Luciano Moresco

Sentinel lymph node mapping in early-stage breast cancer: Technical issues and results with vital blue dye mapping and radioguided surgery

Axillary lymph node status is the most important prognostic factor in patients with operable breast cancer. Recent studies have demonstrated the possibility of identifying the sentinel lymph node (sN) as a reliable predictor of axillary lymph node status in both cutaneous melanoma and breast cancer. Sentinel lymph node identification proved feasible by either peritumoral dye injection (Patent Blue‐V) or radiodetection, with identification rates of 65–97% and 92–98%, respectively. However, some important issues need further definition, namely (a) optimization of the technique for intraoperative detection of the sN, (b) predictive value of the sN with regard to axillary lymph node status, and (c) reliability of intraoperative histology of the sN. We reviewed our experience in sN detection in patients with stage I–II breast cancer to assess the feasibility and accuracy of lymphatic mapping, by vital blue dye or radioguided surgery, and sN histology as a predictor of axillary lymph node status.

Sentinel lymph node mapping opens a new perspective in the surgical management of early‐stage breast cancer: A combined approach with vital blue dye lymphatic mapping and radioguided surgery

Recent studies have demonstrated the possibility of identifying the sentinel lymph node (sN) as a reliable predictor of axillary lymph node status in both cutaneous melanoma and breast cancer. However, some important issues need further definition: (1) optimization of the technique for intraoperative detection of the sN; (2) predictive value of the sN as regards axillary lymph node status, and (3) reliability of intraoperative histology of the sN. We report our experience in sN mapping in patients with Stage I-II breast cancer, with the aim of assessing: (1) the feasibility of lymphatic mapping with a combined approach (vital blue dye lymphatic mapping and radioguided surgery); (2) the agreement of the intraoperative histologic examination of the sN, by means of hematoxylin and eosin staining with final histology, and (3) the accuracy of sN histology as a predictor of axillary lymph node status.

SENTINEL NODE BIOPSY IN PATIENTS WITH CUTANEOUS MELANOMA

The role of elective lymph node dissection (ELND) for treatment of cutaneous melanoma is still debated. Initially, lymphatic mapping technique was performed by an intradermic injection of vital blue dye; subsequently, it was improved by the use of radioguided surgery (RGS). Preliminary experience with this technique proved effective for detection of clinical occult lymph node metastasis; it may also enable the surgeon to perform a selective lymph node dissection (SLND) to concentrate on pathologic node-positive patients for the same potential benefits that have been provided by ELND. We performed sentinel node biopsy on 48 patients with stage pT3N0M0 melanoma. Vital blue dye mapping only was carried out on 39 patients; the remaining nine patients had a combined lymphatic mapping with both blue dye and RGS. The sentinel lymph node (SLN) was identified in 46 of 48 patients (95.8%). Ten patients (20.8%) were found to have metastatic melanoma cells in their SLN(s); all these patients underwent SLND of the affected basin. Our findings confirm that the intraoperative lymphatic mapping of the SLN using both blue dye and radiodetection is an appropriate and simple technique for selecting patients who are more likely to benefit from lymph node dissection.

Empirical first-line treatment with tigecycline for febrile episodes following abdominal surgery in cancer patients

Cancer patients with complicated infections following abdominal surgery represent one of the worst clinical scenarios that is useful for testing the efficacy of empirical antimicrobial therapy. No study so far has evaluated the performance of tigecycline (TIG) when administered as empirical first-line treatment in a homogeneous population of surgical cancer patients with a febrile episode. An observational review of the data records of 24 sequential patients receiving TIG for a febrile episode following a major abdominal procedure in a single cancer institute was performed. Large bowel surgery represented 68% of all procedures, followed by gastric surgery (16%) and urinary-gynaecologic-biliary surgery (16%). Complications following surgery were observed in 68% of febrile episodes, with peritonitis and sepsis accounting for 59% and 24% of complications, respectively. Eight patients needed repeat surgery for source control. The mean duration of TIG treatment was 8 days. Causative pathogens were detected in 16 episodes (64%), and a total of 44 microorganisms were recovered (29% Escherichia coli, 9% Enterococcus faecalis and 9% coagulase-negative staphylococci). TIG was effective in 12 episodes (48%). The success rate was 67% when infectious episodes sustained by intrinsically resistant bacteria and fungi were excluded. Treatment failure was associated with the presence of complications and with microbiologically documented infection. TIG may be useful as a first-line treatment option in cancer patients requiring antibiotic treatment following surgery when complications are not present or suspected on clinical grounds and when local microbial epidemiology shows a low incidence of primary resistant bacteria.

