Comparison of blue dye and probe-assisted intraoperative lymphatic mapping in melanoma to identify sentinel nodes in 100 lymphatic basins.

OBJECTIVE: To determine whether combining isosulfan blue dye with a radiopharmaceutical agent will increase intraoperative detection of sentinel nodes (SNs) in patients with early-stage melanoma. PATIENTS AND DESIGN: Clinical trial with a consecutive sample. Eighty-seven patients with clinical stage I melanoma underwent preoperative lymphoscintigraphy with 1 of 3 radiopharmaceutical agents to identify the lymphatic basin and the site of the SN. All patients subsequently underwent intraoperative lymphatic mapping and selective lymph node dissection (SLND) with isosulfan blue dye and a radiopharmaceutical agent. A handheld gamma probe determined the radioactive counts over the draining lymph node basins and individual blue-stained lymph nodes before (in vivo) and after (ex vivo) their removal. An irrelevant body site was used as the denominator of a count ratio by which absolute counts were standardized for comparison. Completion lymphadenectomy was undertaken in patients whose SLND specimen had histopathologic evidence of tumor cells. SETTING: Tertiary care cancer center. INTERVENTION: Lymph node sampling. MAIN OUTCOME MEASURE: Accuracy of SN detection by blue dye and radiopharmaceutical techniques. RESULTS: Preoperative lymphoscintigraphic images identified 100 lymph node basins and 135 lymph nodes in 87 patients. All 3 radiopharmaceutical agents were equally effective in imaging the SN before surgery. During SLND, we identified and removed 136 blue-stained and radioactive (hot) SNs and 8 additional non-blue-stained hot nodes from 98 basins (98.0%). Of the 144 excised lymph nodes, 132 nodes (91.7%) from 83 basins had either an in vivo- or an ex vivo-background count ratio of 2:1 or more and 125 nodes (86.8%) from 77 basins had a count ratio of 3:1 or more. Twelve blue-stained SNs had count ratios of less than 2:1. Seventeen SNs (11.8%) from 15 basins contained metastases: 16 were identified with blue dye and probe and 1 was identified with blue dye alone. Four (1.1%) of 377 non-SNs excised during completion lymphadenectomy contained metastases. There have been no lymph node recurrences during mean follow-up of 16.3 months (range, 7-42 months). CONCLUSIONS: The blue dye technique remains the criterion standard for SLND in melanoma. The addition of a radiopharmaceutical tracer serves as a useful adjunct to the visualization of blue-stained SNs.

Detection of metastases in sentinel lymph nodes of breast cancer patients by multiple-marker RT-PCR.

This study was undertaken to assess a multiple-marker RT-PCR and Southern blot assay for detection of metastases in frozen sections of sentinel lymph nodes from breast cancer patients. Sentinel lymphadenectomy was performed in 41 AJCC (American Joint Committee on Cancer) stage I-IIIA breast cancer patients and 57 sentinel nodes (SNs) were excised. The SN, which is the first node in the lymphatic basin to receive metastases from the primary tumor, was identified using isosulfan blue dye. Hematoxylin and eosin (H&E), immuno-histochemistry (IHC) and RT-PCR were performed on adjacent sections of the SN. Six consecutive 12-microm frozen sections of each SN were obtained for the RT-PCR assay to determine expression of mRNA tumor markers C-Met, beta1 --> 4GalNAc-T and P97. Metastatic breast cancer was detected by H&E in 10 of 57 (18%) SNs and by IHC in an additional 7 (12%). Only 1 of 17 (6%) SNs with metastases did not express any of the 3 tumor mRNA markers. C-Met, beta1 --> 4GalNAc-T and P97 tumor mRNA markers were expressed in 31 (78%), 21 (53%) and 25 (63%) of 40 SNs without metastases, respectively. At least 2 mRNA tumor markers were expressed in 25/40 (63%) histo-pathologically tumor-free SNs, whereas all 3 mRNA tumor markers were expressed in 17/40 (43%) SNs. Expression of all 3 mRNA tumor markers in a SN was significantly higher in patients with a family history of breast cancer (p = 0.05), prior history of breast cancer (p < 0.05), infiltrating lobular carcinoma (p = 0.06), estrogen receptor-negative (p = 0.04) tumor or a higher Bloom Richardson score (p = 0.04). The multiple-marker RT-PCR and Southern blot assay improves the detection of occult metastases in the SN when compared to conventional H&E and IHC analysis. Expression of all 3 tumor mRNA markers in the SN correlated with poor prognostic clinico-pathologic factors compared to expression of 0 to 2 markers.

