Treatment of recurrent breast cancer following breast conserving surgery.

Patients with isolated ipsilateral breast cancer recurrence face completion mastectomy in the majority of cases. Selected patients may derive good outcomes from repeat breast conservation surgery and indeed repeat irradiation may be employed using one of many different modalities. Tumor biology rather than salvage surgery method is likely to influence outcome. Patients with isolated breast tumor recurrence are treated in the majority of cases with completion mastectomy, when for selected patients there exists little evidence that more radical surgery provides better outcomes in terms of further recurrence and overall survival, than repeated breast conserving surgery. Literature search identifying articles addressing the issue of repeat breast conserving surgery for ipsilateral breast tumor recurrence, and repeat radiotherapy(search terms include: repeat breast conserving surgery, salvage mastectomy, salvage breast conserving surgery,salvage radiotherapy, reirradiation). Thirty-five articles discussed the outcomes of repeat breast conserving surgery versus salvage mastectomy, methods of repeat breast irradiation, repeat sentinel lymph node biopsy and related factors. Repeat breast conserving surgery may represent a safe and feasible treatment method for isolated ipsilateral breast tumor recurrence.

[Optimal treatment of the axilla after positive sentinel lymph node biopsy in early invasive breast cancer. Early results of the OTOASOR trial]. / Az axilla optimális kezelése pozitív orszemnyirokcsomó esetén korai invazív emlorákban. Az OTOASOR vizsgálat elozetes eredményei.

INTRODUCTION: Sentinel lymph node biopsy alone has become an acceptable alternative to elective axillary lymph node dissection in patients with clinically node-negative early-stage breast cancer. Approximately 70 percent of the patients undergoing breast surgery develop side effects caused by the axillary lymph node dissection (axillary pain, shoulder stiffness, lymphedema and paresthesias). AIM: The current standard treatment is to perform completion axillary lymph node dissection in patients with positive sentinel lymph node biopsy. However, randomized clinical trials of axillary dissection versus axillary irradiation failed to show survival differences between the two types of axillary treatment. The National Institute of Oncology, Budapest conducted a single centre randomized clinical study. The OTOASOR (Optimal Treatment of the Axilla - Surgery or Radiotherapy) trial compares completion axillary lymph node dissection to axillary nodal irradiation in patients with sentinel lymph node-positive primary invasive breast cancer. METHOD: Patients with primary invasive breast cancer (clinically lymph node negative and less than or equal to 3 cm in size) were randomized before surgery for completion axillary lymph node dissection (arm A-standard treatment) or axillary nodal irradiation (arm B-investigational treatment). Sentinel lymph node biopsy was performed by the radio-guided method. The use of blue-dye was optional. Sentinel lymph nodes were investigated with serial sectioning at 0.5 mm levels by haematoxylin and eosin staining. In the investigational treatment arm patients received 50Gy axillary nodal irradiation instead of completion axillary lymph node dissection. Adjuvant treatment was recommended and patients were followed up according to the actual institutional guidelines. RESULTS: Between August 2002 and June 2009, 2106 patients were randomized for completion axillary lymph node dissection (1054 patients) or axillary nodal irradiation (1052 patients). The two arms were well balanced according to the majority of main prognostic factors. Sentinel lymph node was identified in 2073 patients (98.4%) and was positive in 526 patients (25.4%). Fifty-two sentinel lymph node-positive patients were excluded from the study (protocol violation, patient's preference). Out of the remaining 474 patients, 244 underwent completion axillary lymph node dissection and 230 received axillary nodal irradiation according to randomization. The mean length of follow-up to the first event and the mean total length of follow-up were 41.9 and 43.3 months, respectively, and there were no significant differences between the two arms. There was no significant difference in axillary recurrence between the two arms (0.82% in arm A and 1.3% in arm B). There was also no significant difference in terms of overall survival between the arms at the early stage follow-up. CONCLUSIONS: The authors conclude that after a mean follow-up of more than 40 months axillary nodal irradiation may control the disease in the axilla as effectively as completion axillary lymph node dissection and there was also no difference in terms of overall survival.

