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PubMed2004

Internal mammary node drainage and its role in sentinel lymph node biopsy: the initial ALMANAC experience.

This study was designed to identify the frequency of internal mammary drainage in patients undergoing sentinel lymph node (SLN) lymphoscintigraphy in a controlled clinical trial. The practicability and relevance of internal mammary SLN biopsy as a method to improve nodal staging and treatment in breast cancer were investigated. A total of 707 evaluable patients with invasive breast cancer underwent SLN biopsy based on lymphoscintigraphy, intraoperative g probe detection, and blue dye mapping using technetium Tc 99m albumin colloid and Patent Blue V injected peritumorally. This was followed by standard axillary treatment in the same operation in all patients. Lymphoscintigraphy showed internal mammary sentinel nodes in 62 patients (9%), and internal mammary drainage was identified perioperatively in an additional 7 patients (1%) using g probe detection. Sampling of the internal mammary basin, based on the results of lymphoscintigraphy and g probe detection, was done in 31 of 69 patients (45%). One patient had a pneumothorax and 2 experienced bleeding during internal mammary sampling. Internal mammary metastases were detected in 4 of 31 patients (13%). In 2 of the patients (6%), internal mammary nodes (IMNs) showed metastatic involvement without accompanying axillary metastases. One of these 2 patients would have received adjuvant endocrine systemic therapy because of the characteristics of the tumor, but may not have been recommended to receive adjuvant chemotherapy. Sampling of the internal mammary basin led to a change of management in these 2 patients, ie, institution of adjuvant chemotherapy. Therefore, a change in management occurred in only 2 of the 69 patients in our series, but 38 patients with unbiopsied "hot" IMNs remained with unknown internal mammary status. Biopsy of IMNs alters staging in few patients, and the impact on indication for adjuvant treatment was low. Internal mammary SLN biopsy may be associated with some additional morbidity. Current evidence suggests that internal mammary SLN biopsy is still a research tool.

Adult↗

PubMed2005

Contralateral uptake and metastases in sentinel lymph node mapping for recurrent breast cancer.

BACKGROUND AND OBJECTIVES: Sentinel lymph node mapping as a constitutive component in the staging process for invasive breast cancer continues to gain acceptance. We have identified two patients with recurrent invasive breast cancer in whom contralateral sentinel lymph node uptake and metastases, respectively, were detected. Such findings have not been previously reported in our review of the medical literature between 1966 and October 2004. METHODS: Sentinel lymph node mapping was performed on two patients with recurrent invasive breast cancer at our institution. At the time of their index diagnosis, both had received breast conserving surgery and an axillary lymph node dissection with post-operative radiotherapy (RT). All lymph nodes and margins of resection were without tumor. Both patients remained with no evidence of disease for years until routine serial screening mammography was interpreted as suspicious. Each underwent a stereotactic biopsy of the ipsilateral breast corresponding to the mammographic abnormality. Pathology confirmed invasive ductal carcinoma. Both patients refused the recommended salvage mastectomy. PRINCIPAL RESULTS: During a second attempt at breast conservation, sentinel lymph node mapping--which is typically contraindicated for patients with prior axillary surgery--revealed contralateral axillary uptake for both patients. The respective contralateral sentinel node was excised with pathology revealing no tumor in one case, and a microscopic focus of metastatic carcinoma in the second case. MAJOR CONCLUSION: Some patients may benefit from sentinel lymph node mapping prior to salvage mastectomy. Identifying uptake in a contralateral sentinel lymph node may change the multi-disciplinary management of recurrent invasive breast cancer to include a contralateral axillary dissection, chemotherapy, and/or RT to the contralateral axilla.

Adult↗

PubMed2002

A selection algorithm for internal mammary sentinel lymph node biopsy in breast cancer.