Complications of hepatic cryosurgery.

Cryosurgery may be considered for patients whose hepatic lesions are not amenable to surgical resection, i.e., patients with multiple hepatic lesions and/or lesions abutting major vascular structures. Because the size of the iceball created during the procedure can be carefully controlled, cryosurgery has the advantage of being a focal technique that spares much more noncancerous liver tissue than surgical resection. The major complications of hepatic cryosurgery are the same as those of hepatic resection: hemorrhage, pleural effusion, bile leak fistula, perihepatic abscess, and hepatic failure. In addition, there is a risk of coagulopathy when large tumors are frozen using multiple freeze-thaw cycles. In general, operative morbidity is related to the volume of frozen tissue, the number of freeze-thaw cycles, and number of cryoprobes. Further experience and accrual of long-term data should better define the indications for hepatic cryosurgery and minimize the incidence of complications.

Intraoperative lymphatic mapping for early-stage melanoma of the head and neck.

BACKGROUND: We previously reported dye-directed intraoperative lymphatic mapping and selective sentinel lymphadenectomy for primary cutaneous melanomas draining to the neck lymph nodes. In this study we determined whether combining the dye with a radiopharmaceutical agent would enhance our rate of sentinel node detection. METHODS: One hundred seventeen patients with primary cutaneous melanomas of the upper chest and head and neck underwent preoperative cutaneous lymphoscintigraphy to confirm lymphatic drainage to neck nodes, followed by intraoperative lymphatic mapping and sentinel lymphadenectomy. In 94 cases, isosulfan blue dye was injected at the primary site; in the remaining 23 cases, a 1:3 mixture of radiopharmaceutical and dye was injected, and a hand-held probe was used to determine the radioactive counts. RESULTS: Preoperative cutaneous lymphoscintigraphy identified 129 drainage basins; 12 patients (10%) had dual-basin drainage. During intraoperative lymphatic mapping and sentinel lymphadenectomy, 183 sentinel nodes were identified and excised from 120 basins (1.5 nodes/basin). The blue dye alone identified sentinel nodes in 93 of 101 basins (92%). The probe identified sentinel nodes in 28 of 28 basins, only one of which failed to reveal blue-staining sentinel nodes; thus, the probe plus dye identified sentinel nodes in 27 of 28 basins (96%). Histopathologic analysis revealed metastasis in sentinel nodes from 11 patients (12%) who underwent sentinel lymphadenectomy with blue dye alone and in 3 patients (13%) who underwent sentinel lymphadenectomy with dye plus probe. There were no same-basin recurrences over a mean follow-up of 46 months (range 1 to 125). CONCLUSIONS: Selective sentinel lymphadenectomy is a highly accurate method of staging the regional nodes in patients with primary tumors of the head and neck. Although we initially demonstrated the utility of this technique with blue dye alone, our results now suggest that the combination of dye and radiopharmaceutical may be a more sensitive method to detect sentinel nodes.

Cryosurgery causes a profound reduction in tumor markers in hepatoma and noncolorectal hepatic metastases.

Cryosurgical ablation of hepatic metastases from colon carcinoma has become a useful adjunct in the management of patients whose tumors are not amenable to surgical resection. We evaluated cryoablation of hepatoma and noncolorectal hepatic metastases by examining its effect on serum levels of tumor markers in 20 patients with primary liver cancer (N = 5) or liver metastases (N = 15) from breast cancer, neuroendocrine tumors, ovarian cancer, and thyroid cancer. All patients had failed conventional therapy and had no evidence of extrahepatic spread. After cryosurgery, 17 patients had a significant decrease in tumor marker levels (median 77%) and a significant improvement in symptoms. One patient died of nontumor causes, and five patients died of recurrent disease. Median interval to death or last follow-up was 28.3 months overall (range, 2-45 months), 17.9 months for nonsurvivors (range, 2-44 months), and 35.2 months for survivors (range, 26-45 months). Median survival was 32 months following curative surgery (range, 16-45 months) and 25 months following palliative surgery (range, 2-42 months). Cryosurgical ablation of noncolorectal hepatic metastases and primary hepatomas produces a profound reduction in serum levels of tumor markers. It is safe, provides excellent palliation of symptoms, and in selected patients can be performed with curative intent.