[Breast care nurse. A new specialist in the multidisciplinary care of breast cancer patients]. / Az emlorák-terápiás novér. Új szakember az emlorák multidiszciplináris ellátásában.

The uniform European structure and professional standards for high quality breast cancer care were established in conjunction with the European Organisation for Research and Treatment, the European Society of Mastology and the European Breast Cancer Coalition with the support of the European Parliament. Well-prepared professional teams including a new member called the breast care nurse serve as ground for special breast cancer centers with international accreditation that provide modern, evidence based, patient centered multidisciplinary oncological care. The responsibilities of the new qualified professional staff member include the psycho-social support of the patient and carers from the moment of diagnosis throughout the whole oncological treatment, the fostering of delivering information and communication between patients and specialists. As a result of the curriculum founded by the European Oncology Nursing Society, breast care nurses have become key members of the practice of holistic breast cancer care in countries where the European recommendations have already been implemented. Considering the expected rearrangement of national oncological care, the new sub-specialty is outlined for the first time in the light of the experiences gained at the National Institute of Oncology, Budapest, a comprehensive cancer center.

[Histologic response after neoadjuvant therapy in rectal adenocarcinoma: own experience and review of the literature]. / Rectumcarcinomák neoadjuváns kezelést követo szövettani regressziójának vizsgálata: saját tapasztalatok és irodalmi áttekintés.

BACKGROUND: Neoadjuvant therapy has improved outcomes for patients with locally advanced rectal cancer. AIM AUTHORS: We studied the degree of histopathological regression after radiotherapy regimens commonly used in their clinical practice, and its effect on the pathology of by clinically founded T3-T4 rectal cancer. PATIENT AND METHODS: A total of 57 patients were investigated who underwent neoadjuvant radiotherapy or chemoradiotherapy--commonly used at our institute--for biopsy proven primary mid or lower third rectum adenocarcinoma between January and December 2004. The standard surgical treatment was anterior resection sec Dixon, Lloyd-Davies--and Hartmann's procedure, all with total mesorectal excision. RESULTS: The surgical specimens were examined by selected pathologists and a modified pathologic staging system the Rectal Cancer Regression Grade (RCRG) was used. (I) "good" response (n=12, 21%), (II) "median" response (n=25, 44%), (III) "poor" response (n=20, 35%). Significant tumor regression (RCRG I-II.) was seen in 37 patients (65%). Six patients (10.5%) have had complete pathological regression and 6 patients (10.5%) have had only microscopic foci of adenocarcinoma. CONCLUSION: Comparing of pretreatment and pathologic staging revealed that the depth of invasion was significantly downstaged. The authors also reviewed the literature of neoadjuvant therapy, total mesorectal excision, prognostic and predictive factors of rectal cancer.

[Cytoreductive surgery and intraperitoneal hyperthermic chemoperfusion for peritoneal carcinomatosis caused by recurrent inflammatory myofibroblastic sarcoma: a case report and review of the literature]. / Peritonealis carcinomatosist okozó recidív inflammatoricus myofibroblastos sarcoma miatt végzett citoreduktív sebészi beavatkozás es intraoperatív intraperitonealis kemohipertermia. Irodalmi attekintés es esetismertetés.