Internal mammary lymph-node (IMN) metastases in breast carcinomas have a major influence on survival, comparable with the influence of axillary lymph-node metastases (ALNM). Prospective, randomized trials have demonstrated that complete IMN dissection as part of extended radical mastectomy does not improve overall or disease-free survival. In the subset of patients with tumours 1cm or less in size and no ALNM, information on IMN status would provide important information. In these cases, the presence of IMN metastases would change the staging from stage I to stage IIIB, according to the current tumour, node and metastasis classification. More importantly, it would influence these patients' adjuvant treatment. Lymphatic mapping for sentinel lymph-node (SLN) biopsy has demonstrated extra-axillary drainage in up to 35% of patients. Recent reports have demonstrated the feasibility of internal mammary sentinel lymph-node (IM-SLN) biopsy. Here we review the general prognostic and clinical significance of tumor location and lymph-node metastases in breast cancer and discuss the specific factors associated with IMN identification, metastases and treatment in the pre-SLN and SLN eras. Based on our review, we propose an algorithm for a selective approach to IM-SLN in breast cancer.

Algorithms↗

PubMed2000

Accuracy of lymph node palpation to determine need for lymphadenectomy in gynecologic malignancies.

OBJECTIVE: To assess the accuracy of intraoperative lymph node palpation for identifying lymph node metastasis in gynecologic malignancies. METHODS: We prospectively evaluated 126 women who had lymphadenectomies for staging of various gynecologic malignancies from August 1995 to June 1997. Surgeries were done by obstetrician-gynecologists with subspecialty certification in gynecologic oncology from the American Board of Obstetrics and Gynecology, who had practiced gynecologic oncology for at least 5 years. Data were collected on gynecologic oncologists' opinions of lymph node status by palpation. Nodes believed to be positive were sent separately. We recorded operating time for lymphadenectomies, and intraoperative and postoperative complications. RESULTS: Mean (range) patient age was 55 (18-83) years. Mean (range) operating time was 188 (85-435) minutes. The mean (range) lymphadenectomy time was 46 (5-150) minutes. The total number of lymph nodes dissected was 2138. One hundred seven of 2138 (5%) nodes were positive for malignancy. Thirty-eight of 107 (36%) positive lymph nodes were missed by palpation. Fifty-six of 2031 (3%) negative lymph nodes were selected as positive. Sixty-nine of 107 (64%) positive lymph nodes were identified correctly. Sensitivity and specificity of palpation were 72% and 81%, respectively. The positive and negative predictive values of lymph node palpation were 56% and 89%, respectively. CONCLUSION: Intraoperative lymph node palpation has low sensitivity and positive predictive value even when done by experienced board-certified gynecologic oncologists.

Adolescent↗

PubMed2002

Paracolic recurrence: the importance of wide excision of the spermatic cord at retroperitoneal lymph node dissection.

PURPOSE: Four patients who underwent retroperitoneal lymph node dissection elsewhere and subsequently had radiographic evidence of expanding ipsilateral paracolic recurrence were referred to our institution for treatment. We evaluated ipsilateral spermatic cord metastatic involvement at retroperitoneal lymph node dissection and identified the possible etiology of these unusual recurrences. MATERIALS AND METHODS: Between January 1988 and February 1998, 34 of 685 patients who underwent a total of 702 retroperitoneal lymph node dissections had metastatic disease in the spermatic cord specimen. Variables examined in this group of patients included other disease sites, lymphovascular invasion in the primary tumor, histopathological findings of the primary tumor and retroperitoneal disease, clinical and pathological stage, disease side and the specific site of anatomical involvement of metastatic disease within the spermatic cord specimen, that is spermatic vessels and/or surrounding lymphatic tissue. RESULTS: Of these 34 positive spermatic cord specimens 18 were in primary retroperitoneal lymph node dissections and 16 were in post-chemotherapy specimens. Histopathological evaluation in 25 (74%) and 9 (26%) of the 34 primary tumors showed a mixed germ cell pattern and pure embryonal carcinoma, respectively. Similarly 9 of the 34 retroperitoneal lymph node specimens (26%) showed pure embryonal cell carcinoma and the remainder showed mixed histopathological findings. Disease was clinical stage I in 13 cases (38%) and lymphovascular invasion was absent in the primary tumor in 11 (32%). Despite disease in the spermatic cord specimen there was none at the primary landing zone in 2 patients (6%), including 1 in whom the spermatic cord was the only disease site. In 12 positive spermatic cord specimens (35%) disease was identified in the surrounding perivascular and lymphatic tissue without gonadal vessel involvement. CONCLUSIONS: Metastatic disease in the spermatic vessels and/or surrounding lymphatic tissue represents a possible site of recurrence when incompletely excised. The lack of lymphovascular invasion in the primary tumor does not preclude metastatic disease in the spermatic cord specimen. Complete and wide excision of the spermatic cord and surrounding lymphatic tissues at retroperitoneal lymph node dissection is necessary and may prevent paracolic recurrence.

