Alan Yahanda

Mitotic Rate and Younger Age Are Predictors of Sentinel Lymph Node Positivity: Lessons Learned From the Generation of a Probabilistic Model

Background: Sentinel lymph node (SLN) biopsy allows surgeons to identify patients with subclinical nodal involvement who may benefit from lymphadenectomy and, possibly, adjuvant therapy. Several factors have been variably, and sometimes discordantly, reported to have predictive value for SLN metastasis to best select which patients require SLN biopsy.Methods: We reviewed 419 patients who underwent SLN biopsy for melanoma from a prospectively collected melanoma database. To derive a probabilistic model for the occurrence of a positive SLN, a multivariate logistic model was fit by using a stepwise variable selection method. The accuracy of each model was evaluated by using receiver operator characteristic curves.Results: On univariate analysis, the number of mitoses per square millimeter, increasing Breslow depth, decreasing age, ulceration, and melanoma on the trunk showed a significant relationship to a positive SLN. Multivariate analysis revealed that once age, mitotic rate, and Breslow thickness were included, no other factor, including ulceration, was significantly associated with a positive SLN. The data suggest that younger patients with tumors <1 mm may still have a substantial risk for a positive SLN, especially if the mitotic rate is high.Conclusions: In addition to Breslow depth, mitoses per square millimeter and younger age were factors identified as independent predictors of a positive SLN. This model may identify patients with thin melanoma at sufficient risk for metastases to justify SLN biopsy.

Laparoscopic splenectomy in patients with hematologic malignancies

BACKGROUND Although laparoscopic splenectomy (LS) for benign hematologic disease is well accepted, its role in hematologic malignancies is not clearly defined. This study examined the efficacy and feasibility of LS for hematologic malignancies. METHODS Records were reviewed from patients who underwent LS at two university hospitals. Charts from 77 open splenectomies for malignancy (OM) during the same period were also reviewed. RESULTS Fifty-three patients underwent LS, 22 for hematologic malignancies (LM) and 31 for benign hematologic disorders (LB). Median splenic weight was greater in the LM group (930 g) than in the LB group (164 g, P = 0.001). LM was associated with longer operations and greater blood loss than was LB. LM had a 41% conversion rate. Morbidity, mortality, and transfusion rates were similar. Median hospital stay was shorter for LM (4 days) than for OM (6 days, P = 0.001). CONCLUSIONS LS is feasible in hematologic malignancies but is associated with increased operative time and blood loss and a high conversion rate. Morbidity and mortality, however, was similar. Shorter hospital stays for LM compared with OM may translate into earlier recovery and initiation of antineoplastic therapy.

The utility of fine needle aspiration in the diagnosis of melanoma metastatic to lymph nodes

BACKGROUND Prompt and accurate diagnosis of melanoma metastatic to the lymph nodes is important with respect to prognosis and treatment. OBJECTIVE The purpose of this study was to determine the utility and diagnostic reliability of fine needle aspiration (FNA) of enlarged nodules in lymph node basins in patients with melanoma. METHODS We retrospectively reviewed the charts of 46 patients with melanoma who underwent a total of 56 FNAs of palpable nodules in lymph node basins. RESULTS Of the 56 FNAs, 24 showed melanoma, 26 did not demonstrate melanoma, five were inadequate, and one gave inconclusive but suspect results. Findings were confirmed by open biopsy (n = 35) or clinical follow-up (n = 21). Fifty of 56 FNAs (89%) yielded a definitive diagnosis (sensitivity/specificity = 100% in these 50). CONCLUSION FNA biopsy of enlarged palpable nodules in nodal basins in patients with melanoma is accurate, rapid, and cost-efficient. An algorithm for management of patients with melanoma who have palpable nodes is provided.