Peritoneal carcinomatosis is a fatal diagnosis, associated with poor prognosis and quality of life. Survival is usually estimated in month. Traditionally surgery for peritoneal carcinomatosis was indicated only for palliative effort. Advances in tumour biology, cytoreductive surgery and pharmacology have improved the approach for this condition. An aggressive combined approach to peritoneal surface malignancy involves peritonectomy and intraperitoneal perioperative hyperthermic chemotherapy. Cytoreductive surgery reduces carcinomatosis to microscopic residual disease so that intraperitoneal hyperthermic chemotherapy is able to eradicate cancer. Hyperthermic chemotherapy enhances the cytotoxicity of the drugs and increases their penetration into the cancerous tissue. Careful patient selection is crucial for this multimodality approach. Quantitative prognostic indicators are useful in the assessment of outcome, like peritoneal cancer index and completeness of cytoreduction score. Cytoreductive surgery combined with intraperitoneal hyperthermic chemotherapy improves survival but is associated with significant morbidity and mortality. This review is based on a case report of a 22-year-old female patient who had peritoneal carcinomatosis of inflammatory myofibroblastic sarcoma and was treated by cytoreductive surgery and intraperitoneal hyperthermic chemotherapy at our department.

[The role of sentinel lymph node biopsy in breast cancer non-invading-duct]. / Az orszemnyirokcsomó-biopszia jelentosége nem invazív duktális emlorákban.

INTRODUCTION AND AIMS: The clinical significance of sentinel lymph node biopsy for staging patients with ductal carcinoma in situ has not yet been solved. Determining the role of this method for the treatment of in situ ductal carcinoma has been the aim of this study. PATIENTS AND METHOD: Dual agent guided sentinel lymph node biopsy with preoperative lymphoscintigraphy was performed on 36 patients with breast ductal carcinoma in situ from January 2001 to March 2004 at the Department of General and Thoracic Surgery, National Institute of Oncology, Budapest. Completion axillary lymph node dissection was not performed routinely. The sentinel lymph nodes were histologically examined at 0.5-1 mm levels with routine hematoxylin and eosin staining. RESULTS: One patient has been excluded from the final analysis because of contralateral invasive breast cancer and simultaneous local recurrence in her medical history. Micro- or submicrometastases were found in 2 patients. If our patient number is completed with the 5 patients operated on for ductal carcinoma in situ during the period of our feasibility study (from December 1997 to March 2000) then the rate of patients with positive sentinel lymph node(s) will be 5% (2/40). All metastases were less than 2 mm in size. Metastases were found only in patients with high risk, extended ductal carcinoma in situ who finally underwent mastectomy. Completion axillary lymphadenectomy has not been performed even for patients with positive sentinel lymph node and no regional recurrence has yet been observed. DISCUSSION AND CONCLUSIONS: Our results corresponds well to the international ones. Performing sentinel lymph node biopsy for ductal carcinoma in situ of the breast is not recommended on the basis of the international and our own experiences. Sentinel lymph node biopsy is essential for patients undergoing mastectomy. In other cases when preoperative diagnostic studies do not verify invasion unequivocally we advise to perform sentinel lymph node biopsy (if necessary) after the final histological result of the excised breast specimen.

[The feasibility and the role of sentinel lymph node biopsy after neoadjuvant chemotherapy in breast cancer]. / Az ôrszemnyirokcsomó-biopszia alkalmazhatósága és jelentôsége neoadjuváns kemoterápia után emlôrákban.