Melanoma-associated antigens as messenger RNA detection markers for melanoma.

Melanoma is heterogeneous for its biological properties and melanoma-associated antigens (MAAs). This diversity is partially observed in the expression of the MAAs involved with the melanin synthesis pathway. We therefore developed a sensitive multimarker reverse transcription-PCR plus Southern blot assay using five MAAs as molecular markers to detect primary and metastatic melanoma cells. Melanoma cell lines, melanocytes (cultured), primary and metastatic malignant melanoma tissues, and blood from patients with American Joint Committee on Cancer stage I-IV melanoma were assessed for tyrosinase, tyrosinase-related proteins 1 and 2, Pmel 17, and MART-1/Melan-A. All of the MAA mRNA markers were expressed in 100% of melanoma cell lines and cultured melanocytes, 74% of primary and metastatic tumors (excluding tumor-draining lymph nodes), 43% of tumor-involved lymph nodes, and 43% of patients' bloods. Hypomelanotic melanoma tissues expressed a lower frequency of individual mRNA markers. Overall, at least one mRNA marker was expressed in more than 86% of specimens assayed. Normal tissue specimens from patients and blood from normal volunteer donors were negative for MAA mRNA expression. The multimarker MAA reverse transcription-PCR plus Southern blot analysis was more reliable and sensitive than a single-molecular marker assay for the detection of melanoma cells. This molecular assay can also provide information on MAA mRNA expression of metastatic melanoma cells that may assist in monitoring the therapeutic efficacy of active specific immunotherapy toward specific MAA-bearing melanomas.

Sentinel lymph node metastasis in experimental melanoma: relationships among primary tumor size, lymphatic vessel diameter and 99mTc-labeled human serum albumin clearance.

BACKGROUND: This study was designed to investigate the relationships among primary tumor size, lymphatic vessel diameters, the incidence of sentinel lymph node (SLN) metastasis and lymphatic clearance from murine footpad melanomas. METHODS: Lymphatic clearance (LC) of [99mTc]HSA from the middle of the footpad of syngeneic C57BL/6 mice, with or without primary melanomas (sizes varying from 1 to 5 mm in anteroposterior diameter), was quantitated using a gamma scintillation detection system. Lymphatic vessel diameters (LD) were measured after injection of aniline blue dye into footpad tumors. The incidence of SLN, femoral lymph node (FLN), and lung metastases was recorded. RESULTS: Metastasis to SLNs increased as tumor growth progressed (r = 0.976, p = 0.001), and there was a correlation between tumor size and both FLN (p = 0.041) and lung (p = 0.055) metastases. There was also a correlation between lymph node metastasis and LC (r = 0.83, p = 0.04) and LD (r = 0.84, p = 0.04). CONCLUSIONS: These studies support the hypothesis that lymph flow and LD is increased in experimental murine melanomas and this relates to both primary tumor size and to lymphatic and hematogenous metastasis.

Lymphatic diameters and radionuclide clearance in a murine melanoma model.

OBJECTIVES: To determine the clearance of a radionuclide from various sizes of footpad melanomas via lymphatics and to measure the diameters of these vessels. DESIGN: Nonrandomized animal study. SETTING: A hospital research laboratory. SUBJECTS: C57BL/6 mice. INTERVENTIONS: Female mice were injected in the right rear footpad with B16 F10 cells that were allowed to grow to either 1, 2, 3, 4, or 5 mm in anteroposterior diameter. Clearance from feet with or without tumors of injected technetium Tc 99m human serum albumin (99mTcHSA) was assessed for 200 minutes. Calf lymphatic diameters were measured using aniline blue dye. RESULTS: The clearance of the injected 99mTcHSA from mouse footpads without tumors was 1.26 +/- 0.18 x 10(-4) mL/min x cm3 of tissue. Clearance increased 2.24-fold to 2.82 +/- 0.12 x 10(-4) mL/min x cm3 of tissue from 1-mm tumors and to 6.20 +/- 0.08, 6.11 +/- 0.13, 6.91 +/- 0.58, and 7.23 +/- 0.48 x 10(-4) mL/min x cm3 of tissue from 2-, 3-, 4-, and 5-mm tumors, respectively (P < .05). Calf lymphatic diameters increased from 75.41 +/- 9.72 microns in naive nontumor-bearing mice to 93.51 +/- 7.12, 111.61 +/- 27.07, 126.69 +/- 25.20, 124.43 +/- 24.75, and 127.44 +/- 25.35 microns in mice bearing 1-, 2-, 3-, 4-, and 5-mm tumors, respectively (P < .01). CONCLUSIONS: There was a size-dependent, direct correlation between increasing tumor size in the footpad and increasing diameter of lymphatics draining the footpad. Clearance of injected 99mTcHSA from these tumors also exhibited a similar positive correlation with tumor size.

