Christopher A. Puleo

Accurate Nodal Staging of Malignant Melanoma.

The incidence of malignant melanoma is increasing at a faster pace than that of any other cancer in the United States. It is estimated that people born in the year 2000 will have a 1:75 risk of developing melanoma sometime during his or her lifetime. Stimulated by novel lymphatic mapping techniques, the surgical care of the melanoma patient is evolving toward more conservative resections that can provide the same staging information but without the added morbidity of more radical surgeries. This approach promises to yield positive results in the age of health care reform, outcome measurements, and cost:benefit considerations.

The Role of Selective Lymphadenectomy in the Management of Patients with Malignant Melanoma

background A novel surgical technique based on selective lymphadenectomy was used to stage 132 patients with intermediate and thick cutaneous malignant melanoma. Preoperative and intraoperative lymph node mapping techniques were used to ascertain regional lymph node basins at risk for metastasis, and to identify the first node(s) the afferent lymphatics encounter in the basin, defined as the “sentinel” node(s). It has been shown that the histology of the sentinel node reflects the histology of the rest of the nodal basin, and according to preliminary studies using this technique, the likelihood of bypassing the sentinel node(s) to “higher” level nodes is less than 2%. Epidemiologic studies indicate that the long‐term survival of patients with melanomas of intermediate thickness or greater is significantly compromised if regional lymph nodes are involved. Yet, the utility of performing lymph node dissections for the purposes of staging only is controversial, not only because of the morbidity and expense of the procedure, but the lack of proven survival benefit. objective In the present study, we performed preoperative and intraoperative lymphatic mapping, harvested clinically normal sentinel nodes, and examined them for micrometastasis by light microscopy. Both conventional stains and immunocytochemistry for S‐100 protein and HMB‐45 antibodies were performed, and only those patients with documented micrometastasis received complete lymph node dissections. results The sentinel node(s) was identified in each of the patients. Micrometastasis disease was detected in 31 (23%) of the patients by selective lymphadenectomy, and the sentinel node(s) was the only node involved in 83% of the cases upon subsequent complete nodal dissection. conclusion Our preliminary results suggest that selective lymphadenectomy following lymphatic mapping is an effective procedure for staging melanoma patients with lesions of intermediate thickness or greater. Our results indicate that sentinel lymph nodes may be successfully identified and harvested in the majority of patients, and that they may be examined for the first evidence of micrometastasis without the need of a complete nodal dissection. Information as to whether micrometastases are present in the sentinel node would be valuable in staging patients, and identifying candidates for complete nodal dissections. We are participating in a National Cancer Institute‐sponsored multicenter trial to ascertain whether this surgical approach can impact on the recurrence rate and survival of patients with stage 1 and 2 melanoma.

Both tumor depth and diameter are predictive of sentinel lymph node status and survival in Merkel cell carcinoma

The purposes of this study were 1) to determine the impact of primary tumor‐related factors on the prediction of the sentinel lymph node (SLN) status and 2) to identify clinical and pathologic factors associated with survival in Merkel cell carcinoma (MCC).

What is the Significance of the In Transit or Interval Sentinel Node in Melanoma

Jonathan S. Zager, MD, Christopher A. Puleo, PA-C, and Vernon K. Sondak, MDDepartment of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FLThe advent of radionuclide lymphoscintigraphy as partof sentinel lymph node biopsy procedures for melanomaled to changes in our understanding of lymphatic anatomy,but the clinical significance of these changes are stillundefined. Although it quickly became clear that primarymelanomas frequently drained to lymph nodes outside ofthe traditional ‘‘major’’ basins (cervical, axillary, and ili-oinguinal), it has been less clear what to do about thesenodes—or even what to call them. Definitions of the threemajor nodal basins and their subdivisions are fairly stan-dardized: the axillary basin consists of levels I–III; theilioinguinal basin can be broken down into inguinofemoral,external, and common iliac and obturator nodes; and thecervical basin consists of levels I–VI. Whether to includeoccipital, pre- and postauricular, and parotid nodes as partof the cervical basin has not been totally standardized, butit seems reasonable to include them. For the extremities,epitrochlear and popliteal nodes are considered ‘‘minor’’nodal basins, and internal mammary nodes often are butnot always classified similarly (but probably should be).Beyond that, there is little standardization about what tocall the many nodes that can be found in small numbersthroughout the body, especially in the soft tissues of theposterior and lateral trunk, which occasionally serve asprimary draining nodes for the skin.We propose the following lexicon: interval nodes areany superficial (i.e., outside the chest and abdominalcavities) lymph nodes identified by conventional or sin-gle photon emission computed tomography (SPECT)lymphoscintigraphy, other imaging studies, incidentally atsurgery, or clinically based on involvement with tumor thatare not located within the defined confines of a major orminor nodal basin. (This definition is similar to but subtlydifferent than that by Verwer et al. in this issue of Annals ofSurgical Oncology.

Dermal melanoma: A report on prognosis, outcomes, and the utility of sentinel lymph node biopsy.

Historically dermal melanoma (DM) has been labeled as either stage IIIB (in‐transit) or stage IV (M1a) disease. We sought to investigate the natural history of DM and the utility and prognostic significance of sentinel lymph node biopsy (SLNB).

Management of Extremity Lymphedema.

Chronic lymphedema is almost always a permanent and often progressive condition. In most cases, neither medical nor surgical means can completely relieve the effects of lymphedema. Surgical management of chronic lymphedema has high morbidity and a success rate of only 30%, and many patients return to their presurgical limb girth within three to four years. Nonsurgical treatment of chronic lymphedema can decrease overall lymphatic edema. Sequential gradient compression systems, which compensate for impaired lymphatic flow, return protein-rich lymphatic fluid from the extracellular regions of the tissues back into the circulatory system where the fluid can be excreted.

Erratum to: What is the Significance of the In Transit or Interval Sentinel Node in Melanoma?

Jonathan S. Zager, MD, Christopher A. Puleo, PA-C, and Vernon K. Sondak, MDDepartment of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FLERRATUM TO: ANN SURG ONCOL(2011) 18:3232–3234DOI 10.1245/S10434-011-1996-5In the original publication of this editorial, Fig. 1 wasnot correctly displayed. It is reprinted here correctly.