INTRODUCTION AND AIMS: The feasibility, accuracy and clinical significance of sentinel lymph node biopsy for patients with breast cancer after neoadjuvant chemotherapy has not yet been determined. The aim of this study was to investigate these questions. PATIENTS AND METHOD: Dual agent-guided sentinel lymph node biopsy with preoperative lymphoscintigraphy was performed on 17 breast cancer patients after neoadjuvant chemotherapy at the Department of General and Thoracic Surgery, National Institute of Oncology, Budapest, from April 2004 to August 2005. Patients with clinically lymph node-negative breast cancer less than 3 cm in size after neoadjuvant chemotherapy were enrolled in the study. RESULTS: Lymphoscintigraphy showed no axillary lymphatic drainage in 7 patients (41%), and no sentinel lymph node could be identified during surgery in these patients. Axillary lymph nodes were histologically positive in 6 (86%) out of these 7 patients. Sentinel lymph node biopsy was successful in 10 patients (59%), and in 8 (80%) of them the sentinel lymph node proved to be positive pathologically. False negative sentinel lymph node biopsy did not occur. Axillary lymph node status was histologically positive in 14 (82%) out of the 17 patients. The predictable value of the clinical examination of the axilla after neoadjuvant chemotherapy, for the histological nodal status, was very low. DISCUSSION AND CONCLUSIONS: Our sentinel lymph node identification rate is lower than the published average in the literature. This difference can be explained by the differences in the indication for neoadjuvant chemotherapy. Our false negative rate (0%) is, however, significantly better than that of others. On the basis of international experiences sentinel lymph node biopsy after neoadjuvant chemotherapy is technically feasible, but its accuracy is not satisfactory and its clinical significance has not yet been determined. Our success rate is specifically low, which cannot be explained by the lack of practice. Taking the histologically very high axillary positive rate into consideration, sentinel lymph node biopsy has no clinical role in our practice after neoadjuvant chemotherapy.

Relationship between sentinel lymph node status and regression of primary malignant melanoma.

The prognostic significance of spontaneous regression of primary melanoma is a controversial issue. Studies on sentinel lymph node status and circulating tumour cells may represent a step towards a better understanding. The clinical details of 269 melanoma patients who underwent sentinel lymph node biopsy were analysed. Correlation was sought between the parameters of the primary tumour, particularly tumours showing a partial intermediate level of regression, and sentinel lymph node status. The presence of circulating tumour cells was studied by reverse transcription-polymerase chain reaction for tyrosinase messenger RNA preoperatively in 94 patients. Of the examined tumours, 27.8% showed histological features of a partial intermediate level of regression. Regressive tumours were localized predominantly on the trunk (P=0.006), were significantly thinner (P<0.0000) and were less frequently ulcerated (P=0.003) than tumours without regression. Moreover, the majority of regressive melanomas were of the superficial spreading type (P<0.0000) and their sentinel node status was more favourable (P=0.026). We demonstrated the presence of circulating tumour cells in five of 26 (19.2%) regressive and 19 of 68 (29.4%) non-regressive tumours. The difference was not significant (P=0.32). By multivariate analysis, however, the Breslow thickness and ulceration of the primary tumour were predictors of the sentinel lymph node status, in agreement with literature data. A partial intermediate level of regression of the primary tumour did not affect unfavourably the sentinel lymph node status in our study. We failed to demonstrate a significant relationship between the presence of circulating tumour cells and either primary tumour regression or the sentinel lymph node status.

[The similarities between the mechanism of wound healing and tumor development--literature review on the occasion of a patient with colonic adenocarcinoma metastasis in a dog-bite wound]. / A sebgyógyulás és a tumorprogresszió mechanizmusának közös lépései. Irodalmi áttekintés egy kutyaharapás sebében kialakult colonadenocarcinoma metasztázis esete kapcsán.

For more than a century, the role of wound healing in the growth of tumours has been implied based on observations in experimental and clinical studies. In the recent 10-15 years processes such as cell adhesion, angiogenesis, metastatic cascade and growth factors (fe: EGF, TGF-alpha, TGF-beta, IGF-1, IGF-II, PDGF) have been identified to play key roles in different stages of wound healing as well as in tumor progression. Experimental and clinical studies have established that wound healing creates a suitable environment favouring tumour growth and metastatic potential. Based on these observations, the clinical relevance of surgical procedures comes up, may playing a role in tumor recurrence after primary resection for cancer. This makes the opportunity of the development of completely new targeted approaches (antiangiogenic therapy, dormancy therapy) for the treatment of cancer. This review article is based on a case report of a 63-year-old female patient who had colonic adenocarcinoma metastasis of the hand after biting by a dog.

