Eugene Morita

Does Intraoperative Quick Parathyroid Hormone Assay Improve the Results of Parathyroidectomy

Preoperative sestamibi (MIBI) and ultrasonography (US) are used to localize parathyroid tumors in patients with primary hyperparathyroidism (pHPT). The intraoperative quick PTH assay (qPTH) has been recommended to determine whether all hyperfunctioning parathyroid tissue has been removed. We questioned whether qPTH improves the results of parathyroidectomy in patients with pHPT. We analyzed 115 unselected patients with pHPT without a family history or multiple endocrine neoplasia but who had undergone parathyroidectomy. All 115 patients had successful operations without complications. Of these patients, 88 (77%) had solitary adenomas, 13 had double adenomas, 1 had triple adenomas, 12 had hyperplasia, and 1 had carcinoma. Overall, MIBI was correct in 72% (76/106), US in 49% (49/99), and qPTH in 80% (92/115). For preoperative studies showing a single tumor, MIBI was correct in 83% (73/88), US was correct in 71% (45/63), and combined MIBI and US were correct in 95% (37/39). Adding qPTH in this subgroup did not improve the successful focused approach: 70% for MIBI, 65% for US, and 87% for combined MIBI and US. However, adding qPTH improved the overall success of parathyroidectomy (MIBI 92%, US 86%, combined MIBI and US 97%), but at the cost of unnecessary further exploration (MIBI 13%, US 6%, combined MIBI and US 8%). We conclude that when the same solitary tumor is identified by both MIBI and US, a focused exploration can be done with a 95% success rate. Adding qPTH to MIBI or US can improve the success rate but at a significant cost. General exploration of all parathyroid glands, however, has the highest success rate (100%).

Accuracy of preoperative localization studies and intraoperative parathyroid hormone assay in patients with primary hyperparathyroidism and double adenoma

BACKGROUND The purpose of this retrospective investigation was to evaluate the results of preoperative localization studies and intraoperative parathyroid hormone (IOPTH) assay in patients with primary hyperparathyroidism and double adenomas. STUDY DESIGN Twenty-one of 287 consecutive patients with primary hyperparathyroidism who had double adenomas identified during first-time parathyroid exploration between July 1999 and September 2002 were analyzed. Individual and combined accuracy of preoperative localization studies, and IOPTH assay and their influence on surgical strategy, were compared. RESULTS Seven percent of these 287 patients had double adenomas. Fifteen of the patients were female and six were male with a mean age of 59 years (range 17 to 76 years). The accuracy of ultrasonography (US) and technetium 99m sestamibi ((99m)TC-sestamibi) was 40% and 30%, respectively, in this select group. Combined accuracy of both tests reached 60% and guided the surgeon to select a bilateral approach. After removal of the first gland, IOPTH failed to decrease by 50% relative to the highest baseline value in 43% of the cases, indicating other hyperfunctioning parathyroid glands. These results prompted the surgeon to explore further after an initially planned focused approach. When the combination of three tests was analyzed, at least one test accurately suggested a double adenoma in 80% of the patients; in 15% of the patients, no test was suggestive of a double adenoma and in 5% the sestamibi scan was false positive. CONCLUSIONS This retrospective investigation documents that neither preoperative localization tests nor IOPTH assay accurately document double adenomas in patients with primary hyperparathyroidism. The combined accuracy of US, sestamibi, and IOPTH assay predicted a double adenoma in 80% of the patients.

Intraoperative frozen section analysis of sentinel lymph nodes in breast cancer patients

Accurate intraoperative pathologic examination of sentinel lymph nodes (SLNs) has been an important tool that can reduce the need for reoperations in patients with SLN‐positive breast cancer. The objective of the current study was to determine the accuracy of intraoperative frozen section (IFS) of SLNs during breast cancer surgery.

