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ABSTRACT: The aim of the study was to determine the incidence of lymph node recurrence in 16 melanoma patients with a minimal metastasis (Starz level I) in a sentinel node in whom a completion lymph node dissection was omitted. A secondary aim was to examine whether other melanoma-related recurrences developed. Sixteen melanoma patients with an SI-involved sentinel node, who did not undergo completion lymph node dissection, were followed for a median of 66 months. Lymph node recurrences did not occur. One of the 16 patients developed a local recurrence and another developed satellite metastases. None of the 16 patients with an SI-positive sentinel node developed a nodal recurrence, which suggests that the risk of refraining from node dissection in such patients is small. This option could be considered and discussed with the patient in terms of the risk of nonsentinel node involvement and the unsolved problem of unknown overall survival advantage.
Melanoma research 09/2012; · 2.06 Impact Factor
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ABSTRACT: BackgroundLymphatic drainage may change after radiation of a breast or its regional lymph node basins, and this may have implications
for lymphatic mapping afterward. The aim of this study was to determine the lymphatic drainage patterns in breast cancer patients
who had undergone mantle field radiation for Hodgkin’s lymphoma in the past.
MethodsBetween January 1999 and November 2008, 22 breast cancer patients underwent a sentinel node procedure after previous mantle
field radiation. Lymphatic drainage patterns were analyzed based on lymphoscintigraphy and sentinel node biopsy. The results
were compared with the drainage patterns in patients without previous treatment from an earlier study.
ResultsSentinel nodes were found in the axilla in 19 patients (86%) and 9 patients (41%) also had drainage toward extra-axillary
regions. Sentinel nodes were more often found outside the axilla compared to the patients in our earlier study (33%, P=0.04), and the nonidentification rate was also higher (14% vs. 3%, P=0.01). Sentinel nodes were involved in 5 patients (23%). These were harvested from the internal mammary chain in two of
them. No lymph node recurrences were observed during a median follow-up time of 49months.
ConclusionLymphatic mapping is feasible and yields a lymph node in 86% of the breast cancer patients after previous mantle field radiotherapy
for Hodgkin’s lymphoma. Nonvisualization and extra-axillary nodes are more frequently encountered than in patients without
a history of mantle field radiation. The finding of involved nodes suggests that sentinel node biopsy improves staging. Long-term
follow-up will determine the sensitivity of the procedure in this specific situation.
Annals of Surgical Oncology 04/2012; 16(8):2295-2299. · 4.17 Impact Factor
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Augustinus P T van der Ploeg,
Alexander C J van Akkooi,
Piotr Rutkowski,
Zbigniew I Nowecki,
Wanda Michej,
Angana Mitra,
Julia A Newton-Bishop,
Martin Cook, Iris M C van der Ploeg,
Omgo E Nieweg,
Mari F C M van den Hout,
Paul A M van Leeuwen,
Christiane A Voit,
Francesco Cataldo,
Alessandro Testori,
Caroline Robert,
Harald J Hoekstra,
Cornelis Verhoef,
Alain Spatz,
Alexander M M Eggermont
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ABSTRACT: Prognosis in patients with sentinel node (SN)-positive melanoma correlates with several characteristics of the metastases in the SN such as size and site. These factors reflect biologic behavior and may separate out patients who may or may not need additional locoregional and/or systemic therapy.
Between 1993 and 2008, 1,080 patients (509 women and 571 men) were diagnosed with tumor burden in the SN in nine European Organisation for Research and Treatment of Cancer (EORTC) melanoma group centers. In total, 1,009 patients (93%) underwent completion lymph node dissection (CLND). Median Breslow thickness was 3.00 mm. The median follow-up time was 37 months. Tumor load and tumor site were reclassified in all nodes by the Rotterdam criteria for size and in 88% by the Dewar criteria for topography.
Patients with submicrometastases (< 0.1 mm in diameter) were shown to have an estimated 5-year overall survival rate of 91% and a low nonsentinel node (NSN) positivity rate of 9%. This is comparable to the rate in SN-negative patients. The strongest predictive parameter for NSN positivity and prognostic parameter for survival was the Rotterdam-Dewar Combined (RDC) criteria. Patients with submicrometastases that were present in the subcapsular area only, had an NSN positivity rate of 2% and an estimated 5- and 10-year melanoma-specific survival (MSS) of 95%.
Patients with metastases < 0.1 mm, especially when present in the subcapsular area only, may be overtreated by a routine CLND and have an MSS that is indistinguishable from that of SN-negative patients. Thus the RDC criteria provide a rational basis for decision making in the absence of conclusions provided by randomized controlled trials.
Journal of Clinical Oncology 06/2011; 29(16):2206-14. · 18.37 Impact Factor
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ABSTRACT: The additional value of single photon emission computed tomography with CT (SPECT/CT) for detection and localization of sentinel nodes in patients with a melanoma of the head and neck was determined.