Computed tomography in staging of patients with melanoma metastatic to the regional nodes

AbstractBackground: This study addresses the yield and clinical impact of computed tomography (CT) imaging in otherwise asymptomatic patients with stage III melanoma metastatic to the regional nodes. Methods: The database from the University of Michigan Mutlidisciplinary Melanoma Clinic was reviewed and identified 127 asymptomatic patients with stage III melanoma (regional nodal disease) who received CT scans of the head, chest, abdomen, and/or pelvis. Scans were confirmed as true positive, false positive, and normal. Results: Four hundred twenty-six head and body CT scans were performed at the time of presentation of stage III disease. Twenty patients had a true-positive CT scan revealing unsuspected metastases. Fifteen patients had abnormal CT scans subsequently shown to be a benign process or second malignancy. The incidence of true-positive CT scans was not different between the groups of patients who had clinically apparent versus occult nodal disease. There was a significantly higher incidence of abdominal and pelvic metastatic sites identified by CT scan in patients with inguinal nodal disease compared with axillary or head and neck node-positive patients. Conclusions: The yield of detection of unsuspected metastases by CT scans in asymptomatic patients with stage III melanoma was not insignificant. Because patients with resected stage III disease are recommended to have adjuvant interferon-α for 1 year, CT staging plays an important role in identifying appropriate candidates for treatment. The toxicity of interferon-α therapy is not insignificant. The value of routine CT in asymptomatic patients with nodal metastasis deserves further prospective study.

Epidermoid cyst of the spleen

the remaining 10%. 1 Patients with true splenic cysts are usually young and present, as our patient did, with an abdominal mass associated with mild symptoms related to cyst enlargement. Often, these cysts are completely asymptomatic and are discovered incidentally during imaging studies or at autopsy. The differential diagnosis may include epidermoid/dermoid cyst, parasitic cyst, splenic infarction, and splenic abscess. A preoperative ultrasound scan or, preferably, abdominal CT scan is helpful in determining both the cyst’s site of origin and its relationship to surrounding structures. Furthermore, these imaging studies can help plan the optimal operative approach, especially if a laparoscopy is being considered. In patients with asymptomatic true splenic cysts, a course of conservative management is reasonable. In a recent collective review of 191 cases of these cysts reported in the literature, only 10 (5.2%) instances of cyst-related complications were reported. 1 Of these 10 complications, 6 involved cyst rupture and 4 involved cyst infection. There were no cases of cyst hemorrhage in this series. When a splenic cyst is symptomatic or if the diagnosis is in question, operative therapy is warranted. Total splenectomy, partial splenectomy, and cystectomy have been reported to be adequate treatments for these cysts. Limited treatments, such as catheter drainage or sclerosis, are associated with high rates of recurrence or infection and have largely been abandoned. After immunization against pneumococci, Haemophilus influenzae B, and meningococci infection, the patient underwent an exploratory laparotomy where a large cystic mass of the spleen was found, displacing the stomach and falciform ligament to the right (Figure 2). A splenectomy was performed without complication. Gross pathologic examination revealed a cystic spleen measuring 21 cm in greatest dimen- sion and weighing 2,100 g. The histologic findings were consistent with an epidermoid cyst. The patient had an uneventful recovery and was discharged home on postoperative day 4. She has remained well for more than 30 months.

Is mammography useful in screening for local recurrences in patients with TRAM flap breast reconstruction after mastectomy for multifocal DCIS

AbstractBackground: Skin-sparing mastectomy with immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction is being used more often for the treatment of breast cancer. Mammography is not used routinely to evaluate TRAM flaps in women who have undergone mastectomy. We have identified the potential value of its use in selected patients. Methods and Results: We report on four women who manifested local recurrences in TRAM flaps after initial treatment for ductal carcinoma in situ (DCIS) or DCIS with microinvasion undergoing skin-sparing mastectomy and immediate reconstruction. All four patients presented with extensive, high-grade, multifocal DCIS that precluded breast conservation. Three of four mastectomy specimens demonstrated tumor close to the surgical margin. Three of the four recurrences were detected by physical examination; the remaining local recurrence was documented by screening mammography. The recurrences had features suggestive of malignancy on mammography. Conclusion: We conclude that all patients undergoing mastectomy and TRAM reconstruction for extensive, multifocal DCIS should undergo regular routine mammography of the reconstructed breast. Our experience with this subgroup of patients raises concern about the value of skin-sparing mastectomy with immediate reconstruction for therapy. Adjuvant radiation therapy should be recommended for those patients with negative but close surgical margins.

Advances in melanoma therapy

This review discusses several advances in melanoma therapy that have recently occurred or are presently in a developmental stage. We discuss the history and present dogma regarding assessment of the regional lymph nodes and adjuvant therapy for melanoma. Of special interest is radiolymphatic sentinel node mapping of the lymph nodes and adjuvant interferon alfa-2b for thick primary lesions and stage III disease. We also discuss several evolving novel and innovative genetic immunotherapy approaches for patients with stage IV disease.