The Effect of Sentinel Node Tumor Burden on Non–Sentinel Node Status and Recurrence Rates in Breast Cancer

BackgroundRoutine axillary lymph node dissection (ALND) after selective sentinel lymphadenectomy (SSL) in the treatment of breast cancer remains controversial. We sought to determine the need for routine ALND by exploring the relationship between sentinel lymph node (SLN) and non-SLN (NSLN) status. We also report our experience with disease relapse in the era of SSL and attempt to correlate this with SLN tumor burden.MethodsThis was a retrospective study of 390 patients with invasive breast cancer treated at a single institution who underwent successful SSL from November 1997 to November 2002.ResultsOf the 390 patients, 115 received both SSL and ALND. The percentage of additional positive NSLNs in the SLN-positive group (34.2%) was significantly higher than in the SLN-negative group (5.1%; P = .0004). The SLN macrometastasis group had a significantly higher rate of positive NSLNs (39.7%) compared with the SLN-negative group (5.1%; P = .0001). Sixteen patients developed recurrences during follow-up, including 6.1% of SLN-positive and 3.3% of SLN-negative patients. Among the SLN macrometastasis group, 8.7% had recurrence, compared with 2.2% of SLN micrometastases over a median follow-up period of 31.1 months. One regional failure developed out of 38 SLN-positive patients who did not undergo ALND.ConclusionsALND is recommended for patients with SLN macrometastasis because of a significantly higher incidence of positive NSLNs. Higher recurrence rates are also seen in these patients. However, the role of routine ALND in patients with a low SLN tumor burden remains to be further determined by prospective randomized trials.

Internal Mammary Sentinel Lymph Node Mapping for Invasive Breast Cancer: Implications for Staging and Treatment

Abstract:  The optimal staging and treatment of the internal mammary nodes (IMNs) among patients with invasive breast cancer (IBC) is controversial. Although medial tumors have been reported to more commonly drain to IMNs, other variables predictive for IMN drainage may help identify those patients who may benefit from further IMN assessment. Factors associated with IMN drainage were analyzed among 141 patients who underwent lymphatic mapping and selective sentinel lymphadenectomy using intradermal injection (ID) or peritumoral (PT) injection. Fourteen of 83 patients (17%) receiving PT injections had IMN drainage, compared to none among the 58 patients who underwent ID injection alone (p = 0.0004). There were no differences in patient or tumor variables detected between the two groups. Among patients receiving PT injections, no factors examined were significantly associated with IMN drainage on univariate analysis. Using the multivariate logistic regression model, palpable disease was the most important factor associated with IMN drainage (risk ratio [RR] = 6.02; 95% confidence interval [CI] 0.64–56.34; p = 0.05). In addition, lymphatic/vascular invasion (LVI) and age less than 50 years were associated with IMN drainage (RR = 6.17; 95% CI 1.02–37.50; p = 0.09 and RR = 2.94; 95% CI 0.82–10.49; p = 0.09, respectively). IMN drainage occurred in a significant proportion of patients after PT injection, but not ID injection. In the final model, palpable disease was the most important factor associated with IMN drainage; LVI and age less than 50 years were of borderline significance. These factors may aid in the selection of patients who might benefit from further staging or treatment of the IMNs. 

Clinical Significance of Occult Metastatic Melanoma in Sentinel Lymph Nodes and Other High-risk Factors Based on Long-term Follow-up

Selective sentinel lymphadenectomy (SSL) following preoperative lymphoscintigraphy is the most significant recent advance in the management of patients with primary melanoma. This study evaluates the prognostic value of sentinel lymph node (SLN) status and other risk factors in predicting survival and recurrence in patients with primary cutaneous melanoma. From October 1993 to July 1998 a series of 412 patients with primary invasive melanoma underwent SSL at the UCSF/ Mt. Zion Melanoma Center. The outcome of 363 evaluable patients is summarized in this study. The factors related to survival and disease recurrence were analyzed by Cox proportional hazard regression models. The overall incidence of patients with positive SLNs was 18%. Over a median follow-up of 4.8 years, the overall mortality rate in patients with primary cutaneous melanoma was 18.7%, and 74 recurrences occurred (20.4%). Mortality was significantly related to SLN status [HR = 2.06; 95% Confidence interval (CI) 1.18, 3.58], angiolymphatic invasion (HR = 2.21; 95% CI 1.08, 4.55), ulceration (HR = 1.79; 95% CI 1.02, 3.15), mitotic index (HR =1.38; 95% CI 1.01, 1.90), and tumor thickness (HR = 2.20, 95% CI 1.21, 3.99). Factors significantly related to disease-free survival included SLN status (HR = 2.09; 95% CI 1.31, 3.34), tumor thickness (HR = 1.89; 95%. CI 1.20,2.98), and age (HR= 1.26 95% CI 1.08, 1.47). SLN status was the most significant factor for melanoma recurrence and death. Other important predictors include tumor thickness, ulceration, lymphatic invasion, and mitotic index.