Cryosurgical palliation of metastatic neuroendocrine tumors resistant to conventional therapy.

BACKGROUND: Hepatic cryosurgery is a well-recognized modality for hepatic colon metastases. We examined its potential use for refractory neuroendocrine tumors causing progressive symptoms. METHODS: Between July 1992 and February 1997, 19 patients (with islet cell, 7; carcinoid, 8; vasoactive intestinal peptide, 1; gastrinoma, 3) underwent cryosurgery with ultrasonography. The number of lesions frozen ranged from 1 to 16 (median, 8), and their diameters ranged from 2 to 15 cm with an average of 4 cm. Patients underwent resection of the primary tumor either before (37%) or concurrent with (32%) cryosurgery, and half underwent excision of metastases with cryosurgery. Before cryosurgery, patients received chemotherapy (63%), somatostatin (47%), interferon (10%), hepatic artery ligation (5%), radiation (10%), and/or omeprazole (16%). RESULTS: The reduction in tumor markers reached 90% (5-hydroxyindoleacetic acid), 80% (vasoactive intestinal peptide), 90% (gastrin), 90% (pancreatic polypeptide), and 80% (serotonin). At a median follow-up of 17 months, the metastases had progressed in 11 patients (two underwent a second cryosurgical procedure that eliminated symptoms) and five had died. Subsequently an additional five patients received chemotherapy and three somatostatin. Median symptom-free and overall survival were 10 months and more than 49 months, respectively. CONCLUSIONS: Cryosurgery dramatically relieved symptoms with significant reduction in tumor markers. The reduced tumor burden may explain the subsequent response to systemic therapy. Cryosurgery is a useful adjuvant in symptomatic patients with refractory hepatic neuroendocrine metastases.

Detection of metastatic breast cancer by beta-hCG polymerase chain reaction.

Reverse transcriptase-polymerase chain reaction (RT-PCR) for detection of occult malignancies in breast cancer patients is evolving as a useful diagnostic tool. However, no reliable molecular mRNA markers are available. We developed an RT-PCR plus Southern blot assay using beta-hCG (beta-subunit of human chorionic gonadotropin) gene expression as a tumor marker for detection of breast malignancies metastatic to tumor-draining lymph nodes and blood. Breast carcinoma cell lines, primary breast malignancies and human placenta were used as positive controls for establishing the beta-hCG RT-PCR assay. Peripheral blood leukocytes (PBL) from normal volunteer donors, normal breast tissue and lymph nodes from cancer-free patients were used as negative controls. beta-hCG RT-PCR was used to assess tumor cell presence in PBL and tumor-draining axillary nodes from patients with AJCC stage I-IV breast cancer. The assay sensitivity and specificity were enhanced by restriction endonuclease digestion of an Sty I site of the RT-PCR cDNA product followed by Southern blot analysis. beta-hCG mRNA was expressed in all breast cancer cell lines and 80% of primary breast cancers; it was not expressed in negative controls. The assay reliably detected one cancer cell in > 10(7) PBL, with a sensitivity of 10(-5) microgram RNA. Eighty percent of PBL and 61% of tumor-draining axillary nodes from breast cancer patients expressed beta-hCG mRNA. The assay is a sensitive and specific method of identifying breast cancer cells in breast tissues, lymph nodes and blood.

Metachronous second primary malignant fibrous histiocytoma in two skeletal muscles.

The first recorded case of a metachronous second primary malignant fibrous histiocytoma (MFH) of soft tissue is presented. The patient, who has been followed every two months since the treatment of his buttock sarcoma by neoadjuvant therapy, is free of disease 24 months later. The clinical presentations, different histologies, and DNA contents of these two MFHs are consistent with metachronous primary sarcomas. The literature on second primary neoplasms is discussed.