Using Nomograms Wisely: Predicting Sentinel Node Positivity in Melanoma.

BACKGROUND: Four externally validated sentinel node biopsy (SNB) prediction nomograms exist for malignant melanoma that each incorporate different clinical and histopathologic variables, which can result in substantially different risk estimations for the same patient. We demonstrate this variability by using hypothetical melanoma cases. METHODS: We compared the MSKCC and MIA calculators. Using a random number generator, 300 hypothetical thin melanoma "patients" were created with varying age, tumor thickness, Clark level, location on the body, ulceration, melanoma subtype, mitosis, and lymphovascular invasion (LVI). The chi-square test was used to detect statistically significant differences in risk estimations between nomograms. Multivariate linear regression was used to determine the most relevant contributing pathologic features in cases where the predictions diverged by > 10%. RESULTS: Of 300 randomly generated cases, 164 were deleted as their clinical scenarios were unlikely. The MSKCC nomogram generally calculated a lower risk than the MIA (p < 0.001). The highest risk score attained for any "patient" using MSKCC calculator was 15% achieved in one of 136 patients (0.7%), whereas using the MIA nomogram, 58 of 136 patients (43%, p < 0.001) had predicted risk >15%. Regression analysis on patients with >10% difference between nomograms revealed LVI (26, p < 0.001), mitosis (14, p < 0.001), and melanoma subtype (8, p < 0.001) were the factors with high coefficients within MIA that were not present in MSKCC. CONCLUSIONS: Nomograms are useful tools when predicting SNB risk but provide risk outputs that are quite sensitive to included predictors.

The clinico-pathological spectrum of plaque-type blue naevi and their potential for malignant transformation.

AIMS: Plaque-type blue naevi are rare melanocytic tumours presenting as large, pigmented plaques at birth or during childhood. There is a risk for malignant transformation, but no larger comprehensive studies exist and the diagnosis is challenging, especially on limited biopsy material. The aim is to describe the clinicopathological features and behaviour of the disease more comprehensively. METHODS AND RESULTS: We retrieved eight plaque-type blue naevi, presenting as large, pigmented plaques (median = 7 cm; range = 3-26) most frequently affecting the scalp (four) followed by the cheek, arm, abdominal wall and gluteal cleft (one each), with a slight female predilection. Median age at time of biopsy was 39.5 years (range = 15-90), but three tumours had been present at birth and one since childhood. Histopathologically, the tumours were poorly circumscribed and composed of cellular fascicles of uniform spindle cells in a background of variably prominent pigmented dendritic cells affecting dermis and subcutaneous tissues. The majority had mutations in GNAQ. One tumour showed malignant transformation, characterised by an expansile nodule of pleomorphic epithelioid melanocytes with rhabdoid morphology, high mitotic activity and areas of necrosis. This patient developed metastatic melanoma to lymph nodes. All patients are alive with a median follow-up of 60 months. CONCLUSION: Plaque-type blue naevi are diagnostically challenging tumours with risk for malignant transformation. Awareness and familiarity with the salient clinicopathological features are necessary for reliable diagnosis, and long-term clinical follow-up is required to monitor for malignant transformation.

Factors associated with breast symmetry after breast conserving surgery for cancer.

INTRODUCTION: Breast-conserving surgery (BCS) is the standard of care for treatment of early breast cancer. Factors associated with poor cosmetic results are not well described. The aim of the present study was to evaluate factors associated with breast asymmetry after BCS for invasive breast cancer. MATERIAL AND METHODS: Patients who underwent unilateral BCS for invasive breast cancer and completed at least six months after radiation therapy were included. After informed consent, patients answered a validated questionnaire for breast symmetry. Demographic, clinical-pathological and surgical variables were recorded. Bilateral breast volume was measured in office and volume difference > 20% was considered objective asymmetry. Variables were analyzed with χ(2) test and significance was considered at p < 0.05. RESULTS: One-hundred and thirtythree patients were included. Mean patient age was 56 ± 9 years. Most patients were married (78%) with educational level of high school or greater (50.8%). Mean body mass index (BMI) was 25 ± 8. Twelve percent of patients underwent ≥ 2 surgical procedures. Eighty-one percent of patients had tumors > 1 cm. Twenty-two percent of patients had objective breast asymmetry and 27% perceived themselves with asymmetry. There were no significant relationship between objective and subjective asymmetry. The only variable significantly associated with perception of breast asymmetry was educational level ≥ high school. CONCLUSIONS: There was no relationship between subjective and objective breast asymmetry after BCS, suggesting that cosmetic results are mainly related to patient subjective perception. The only variable associated with subjective breast asymmetry was high educational level, possibly because higher cosmetic expectations in this group of patients.

Current Controversies in Melanoma Treatment.

