Haim Gutman

Melanoma Patients with Positive Sentinel Nodes Who Did Not Undergo Completion Lymphadenectomy: A Multi-Institutional Study

BackgroundCompletion lymph node dissection (CLND) is considered the standard of care in melanoma patients found to have sentinel lymph node (SLN) metastasis. However, the therapeutic utility of CLND is not known. The natural history of patients with positive SLNs who do not undergo CLND is undefined. This multi-institutional study was undertaken to characterize patterns of failure and survival rates in these patients and to compare results with those of positive-SLN patients who underwent CLND.MethodsSurgeons from 16 centers contributed data on 134 positive-SLN patients who did not undergo CLND. SLN biopsy was performed by using each institution’s established protocols. Patients were followed up for recurrence and survival.ResultsIn this study population, the median age was 59 years, and 62% were male. The median tumor thickness was 2.6 mm, 77% of tumors had invasion to Clark level IV/V, and 33% of lesions were ulcerated. The primary melanoma was located on the extremities, trunk, and head/neck in 45%, 43%, and 12%, respectively. The median follow-up was 20 months. The median time to recurrence was 11 months. Nodal recurrence was a component of the first site of recurrence in 20 patients (15%). Nodal recurrence–free survival was statistically insignificantly worse than that seen in a contemporary cohort of patients who underwent CLND. Disease-specific survival for positive-SLN patients who did not undergo CLND was 80% at 36 months, which was not significantly different from that of patients who underwent CLND.ConclusionsThis study underscores the importance of ongoing prospective randomized trials in determining the therapeutic value of CLND after positive SLN biopsy in melanoma patients.

Applicability of the Sentinel Node Technique to Merkel Cell Carcinoma

Background. Merkel cell carcinoma (MCC) resembles malignant melanoma in several ways. Both are cutaneous lesions of the same embryonic origin. Both have an unpredictable biologic behavior, early regional lymph node involvement, early distant metastases, and high recurrence rate. Objective. To apply the sentinel node technique described for melanoma to MCC in light of the common biologic features of these two tumors. Methods. Preoperative lymphoscintigraphy, intraoperative lymphatic mapping, and sentinel node biopsy and frozen section histology were performed to guide the surgical treatment of three patients with MCC. Results. Application of this approach in patients with MCC is feasible, reproducible, and seems reliable. Conclusion. The use of the sentinel node technique for MCC will reduce the number of unnecessary lymphadenectomies, will enable identification of microscopic metastases to lymph nodes, and will improve the stratification and accrual of patients into adjuvant treatment protocols. It may even lead to a survival benefit.

Surgical management of gastrointestinal stromal tumors: Analysis of outcome with respect to surgical margins and technique

This report reviews the methods and goals of treatment of gastrointestinal stromal tumor (GIST), the most common mesenchymal tumor of the gastrointestinal tract. GISTs express CD117, which serves as an immunohistochemical diagnostic marker. Surgical excision is the definitive treatment for all primary GISTs greater than 2 cm without evidence of peritoneal seeding or metastasis. Preoperative or intraoperative biopsy is not indicated except when the differential diagnosis includes another type of malignancy. Resection may be performed by traditional open surgery or by laparoscopic or laparoscopy‐assisted procedures. Regardless of the approach, oncological precautions must be strictly observed. Tumor disruption is to be avoided at all costs; tumor enucleation leaves a tumor‐seeded pseudocapsule behind and is considered insufficient. Because GISTs rarely metastasize through the lymphatics, routine lymphadenectomy is not indicated. The importance of achieving negative microscopic margins is controversial, although patients who undergo incomplete microscopic resection may be at greater risk of locoregional recurrence. Other factors, such as tumor grade and size, may play a more significant role in predicting recurrence. Cases of advanced disease or involvement of adjacent structures should be evaluated on an individual basis by a multidisciplinary team. J. Surg. Oncol. 2008;98:588–593.

Primary Squamous Cell Carcinoma (SqCC) of the Breast

Primary squamous cell carcinoma (SqCC) of the breast is a rare tumor that presents a unique biologic behavior. Thus, it challenges the justification for routine axillary dissection and adjuvant therapy. A MEDLINE search of all reported cases of primary SqCC of the breast was performed. Data on lymph node status, estrogen receptor (ER) and progesterone receptor (PR) status, and surgical and adjuvant treatment modalities were collected. We add three cases from our own experience. SqCC has several unique biologic characteristics; it is associated with a lower rate of lymph node metastasis at presentation (22% vs. 40–60% for infiltrating ductal carcinoma [IDC]) and a significant rate of distant metastasis without lymph node involvement. ER and PR receptor levels are usually very low. Because lymph node involvement plays a lesser prognostic and therapeutic role in this disease, we propose a more selective approach (i.e., sentinel node biopsy). The issue of adjuvant treatment remains unresolved, owing to lack of data. Surgical and medical treatment of SqCC of the breast should be tailored to fit its distinct biologic characteristics. The 5-fluorouracil–doxorubicin–cisplatin combination may be warranted in lieu of the combinations used for IDC.

Role of radiation therapy in the management of cutaneous malignant melanoma.

