A biópsia de linfonodo sentinela não deve ser recomendada para pacientes portadores de melanoma espesso / Sentinel node biopsy should not be recommended for patients with thick melanoma

OBJETIVO: verificar se há alguma relação entre o estado histopatológico do linfonodo sentinela, a recorrência e a mortalidade decorrente do melanoma espesso em pacientes submetidos à BLS ao longo de um seguimento significante. MÉTODOS: Oitenta e seis pacientes portadores de melanoma espesso submetidos à BLS foram selecionados de um banco de dados prospectivo. A linfocintilografia, o mapeamento linfático e a detecção gama intraoperatória foram realizados em todos pacientes. O linfonodo sentinela (LS) foi analisado por HE e por imunoistoquímica. Linfadenectomia total foi indicada para os pacientes com LS positivo. O estado histopatológico do LS foi relacionado à taxa de recorrência e de mortalidade por melanoma. RESULTADOS: Cento e sessenta e seis LS foram retirados dos 86 pacientes. As idades variaram de 18 a 73 anos. Havia 47 mulheres e 39 homens. Micrometástases foram encontradas em 44 pacientes. Quarenta e dois pacientes foram submetidos à linfadenectomia total. Sete pacientes tiveram outro linfonodo positivo. Entre os 44 pacientes com LS positivo houve 20 recorrências e 15 mortes. Houve 18 recidivas e 12 mortes no grupo de LS negativo. A espessura de Breslow não apresentou correlação com o estado histopatológico do LS. O estado histopatológico do LS não interferiu nas taxas de recorrência e de mortalidade (teste de Fisher, p=1.00). A mediana de seguimento foi 69 meses. CONCLUSÃO: Considerando a falta de evidência de benefício, a BLS não deve ser indicada para pacientes com melanoma espesso fora de estudos clínicos.

OBJECTIVE: To ascertain whether there is any relationship between the state of the sentinel lymph node histopathology, recurrence and mortality from thick melanoma in patients undergoing SLNB over a long follow-up. METHODS: Eighty-six patients with thick melanoma undergoing SLNB were selected from a prospective database. Lymphoscintigraphy, lymphatic mapping and intraoperative gamma probe detection were performed in all patients. The sentinel lymph node (SLN) was analyzed by HE and immunohistochemistry. Complete lymphadenectomy was indicated for patients with positive sentinel node. The histopathological SLN status was related to the rate of recurrence and mortality from melanoma. RESULTS: One hundred and sixty-six SLNs were taken from the 86 patients. Ages ranged from 18 to 73 years. There were 47 women and 39 men. Micrometastases were found in 44 patients. Forty-two patients underwent complete lymphadenectomy. Seven other patients had positive lymph node. Among the 44 patients with positive sentinel node, there were 20 recurrences and 15 deaths. There were 18 recurrences and 12 deaths in the group with negative SLN. The Breslow thickness was not correlated with the histopathological SLN status. The histopathological SLN status did not affect the rates of recurrence and mortality (Fisher test, p = 1.00). The median follow-up was 69 months. CONCLUSION: Considering the lack of evidence of benefit, SLNB should not be indicated for patients with thick melanoma outside of clinical studies.

Vital dye is enough for inguinal sentinel lymph node biopsy in melanoma patients.

PURPOSE: The importance of gamma probe detection (GPD) combined with vital dye for sentinel node (SN) biopsy is well accepted. We evaluated the efficacy of patent blue dye (PBD) in identifying inguinal SN. METHODS: Ninety-four cutaneous melanoma patients with inferior extremity lesions were submitted to SNB according to a established protocol. Patients were randomized in two groups: Blue group, where SN was identified by PPD and Probe group, where SN was identified by GPD. The median age was 44.2 years and median Breslow thickness was 2.1 mm. Preoperative lymphoscintigraphy, lymphatic mapping with PBD and intra-operative GPD was performed on all patients. Histological examination of SN consisted of hematoxylin-eosin and immunohistochemical staining. If micrometastases were present complete lymphadenectomy was performed. The SN was considered as identified by PBD if it was blue and identified by GPD if it demonstrated at least ten times greater radioactivity than background. RESULTS: It was explored 94 inguinal lymphatic basins, 145 SN were excised (70 guided primarily by blue dye and 75 guided primarily by probe). All SN identified by preoperative lymphoscintigraphy were excised. In the Blue group PPD identified all SN and all of them were hot. In the Probe group all SN were identified by probe and were blue. The coincidence of PPD and GPD was 100%. CONCLUSION: Patent blue dye is enough to identify superficial inguinal SN in cutaneous melanoma.