Thirty-eight patients received conventional lymphoscintigraphy followed by hybrid SPECT/CT. The number of sentinel nodes visualized and anatomic information provided were analyzed. Changes in surgical approach due to additional information from the SPECT/CT were evaluated in 20 patients.
SPECT/CT visualized a mean of 2.6 sentinel nodes per patient (range, 1-6). SPECT/CT depicted an additional sentinel node in 16% of the patients and clearly showed the anatomic location of the hot nodes in all patients. The surgical approach was adjusted on the basis of SPECT/CT images in 11 patients (55%).
SPECT/CT visualizes more sentinel nodes than conventional images and shows their anatomic location. SPECT/CT is recommended in patients with a melanoma in the head or neck.
Head & Neck 01/2011; 33(1):1-6. · 2.40 Impact Factor
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ABSTRACT: The value of SPECT/CT for detection and localization of sentinel nodes is reviewed. SPECT/CT depicts extra sentinel nodes and identifies non-nodal tracer accumulation. SPECT/CT is indicated in patients with complex lymphatic drainage as often present in patients with head, neck and scapular melanoma, breast cancer patients with extra-axillary sentinel nodes and patients with tumors draining to pelvic nodes. SPECT/CT also clarifies the drainage pattern of inconclusive conventional images (non-visualization or unclear location of the nodes).
Journal of Surgical Oncology 11/2009; 101(2):184-90. · 2.10 Impact Factor
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ABSTRACT: The purposes of this study were to determine which classification best predicts additional lymph node disease and survival, and to suggest a threshold below which a completion dissection may be omitted.
Three micromorphometric parameters of melanoma sentinel node metastases were compared: invasion depth from the capsule (Starz-classification), maximum diameter (Rotterdam-criteria), and location within the node (Dewar-classification).
The pathology slides of 116 patients with tumor-positive sentinel nodes were reviewed. The follow-up data were obtained from the prospectively kept database. The median follow-up duration was 53 months.
Metastases with an invasion depth under 0.3 mm or diameter less than 0.1 mm were not associated with additional involved nodes. Four percent of the patients with metastases with an invasion depth of 0.3 to 1.0 mm had other involved nodes and 3% of the patients with metastases with a diameter of 0.1 to 1.0 mm. Other nodes were involved in 3% of subcapsular metastases, 9% of both subcapsular and parenchymal metastases, and 33% in case of multifocal or extensive disease. The smallest tumor invasion depth and diameter associated with additional involved nodes was 0.4 mm. Only 5-year overall survival in the 3 successive invasion depth categories were statistically significant: 92%, 83%, and 68%. Five-year overall survival was 81% in patients with one involved sentinel node and 60% if there were more.
Invasion depth and diameter of the metastasis correlate best with the presence of additional nodal disease. Invasion depth best predicts overall survival. It seems justified to refrain from completion dissection in patients with a sentinel node tumor invasion depth up to 0.4 mm.
Annals of surgery 09/2009; 250(2):301-4. · 7.90 Impact Factor
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ABSTRACT: The purpose of this study was to evaluate the micromorphometric Starz-classification in melanoma patients.
The micromorphometric Starz-classification suggests that melanoma patients with a sentinel node metastasis invading no more than 0.3 mm (S-I) or 0.31 to 1.0 mm (S-II) below the capsular level can be spared further surgery, while invasion of the metastasis of more than 1.0 mm (S-III) implies a need for completion dissection.
Seventy patients with sentinel node metastases were studied. Twenty patients with an S-I or S-II classification were spared further surgery and 50 S-III patients underwent completion dissection. The median follow-up time was 33 months.
No lymph node recurrences were detected in the 20 S-I, II patients. Six of the 50 S-III patients (12%) had additional involved nodes in the dissection specimen. In these patients no recurrences developed in the cleared regional basins. Overall 3-year survival was 100% in the S-I, II patients and 80% in the S-III patients (P = 0.04). Three-year disease-free survival rates were 83% and 60%, respectively (P = 0.40).
: This study suggests that further surgery is unnecessary in S-I and S-II patients, while it does seem prudent to carry out completion dissection in S-III patients. The distinct survival difference between the 2 groups of patients suggests that the S-classification also has prognostic implications.
Annals of surgery 07/2009; 249(6):1003-7. · 7.90 Impact Factor
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ABSTRACT: The reliability of sentinel node biopsy is dependent on the accurate visualization and identification of the sentinel node(s). It has been suggested that extensive metastatic involvement of a sentinel node can lead to blocked inflow and rerouting of lymph fluid to a "neo-sentinel node" that may not yet contain tumor cells, causing a false-negative result. However, there is little evidence to support this hypothesis. Recently introduced hybrid SPECT/CT scanners provide both tomographic lymphoscintigraphy and anatomic detail. Such a scanner enabled the present study of the concept of tumor blockage and rerouting of lymphatic drainage in patients with palpable groin metastases.
Seventeen patients with unilateral palpable and cytologically proven metastases in the groin underwent bilateral conventional lymphoscintigraphy and SPECT/CT before sentinel node biopsy of the contralateral groin. The pattern of lymphatic drainage in the 17 palpable groin metastases was evaluated for signs of tumor blockage or rerouting.