Traditionally, cutaneous malignant melanoma is regarded as a radioresistant tumor. Recently, however, an increasing number of clinical studies have refuted this notion. The authors examined the role of radiation therapy in the palliative and/or adjuvant treatment of cutaneous malignant melanoma. The records of 69 patients with cutaneous malignant melanoma were reviewed. Twenty-five patients with extensive regional lymph node involvement received adjuvant radiation therapy after primary surgical treatment, and the remainder received palliative radiation therapy. The therapeutic significance of fraction size was analyzed. In the palliative radiation therapy group, the response rate was 52% with a fraction size < or = 300 cGy and 35% with a larger fraction size (p > 0.05, NS). Local regional control rates after adjuvant radiation therapy using conventional fractionation and larger fraction size were 87% and 82%, respectively (p > 0.05, NS). Radiation therapy is effective in the management of cutaneous malignant melanoma. It plays an important role in the palliation of metastatic disease and as an adjuvant treatment. No advantage in using a large fraction size over conventional dose schedules was found.

Post-traumatic soft tissue tumors: Case report and review of the literature a propos a Post-traumatic paraspinal desmoid tumor

BackgroundAntecedent trauma has been implicated in the causation of soft tissue tumors. Several criteria have been established to define a cause-and-effect relationship. We postulate possible mechanisms in the genesis of soft tissue tumors following antecedent traumatic injury.Case presentationWe present a 27-year-old woman with a paraspinal desmoid tumor, diagnosed 3-years following a motor vehicle accident. Literature is reviewed.ConclusionSoft tissue tumors arising at the site of previous trauma may be desmoids, pseudolipomas or rarely, other soft tissue growths. The cause-and-effect issue of desmoid or other soft tissue tumors goes beyond their diagnosis and treatment. Surgeons should be acquainted with this diagnostic entity as it may also involve questions of longer follow-up and compensation and disability privileges.

Resection margins in modern rectal cancer surgery.

At present, the preferred treatment for rectal cancer is low anterior resection with total mesorectal excision and sphincter preservation. Complete removal of the tumors lymphatic and vascular pad with free resection margins has led to a reduction in rates of local recurrence and improved disease‐specific survival. In addition to the distal and proximal margins from the tumor edge, for an optimal outcome, it is essential to consider distal mesorectal spread and the circumferential mesorectal margin. J. Surg. Oncol. 2008;98:611–615.

Deep Venous Thrombosis of the Upper Limbs

Deep venous thrombosis of the upper limbs is rare and represents less than 2-3% of all cases of deep venous thrombosis. Reviewing our series of 25 patients we decided that follow-up and symptomatic treatment produce acceptable results, since the disease has a benign natural history. Fibrinolytic agents administered under strict limitations (The Consensus Conference 1980, Ann Int Med) are efficient in early cases, but its ability to change the natural course of the disease has not been proved. Surgical approach should be reserved for cases with secondary ischaemia and/or a resectable extraluminal mass.

Standard and Nonstandard Applications of Sentinel Node-guided Melanoma Surgery

Abstract. Identification and histologic study of the sentinel node (SN) is an acceptable, yet not firmly established, guide for treating intermediate-thickness melanoma. This study widens the range of applications of this technique. We included 97 patients with intermediate-thickness melanoma lesions or lesions for which there is no standard treatment. Fifty-six underwent preoperative lymphoscintigraphy, and all underwent intraoperative lymphatic mapping (IOLM) using blue dye, followed by frozen section study and total node processing by serial sections. Elective lymph node dissection was performed in cases of metastasis to the sentinel node or technical failures with high risk. Four categories were defined: (A) intermediate-thickness lesions (mean 2.27 mm) (n= 45); (B) thin lesions (mean 1.14 mm) with risk factors of regional failure (n= 27); (C) lesion thickness close to but more than 4 mm (n= 10); and (D) lesions of undetermined thickness (n= 15). Median follow-up was 30 months (range 13–51 months). Intraoperative lymphatic mapping successfully identified the sentinel node (SN) in 93% of basins explored. Metastases were detected in 11 SNs. There were three lymph basin recurrences in patients with previously negative SNs, all salvaged by therapeutic lymph basin dissection and are NED (no evidence of disease). Two SN+ patients had systemic recurrences; one died of his disease, and the other is alive with disease. One SN− patient died NED owing to other cause. This technique spared 83% of category A patients from lymph node dissection. It allowed better staging and better decision making for treatment in categories B and D; and it prevented early regional recurrences in category C patients. Intraoperative lymphatic mapping with SN guidance is a novel, low-morbidity approach applicable and advantageous for a wide range and subgroups of melanoma patients.

Myxoid Liposarcoma: An Unusual Presentation

3Department of Gynecology–Oncology, Rabin Medical Center, Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel. iposarcoma is the second most common soft-tissue sarcoma in adults. Myxoid liposarcoma is the second most common type of liposarcoma, representing 30–40% of all liposarcomas in the extremities. It occurs most commonly in the extremities, particularly the thighs [1, 2]. Liposarcomas involving the pelvis are uncommon. The more frequent sites of myxoid liposarcomas, in decreasing order of frequency, are the buttocks, retroperitoneum, trunk, ankle, proximal limb girdle, head and neck, and wrist [1, 2]. Establishing the correct diagnosis in cases of myxoid liposarcoma using imaging may be difficult. On images obtained without the administration of contrast material, the tumor may mimic a fluid-filled cyst on both CT and MRI, and the tumor lacks the signal intensity of fat. Sonography may help in establishing the presence of solid components and in differentiating between a cyst and a solid tumor. The combination of different imaging techniques helps in defining the extent of the tumor for preoperative planning. We present an unusual case of a giant myxoid retroperitoneal and pelvic liposarcoma that presented as a large buttock mass (Fig. 1A). The combined information gathered from MRI, CT, and sonography was crucial for defining the extent of the tumor and for preoperative planning.