Adult↗

PubMed2002

Intraoperative lymphatic mapping and sentinel lymph node biopsy in patients with papillary carcinoma of the thyroid gland.

We examined the feasibility of sentinel lymph node biopsy for thyroid cancer. Thirty-eight patients with papillary thyroid carcinoma underwent intraoperative lymphatic mapping and sentinel lymph node biopsy. At surgery, we exposed the thyroid gland and used a tuberculin syringe to inject 0.2 ml of 1% patent blue dye directly into the thyroid mass. The lymphatics and the lymph node dyed with blue dyes, was excised as a sentinel lymph node. Modified radical neck dissection was performed following sentinel lymph node biopsy and the diagnostic ability of sentinel lymph node biopsy was examined. A sentinel lymph node was identified successfully in 27 (71%) of 38 patients. Sentinel lymph node biopsy removed one to three lymph nodes (median, two nodes). Eighteen patients had paratracheal sentinel lymph nodes, five patients had jugular sentinel lymph nodes, and four patients had both. Histological nodal metastasis was recognized in 16 of 27 cases. The positive rate of cancer metastases in sentinel lymph nodes was 58%, which was significantly higher than 11% in non-sentinel lymph nodes. Diagnostic ability of sentinel lymph node biopsy showed that accuracy was 89%, sensitivity was 84%, and specificity was 100%. Our preliminary study indicated that sentinel lymph node biopsy was available on detection of non-palpable nodal metastasis in the patients with thyroid cancer; however, further experience and refinement are needed.

Adult↗

PubMed2005

Lymph node revealing solution in gastric carcinoma does not provide upstaging of the N-status.

Staging of gastric carcinoma depends on exact lymph node status. However, very small lymph nodes can easily be missed during routine examination as they are obscured by the surrounding adipose tissue. The purpose of the present study was to verify the usefulness of a lymph node revealing solution (LNRS) in gastric cancer and compare its accuracy concerning the detection of lymph node metastases to immunostaining with cytokeratin antibodies. A total of 11 consecutive patients underwent standardized D2 gastrectomy for primary gastric adenocarcinoma. Non-fixed, the entire surgical specimen was searched for lymph nodes by palpation and visualization. The remaining tissue was immersed for 24 h in LNRS. The lymph nodes stood out as white chalky nodules on the background of yellow fat. All identified lymph nodes were resected and analyzed histologically. In 5 patients with pN0 status, immunostaining of the lymph nodes was performed using cytokeratin-specific antibodies. The conventional preparation of lymph nodes from the unfixed tissue yielded a total of 452 lymph nodes (mean 41.1 lymph nodes/patient; range, 26 to 56), and 201 of them had a pN0 status. After fixation using LNRS, 138 additional nodes could be detected (mean 12.5 lymph nodes/patient; range, 3 to 21), and 70 of them with a pN0 status. The detection rate of extremely small lymph nodes (<3 mm) increased by 27% compared to the conventional preparation technique (p=0.0017). After application of the LNRS lymph node analysis, it was not necessary to change the UICC node (N) stage in any cases. Additionally, we performed immunostaining in 5 specimens with pN0 status. In one patient, 10 micrometastases/disseminated tumour cells were detected. Thus, after immunohistochemical re-evaluation, one patient had to be upstaged pN(i+). By performing standardized LAD systematically and detailed lymph node preparation by the pathologist, a routine application of the LNRS method in gastric carcinoma is not recommended. Immunohistochemical techniques aid in identifying micrometastatic disease in lymph nodes missed in routine H&E staining in order to define the pN(i) status according to the TNM classification.

Acetic Acid↗

PubMed1994

[Pelvic lymph node metastasis in endometrial cancer].