Micrometastasis to In-Transit Lymph Nodes From Extremity and Truncal Malignant Melanoma

Background: The sentinel lymph node (SLN) is the first lymph node in the regional nodal basin to receive metastatic cells. In-transit nodes are found between the primary melanoma site and regional nodal basins. To date, this is one of the first reports on micrometastasis to in-transit nodes.Methods: Retrospective database and medical records were reviewed from October 21, 1993, to November 19, 1999. At the UCSF Melanoma Center, patients with tumor thickness >1 mm or <1 mm with high-risk features are managed with preoperative lymphoscintigraphy, selective SLN dissection, and wide local excision.Results: Thirty (5%) out of 557 extremity and truncal melanoma patients had in-transit SLNs. Three patients had positive in-transit SLNs and negative SLNs in the regional nodal basin. Two patients had positive in-transit and regional SLNs. Three patients had negative in-transit SLNs but positive regional SLNs. The remaining 22 patients were negative for in-transit and regional SLNs.Conclusions: In-transit SLNs may harbor micrometastasis. About 10% of the time, micrometastasis may involve the in-transit and not the regional SLN. Therefore, both in-transit and regional SLNs should be harvested.

PRINCIPLES AND CONTROVERSIES IN LYMPHOSCINTIGRAPHY WITH EMPHASIS ON BREAST CANCER

The concept of the sentinel node lay fallow until lymph node mapping was developed. This article provides a brief history of the sentinel lymph node concept, discusses reproducibility, radiopharmaceuticals, equipment, techniques, and radiation safety, and addresses metastasis in breast cancer and controversies in breast lymphoscintigraphy.

Ratio of Positive to Total Number of Sentinel Nodes Predicts Nonsentinel Node Status in Breast Cancer Patients

Abstract:  Selective sentinel lymphadenectomy (SSL) has replaced axillary lymph node dissection (ALND) for many patients with early breast cancer and negative sentinel lymph nodes (SLNs). Yet many patients with a positive SLN are undergoing unnecessary ALND, as no further disease is found in the axilla. The aim of our study was to determine factors associated with additional positive lymph nodes in the axilla in patients who have a positive SLN. This was a retrospective study of patients undergoing SSL with ALND as part of their treatment for breast cancer at a single institution from November 1997 to August 2003. Only patients with one or more positive SLNs were selected for this study. There were 86 patients who fit our study criteria. Of these, 38% had further positive lymph nodes upon ALND. More than one positive SLN and a ratio of positive SLNs to total SLNs of greater than 0.5 were found to be predictors for additional axillary nodal involvement in both univariate and multivariate analyses. The number of positive SLNs and the ratio of positive SLNs to total SLNs is an indication of total tumor burden in the sentinel nodes and may be a reflection of the propensity of the tumor for further lymphatic invasion in the axillary basin. 

Heterogeneous patterns of lymphatic drainage to sentinel lymph nodes by primary melanoma from different anatomic sites

We want to define the patterns of lymphatic drainage for primary melanoma to sentinel lymph nodes (SLNs) based on a large lymphoscintigraphic database. Preoperative lymphoscintigraphy was used to identify and classify SLN drainage basins and patterns of drainage. Methods: Lymphoscintigraphy using intradermally administered technetium-99m labeled sulfur colloid was performed on 400 consecutive patients with malignant melanoma to define lymphatic drainage channels and draining SLN basins before surgery. Primary tumor sites consisted of head and neck, upper extremity, trunk, and lower extremity. Different types of drainage patterns were classified and correlated with different anatomic sites. Results: SLN(s) were identified in over 98% of the patients, whereas lymphatic drainage channels were successfully identified in 90% of the patients. Drainage from the primary site to a single SLN through a single lymphatic channel (type IA) was seen in 186 of 400 patients (47%) as the most common type. In patients with a single SLN within a single basin (type I–V), the percentage of patients with primary lesions in the head and neck, upper extremity, trunk, and lower extremity regions were 61%, 79%, 55%, and 78%, respectively. In cases of multiple lymphatic channels (type VI–VII), the percentages of patients with primary lesions in the head and neck, upper extremity, trunk, and lower extremity regions were 24%, 8%, 36%, and 19%, respectively. Conclusion: Various drainage patterns were noted from primary melanomas in different anatomic sites. Preoperative lymphoscintigraphy is important in establishing the SLN basins for harvesting the SLN(s).