[Administration of clexane 4000 U/0.4 ml (40 mg) for preventing venous thromboembolic complications in patients undergoing surgery for malignant tumors. A follow-up study]. / A Clexane 4000 E/0.4 ml (40 mg) injekció alkalmazásának nyomonkövetése vénás thromboemboliás szövodmény profilaxisa során onkológiai mutéten átesett bete- gek esetében.

It has been evident since the first publication by Armand Trousseau (1865) that there is correlation between venous thromboembolism (VTE) and malignant tumors. This correlation has also been shown by recent studies. In patients with malignant tumors not only the incidence of VTE is higher but the course of VTE is more severe and relapses are more frequent. The procedures applied for the management of tumors (surgery, chemotherapy, radiotherapy, tamoxifen, central venous catheters) also increase the risk of VTE. It is generally accepted in Europe and in the U.S.A. (and also this constitutes the basis of the Hungarian guidelines) to group surgical patients by the risk of VTE by taking into account the characteristics of both the patients and the procedures. Recommendations also agree that for patients with medium or higher risk pharmacological prophylaxis is needed. Heparin or low molecular weight heparins in risk dependent doses and duration are administered most frequently. According to the recommendation of the American College of Chest Physicians (ACCP) patients with malignant tumors should receive thromboprophylaxis in accordance with their actual risk category and independent of the treatment they are receiving (surgery or chemotherapy). In a placebo controlled study with prolonged pharmacological thromboprophylaxis for patients with operated malignancies 60% VTE risk reduction could be reached and this risk reduction could also been observed after 3 months while the incidence of hemorrhagic complications was not significantly increased. Recent guidelines recommend 4 week long prophylaxis for patients with malignancies.

[Experience with radiofrequency ablation in the treatment of unresectable pelvic recurrence of rectal cancer]. / A radiofrekvenciás tumorablatió alkalmazásának lehetóségei recidív, kismedencei, irreszekábilis carcinomák kezelésében.

More than half of colorectal cancers are located in the rectum, and the number of such cancers is increasing. In Hungary colorectal cancers are diagnosed predominantly in advanced stages. In the last five years 736 patients with colorectal cancer were operated on at our Department, with the following stage distribution: Dukes A 10%, BI 10%, B2 31%, C 36% and D 13%. The local recurrence rate is decreasing since the introduction of total mesorectal excision and preoperative radiation. Effective treatment options are however poor for unresectable pelvic recurrences. Chemo- and radiotherapy have severe limitations in this advanced stage cancer. In recent years there are a few publications on the minimal-invasive radiofrequency tumour ablation (RFTA) technique, which is an effective treatment for primary and metastatic liver carcinomas and is a new palliative for the local treatment of pelvic recurrence. The aim of this study was to assess the response to treatment using ultrasound-guided radiofrequency ablation in two patients with unresectable pelvic recurrent rectal cancer.

Clinical significance of sentinel lymph node involvement in malignant melanoma.

In the period 1997-2002, sentinel lymph node (SLN) surgery was performed on 179 primary skin melanoma patients, one to two months after the removal of the primary. Staining with patent blue was combined with an isotope technique. Histological evaluation of the sentinel lymph nodes was performed in serial sections. Immunohistochemical detection of S100, HMB-45, or Melan-A was used in the case of suspected micrometastases. Demonstration of positive sentinel lymph node was followed, preferably within 2-3 weeks, by regional block dissection. In these cases interferon-a2 in low doses or BCG immune therapy were applied as adjuvant therapy. Bimonthly follow-up of the patients included physical examination and the use of imaging techniques as specified in the melanoma protocol. Sentinel lymph node surgery was successful in 177/179 cases (98%). Positive sentinel lymph node was identified in 26/177 patients (14.7%). In node positive patients the thickness of the primary tumour was significantly greater than that of node negative ones (p<0.00001). Patients with micrometastases had significantly poorer symptom-free and overall survival by the Mantel-Cox test than those of the other group (p=0.0001 and p=0.0007 respectively). Comparison of the tumor thickness and positive SLN by discriminance analysis, yielded 81.7% and 79.9%, respectively for correct classification rates. Based on our study and data from the literature, we suggest SLN-positivity as equally strong poor prognosis factor for skin melanoma as the tumor thickness.