Various factors associated with pelvic lymph node metastasis were analysed in 393 cases with stage I endometrial cancer treated with extended total hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy. The results are as follows. 1. The positive rates for lymph node metastasis and the relapse rate in 393 cases were 8.4% and 12.5%, respectively. 2. Myometrial invasion, tumor size, vessel permeation, cervical involvement, peritoneal cytology and adnexal metastasis were significant factors for lymph node metastasis. 3. Internal iliac nodes were the most common metastatic sites for cases with a single node metastasis, whereas external iliac nodes were the most common in all cases with lymph node metastasis. 4. The relapse rate for cases with single node metastasis was 40%, while the relapse rate for cases with three or more metastatic lymph nodes was 70%. 5. The relapse rate for 33 cases with lymph node metastasis was 54.5% and all of the relapse cases showed distant recurrence, whereas the relapse rate for 360 cases without lymph node metastasis was only 8.6%. It is therefore considered that pelvic lymphadenectomy is important in detecting high-risk patients and to reduce the relapse rate. Cytotoxic chemotherapy seems to be more adequate as adjuvant therapy for cases with lymph node metastasis.

Adult↗

PubMed2004

Photodynamic detection of diseased axillary sentinel lymph node after oral application of aminolevulinic acid in patients with breast cancer.

Benign as well as malignant tumour tissues of the breast demonstrate higher fluorescence intensity (FI) than normal breast tissue after application of a photosensitiser. As a follow-up study, we evaluated the FI of metastatic sentinel lymph nodes and metastatic axillary lymph nodes compared to nonmetastatic sentinel and axillary lymph nodes in patients with breast cancer. In all, 11 patients received 30 mg 5-aminolevulinic acid (ALA) kg(-1) bodyweight orally 3 h prior to surgery. The sentinel lymph node was marked with Nanocoll preoperatively and with a blue dye intraoperatively. Tumour excision, excision of the sentinel lymph node and an axillary lymph node dissection were performed during the same surgical session. The operation site was illuminated with blue light (400 nm) to obtain macroscopic tissue characterisation of fluorescence. Tissue samples were stored protected from light, and analysed using a fluorescence microscope. Results were correlated with histopathology. In all, 14 sentinel lymph nodes, seven axillary lymph nodes and seven primary tumours were analysed. Metastatic sentinel lymph nodes demonstrated a statistically significant higher FI than nonmetastatic sentinel lymph nodes (2630 vs 526, P<0.0001). The FI of metastatic sentinel lymph nodes, of metastatic axillary lymph nodes and of the primary tumour were comparably high, and were statistically significantly higher compared to the normal mammary tissue. Intraoperatively, only in a few cases, it was possible to recognise the metastatic sentinel lymph node macroscopically with blue light. Our study indicates that photodynamic diagnosis with ALA has a potential in the diagnosis and detection of the sentinel lymph node in patients with breast cancer, and is worth to be further investigated and developed for intraoperative photodynamic diagnosis and possibly therapy.

Administration, Oral↗

PubMed1980

Immunohistochemical demonstration of Fc receptors of human lymph node cells using peroxidase-antiperoxidase (IgG).

Human lymph node cells, prepared from regional lymph nodes excised from four patients with gastric cancer, were incubated with peroxidase-antiperoxidase (IgG) (PAPIgG). After being washed, they were reacted with diaminobenzidine tetrahydrochloride in the presence of H2O2. Light microscopic examination revealed that a certain proportion of lymph node cells (18.2-32.2%) were labeled on their cell surface with brown-colored reaction products and that the labeled cells were composed of small lymphocytes. Electron microscopic examination demonstrated electron-dense irregular-shaped aggregates of reaction products on the cell surface of lymphocytes. Characterization experiments confirmed that the immune complexes of PAPIgG bound specifically with Fc receptors. PAPIgG, therefore, can be used as a specific indicator for Fc receptor of human lymph node cells.

Cell Membrane↗

PubMed2005

Mesenteric lymph nodes: detection and significance on MDCT.