Laparoscopic biopsy of abdominal retroperitoneal lymphadenopathy for the diagnosis of lymphoma1

Evaluation of the patient with abdominal retroperitoneal lymphadenopathy is a common clinical situation encountered by general surgeons. If there is associated peripheral lymphadenopathy more accessible for biopsy, obtaining a tissue sample for pathologic diagnosis can be relatively straightforward. In these cases, either an incisional or excisional biopsy can be performed on these enlarged lymph nodes, usually under local anesthesia. If there is no palpable peripheral adenopathy present, diagnostic tissue may be more difficult to obtain. Accurate pathologic diagnosis of lymphoma requires that an adequate tissue specimen be biopsied for review. The amount of tissue must be sufficient for routine microscopic examination and flow cytometry, immunophenotyping, and gene rearrangement studies. The exact subclassification of the lymphoma is crucial because it will ultimately dictate the type of treatment the patient will receive. Image-guided core-needle biopsy is an accurate, minimally invasive means of obtaining a pathologic specimen from these enlarged retroperitoneal lymph nodes, and it represents the biopsy method of choice in the majority of patients. In some cases, core-needle biopsy yields an inadequate amount of tissue or tissue that has lost its normal architecture, making diagnosis impossible. Also, the proximity of enlarged abdominal retroperitoneal lymph nodes to structures such as major blood vessels, bowel, or other viscera makes percutaneous biopsy, even under skilled radiologic guidance, hazardous and technically challenging. Advances in laparoscopic techniques and equipment have made it possible to dissect and expose these retroperitoneal lymph nodes and to biopsy them under direct visualization. The laparoscopic approach is ideally suited for patients deemed poor candidates for core-needle biopsy or for those who have had nondiagnostic or inadequate specimens on previous core biopsy attempts. It allows tissue to be obtained in a minimally invasive manner while maintaining good diagnostic accuracy, adequate tissue retrieval, and low operative morbidity. The retroperitoneal location of the adenopathy may, on first glance, appear to be technically difficult and daunting to access using the laparoscope. But in most cases, these areas can be approached and biopsied in a straightforward manner. We describe our simplified approach to the laparoscopic biopsy of abdominal retroperitoneal lymphadenopathy and review our experience with this technique.

Reproducibility of lymphoscintigraphic drainage patterns in sequential 99mTc human serum albumin and 99mTc sulfur colloid studies: Implications for sentinel node identification in melanoma

BACKGROUND Selective lymphadenectomy, based on prior lymphatic mapping and sentinel node identification and excision, is now the standard management for intermediate-thickness melanomas in many cancer centers worldwide. At our center 99m-labeled technetium human serum albumin (HSA) scans are performed before the day of surgery in some patients with truncal lesions to detect multiple sites of lymphatic drainage. 99mTc sulfur colloid (SC) is then injected before the operation to delineate the sentinel node(s) for gamma-probe-guided excision. Our purpose was to retrospectively evaluate whether comparable diagnostic information resulted from lymphoscintigraphy performed with these 2 different agents. METHODS All patients with melanoma who had dual sequential 99mTc HSA and 99mTc SC studies between January 1, 1996, and December 31, 1997, were reviewed. RESULTS Thirty-eight patients underwent paired HSA and SC imaging. Thirty-two patients had concordant scan findings. In all 6 discordant studies, 2 separate drainage areas were defined by HSA, but only 1 drainage area was defined by SC. CONCLUSIONS In 15.8% of dual studies (6/38 studies), discordant imaging results were obtained between HSA and SC. SC studies alone may result in nonvisualization of at-risk draining lymph node beds and hence failure to identify and excise all sentinel nodes. This could result in inaccurate staging, inappropriate therapy, and altered prognosis. A reduction in SC dose from 3 to 1 mCi was probably the most significant causal factor leading to these discrepancies, which suggests that the 3-mCi dose is preferable.

Extraskeletal mesenchymal chondrosarcoma of the rectus sheath

Abstract Mesenchymal chondrosarcomas (MSCs) are a rare form of chondrosarcoma which usually arise in bone. Extraskeletal chondro-sarcomas constitute a minority (14–25%) of MSCs. We describe the imaging features of an extraskeletal mesenchymal chondrosarcoma that arose from the rectus abdominus muscle.