Biological value of melanoma inhibitory activity serum concentration in patients with primary skin melanoma.

Melanoma inhibitory activity (MIA) protein was identified in significant quantities in primary and metastatic malignant melanomas, where it has an important role in promoting tumor development and progression. Our hypothesis was that MIA serum level will be elevated in patients with metastases or local spreading of the disease before any symptom of such progression is clinically apparent. We compared MIA serum levels in two groups of patients with primary melanoma; those with positive as opposed to those with negative sentinel lymph nodes. In addition, MIA serum levels were studied in two control groups; patients with dysplastic nevi and patients with basal cell carcinoma. A blood sample was obtained from each patient included in the study and MIA levels were assessed using standard enzyme-linked immunosorbent assay method. Patients with histologically positive sentinel lymph nodes, meaning that tumor cells were found in the lymph nodes, had much higher mean MIA values than any other patient group considered in this study. With mean value of 14.53 ng/ml, it was almost twice as high as mean MIA value in patients with histologically negative sentinel lymph nodes (7.32 ng/ml) and more than twice as high than any of the two control groups (P<0.001). However, neither the classification by Clarke nor the classification by Breslow could be used to distinguish patients with positive sentinel lymph nodes from those with negative sentinel lymph nodes. In our opinion, MIA serum level is the ideal test for screening the tumor spread to sentinel lymph nodes.

Our experience of melanoma thickness as a predictor of outcome of sentinel node biopsy.

All follow up protocols for patients with malignant melanoma (MM) are oriented to early detection of metastases. As most of the relapses happened in regional lymph nodes, special attention is given to this region, using different diagnostic tools. Sentinel lymph node biopsy (SLNB) is generally accepted method in determining status of lymph nodes in MM patients, in their staging. This method provides valuable prognostic information, facilitates early therapeutical lymphadenectomy and so provides good base for identification of those patients who are candidates for different adjuvant modalities of treatment. (In 2001 American Joint Committee on Cancer introduced new staging system for melanoma patients which presents good frame for prognosis and therapeutical approach. Inclusion of new criteria will allow better and more individualized prognosis and treatment.) The most important predictor of SLNB outcome is thickness of tumor according to Breslow, while there is no sufficient data to show correlation with other factors. We retrospectively studded 431 patients, out of which SLNB was performed on 188. Forty patients or 21.3% had positive lymph nodes. Our results showed strong correlation of tumor thickness and Clark level of invasion with SLNB outcome. Metastatic lymph nodes were founded in all acral-lentiginous melanoma patients, followed by nodular melanoma--55.6% and superficial spreading melanoma--14.1%. Results showed statistically significant predilection of positive SLNB in male patients and no correlation of positive SLNB with histological type of tumor. On the contrary, it showed significant correlation with development of metastases. Thus our results are similar to other comparable studies.

The role of preoperative lymphoscintigraphy in surgery planning for sentinel lymph node biopsy in malignant melanoma.

AIM: To evaluate four years of preoperative lymphoscintigraphy experience and the accuracy of sentinel lymph node biopsy in our institution in melanoma patients with various tumor thicknesses. An additional aim was to evaluate the recurrence rate related to pathohistological findings. METHODS AND PATIENTS: During the period from February 2002 to November 2005, 201 patients underwent sentinel node biopsy. Lymphoscintigraphy for identification of sentinel nodes was performed four to six hours prior to operation of the patient. Sentinel lymph node biopsy using an intraoperative hand-held gamma probe was performed in all patients, together with wide local excision of biopsy wound or primary lesion (N=56). Immediate complete basin dissection was performed in patients with sentinel node metastases. In four patients delayed complete lymph node dissection was performed after definitive histopathologic examination of sentinel nodes. The accuracy of sentinel node biopsy was determined by comparing the intraoperative rates of sentinel node identification and the subsequent development of nodal metastases in regional nodal basins in patients with tumor-negative sentinel nodes and in those with tumorpositive sentinel nodes. RESULTS: Using preoperative lymphoscintigraphy, we identified sentinel nodes in all but one of the 201 patients (99.0%), and in 248 nodal basins (1.2/patient) we observed 372 sentinel nodes (1.52 sentinels/basin; 1.8 sentinels/patient). The highest number of sentinel nodes was noticed in the groin of patients with melanoma on the lower extremities (1.5/patient), followed by the axilla (1.3/patient). Anomalous lymphatic drainage patterns were observed in 15.0% of all patients. The identification rate of sentinel nodes was 99.0% overall: 100% for the groin basins, and 98.0% for the axilla and head and neck basin. Forty-two patients (20.8%) had tumor-positive sentinel nodes. Ten patients (5.0%) had local or distant recurrences during a median follow-up of 23.1 months (range 2-46). The rate of false-negative lymphatic mapping and sentinel node biopsy as measured by nodal recurrence in patients with tumor-negative sentinel nodes was 1.3%. During the follow-up period, three of 201 patients died from other diseases and three patients died as the result of melanoma metastases, with a median follow-up of 13.5 months (range 12-22). CONCLUSION: Preoperative lymphoscintigraphy is a sensitive, inexpensive and essential method for the identification of drainage basins, determination of the number and position of sentinel nodes and their location outside the usual nodal basins. Scintigraphic findings may lead to changes in surgical management due to the unpredictability of lymphatic drainage. The low incidence of regional disease recurrence in patients with tumor-negative sentinel nodes supports the use of preoperative lymphoscintigraphy and sentinel node biopsy as a safe and accurate procedure for staging the regional nodal basin in patients with malignant melanoma.

Infrequent life-threatening complication of descending necrotizing mediastinitis; vertebral artery, internal jugular and subclavian vein rupture.

We present a case of left proximal vertebral artery (PVA), internal jugular and subclavian vein rupture after descending necrotizing mediastinitis (DNM) initially treated in another surgical institution with antibiotic therapy and left-sided cervicotomy, collar incision and drainage of the left thorax. On day 23 followed by surgical intervention due to the disease propagation, after daily dressing exchange of wound healed on second intention, a life-threatening complication of mixed, massive arterial and venous bleeding developed. The patient was emergency transferred to University Clinic and undergo prompt surgical repair. The jugular and subclavian veins destroyed by suppurative process were sutured. Vein bypass to the PVA was performed. His postoperative course was uneventful and he was discharged home on the 30th postoperative day. We performed the evaluation of DNM-literature review. The articles were collected from 1970 to 2005 (44 reports). Our search did not find any adequate published studies of the relationship between vascular complications described in these case and DNM. We report this case because there have been no previous reports in the literature.