Sentinel lymph node biopsy for high risk cutaneous squamous cell carcinoma: case series and review of the literature.

AIMS: Cutaneous squamous cell carcinoma (SCC) is the second most common skin cancer. The metastatic potential is generally low. However, there are subgroups of patients at higher risk, for whom sentinel lymph node biopsy (SLNB) might be useful. SLNB might allow the timely inclusion of high risk patients in more aggressive treatment protocols, sparing at the same time node-negative patients the morbidity of potentially unnecessary therapy. Our aim was to introduce the concept of SLNB for patients with high risk cutaneous SCC. PATIENTS AND METHODS: We examined a consecutive series of high risk cutaneous SCC patients undergoing SLNB at our large dermatological hospital, and performed a literature review and pooled analysis of all published cases of SLNB for cutaneous SCC. RESULTS: Among the 22 clinically node-negative patients undergoing SLNB at our hospital, one patient (4.5%) showed a histologically positive sentinel node and developed recurrences during follow-up. Sentinel node-negative patients showed no metastases at a median follow-up of 17 months (range: 6-64). The incidence of positive sentinel nodes in previous reports ranged between 12.5% and 44.4%. Pooling together patients from the present and previous studies (total 83 patients), we calculated an Odds Ratio of 2.76 (95% CI 1.2-6.5; p=0.02) of finding positive sentinel nodes for an increase in tumor size from <2 cm to 2.1-3 cm to >3 cm. CONCLUSIONS: Our case series and the pooled analysis support the concept that SLNB can be performed for high risk cutaneous SCC. Prospective multicenter studies are needed to examine the role, utility and cost-effectiveness of SLNB for this population.

Sentinel node biopsy for malignant melanoma: analysis of a four-year experience.

AIMS AND BACKGROUND: Sentinel node (SN) biopsy has been introduced to solve the controversy concerning the effectiveness of prophylactic lymphadenectomy in intermediate thickness melanoma. The aim of this study was to evaluate the rate of metastases, the technical details of the procedure, and the main reasons of failure. METHODS: 235 patients affected by intermediate thickness melanoma (tumor thickness >0.75 mm and <4 mm) without clinical signs of systemic spread (N0M0) were submitted to sentinel node biopsy between 1996 and 2000. Preoperative lymphoscintigraphy was routinely performed in the last 184 patients. Intraoperative mapping with gamma probe was combined with the use of vital dye for identification of sentinel nodes in the last 113 patients. RESULTS: The SN detection rate was 95.6%, with significant differences depending on the site of dissection and the use of a gamma probe. The overall rate of micrometastases was 14.7%, but relevant differences were recorded between different subgroups of patients (T2, 5.1%; T3a, 19.6%; T3b, 29%). CONCLUSIONS: Sentinel node biopsy requires a multidisciplinary approach (surgery, pathology and nuclear medicine) for reliable results. The association of vital dye and intraoperative gamma probe for sentinel node harvesting has made the procedure more effective, less time-consuming and less invasive. Failures may be due not only to surgical mistakes, but also to improper nuclear medicine procedures or inaccurate histological evaluation of SNs. Methods for histological examination of the SN are still debated and not standardized but promising results have recently been obtained with molecular oncology techniques (RT-PCR).

Lymphatic mapping and sentinel node identification in squamous cell carcinoma and melanoma of the head and neck.