Vital dye is enough for inguinal sentinel lymph node biopsy in melanoma patients

OBJETIVO: a importância da detecção gama intra-operatória combinada com corante vital para biópsia de linfonodo sentinela é bem aceita. Nós avaliamos a eficácia do azul patente V na identificação do linfonodo sentinela inguinal. MÉTODOS: Noventa e quatro pacientes portadores de melanoma cutâneo de membro inferior foram submetidos a biópsia de linfonodo sentinela de acordo com protocolo estabelecido. Foram randomizados em dois grupos: Grupo Azul, onde o linfonodo sentinela foi identificado primariamente com o corante vital azul patente V (Guerbet) e o Grupo Sonda, onde o linfonodo sentinela foi identificado primariamente pela sonda de detecção gama (Neoprobe). A idade mediana foi de 44,2 anos e a espessura mediana de Breslow foi 2,1 mm. Linfocintilografia pré-operatória, mapeamento linfático com azul patente V e detecção gama intra-opertaória foram realizados em todos os pacientes. O exame histopatológico do linfonodo sentinela consistiu de hematoxilina-eosina e imunohistoquímica. Se micrometástase estivesse presente, linfadenectomia completa era realizada. O linfonodo sentinela era considerado como identificado pelo corante vital se estivesse azul e identificado pela sonda de detecção gama se demonstrasse pelo menos 10 vezes ou mais radioatividade do que o fundo. RESULTADOS: Foram exploradas 94 regiões inguinais, 145 linfonodos sentinelas foram excisados (70 dirigidos primariamente pelo corante vital e 75 dirigidos pela sonda de detecção gama). Todos os linfonodos sentinelas identificados pela linfocintilografia foram excisados. No grupo azul, todos os linfonodos sentinela foram primariamente idenficados pelo corante vital e todos se apresentavam quentes na leitura pela sonda. No grupo sonda, todos os linfonodos sentinelas foram primariamente identificados pela sonda e estavam corados pelo azul. A coincidência da sonda com o corante vital foi de 100%. CONCLUSAO: Azul patente V foi suficiente para identificar linfonodo sentinela inguinal em pacientes com melanoma cutâneo.

Recorrência em pacientes portadores de melanoma cutâneo submetidos a biópsia de linfonodo sentinela: seguimento mediano de 37 meses / Patterns of recurrence following sentinel lymph node biopsy for cutaneous melanoma: outcome after 37 months of follow-up

OBJETIVO: A biópsia de linfonodo sentinela (BLS) representa um avanço na cirurgia oncológica para o microestadiamento do melanoma. Apresentamos nossa experiência dando ênfase para a recorrência. MÉTODO: A BLS foi realizada em 133 pacientes portadores de melanoma cutâneo localizado envolvendo linfocintilografia, mapeamento linfático e detecção gama intra-operatórios em todos os pacientes. O exame histopatológico foi realizado por HE e imunohistoquímica (IHC). RESULTADOS: Encontrou-se LS em 128 pacientes (96,2 por cento). Micrometástase foi diagnosticada em 20 pacientes (15,6 por cento). Houve nove recorrências, sendo quatro no grupo com LS negativo (108 pacientes). Neste grupo, houve uma recorrência sistêmica e três (2,8 por cento) na região linfática de drenagem (falso negativo). No grupo com LS positivo (20 pacientes) ocorreram cinco recorrências. Houve diferença significativa de recorrência entre os grupos, tendo sido menor no grupo LS negativo (p=0,0048). Através de análise de regressão logística univariada a ulceração (p=0,029) e a positividade do LS (p=0,003) apresentaram significância estatística como fatores de risco. Porém, apenas a positividade do LS manteve singificância na análise multivariada (p=0,024). O seguimento mediano foi de 37 meses. CONCLUSÕES: Pacientes com LS positivo apresentam recorrência significativamente maior que pacientes com LS negativo. O índice de falso negativo foi de 2,8 por cento e os pacientes não apresentaram seqüelas o que permite considerar a BLS como procedimento seguro para o microestadiamento do melanoma cutâneo.

