoperation in this region. All patients had one adenoma removed and became normocalcaemic postoperatively. The time between the start of the operation until the extirpation of the adenoma was 13-25 min, a lot shorter than bilateral cervical exploration takes, even in the two reoperations. These results confirm the literature that this approach minimizes operative intervention, thereby shortening operative time and reducing potential surgical complications.

Sentinel lymph node biopsy in breast cancer: guidelines and pitfalls of lymphoscintigraphy and gamma probe detection.

BACKGROUND: Sentinel node (SN) biopsy appears to offer an alternative to routine axillary lymph node dissection (ALND) for staging patients with breast cancer. Various techniques have been studied for identifying the SN, using vital blue dye or radioactive colloid, and initial reports are promising. The inherent limitations and pitfalls must be clearly understood before SN biopsy can be implemented in dinical practice. STUDY DESIGN: In a prospective trial, the feasibility of using lymphoscintigraphy and gamma probe detection for performing SN biopsy was studied. In 130 consecutive patients with T1-T2, N0 breast cancer, preoperative lymphoscintigraphy was performed with technetium 99m-colloidal albumin. During ALND, the radioactive axillary SNs were localized by the gamma probe. Histopathologic examination of the harvested SNs was compared with the status of the axillary lymph nodes. RESULTS: Axillary focal accumulations were clearly identified on lymphoscintigraphy in 116 patients (89%). The failure rate was significantly higher in patients who had a previous excision biopsy (36%) than in those with a palpable tumor in situ (4%). Using the gamma probe, radiolabeled axillary SNs were successfully biopsied in 122 patients (94%). Because 18 of these patients did not undergo formal lymphadenectomy, the predictive accuracy of SN biopsy was analyzed in 104 patients. Radioactive nodes revealed metastases in 44 of 104 patients (42%); in 26 of them (59%), these were the only involved axillary nodes. The SN was negative in 60 patients (58%); in one patient the ALND was found to contain metastatic disease (1.7% false negatives). Biopsy of the SN was 98% accurate in predicting the absence of nodal metastases. CONCLUSIONS: There are certain guidelines for performing SN biopsy by lymphoscintigraphy and gamma probe detection. Success depends primarily on an adequate functional capacity of the SN, necessary for sufficient nodal uptake to ensure accurate identification. Lymphoscintigraphy defines the pattern of lymph flow and may prevent failure or false-negative biopsies. Biopsy of the SN is a highly accurate, minimally invasive method of staging patients with breast cancer and can substantially reduce the morbidity and costs of surgical treatment by avoiding unnecessary ALND in the majority of patients.

Impact of lymphoscintigraphy on sentinel node identification with technetium-99m-colloidal albumin in breast cancer.

UNLABELLED: Identification of the sentinel node by using colloidal tracers and a gamma probe or lymphoscintigraphy could be an effective alternative for the complicated original dye-oriented approach. We studied the sentinel node detection rate using early and delayed imaging in breast cancer patients. METHODS: Thirty-seven patients were imaged 2 hr and 18 hr after peritumoral injection of 99mTc-colloidal albumin. Preoperatively, axillary foci were located with a handheld gamma probe that was also used to isolate radiolabeled nodes from the axillary dissection specimens. The predictive value of the sentinel node for the axillary tumorstatus was evaluated with histological examination. RESULTS: Two and 18 hr after injection, lymphoscintigraphy revealed one to three separate axillary lymph nodes in 33 and 34 patients, respectively. In 30 patients the axillary foci were easily localized with the gamma probe preoperatively. In all 34 patients (92%), with visualized axillary foci, at least one radioactive sample could be retrieved using the gamma probe (total 53 samples). Metastases were found in the sentinel nodes of 11 patients, in seven of 11 being the only tumor-positive lymph node in the axilla. There were no false-negative sentinel nodes. CONCLUSION: The selective targeting and prolonged intranodal retention of 99mTc-colloidal albumin allows successful sentinel node identification in most (92%) patients.

Squamous carcinoma of the oropharynx.

One hundred and ten patients with an oropharyngeal carcinoma seen in the period 1961--1971 at the Antoni van Leeuwenhoek Hospital in Amsterdam are analysed. Approximately 75% of the patients were older than 60 years. About 60% of the patients had a cervical lymph node metastasis at the time of admission. Virtually all patients were treated exclusively by radiotherapy. Of the total group, the absolute survival was 26%, for tumours of the tonsil 35%, and for the base of the tongue 17%. There was no significant correlation between the histological degree of differentiation and the survival. The possibility of improving the results of selected patients is discussed.