AIM: The aim of our study was to evaluate the role of scintigraphy in lymphatic mapping and in the identification of the sentinel lymph node (SLN) in patients with head and neck cancer. METHODS: Between September 1999 and February 2001 we enrolled 22 consecutive patients with cancer in the head and neck region: five squamous cell carcinomas, one Merkel cell tumor of the cheek, and 16 malignant melanomas. Lymphoscintigraphy was performed three hours before surgery after injection of 30-50 MBq of 99mTc -Nanocoll in 0.3 mL; the dose was fractionated by injecting the radiotracer at two points around the lesion. Static acquisition (anterior and/or lateral views, 512 x 512 matrix, 5 mins pre-set time) was started immediately after the injections so as to visualize the pathways of lymphatic drainage. The skin projection of the SLN was marked with ink. Intraoperative SLN detection was performed with perilesional injection of patent blue. RESULTS: SLNs were found with lymphoscintigraphy in all patients. Thirty-three SLNs were identified: one occipital node, three nodes at the base of the tongue, 10 superficial lateral nodes (external jugular), five submandibular nodes, five submental nodes, three mastoid nodes and six supraclavicular nodes. Biopsy was performed in 21/22 patients. In 20/22 patients the first lymph nodes were visualized in the proximal cranial regions (retroauricular, jugular and submandibular) at five minutes post injection. The SLN positivity rate was 13.6% (three patients). All patients with tumor-positive SLNs were submitted to radical dissection. Poor concordance in the detection of sentinel nodes was observed with patent blue. CONCLUSIONS: The flow of nanocolloid in the lymph vessels of the head is rapid. In our experience immediate scintigraphic imaging was essential to visualize the pathways of lymphatic drainage and the first SLN. Radioguided SLN biopsy is therefore recommended within three hours. Injection of patent blue is inadvisable because of the poor concordance with lymphoscintigraphy and the risk of permanent tattooing of the face.

[Sentinel node biopsy for malignant melanoma. Technical details and clinical results on 390 patients]. / La biopsia del linfonodo sentinella nel melanoma maligno. Dettagli tecnici e risultati in 390 pazienti.

BACKGROUND: The purpose of this paper is to present personal experience with sentinel node biopsy for the treatment of malignant melanoma. Technical details influencing the efficacy of the procedure are presented and the clinical, therapeutic and prognostic advantages of this technique discussed. METHODS: A total of 390 consecutive patients with primary skin melanoma (T2-3,N0,M0) underwent sentinel node biopsy between March 1996 and May 2001. All patients underwent previous excisional biopsy of the primary lesion and clinical and radiographic examination to exclude lymphatic or systemic macroscopic spreading of the disease. Preoperative lymphoscintigraphy (99mTc nanocoll) was routinely performed in the last 315 patients. Intraoperative detection of the sentinel nodes was performed by perilesional, intradermical, injection of blue dye associated with a g probe (Neoprobe(R) 2000) in the last 315 patients. Sentinel nodes, serially sectioned, were all Haematoxylin-Eosin and immunohistochemically stained. All patients positive for micro-metastasis underwent radical lymphadenectomy. Comparative analysis between the incidence of metastasis in sentinel and non-sentinel nodes, according to the clinical stage of the disease, was done. RESULTS: The overall detection rate of sentinel nodes was 97.4%. Relevant differences were found according to the site of dissection and the use of a g probe. The g-probe makes the procedure more effective, less invasive and less expensive. Timing and accuracy of the preoperative lymphoscintigraphy is a basic step of the procedure. The overall incidence of positive sentinel nodes was 14.7% with differences correlated with thickness of primary lesion (0.75-1.5 mm: 5,8%; 1.5-3 mm:18%; 3-4 mm: 24.6%). Metastasis in other non-sentinel nodes was found only with primary tumour thickness exceeding 2 mm. CONCLUSIONS: Sentinel node biopsy is a procedure requiring a multidisciplinary approach (surgery, nuclear medicine and pathology). A specific learning phase (>30 patients) is recommended to obtain reliable results.

[Penal deterrents and benefits of clemency: marginal notes on research]. / Deterrente penale e benefici di clemenza: notazioni in margine ad una ricerca.

The article refers to a volume recently issued by the Criminology Department of the National Centre for Prevention and Social Protection, which illustrates the results of some research carried out in order to verify the effects, if any, of the application of the benefits of amnesty and free pardon (not infrequent in the history of Italy) and of the application of the benefits of mercy, on recidivism. Although the research is focused on the formal figures of sentences of punishment, an attempt has been made to reach indicative conclusions based on the behaviour of those to whom these benefits were granted, in order to discover whether their application has reinforced or weakened the crimino-resistance of the subjects. The indications found in the examination lead to the conclusion that those who are predisposed to a certain type of delinquency, greater or lesser, (for example, towards crimes against the patrimony, especially if recidivous) continued to commit crimes at the same rhythm, or even in some cases at a greater rhythm, while those who may have fallen only rarely into crime (particularly women) tended to relapse less into crime. This is the case also with pardon, although in this case the benefit is individualized and conceded generally as a consequence of favourable prognostic evaluations. It is interesting to note that each time a general measure of amnesty or pardon is issued, the percentages of criminality are increased. The article brings these results to the attention of the reader, as material for reflection on the efficacy of reinforcement of the measures of pardon, with respect to the penal system.