OBJECTIVE: Unsuspected mesenteric lymph nodes are frequently found on abdominal CT scans in everyday clinical practice. What to do with these findings has not been well established. The purpose of this study is to document the incidence of mesenteric lymph nodes in a previously healthy population and to provide guidelines for further management. MATERIALS AND METHODS: We examined the CT scans of 132 consecutive patients (84 men and 36 women; age range, 12-90 years; mean age, 43 years) who presented to the emergency department after experiencing blunt abdominal trauma. Twelve patients were excluded because they had disease processes known to be associated with lymphadenopathy. All imaging was performed using 3.2-mm collimation on MDCT scanners with IV contrast material. Two radiologists evaluated the images by consensus and recorded the presence of mesenteric lymph nodes greater than 3 mm in the short axis. Lymph node size, number, and location (central, peripheral, or right lower quadrant) were documented. All studies were reviewed on a PACS workstation. RESULTS: Of the 120 patients with otherwise normal CT scans, 47 had mesenteric lymph nodes greater than 3 mm. Of these 47 patients, 22 (47%) had five or more lymph nodes detected. Twenty-five (53%) of the 47 patients had four or fewer nodes. The mean size of the largest nodes was 4.8 mm (range, 3-9 mm), and the mean size of the nodes found per patient was 3.6 mm (range, 3-6 mm). These nodes were identified only at the mesenteric root in 32 patients (68%), only in the mesenteric periphery in eight patients (17%), and only in the right lower quadrant in five patients (11%). Nodes were identified in more than one location in two patients (4%). CONCLUSION: Incidental finding of mesenteric lymph nodes is common, reflecting more widespread use of thin-collimation MDCT and PACS workstations. In general, these nodes are small, measuring less than 5 mm. Such nodes when found in an otherwise healthy population are clinically insignificant and require no further imaging.

Adolescent↗

PubMed1997

The extent of lymph node dissection for colon carcinoma: the potential impact on laparoscopic surgery.

BACKGROUND: The surgeon is no longer able to palpate the mesocolon for lymph node metastases during laparoscopic colectomy. The extent of lymph node dissection should be determined beforehand for cancer control. METHODS: The distribution of lymph node metastases was obtained by the clearing method on colon carcinomas for 164 patients. RESULTS: For pericolic spread: for pT1 tumors, the distance from the primary tumor to a metastatic lymph node was 2.5 cm; for pT2, the distance was within 5 cm; for 97.0 % of pT3 tumors with lymph node metastases, the distance was within 7 cm; for 93.3 % of pT4 tumors with lymph node metastases, the distance was within 7 cm. For central spread: for pT1 tumors, the rate of metastasis to central lymph nodes was 0 %; for pT2, the rate of metastasis was 20.0 % to intermediate lymph nodes; for pT3, the rate of metastasis was 30.6 % to intermediate lymph nodes and 15.3 % to main lymph nodes; for pT4, the rate of metastasis was 44.4 % to intermediate lymph nodes and 22.2 % to main lymph nodes. CONCLUSIONS: Central lymph node dissection is not required for patients with T1 carcinomas, but proximal and distal 3-cm margins of resection are required. For T2, central lymph node dissection that includes the intermediate lymph node should be performed, as well as 5-cm proximal and distal margins of resection. For T3 and T4, central lymph node dissection including the main lymph node should be performed, as well as 7-cm proximal and distal margins of resection. [See editorial on pages 177-8, this issue.]

Colectomy↗

PubMed2003

Sentinel lymph nodes and breast carcinoma: which micrometastases are clinically significant?

Sentinel lymph node biopsy is changing surgical management of breast cancer and pathologic evaluation of lymph nodes. Although it has long been known that lymph nodes contain occult metastases, pathologists have not generally pursued their identification. Compared with level I-II axillary dissection, the reduced number of sentinel lymph nodes has made additional evaluation more attractive; however, the consequences of increased detection of micrometastases has not been fully explored or appreciated. National data suggest that the composition of traditional TNM stage groupings is changing, with a recent increase in node-positive, stage II breast cancer, most likely the result of increased pathologic scrutiny. Clinical management of this new group of stage II patients is complicated by the lack of a historic prognostic comparison group because many of these patients would have been classified as stage I, node-negative in the past. Early outcome data in sentinel lymph node biopsy suggest no adverse outcome for patients with metastases no larger than 2.0 mm, a finding aligned with the current definition of micrometastasis. When sentinel lymph nodes are sliced at 2.0-mm intervals and totally embedded, the probability of identifying all metastases >2.0 mm is high. Using reasonable sampling strategies, minute metastases have a nearly equal chance of being missed or detected. New staging guidelines have established a lower limit for micrometastases and defined metastases no larger than 0.2 mm as isolated tumor cells or tumor cell clusters; nodes with isolated tumor cells will be classified as node negative (pN0) for stage grouping. Rigorous strategies designed to reliably detect single cells or small cell clusters in sentinel nodes remain time-intensive and cost prohibitive.