LEARNING OBJECTIVES: After reading this article and viewing the videos, the participant should be able to: 1. Discuss margins for in situ and invasive disease and describe reconstructive options for wide excision defects, including the keystone flap. 2. Describe a digit-sparing alternative for subungual melanoma. 3. Calculate personalized risk estimates for sentinel node biopsy using predictive nomograms. 4. Describe the indications for lymphadenectomy and describe a technique intended to reduce the risk of lymphedema following lymphadenectomy. 5. Offer options for in-transit melanoma management. SUMMARY: Melanoma management continues to evolve, and plastic surgeons need to stay at the forefront of advances and controversies. Appropriate margins for in situ and invasive disease require consideration of the trials on which they are based. A workhorse reconstruction option for wide excision defects, particularly in extremities, is the keystone flap. There are alternative surgical approaches to subungual tumors besides amputation. It is now possible to personalize a risk estimate for sentinel node positivity beyond what is available for groups of patients with a given stage of disease. Sentinel node biopsy can be made more accurate and less morbid with novel adjuncts. Positive sentinel node biopsies are now rarely managed with completion lymphadenectomy. Should a patient require lymphadenectomy, immediate lymphatic reconstruction may mitigate the lymphedema risk. Finally, there are minimally invasive modalities for effective control of in-transit recurrences.

Body image perception and quality of life in patients who underwent breast surgery.

Quality of Life (QoL) has become a standard measure in assessing the effectiveness of medical interventions. We compared the differences between QoL and body image scale (BIS) in a group of patients who underwent breast surgery, including lumpectomy or conservative surgery, modified radical mastectomy and radical mastectomy with breast reconstruction. We included patients who underwent breast surgery between August of 2005 and June of 2006 in two tertiary referral centers in Mexico City. Two self-administered questionnaires assessing body image perception, BIS and quality of life (SF-36), were assigned and a physician-conducted interview was done. We stratified patients by age, marital status, and scholar grade. The sample comprised 202 patients. The BIS results yielded: the group with a benign lesion demonstrated favorable body image perception when compared with the malignant lesion group. A confirmed diagnosis of malignancy hinders QoL in older and younger age groups. Conservative surgery and breast reconstruction improves QoL in younger patients without significance in the older group. The most significant variable that hinders the BIS and QoL is the cancer diagnosis. Impact of conservative surgery and breast reconstruction in body image perception and quality of life is influenced by patient age and educational level.

Thrombocytosis as a predictor of distant recurrence in patients with rectal cancer.

BACKGROUND AND AIMS: Thrombocytosis is frequently observed in patients with malignancy. We undertook this study to determine the prognostic value of thrombocytosis in patients with rectal cancer. METHODS: We performed a retrospective study of patients undergoing low anterior resection for rectal cancer between January 2000 and March 2007. Preoperative platelet count was measured before surgery. Postoperative platelets were determined 1 month after surgery. Two-tailed p values <0.05 were considered statistically significant. RESULTS: One hundred sixty three patients with rectal cancer were included in the study. Preoperative platelet count >350,000 was found in 8% of patients. Postoperative platelet count >350,000 was found in 6% of patients. Distant metastases were found in 17 patients (10.4%). Significant variables in the multivariate analyses were preoperative platelets >350,000 (p = 0.001), postoperative platelets >350,000 (p = 0.002), carcinoembryonic antigen >13 ng/dL (p = 0.003). Patients with preoperative platelet count <350,000 showed a 5-year survival rate of 81%, whereas patients with platelet count >350,000 had a 25-month survival [95% confidence interval (CI): 20-26]; p <0.001. Patients with postoperative platelets <350,000 showed a 5-year survival rate of 80%, whereas patients with platelets >350,000 showed a 3-year survival rate of 37.5% (p <0.05). CONCLUSIONS: Pre- or postoperative platelet count >350,000 is associated with poor survival in patients with rectal cancer. The measurement of platelets is a clinical marker useful to define the prognosis for patients with rectal cancer.

Pathological implications of areas of lower enhancement on contrast-enhanced computed tomography in renal-cell carcinoma: additional information for selecting candidates for surveillance protocols.

PURPOSE: Areas of lower enhancement on computed tomography are frequently seen in renal-cell carcinoma. We investigated whether tumor enhancement on the most prominent hypodense areas correlates with the nuclear grade and other pathologic variables. METHODS: From 2004 to 2009, all consecutive patients with a preoperative tomography who underwent radical or partial nephrectomy for renal-cell carcinoma at our tertiary referral center were retrospectively analyzed. Enhancement of the entire tumor on the slice with most prominent areas of lower enhancement was determined. RESULTS: Forty-eight patients were included. Clear-cell carcinoma comprised 91.6 %. Mean areas of lower enhancement for nuclear grade tumors 1-4 were 67.4, 38.7, 27.9, and 15.1 HU, respectively. Areas of lower enhancement negatively correlated with size, nuclear grade, T stage, and pathological stage. Tumors with extension beyond Gerota's fascia (10.5 vs. 35.9 HU, p < 0.001) and positive surgical margins (21.2 vs. 34.8 HU, p = 0.04) had more prominent areas of lower enhancement than organ-confined tumors. When comparing nuclear grade 1-3 to nuclear grade 4 tumors, these areas were significantly lower in the later (36.5 vs. 15.1 HU, p < 0.001). Receiver-operating characteristics curves for detecting nuclear grade 4 showed an area under the curve of 0.808 (95 % CI 0.659-0.957). CONCLUSIONS: Lower enhancement of the entire tumor at the point where hypodense tumor areas are more predominant on tomography is associated with higher nuclear grade and more advanced stage.