Heterogeneity of the zona pellucida carbohydrate distribution in human oocytes failing to fertilize in vitro.

The mammalian zona pellucida contains several glycoproteins whose oligosaccharide moieties are known to play a key role in the interaction with spermatozoa. Since zona pellucida defects may represent one of the most likely causes of failed fertilization in human in-vitro reproduction, we have studied the carbohydrate composition and distribution over the human zona pellucida by means of lectins. Donated, not inseminated cumulus-oocyte complexes, from cohorts with high fertilization rates, and fertilization-failed oocytes from cohorts inseminated with proven fertile donor semen, were analysed using 11 fluorescein-labelled lectins, on deplasticized semi-thin epoxy sections. Results showed that wheat germ agglutinin (WGA), Maclura pomifera (MPA) and Pisum sativum (PSA) bound to the extracellular matrix bordering the zona pellucida-corona radiata interface of cumulus-oocytes complexes, while the zona pellucida was labelled by WGA, Concanavalin A (ConA) and PSA. WGA labelling and correlative electron microscopy on the cumulus-oocyte complexes demonstrated that this lectin is a useful tool to trace the cortical granule distribution in the human oocyte. Surprisingly, in the failed-fertilized oocytes the zona pellucida was also labelled by MPA and showed three different patterns: (i) labelling of the zona pellucida outer surface; (ii) uniform labelling; (iii) labelling of an outer zona pellucida layer with variable thickness. Comparative analysis of WGA and MPA labelling on single failed-fertilized oocytes demonstrated that MPA zona pellucida patterns are not related to the cortical reaction. The nature and meaning of the MPA pattern of failed-fertilized oocytes were discussed in the light of zona pellucida defects impairing sperm receptivity.

[Optimization of lymphoscintigraphy in sentinel node biopsy in the staging of malignant melanoma]. / Ottimizzazione della linfoscintigrafia nella biopsia del linfonodo sentinella per la stadiazione dei melanomi.

PURPOSE: To optimize the lymphoscintigraphic procedure in the staging of malignant cutaneous melanoma. MATERIAL AND METHODS: Fifty-five patients (21 men and 34 women) were enrolled. Breslow thickness of the lesions ranged 0.75-1 mm (Clark III-IV) to 1-4 mm. Lymphoscintigraphy was performed with a large-view gamma camera equipped with a low-energy general purpose collimator, two weeks after melanoma excision. A single perilesional dose of 30-50 MBq nanocoll-Tc99m (volume 0.2-0.3 mL) was injected 18 hours before surgery (6 hours in head localizations). After injection a gentle local massage was applied. A planar static scintigraphy (matrix 512 x 512, pre-set time 5 min) in anterior and/or oblique view(s) was obtained 5-10 min after radiotracer injection. The skin projection of the first node was stained with an external radioactive marker. Fifteen minutes before surgery a blue-vital dye was injected around the lesion. A radioguided biopsy of the sentinel node was performed. RESULTS: The site of the sentinel node was typical in 80% of patients. Two or three nodes were identified in 20% of patients. An unexpected node site was detected in 9% of patients. The total rate of micrometastasis to the sentinel node was 14.7% but significant differences were observed relative to the melanoma thickness. CONCLUSIONS: Preoperative scintigraphy increases the accuracy of sentinel node identification in unusual lymphatic drainage pathways, in unexpected sites and in fast lymphatic drainage. Radioguided biopsy reduces surgical time, requires only local anesthesia and permits shorter hospitalization.