Breast Neoplasms↗

PubMed1999

Occult metastases in the sentinel lymph nodes of patients with early stage breast carcinoma: A preliminary study.

BACKGROUND: Thirty percent of lymph node negative patients with operable breast carcinoma experience disease recurrence within 10 years. Retrospective serial sectioning of axillary lymph nodes has revealed undetected metastases in 9-30% of these patients. These occult metastases have been shown to have an adverse effect on survival. Serial sectioning (SS) is impractical for all axillary lymph nodes harvested from Levels I and II, but it is feasible if applied only to sentinel lymph nodes. METHODS: Sentinel lymph nodes from 52 patients with invasive breast carcinoma were cut at 2 mm intervals, fixed in 10% formalin, and embedded in paraffin. Sections were taken from the blocks, stained with hematoxylin and eosin (H & E), and compared with cytokeratin-stained sections taken at 0.25 mm intervals throughout the entire blocks. RESULTS: Tumor metastases were found in 6 patients (12%) when the sentinel lymph nodes were sectioned at 2 mm intervals and stained with H & E, compared with 30 patients (58%) when the same lymph nodes were serially sectioned at 0.25 mm intervals and stained with cytokeratin. Of 24 patients whose metastases were detected by SS and cytokeratin staining, 12 had isolated tumor cells and 12 had colonies of several thousand malignant cells. CONCLUSIONS: Routine histologic examination of axillary lymph nodes, including sentinel lymph nodes, in cases of breast carcinoma significantly underestimates lymph node metastases. This deficiency may be overcome by SS of the entire lymph nodes and staining with a specific monoclonal antibody. The percentage of patients found to have colonies of cells that were missed by routine sectioning corresponds closely to the percentage of "lymph node negative" patients who would be expected to relapse. The true clinical significance of these occult metastases will be determined by long term follow-up. [See editorial on pages 905-7, this issue.]

Adult↗

PubMed2001

Patterns of age-dependent changes in the numbers of lymph follicles and germinal centres in somatic and mesenteric lymph nodes in growing C57Bl/6 mice.

The timing of the first appearance of lymph follicles and germinal centres in various lymph nodes, and the ways in which numbers of these and IgM-synthesising cells increase within the nodes, were investigated in male and female C57Bl/6N mice aged from 4 d to 16 wk. The lymphoid organs examined were the Peyer's patches, spleen, somatic (submandibular, deep cervical, brachial, axillary, inguinal and popliteal) and visceral (mesenteric and lumbar) lymph nodes. Primary follicles appeared in most somatic lymph nodes 6 d after birth. The number of follicles per node then increased rather sharply in larger lymph nodes and slowly in smaller nodes, up to 28 d of age, reaching a level which varied according to the location of the node. Thereafter, the number of follicles in the somatic lymph nodes increased only slightly to moderately, reaching a peak or plateau at 8-12 wk. In the mesenteric (ileocaecal) nodes, primary follicles first appeared at 12 d, then increased linearly during the suckling period and after weaning to reach a plateau at 8 wk of age. Germinal centres appeared in the submandibular and mesenteric nodes at 28 d and their numbers increased consistently in the latter, while remaining low in the former. The impact of possible 'natural' exogenous antigen stimulation of the various lymph nodes was estimated from the presence of IgM-synthesising cells and germinal centres. Differences between the patterns of age-dependent changes in the numbers of lymph follicles observed in the somatic and mesenteric lymph nodes during their ontogeny are discussed in relation to differences in the magnitude of the exogenous antigen stimulatory effect. We also found that the variations in the numbers of lymph follicles produced in somatic lymph nodes at different locations during the first 28 d after birth reflected differences in the dimensions of the body regions drained by a particular somatic lymph node at this stage of development.

Aging↗

PubMed1999

Outcome of patients with melanoma and histologically negative sentinel lymph nodes.

