The use of lymphoscintigraphy and PET in the management of head and neck melanoma.

OBJECTIVES: Lymphoscintigraphy with sentinel node dissection and 18 fluoro-2-deoxyglucose positron emission tomography (PET) are being used independently in the management of many intermediate and thick melanomas of the head and neck. We report a series of patients with melanoma of the head and neck with Breslow depths greater than 1.0 mm and clinically negative regional nodes that were evaluated prospectively with PET and lymphoscintigraphy. STUDY DESIGN AND SETTING: Between July 1, 1998 and December 30, 2000 PET scans were obtained preoperatively on 18 patients undergoing resection of head and neck melanoma. Lymphoscintigraphy and sentinel node dissection was performed. Resection of the primary lesion was then carried out with adequate margins and the defects were reconstructed. RESULTS: Sentinel node(s) were found in 17/18 patients (94.4%); 5/18 (27.8%) of cases had metastases. PET detected nodal metastasis preoperatively in 3 patients (16.7%), one of which had a positive sentinel node dissection. CONCLUSION: PET and lymphoscintigraphy offer complimentary ways of evaluation for metastatic melanoma.

National practice patterns of sentinel lymph node dissection for breast carcinoma.

BACKGROUND: The sentinel node is the first regional lymph node to receive tumor cells that metastasize through the lymphatic channel from a primary tumor. The tumor status of the sentinel node should reflect the tumor status of the entire regional node basin. Sentinel lymph node dissection (SLND) has recently been investigated for use in patients with early breast carcinoma to avoid the sequelae of complete axillary lymph node dissection (ALND). Published studies of SLND in breast cancer patients identify marked variations in technique, and there are few guidelines for credentialing surgeons to perform SLND. STUDY DESIGN: The purpose of this study was to assess the current practice of SLND for breast cancer in the United States. A 27-item questionnaire was mailed to 1,000 randomly selected Fellows of the American College of Surgeons. Responses were anonymous. Statistical analysis was performed using SAS software (SAS Institute, Cary, NC). RESULTS: Response rate was 41% (n = 410), and 77% of those who responded performed SLND for breast cancer. The majority (60%) of surgeons responding routinely ordered preoperative lymphoscintigraphy. Of those who did lymphoscintigraphy, 28% removed internal mammary lymph nodes when lymphoscintigraphy showed drainage to these nodes. Ninety percent of surgeons used both blue dye and radiocolloid. Eighty percent of centers responding performed routine immunohistochemistry on sentinel lymph nodes, and 15% performed reverse transcription polymerase chain reaction. Ninety-six percent of surgeons performed SLND for primary tumors 5 cm or smaller, and 95% performed SLND for an excisional cavity 6 cm and smaller. Twenty-eight percent performed SLND for high-grade ductal carcinoma in situ, and 28% of respondents performed 10 or fewer SLND procedures with subsequent ALND before performing SLND alone. Surgeons learned SLND through courses (35%), oncology fellowships (26%), observation of other surgeons (31%), or were self-taught (26%). CONCLUSIONS: The majority of surgeons in the United States use similar technique for SLND breast cancer. But, there was marked variation in the number of SLND cases validated by an ALND before performing SLND only.

Comprehensive review of sentinel lymphadenectomy in breast cancer.

Sentinel lymph node dissection (SLND) is a minimally invasive technique to stage axillary lymph nodes in breast cancer. The complications associated with SLND are minimal, especially when compared to routine axillary lymph node dissection (ALND), and it can be performed with an overall identification rate of greater than 90% and a false-negative rate less than 5%. Despite this, SLND is not ready to replace routine axillary dissection, since we have no long-term results for these patients. What the clinical recurrence rates will be in women who undergo SLND only and how that will translate into survival rates has yet to be discovered. SLND is also a difficult technique to perform, as documented in the early SLND studies. It is imperative that each individual surgeon perform a series of cases in which SLND is combined with immediate ALND, so that identification rates and false-negative rates can be determined. Once a track record of successfully performed SLND has been established, SLND can be solely used for node-negative women. It is strongly recommended that all surgeons join one of the National Cancer Institute (NCI)-sponsored clinical trials for SLND in early breast cancer, so that many of these questions concerning SLND can finally be answered.

