Pelvic lymph node dissection in metastatic melanoma to the groin should not be abandoned yet.

BACKGROUND: In recent years there has been a plea to abandon the pelvic lymph node dissection in the treatment of patients with metastatic melanoma to the groin. A trend towards a conservative surgical treatment is already evolving in several European countries. The purpose of this study is to identify factors associated with pelvic nodal involvement, in order to improve selection of patients whom might benefit from a pelvic nodal dissection. METHODS: A retrospective analysis was performed on prospectively collected data concerning patients who underwent an inguinal lymph node dissection (ILND) with pelvic lymph node dissection for metastatic melanoma at the University Medical Center Groningen. Multivariable logistic regression analysis was performed to determine factors associated with pelvic nodal involvement. Diagnostic accuracy was calculated for 18F-FDG PET + contrast enhanced CT-scan and 18F-FDG PET + low dose CT-scan. RESULTS: Two-hundred-and-twenty-six ILND's were performed in 223 patients. The most common histologic subtype was superficial spreading melanoma (42.6%). In patients with micrometastatic disease, 15.7% had pelvic nodal involvement vs 28.2% in patients with macrometastatic disease (p: 0.030). None of the characteristics known prior to the ILND, were associated with pelvic nodal involvement. Imaging methods were unable to accurately predict pelvic nodal involvement. Negative predictive value was 78% for 18F-FDG PET + low dose CT-scan and 86% for an 18F-FDG PET + contrast enhanced CT-scan. CONCLUSION: There are no patient- or tumor characteristics available that can predict pelvic nodal involvement in patients with melanoma metastasis to the groin. As no imaging technique is able to predict pelvic nodal involvement it seems unjust to abandon the pelvic lymph node dissection.

Optimal extent of completion lymphadenectomy for patients with melanoma and a positive sentinel node in the groin.

BACKGROUND: The optimal extent of groin completion lymph node dissection (CLND) (inguinal or ilioinguinal dissection) in patients with melanoma is controversial. The aim of this study was to evaluate whether the extent of groin CLND after a positive sentinel node biopsy (SNB) is associated with improved outcome. METHODS: Data from all sentinel node-positive patients who underwent groin CLND at four tertiary melanoma referral centres were retrieved retrospectively. Baseline patient and tumour characteristics were collected for descriptive statistics, survival analyses and Cox proportional hazards regression analyses. RESULTS: In total, 255 patients were included, of whom 137 (53·7 per cent) underwent inguinal dissection and 118 (46·3 per cent) ilioinguinal dissection. The overall CLND positivity rate was 18·8 per cent; the inguinal positivity rate was 15·5 per cent and the pelvic positivity rate was 9·3 per cent. The pattern of recurrence, and 5-year melanoma-specific survival, disease-free survival and distant-metastasis free survival rates were similar for both dissection types, even for patients with a positive CLND result. Cox regression analysis showed that type of CLND was not associated with disease-free or melanoma-specific survival. CONCLUSION: There was no significant difference in recurrence pattern and survival rates between patients undergoing inguinal or ilioinguinal dissection after a positive SNB, even after stratification for a positive CLND result. An inguinal dissection is a safe first approach as CLND in patients with a positive SNB.

4-Aminopyridine improves clinical signs in multiple sclerosis.

Twelve temperature-sensitive male patients with multiple sclerosis and 5 normal men were monitored before, during, and after the intravenous injection of 7 to 35 mg of 4-aminopyridine (4-AP) in 1- to 5-mg doses, every 10 to 60 minutes. Static quantitative perimetry, flicker-fusion frequency, visual acuity, and videotaped neurological examinations were performed. Ten of the 12 patients showed mild to marked improvement. Vision improved in 7 patients, oculomotor function in 5, and motor function (power, coordination, gait) in 5. Improvements developed gradually within minutes of drug injection at doses as low as 2 mg, and gradually reversed around 2 to 4 hours after the peak drug effect. No effects were observed in 5 patients given saline injections. No serious side effects occurred in either the normal subjects or the patients receiving 4-AP. It is concluded that 4-AP lessens multiple neurological deficits in multiple sclerosis and, furthermore, that the K+ channel is functional in demyelinated central nervous system axons in humans. The improvements with 4-AP are substantial enough to be of transient therapeutic benefit in selected patients.

Severe lumbosacral spondylolisthesis in adolescents and children. Reduction and staged circumferential fusion.

Using a new surgical regimen, fourteen patients with lumbosacral spondylolisthesis and more than 50 per cent slipping were treated by reduction of the slip with two Harrington distraction rods extending from the first lumbar laminae to the sacral alae and bilateral posterolateral fusion from the fourth lumbar to the second sacral segment. Then, at a second procedure, thirteen had an anterior lumbosacral fusion using two bicortical wedge-shaped iliac grafts. The distraction rods were removed six to twelve months later. At follow-up, correction of the slips ranged from 70 to 100 per cent. In four of the thirteen patients the reduction was improved by 10 to 13 per cent during the anterior procedure. In one patient, a twenty-one-year-old women with a slip of more than 100 per cent, a cauda equina syndrome developed after the reduction and posterolateral fusion, and this necessitated removal of th rods and cancellation of the anterior fusion. This patient recovered completely and her final result was a solid posterolateral fusion in situ, with her abnormal posture and gait unchanged. The other thirteen patients, after follow-up ranging from two years to six years and seven months, had solid fusion, normal spinal alignment, normal anatomy of the spinal canal, and normal posture and gait. Only one patient had loss of correction during follow-up, which amounted to 7 per cent. We concluded that correction of severe spondylolisthesis (50 per cent or more) in properly selected patients can be accomplished by this two-stage procedure without risk of further slipping, pseudarthrosis, persistent deformity, or recurrence of the slip due to late remodeling.

Anterior and posterior spinal fusion for paralytic scoliosis.

Twenty-three patients with paralytic scoliosis were treated with a combination of anterior and posterior spinal instrumentation and fusion. The sequence was anterior surgery first in 19 patients and posterior surgery first in 4. The average age was 14.4 years. Preoperative correction with a halo-hoop apparatus was performed in 12 patients. The average preoperative curve for the group measured 100 degrees, and the average postoperative curve at a mean follow-up time of 21 months was 37 degrees. The mean loss of correction was 8 degrees. Although superior hook dislodgment occurred in 5 patients, no pseudarthrosis or beinding of the fusion mass was documented.