Subareolar injection of radioactive colloid for sentinel lymph node identification in breast cancer patients.

Sentinel lymph node biopsy (SLNB) is becoming the standard for staging the axilla in breast cancer patients in many institutions. The best method of injection is still questionable. The purpose of this study was to compare the results of SLNB using the peritumoral or the subareolar injection site. Between December 1997 and March 2000, we performed 100 SLNBs. Technecium-labeled colloidal human serum albumin was injected peritumorally (Group A, 31 patients; Group B, 31 patients) or subareolarly (Group C, 38 patients). Patent blue dye was given periareolarly (Group A) or peritumorally (Groups B and C). Preoperative lymphoscintigraphy was performed in all patients. SLNB was successful in 94 patients (94%). The identification rate improved from 80 per cent (first 25 patients) to 99 per cent (last 75). The subareolar injection of the colloid did not adversely influence the results of SLNB compared with the peritumoral injection (identification rate, 100% vs 97%; false negative rate, 6% vs 14%). The subareolar injection of colloid is a simple and at least as accurate technique as the peritumoral one. This technique can also improve the identification rate of SLNB for breast cancer patients.

[Clinical significance of bone marrow micrometastases of breast tumors]. / Az emlótumor csontveló mikrometasztázisának klinikai jelentósége.

Detection of hematogenous micrometastases (MM) in bone marrow might play important role in determining stage, prognosis and multimodality treatment strategy of invasive breast cancer. Therefore we studied the presence of occult tumor cells in bone marrow of outpatients operated on with breast cancer by detecting cytokeratin 20 mRNA using the RT-PCR method. In 182 primary breast cancer patients 54 (29.7%) micrometastases were detected while in 128 patients (70.3%) no tumor cells were found in the bone marrow aspirates. Correlation of MM with HER-2, c-met, nm23, p53 and estrogen receptor (ER) were studied. The presence of MM was correlated with HER-2, nm23- and p53 positivity and with low frequency of nm23 and ER. The possible role of bone marrow MM in selecting node negative breast cancer patients for adjuvant therapy should be tested in randomized prospective clinical trials.

[Radioguided excision of non-palpable breast lesions with simultaneous sentinel lymph node biopsy]. / Nem tapintható emlóelváltozások radioizotópos jelöléses eltávolítása egyidejú órszem nyirokcsomó-biopsziával.

As a result of mammographic screening nonpalpable breast lesions are found with increasing frequency. The surgical management of these lesions presents two main problems: (1) How to localize the lesion pre- and intraoperatively; (2) What should be the extension of the axillary dissection for malignant lesions. This study is aimed to evaluate the technical feasibility of radioguided excision of nonpalpable breast lesions and the possibility of performing simultaneous sentinel lymph node biopsy for malignant lesions. Radioguided breast excisions have been performed in our Department since November 2000. The basis of this method is that radioisotope labelled colloid is injected into the lesion under stereo tactic or sonographic guidance. A gamma-probe is used intraoperatively to locate the lesion and guide its excision. Dual agent guided technique is used for sentinel lymph node biopsy. Radioguided breast excision was performed on 85 patients (93 lesion) till February 2002. The localization and excision were successful in 84 patients (92 lesions) (99%). Multifocal lesions were successfully localized and excised in 7 patients. There were 61 parenchyma lesions (66%) and 31 microcalcifications (34%). Localization was performed under sonographic guidance in 44 patients (52%) and under stereotactic guidance in 40 patients (48%). There were 25 benign (27%) and 67 malignant (73%) lesions. Second surgical procedure (mastectomy) was needed in 4 patients (6.5%) because of histologically incomplete excision. Sentinel lymph node biopsy was performed in 50 patients. The biopsy was successful in 45 patients (90%). The sentinel lymph node was histologically positive in 2 patients (4.4%). Radioguided localization with the intraoperative use of a gamma-probe is an easy, rapid and highly accurate technique for removing nonpalpable breast lesions and allows simultaneous sentinel lymph node biopsy for malignant lesions.