Lymphatic mapping and sentinel lymphadenectomy after wide local excision of primary melanoma.

BACKGROUND: Lymphatic mapping and sentinel lymphadenectomy (LM/SL) are generally avoided in patients who have already undergone wide local excision (WLE) of a primary melanoma, because of concern that disruption of the cutaneous lymphatics might alter lymphatic flow to the sentinel node. We reviewed carefully chosen patients who had undergone LM/SL after WLE to identify circumstances that might make this approach otherwise safe and clinically accurate. STUDY DESIGN: From our melanoma database of 8,300 patients, of whom 1,015 had undergone LM/SL, we retrospectively identified 47 patients who had previously undergone WLE. Patient and tumor characteristics were collected and compared with followup data from clinic files. RESULTS: Median WLE surgical margins before LM/SL were 2.0 cm and most patients had extremity lesions. Eleven of the 47 patients (23%) had tumor-involved sentinel nodes, and 8 of these patients (73%) had a solitary nodal metastasis. With a median followup period of 36 months, 3 sentinel node-negative patients developed nodal recurrences. Two of these patients had positive sentinel nodes on pathology re-review and were not considered failures of the lymphatic mapping surgical procedure. The third patient developed in-transit metastases and delayed nodal recurrence. An additional patient, who had a primary tumor on the trunk, developed a nodal recurrence in the basin opposite that identified by lymphoscintigraphy. The overall error rate of the technique was 4 in 36 (11%). This included 2 pathology misdiagnoses (5.6%), 1 nodal recurrence associated with in-transit regional metastases (2.8%), and 1 lymphatic mapping error (2.8%). CONCLUSIONS: LM/SL can be cautiously performed in patients who have undergone previous WLE if the primary resection margin was no greater than 2.0 cm and the primary was not in a region of ambiguous drainage. Lymphatic mapping may be inaccurate when melanomas have been resected with large margins, especially if the wound was closed with rotation flaps, and when melanomas are on the head and neck or trunk regions.

Lymph node biopsy does not impair survival after therapeutic dissection for palpable melanoma metastases.

BACKGROUND: To determine the effects of disrupting a nodal basin in patients with American Joint Committee on Cancer stage III melanoma with clinically palpable lymph nodes, we studied patients who underwent therapeutic lymph node dissection after excisional lymph node biopsy, after fine-needle aspiration (FNA) biopsy, or without a preoperative biopsy. METHODS: We performed a retrospective review of our patients with American Joint Committee on Cancer stage III melanoma who were treated between January 1972 and June 1995, using data acquired from our 8200-patient database. The study group included 670 patients with melanoma, with known primary tumors, who underwent therapeutic lymph node dissection for palpable nodal metastases diagnosed by open biopsy (227 patients), by FNA (66 patients), or by clinical observation without biopsy (377 patients). Regional node recurrence, 5-year disease-free survival, and overall survival rates were calculated. RESULTS: The same-basin regional node recurrence rates were similar for the three groups (open biopsy, 4.6%; FNA, 3.2%; no biopsy, 4.6%; P = .14). The 5-year disease-free survival rates were 36.8% for the open-biopsy group, 29.6% for the FNA group, and 28.9% for the no-biopsy group (P = .08); corresponding 5-year overall survival rates were 40.6%, 43.9%, and 36.1%, respectively (P = .18). Multivariate analysis failed to identify preoperative biopsy as a significant risk factor. Matched-pair analysis using age, gender, primary tumor site, Breslow thickness, and tumor burden showed no differences in the 5-year disease-free survival rates (33% for the open-biopsy group vs. 27% for the FNA and no-biopsy groups, P = .42) and the 5-year overall survival rates (41% vs. 35%, P = .32). CONCLUSIONS: For patients with melanoma with palpable regional adenopathy, histological confirmation of clinical suspicion with either FNA or excisional lymph node biopsy does not adversely affect survival or recurrence rates.

Sentinel lymphadenectomy in thyroid malignant neoplasms.