The Anatomy and Physiology of Lymphatic Circulation

The lymphatic system is formed by a network of vessels, nodes, and specialized organs that are vital in maintaining both localized and systemic immunity. Lymph nodes are the first place where lymphocytes are exposed to foreign antigens, leading to the production and dissemination of antigen-specific T lymphocytes and plasma cells. By delivering immunocompetent cells to sites where they are needed through the lymph, locally initiated immunity becomes generalized (1).

Radioimmunoguided surgery benefits in carcinoembryonic antigen-directed second-look surgery in the asymptomatic patient after curative resection of colorectal cancer.

Radioimmunoguided surgery (RIGS) with radiolabeled monoclonal antibodies (MoAbs) has been reported as useful in second-look colorectal cancer procedures to improve surgical decision-making by helping avoid needless extensive surgery and expanding curative resection to sites of recurrence that have been missed previously. Sixteen asymptomatic patients with an history of colorectal cancer surgery underwent second-look surgery using the RIGS system, solely on the basis of rising serum levels of carcinoembryonic antigen (CEA). All patients were injected preoperatively with the anti-tumor-associated glycoprotein (TAG) 125I-labeled MoAb B72.3. Both traditional and RIGS exploration were used to determine the extension of a possible recurrence and its resectability for cure. Recurrent disease was observed in 14 of the 16 patients as the result of this combined exploration. Exploration alone showed the presence of recurrent disease in 9 of 16 patients (56.2%). Thus, RIGS found overlooked tumor in five patients (31.2%). All the additional RIGS-detected tumor sites were locoregional recurrences resectable for cure; conversely, no diagnostic improvements were shown in patients with liver metastases. Resection for cure was obtained by this approach in 9 of 16 patients (56.2%). Two patients without disease at the exploratory laparotomy recurred within 2 months at sites away from the abdomen. RIGS improved the results of colorectal cancer CEA-guided second-look procedures in asymptomatic patients by recruiting one-third of patients to curative resections.

Immunoglobulin prophylaxis in “septic risk” patients undergoing surgery for sub-diaphragmatic gastrointestinal cancer

Abstract The results of a randomized, multi-center clinical trial of immunoprophylaxis of post-operative infections with intravenous immunoglobulins (IVIG) (Sandoglobulin ® ) in “septic risk” patients undergoing surgery for gastrointestinal cancer are presented. “Septic risk” patients were selected by an original multiparametric test based on delayed hypersensitivity skin testing and serum protein electrophoretic subfractions. This screening test had shown 76% positive predictivity in a previous validation assessment. In the present study, 159 “septic risk” patients were selected prospectively from 369 patients undergoing colo-rectal (Colon) and other kinds of gastrointestinal (Non-colon) oncologic surgery; 80 “septic risk” patients were included in the Colon and 79 in the Non-colon group. Immunoprophylaxis with IVIG (15 g on the day prior to operation, and on the 1st and 5th post-operative days) was randomly associated to antibiotic prophylaxis (cefoxitin: 2 g 1 h prior to, followed by 2 g at the end of operation plus 2 g every 6 h for 24 h) in Colon surgery while the prophylactic schedule in Non-colon surgery was only based on random administration of IVIG, at the same dosage as in the Colon group. There was a clear-cut reduction of post-operative infections both in Colon and Non-colon “septic risk” patients who had IVIG prophylaxis; in the Colon group, 37 and 21 infections ( P ⩽ 0.004) in the antibiotic (A) versus IVIG plus antibiotic (IVIG+A) subsets, respectively; in the Non-colon group there were 33 and 19 infections ( P