HYPOTHESIS: Patients with melanoma and histologically negative sentinel lymph nodes identified by lymphatic mapping have a very good prognosis. DESIGN: Cohort study with follow-up information obtained from medical records and telephone interviews. SETTING AND PATIENTS: Of all patients with cutaneous melanoma who underwent intraoperative sentinel lymph node mapping between November 15, 1993, and April 18, 1997, at the Massachusetts General Hospital, Boston, 89 were found to have no evidence of melanoma in their sentinel nodes. Forty-six lesions (51%) were on an extremity and 44 (49%) were of axial location. The median tumor thickness was 1.8 mm (range, 0.36-12.0 mm) and 11 tumors (12%) were ulcerated. INTERVENTIONS: Patients underwent intraoperative sentinel lymph node mapping with lymphazurin and radiolabeled sulfur colloid. Sentinel lymph nodes were analyzed by standard hematoxylin-eosin staining. Only 2 patients received adjuvant therapy following wide excision of the primary lesion. MAIN OUTCOME MEASURES: Site of initial recurrence and time to initial recurrence. RESULTS: The median follow-up for all patients was 23 months (range, 2-54 months). Eleven patients (12%) developed melanoma recurrences, and 78 (88%) patients remain disease free. Regional lymph nodes were the initial site of recurrence in 7 (8%) of 89 patients, and 7 (7%) of 106 mapped basins. Four patients had recurrence without involvement of regional lymph nodes: 2 with distant metastases and 2 with in transit metastases. The median time to recurrence was 12 months (range, 2-35 months). Sentinel lymph nodes were reanalyzed using serial sections and immunoperoxidase stains in 7 patients with recurrence and metastatic melanoma was identified in 3 (43%). CONCLUSIONS: The risk for melanoma recurrence is relatively low in patients with histologically negative sentinel nodes identified by lymphatic mapping. Longer follow-up will improve our understanding of the prognostic value of this procedure.

Adult↗

PubMedDate not supplied

Sentinel lymph node biopsy reveals a positive popliteal node in clear cell sarcoma.

Clear cell sarcoma of the tendons and aponeuroses is an aggressive, rare soft tissue tumor with frequent metastases to regional lymph nodes. Sentinel lymph node biopsy, which has dramatically changed the management of melanoma, was used for clear cell sarcoma for an evaluation of popliteal and groin lymph node status. Although all isosulfan blue-stained groin lymph nodes were negative for malignancy, a popliteal lymph node was positive. Adjuvant 50 Gy of radiotherapy to the popliteal node might have been effective for local control for one year.

Adolescent↗

PubMedDate not supplied

Correlation of lymph node metastases and expression of matrix metalloproteinase-7 in patients with gastric cancer.

BACKGROUND/AIMS: Matrix metalloproteinase-7 (MMP-7) is thought to play an important role in the progression of cancer invasion. However, the expression of MMP-7 in primary and nodal lesions of gastric cancer is unknown. METHODOLOGY: Expression of MMP-7 protein in primary and nodal lesions of human gastric cancer was evaluated by immunohistochemistry. Expression of MMP-7 mRNA in the sentinel node, i.e. the first lymph node in the lymphatic basin to receive metastases from the primary tumor, was evaluated by reverse transcription-polymerase chain reaction (RT-PCR). RESULTS: Among primary lesions, 73 (48%) of 153 tumors were strongly positive for MMP-7. Strong positivity rates in the primary lesion were associated with deep invasion of the gastric wall, nodal metastases, and infiltration of vessels or lymphatics. Five-year survival rates were 43.8% in patients with strongly positive tumors and 75.0% in patients with weakly positive tumors. Among nodal metastases, 53 (76%) of 70 lesions were strongly positive for MMP-7, which was significantly higher than the strong positivity rate for primary lesions. Strong positivity rates in metastatic lesions were significantly higher when metastatic lymph nodes were present in group 2 or more. All of six patients with peritoneal dissemination in the absence of gastric serosal invasion had nodal metastases strongly positive for MMP-7. Five-year survival rates were 17.5% in patients with strongly positive nodal metastases and 68.6% in patients with weakly positive nodal metastases. RT-PCR demonstrated MMP-7 expression in sentinel nodes of 3 cases of 30. All 3 cases had metastases not only in the sentinel node but also in non-sentinel nodes. However, in 27 cases, including 24 without metastases and 3 with metastases in the sentinel nodes only, expression of MMP-7 in the sentinel nodes was not observed. CONCLUSIONS: MMP-7 may contribute to the invasion of both primary and nodal lesions in patients with gastric cancer. The MMP-7 expression is a useful prognostic factor, and evaluating the expression in sentinel node may help surgeons determine what level of lymph node dissection should be performed.

Humans↗