BACKGROUND: Lymph node metastases for well-differentiated thyroid cancer are associated with high recurrence rates. Surgical options consist of blind nodal sampling, "berry-picking" procedures, and modified radical neck dissections. Sentinel lymph node dissection (SLND) has been described by our institution for melanoma and breast cancer. We have investigated the feasibility of SLND for thyroid cancer. DESIGN: From August 1994 to October 1996 we investigated the technique of intraoperative lymphatic mapping and SLND in 17 patients undergoing surgical management of a suspicious thyroid nodule not accompanied by palpable cervical adenopathy. SETTING: Patients were referred from endocrinologists in community and academic practices. Procedures were performed in a community hospital. PATIENTS: There were 14 women and 3 men, ranging in age from 22 to 69 years (median, 48 years). INTERVENTIONS: At surgery, we exposed the thyroid lobe and used a tuberculin syringe to inject 0.1 to 0.8 mL of 1.0% isosulfan blue dye (mean, 0.5 mL) directly into the thyroid mass. Within seconds the blue dye passed along the lymphatics to the sentinel lymph node, which was then excised. Nodes were examined by routine processing and keratin immunohistochemical analysis to detect micrometastasis. MAIN OUTCOME MEASURES: The feasibility of lymphatic mapping in determining primary drainage of suspicious thyroid nodules. RESULTS: Lymphatic mapping and SLND was followed by total thyroidectomy, except in 1 patient who underwent lobectomy for benign disease. Of the 17 nodules, 12 were ultimately diagnosed as thyroid carcinoma, 3 were follicular adenomas, and 2 were colloid nodules. Tumor sizes ranged from 0.8 to 4.0 cm. Lymphatic mapping was unsuccessful in 2 patients, whose lymphatics mapped to the retrosternum. All of the sentinel lymph nodes were paratracheal except in 2 women who also had jugular nodes that stained blue. Five (42%) of the 12 tumor nodules were associated with positive sentinel lymph nodes. Central neck dissections were performed in 5 patients; in 2 instances (17%), the sentinel node was the only tumor-bearing lymph node. CONCLUSIONS: This is the first report of SLND for thyroid carcinoma. Our preliminary findings indicate that SLND can detect nonpalpable nodal metastasis with the same ease as in melanoma and breast cancer. The clinical significance of this technique in thyroid cancer remains to be determined.

Immunomagnetic separation can enrich fixed solid tumors for epithelial cells.

Immunomagnetic separation is a highly specific technique for the enrichment or isolation of cells from a variety of fresh tissues and microorganisms or molecules from suspensions. Because new techniques for molecular analysis of solid tumors are now applicable to fixed tissue but sometimes require or benefit from enrichment for tumor cells, we tested the efficacy of immunomagnetic separation for enriching fixed solid tumors for malignant epithelial cells. We applied it to two different tumors and fixation methods to separate neoplastic from non-neoplastic cells in primary colorectal cancers and metastatic breast cancers, and were able to enrich to a high degree of purity. Immunomagnetic separation was effective in unembedded fixed tissue as well as fixed paraffin-embedded tissue. The magnetically separated cells were amenable to fluorescence in situ hybridization and polymerase chain reaction amplification of their DNA with minimal additional manipulation. The high degree of enrichment achieved before amplification contributed to interpretation of loss of heterozygosity in metastatic breast cancers, and simplified fluorescence in situ hybridization analysis because only neoplastic cells were hybridized and counted. Immunomagnetic separation is effective for the enrichment of fixed solid tumors, can be performed with widely available commercial antibodies, and requires little specialized instrumentation. It can contribute to interpretation of results in situations where enrichment by other methods is difficult or not possible.

Mapping of the pulmonary surfactant SP5 (SFTP2) locus to 8p21 and characterization of a microsatellite repeat marker that shows frequent loss of heterozygosity in human carcinomas.

We have identified 4 cosmids at the SFTP2 locus by cDNA hybridization. SFTP2 was mapped using a polymorphic CA repeat and localized to 8p21 by FISH. Allele loss in carcinomas was detected using this PCR marker. Among 11 lung and colon tumors, 6 of 9 informative cases exhibited allelic loss.