BACKGROUND: Sentinel node biopsy (SNB) has been considered as an advance in surgical oncology for microstading melanoma. We report our experience with this procedure focusing on recurrence. METHODS: SNB was performed in 133 cutaneous melanoma patients submitted to preoperative lymphoscintigraphy, lymphatic mapping and gamma probe detection. Histologycal samples were analysed by HE and immunohistochemistry (IHC). RESULTS: The sentinel node was detected in 126 patients (96.2 percent). Micrometastasis were diagnosed in 20 patients (15.6 percent). There were nine recurrence, four in negative sentinel node group (108 patients). In this group, there was one systemic recurrence and three (2.8 percent) on lymphatic drainage region (false negative). In positive sentinel node group (20 patients) there were five recurrences. The recurrence was lower among negative sentinel node patients (p=0.0048). Ulceration (p=0.029) and positivity of the sentinel node (p=0.003) were considered significant risk factor by logistic analisys. Only sentinel node positivity maintained significance on multivariate analysis (p=0.024). The median follow up was 37 months. CONCLUSION: Patients with positive sentinel node presented more recurrence than negative sentinel node patients. The false negative rate was 2.8 percent and patients didn't have long-term sequelae ,allowing us to consider SNB as a secure and accurate procedure for melanoma staging.

Relevance of micrometastases detected by reverse transcriptase-polymerase chain reaction for melanoma recurrence: systematic review and meta-analysis

CONTEXT: Cutaneous melanoma presents significant morbidity and mortality. Nowadays, about 90 percent of them are diagnosed by clinical examination and most are localized melanomas. Sentinel node biopsy has brought about a new and interesting approach towards localized cutaneous melanoma. The meaning of micrometastases in sentinel nodes diagnosed by the reverse transcriptase-polymerase chain reaction is not well established. OBJECTIVE: To define the real value of micrometastases diagnosed by the reverse transcriptase-polymerase chain reaction in relation to melanoma recurrence. METHODS: Systematic literature review and meta-analysis. The Cochrane Library, Medline, Embase and Lilacs were the databases searched. We used the following key words: sentinel node and melanoma; sentinel node and reverse transcriptase-polymerase chain reaction; melanoma and reverse transcriptase-polymerase chain reaction. Cohort studies enrolling localized cutaneous melanoma patients who underwent sentinel node biopsy were selected. Sentinel node evaluations included hematoxylin and eosin, immunohistochemistry and reverse transcriptase-polymerase chain reaction. RESULTS: Out of the 1,542 studies evaluated, four were eligible. The four studies, when combined, were statistically homogeneous. The sample totaled 450 patients grouped as follows: 163 with a sentinel node negative to hematoxylin eosin and immunohistochemistry and positive to the reverse transcriptase-polymerase chain reaction; 192 with a sentinel node negative to hematoxylin eosin, immunohistochemistry and the reverse transcriptase-polymerase chain reaction and 95 patients with a sentinel node positive to hematoxylin eosin and/or immunohistochemistry. We analyzed the first two groups. The meta-analysis for the random model showed an increased effect from a positive reverse transcriptase-polymerase chain reaction on the recurrence rate. A similar result occurred in the meta-analysis for the fixed effect model. CONCLUSION: Patients with a positive reverse transcriptase-polymerase chain reaction had a greater recurrence rate than those with a negative reverse transcriptase-polymerase chain reaction. This suggests an important role for the reverse transcriptase-polymerase chain reaction in sentinel node examinations. In view of the small sample, a clinical trial could better evaluate this question