[Expression of oestrogen receptor-beta in invasive breast tumours]. / Az ösztrogénreceptor-béta expressziója invazív emlôtumorokban.

UNLABELLED: Steroid hormone receptors are used routinely to predict endocrine responsiveness in patients with breast cancer. Two oestrogen receptors (ERs): ER alpha and ER beta have been identified. Although ER alpha and ER beta genes share a large degree of homology, it is generally thought that their distribution and function are substantially different in many tissues. Both of them may be expressed in normal and neoplastic tissues of the breast. While much is known about ER alpha, the role of ER beta is still undefined, especially at the protein level. Recent development of reliable antibodies to ER beta has provided opportunity to test immunohistochemical reactions detecting ER beta in archival breast tumours. The aim of our study was to learn more about the cellular mechanisms underlying the relationship of ER beta and progesterone receptor (PR) in breast cancer tissues, discriminating between hormone-dependent and hormone-independent tumours. ER alpha and PR content of tumour tissues of 154 patients with breast cancer were tested by in situ indirect immunohistochemical method parallel with ligand binding biochemical assay. ER beta was detected in 8 ER alpha-/PR+ breast carcinomas by immunohistochemical method too. Steroid hormone receptor content was analysed comparing to the histologic type and grading of the tumours. CONCLUSIONS: A considerable part of breast carcinomas belongs to the ER+/PR+ and ER-/PR- groups. About 1-2% of the tumours is expected to be ER alpha-/ER beta+/PR+ type. In such cases ER alpha negative reaction together with PR positivity can signal the necessity of the immunohistochemical detection of ER beta in routine histopathological practice, presenting the precise steroid hormone receptor status for the most effective endocrine therapy of the patients.

[Preoperative lymphoscintigraphy guided sentinel lymph node biopsy in malignant melanoma] / Preoperatív limfoszcintigráfiával végrehajtott sentinel nyirokcsomó mûtétek melanoma malignumban.

The authors present preliminary experience with preoperative sentinel lymph node biopsy carried out with lymphoscintigraphy in patients with malignant melanoma. PATIENTS AND METHODS: In the present study patients operated for primary cutaneous malignant melanoma of moderate and high severity were included. On the day of surgery isotope labelled colloid was injected intradermally around the tumor to indicate the lymphatics and to obtain basic information about the localization of the sentinel lymph node(s).During surgery the lymph node(s) previously visualized by the injection of patent-blue staining were detected with the aid of a gamma probe. Simultaneously, the excision of the primary tumor was extended. Histologically verified metastasis in the surgically removed lymph node(s) necessitated block dissection possibly within two weeks. RESULTS: The distribution of patients (19) according to tumor localisation: 2 - upper extremities; 9 - lower extremities; 2 - sacral region; 6 - trunk. Tumor thickness ranged from <1.5 mm (6 patients) to 1.5-3 mm (5 patients) and to >3 mm (8 patients). In two cases the identification of the lymph node has failed. Positive sentinel ymph nodes were detected in two patients. It is noteworthy that with one patient the sentinel lymph node was not regional but intransit. This study was aimed at the development of a suitable method. Further on we wish to try it in prospective randomized studies.

[The role of surgery in the treatment of malignant melanoma]. / A sebészet szerepe a melanoma malignum kezelésében.

