Standard and nonstandard applications of sentinel node-guided melanoma surgery.

Identification and histologic study of the sentinel node (SN) is an acceptable, yet not firmly established, guide for treating intermediate-thickness melanoma. This study widens the range of applications of this technique. We included 97 patients with intermediate-thickness melanoma lesions or lesions for which there is no standard treatment. Fifty-six underwent preoperative lymphoscintigraphy, and all underwent intraoperative lymphatic mapping (IOLM) using blue dye, followed by frozen section study and total node processing by serial sections. Elective lymph node dissection was performed in cases of metastasis to the sentinel node or technical failures with high risk. Four categories were defined: (A) intermediate-thickness lesions (mean 2.27 mm) (n = 45); (B) thin lesions (mean 1.14 mm) with risk factors of regional failure (n = 27); (C) lesion thickness close to but more than 4 mm (n = 10); and (D) lesions of undetermined thickness (n = 15). Median follow-up was 30 months (range 13-51 months). Intraoperative lymphatic mapping successfully identified the sentinel node (SN) in 93% of basins explored. Metastases were detected in 11 SNs. There were three lymph basin recurrences in patients with previously negative SNs, all salvaged by therapeutic lymph basin dissection and are NED (no evidence of disease). Two SN(+) patients had systemic recurrences; one died of his disease, and the other is alive with disease. One SN(-) patient died NED owing to other cause. This technique spared 83% of category A patients from lymph node dissection. It allowed better staging and better decision making for treatment in categories B and D; and it prevented early regional recurrences in category C patients. Intraoperative lymphatic mapping with SN guidance is a novel, lo

Technetium-99m-MIBI scintimammography in palpable and nonpalpable breast lesions.

UNLABELLED: The aim of this study was to determine the diagnostic accuracy of 99mTc-MIBI scintimammography in patients with palpable and nonpalpable breast cancer. METHODS: One hundred and forty patients with a clinically palpable breast mass and/or suspicious mammographic finding had prone scintimammography after the intravenous injection of 740 MBq 99Tc-MIBI within 5 days before open biopsy or surgery. All patients had mammography within 2 mo before the scintimammography. The mammography was read as probably benign, probably malignant or indeterminate. The scintimammography was read as positive or negative for breast cancer. The scintigraphic studies were correlated with mammographic findings and with histopathology. RESULTS: Histopathological studies showed that the mean tumor size for 61 palpable tumors was 2.57 cm with a range of 1-6 cm, and for 24 nonpalpable tumors the mean size was 1.34 cm with a range of 0.5-3 cm. Mammography had an overall sensitivity of 91.58% and a specificity of 42.87%; the sensitivity was 90.16% and 95.45% and specificity was 57.14% and 32.14% for palpable and nonpalpable tumors, respectively. Eight cases were considered indeterminate. Scintimammography was true-positive for 71 breast cancers, true-negative for 47, false-positive for 8 and false-negative for 14. The overall sensitivity was 83.5% and the specificity 85.4%. In the patients with palpable masses, sensitivity was 95.1% and specificity 75%; in those with nonpalpable lesions, sensitivity was only 54.2% and specificity, 93.5%. Among 18 cases of palpable abnormalities with probably benign mammography, six had true-positive scintimammography. Of eight patients with indeterminate mammography, one was true-positive on scintimammography. CONCLUSION: Scintimammography is an accurate and clinically useful tool for evaluating patients with palpable breast abnormalities when mammography is negative and in the cases of indeterminate mammography. A significant improvement in lesion detectability is necessary in nonpalpable breast abnormalities.

Effective treatment of painful bone crises in type I gaucher's disease with high dose prednisolone.

In type I Gaucher's disease, episodes of severe disabling bone pain, the so called bone crises, may be resistant to all analgesics, including narcotics. The demonstration of subperiosteal oedema on magnetic resonance imaging (MRI) led to an attempt to use steroids to relieve the oedema and thereby the pain. On eight occasions, five patients with documented bone crises received conventional dose steroids (20 mg/m2/day) with considerable shortening of the attacks. On six occasions five further patients received high dose methylprednisolone (30 mg/kg intravenously or 1 g/m2 orally daily for two days), which was followed by oral prednisone for three to five days on the last four occasions. In this later group, pain relief was evident within several hours. Three treatments were given on an ambulatory basis. The MRI scan of one of these patients showed no subperiosteal fluid collection five days after high dose steroids had been started, and on subsequent x ray examination, there was no periosteal elevation. This treatment should be considered in cases of Gaucher's disease with bone crises.

Utility of 24 hour bone scan in evaluation of bone involvement by soft tissue sarcoma.

Accumulation of Tc-99m MDP in soft tissue malignancies occurs frequently. When tumor overlaps adjacent bone structures, the bone margins can be indiscernible on a regular bone scan. Additional views should be taken to differentiate bone from tumor, however, separation is sometimes difficult and not always successful. This report presents a patient in whom accumulation of Tc-99m MDP in a liposarcoma of the thigh disappeared on a 24 hour scan and bone margins were seen clearly. A possible mechanism for this phenomenon and its utility are discussed.

Metabolic studies in a patient with idiopathic hypophosphatemic osteomalacia.

Studies were conducted in a patient with idiopathic hypophosphatemic osteomalacia to delineate the roles of parathyroid hormone (PTH), vitamin D and renal tubular function. A 43-year-old woman presented with progressive skeletal pains resulting in severe incapacity. Workup revealed: hypophosphatemia with a low tubular maximal phosphate reabsorption per glomerular filtrate (TmP/GFR) of 1.05 mg/dl, normocalcemia, hypocalciuria, elevated alkaline phosphatase and glycinuria. PTH and urinary cyclic AMP (UcAMP) were normal, while calcitriol was low. Renal tubular acidosis or other transport defects were not present and no tumor was found. Biopsy was diagnostic for osteomalacia, and the patient responded to 1-alpha OHD3 and phosphate therapy. Hyperparathyroidism was ruled out by 1) normocalcemia persisting after 1-alpha OHD3 and calcium loading and 2) normal PTH and UcAMP challenged by phosphate supplements. Combined calcium and 1-alpha OHD3 administration resulted in hypercalciuria, decreased UcAMP and increased, but not corrected, TmP/GFR. These findings suggest that the osteomalacia was due to hypophosphatemia caused by a renal leak. PTH is only contributory to the phosphaturia. Low calcitriol level contributes to the osteomalacia directly and indirectly through impaired mineral absorption and, therefore, is also responsible for the hypocalciuria.