On the CT images, the palpable node metastases could be identified in all 17 groins. Four of the 17 palpable node metastases (24%) showed uptake of radioactivity on the SPECT/CT images. In 10 groins, rerouting of lymphatic drainage to a neo-sentinel node was seen; one neo-sentinel node was located in the contralateral groin. A complete absence of lymphatic drainage was seen in the remaining 3 groins.
The concept of tumor blockage and rerouting was visualized in 76% of the groins with palpable metastases. Precise physical examination and preoperative ultrasound with fine-needle aspiration cytology may identify nodes with considerable tumor invasion at an earlier stage and thereby reduce the incidence of false-negative results.
Journal of Nuclear Medicine 03/2009; 50(3):364-7. · 6.38 Impact Factor
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ABSTRACT: The extent of a completion groin dissection in sentinel node-positive melanoma patients was guided by the location of the second-echelon nodes on the preoperative lymphoscintigram. The purposes of the current study were to investigate the pathological findings, the lymph node recurrences and (disease-free) survival associated with this approach.
Between June 1996 and April 2007, 42 patients underwent completion groin dissection after a tumor-positive sentinel node biopsy. Eighteen patients had femoro-inguinal second-echelon nodes on their lymphoscintigram and underwent a superficial lymph node dissection. Twenty-four patients had iliac-obturator second-echelon nodes found by scan and underwent a combined superficial and deep dissection.
The median follow-up time was 61 months. One of the 18 patients who underwent a superficial groin dissection developed a deep (obturator) lymph node recurrence after 12 months. Revision of the lymphoscintigram showed that the images had been interpreted incorrectly and that the second-echelon node was located in the obturator area after all. A combined superficial and deep dissection revealed additional involved nodes in the deep lymph node compartment in 2 of the 24 patients. At 5 years, 77% of all patients were alive, and 56% were alive and free of disease. These figures were 76% and 53%, respectively, in the patients who underwent superficial dissection only, and 80% and 61%, respectively, in the patients who also underwent deep dissection.
This study suggests that a strategy to determine the extent of the groin dissection that is based on the location of the second-tier nodes may be valid.
Annals of Surgical Oncology 06/2008; 15(5):1485-91. · 4.17 Impact Factor
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ABSTRACT: At our institution, tracer fluids are administered in the primary breast cancer and, in addition to the ones in the axilla, sentinel nodes outside the axilla are rigorously pursued. The objective of the present study of sentinel node-negative breast cancer patients was to determine the lymph node recurrence rates in the axilla and elsewhere, the false-negative rates, and the survival.
Between January 1999 and November 2005, 1,019 breast cancer patients underwent a sentinel node biopsy. In 748 of them, 755 sentinel node biopsies did not reveal a tumor-positive sentinel node and they did not undergo axillary node dissection. Metastases were revealed in 284 sentinel node biopsies performed in the remaining 271 patients: 247 in the axilla, 20 outside the axilla, and 17 both in the axilla and elsewhere. The median follow-up duration was 46 months.
Two of the 748 sentinel node-negative patients developed an axillary lymph node recurrence (0.25%) and two others developed a supraclavicular lymph node recurrence (0.25%). The overall lymph node recurrence rate was 0.5%. The false-negative rates were 1.4% overall, 0.8% for the axilla, and 5.1% for the extra-axillary nodes. After five years, 95.9% of all sentinel node-negative patients were alive and 89.7% were alive without evidence of disease.
The low recurrence and false-negative rates and promising survival figures show that our lymphatic mapping method with intralesional tracer administration is accurate for the axilla. Outside the axilla, 5.1% of involved sentinel nodes were missed.
Annals of Surgical Oncology 05/2008; 15(4):1025-31. · 4.17 Impact Factor
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ABSTRACT: The recently introduced SPECT/CT integrates the physiologic data of SPECT with the anatomic data of CT into a single image. The purpose of this pilot study was to explore the additional value of SPECT/CT in breast cancer patients and melanoma patients with inconclusive planar image findings.
Thirty-one patients had planar lymphoscintigrams showing unexpected lymphatic drainage, 6 had lymphoscintigrams that were difficult to interpret, and 3 showed no drainage on planar imaging. SPECT/CT was performed immediately after delayed planar imaging.
In 4 patients, SPECT/CT showed 6 additional sentinel nodes, of which 2 were tumor-positive and led to upstaging and tailored management in 5% of patients. SPECT/CT depicted sentinel nodes in 3 patients whose delayed planar imaging had shown no drainage.
SPECT/CT was of additional value in finding the exact anatomic location of sentinel nodes in patients with inconclusive planar image findings. SPECT/CT also detected sentinel nodes in addition to those found on planar images, and SPECT/CT detected sentinel nodes in patients whose planar images had shown none.
Journal of Nuclear Medicine 12/2007; 48(11):1756-60. · 6.38 Impact Factor
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