Surgical interventions have important role in the treatment of all stages of malignant melanoma. Surgery is the primary treatment of localized cutaneous melanoma. Excision of the primary tumor makes it possible to set up the histological diagnosis and to determine pathological prognostic factors. Appropriate surgical margin is important for local disease control. Sentinel lymph node biopsy with detailed histological examination has gained prominent importance for correct histological staging and for determining adjuvant oncological treatment. Surgery is the primary treatment of isolated regional metastases. Surgical methods also have a role in the palliative management of distant metastatic melanoma. In the present review the most important issues of the surgical treatment of malignant melanoma have been discussed in detail.

[Prognostic factors of breast cancer] / Emlôdaganatok prognosztikai faktorai.

OBJECTIVES: Characterization of breast cancers by various tumour markers which are appropriate for the identification of high risk groups. Markers related to the metastasis cascade and tumour recurrence have been investigated. MATERIALS AND METHODS: RT-PCR was used to determine the expression of cytokeratin 20 in the bone marrow and sentinel lymph node of breast cancer patients (n=45). The expression of HER2, Cadherin E, Cyclin D, Bcl2 and Bax has been evaluated by Western blot (n=744 invasive ductal carcinomas and 117 invasive lobular carcinomas, 124 recurrent breast cancers). Mutations of p53, APC and beta Catenin genes were detected by PCR-SSCP method. RESULTS: Expression of cytokeratin 20 was found in 30% of the bone marrow samples indicating the presence of micrometastasis. The level of Cyclin D, HER2 and Bcl2 is elevated four-fold in the recurrent breast cancers. The metastasis of invasive ductal carcinomas is accompained by high frequency of p53 mutations (24%) and APC mutations (18%). The invasive lobular carcinomas could be characterized with low frequency of p53 mutation (3%), low level of Cadherin E and high level of catenin beta. CONCLUSIONS: Identification of micrometastasis can promote the development of therapeutic strategy. Evaluation of HER2 level and determination of p53 mutations contribute to the identification of high risk patients. Our results suggest that the progression of invasive ductal carcinomas depends on the APC mutations, while metastasis of invasive lobular carcinomas depends on beta catenin mutations.

[Report on clinical observations obtained with sentinel lymph node surgery in malignant melanoma and during their follow-up at the Department of Dermatology, National Institute of Oncology, Budapest]. / Sentinel nyirokcsomó-biopszia melanomában. Klinikai tapasztalatok az Országos Onkológiai Intézetben.

OBJECTIVES: Report on clinical observations obtained with sentinel lymph node surgery for malignant melanoma and during follow-up at the Department of Dermatology, National Institute of Oncology, Budapest. PATIENTS AND METHOD: In the period from November, 1997 to September, 2002, the above surgical intervention was made with 179 patients having primary tumour, one to two months after primary tumour removal. Staining with patent blue was combined with isotope technique. The primary melanoma and the pertaining sentinel lymph node(s) were removed. Histological evaluation of the sentinel lymph nodes was performed in serial sections. Immunohistochemical detection of S100, HMB-45, or Melan-A was used in the case of suspected micrometastases. Demonstration of positive sentinel lymph nodes was followed, preferably within 2-3 weeks, by regional block dissection. Interferon in low doses or BCG immune therapy were applied as adjuvant therapy. Bimonthly follow-up of the patients included physical examination and the use of imaging techniques as specified in the melanoma protocol. RESULTS: Sentinel lymph node surgery was successful in 177/179 cases (98%). Positive sentinel lymph node was identified in 26/177 patients (14%). In node positive patients the thickness of the primary tumour was significantly greater than that of node negative ones (p<0.0000). Patients with micrometastases had significantly poorer symptom-free and overall survival by the Mantel-Cox test than those of the other group (p=0.0001 and p=0.0007, respectively). In the discriminance analysis of our data, the discriminant function established from tumour thickness yielded 81.7% and the positivity of sentinel lymph nodes 79.9% correct classification rates. CONCLUSION: In good harmony with literature data, positive sentinel lymph node(s) were found in the case of thicker tumours. The involvement of sentinel lymph node indicated a significantly poorer prognosis.