Loss of heterozygosity in 8p is associated with microinvasion in colorectal carcinoma.

Loss of heterozygosity (LOH) from the short arm of chromosome 8 is frequent in a variety of malignancies, suggesting the presence of a tumor suppressor gene in this region. Previous studies suggested that this deletion may correlate with higher clinicopathologic stages in colorectal cancer, but others did not support this finding; in part, this difficulty is due to the low heterozygosity of the RFLP markers that were used. Here we report on a preliminary investigation in which we used highly informative microsatellite markers to determine whether deletions of 8p are correlated with poor prognostic features. Paraffin-embedded tumor tissue from 15 patients was analyzed with a panel of three microsatellite markers that are known to be sites of frequent LOH. Fourteen of the 15 cases were informative with at least one marker, and 7 showed LOH. Analysis of clinical features showed that there was no relation of 8p LOH with patient age or tumor stage, grade, location, or pattern of growth. However, a statistically significant correlation was seen between LOH and lymphatic, vascular, or perineural microinvasion (Fisher exact test, P = 0.01). This histologic feature is known to be a stage-independent indicator of prognosis. Our data suggest that 8p LOH may be associated with poor outcome and demonstrate the utility of these microsatellite markers for its detection.

Specific attachment of mesenteric IgA lymphoblasts to specialized endothelium of intestinal mucosa lamina propria capillaries.

The bulk of IgA secreted in the gut is mostly contributed by locally dwelling plasma cells derived from B cells originating in the gut-associated lymphoid tissues (GALT). These IgA cells originate in Peyer's patches and recirculate, returning to the gut upon maturity. The precise mechanism of homing to secretory mucosae is to date not fully understood. It has been demonstrated, however, that specialized endothelium of small vascular spaces in peripheral nodes (PN) and endothelia of mucosal vessels are the site of receptor recognition for B and T cells. In their sojourn, IgA blasts have been shown to stop momentarily in mesenteric nodes (MN) before proceeding to their final destination, the lamina propria (LP) of the gut mucosa. They then develop into IgA-secreting plasma cells. In the present work, we show that IgA MN lymphoblasts, when compared to PN lymphoblasts, attach preferentially to LP venule and capillary endothelium, The B-cell maturation in the mesenteric lymph nodes, where IgA is the sole membrane-bound immunoglobulin, allows attachment of most of these cells. Our work suggests that the site of exit of IgA cells from the circulation are these specialized lamina propria venules and capillaries.

Nucleolar prominence as a diagnostic variable in prostatic carcinoma.

The diagnosis of well-differentiated adenocarcinoma of the prostate can be difficult on needle biopsy specimens. Nucleolar prominence has proven to be a useful diagnostic variable, but its objective evaluation has had limited study. To find nucleolar criteria that might differentiate benign from malignant conditions, we examined 41 open prostatectomy specimens, 25 of which were removed for well-differentiated adenocarcinoma and 16 of which were removed for benign prostatic hypertrophy (BPH). Four acini of carcinoma, prostatic intraepithelial neoplasia (PIN), atypical adenomatous hyperplasia (AAH), nodular hyperplasia, and normal tissue were examined. The total number of nuclei with nucleoli 3 microns or greater (N'), the fraction of nuclei with nucleoli 3 microns or greater (N'/N), and the average diameters of nucleoli 3 microns or greater (AVG) were recorded. Hyperplastic and normal areas, when compared with carcinoma, had significantly smaller N',N'/N, and AVG values (P less than 0.005). The N' and N'/N values were significantly higher in hyperplasia when compared with normal acini (P less than 0.005). In addition, N' and N'/N values in PIN were significantly greater than those in AAH (P less than 0.0001). In comparing prostates with and without carcinoma, N' and N'/N were significantly different for hyperplastic areas. In only two cancer areas and one PIN area was the N'/N ratio less than 0.31, which was the highest value for either hyperplastic or normal areas. Although AVG also were significantly different, they did not improve discrimination between the groups. We conclude that N'/N ratios are useful in diagnosing well-differentiated prostatic adenocarcinoma on small tissue samples.