Intraoperative Histological Examination Research Articles

Lower gastrointestinal tract tuberculosis: an important but neglected disease

Difficulties in early and accurate diagnosis of intestinal tuberculosis lead to frequent misdiagnosis even in endemic areas. This study aimed to investigate clinical and laboratory characteristics of patients with lower gastrointestinal tract tuberculosis (LGITB). Patients who met the criteria for LGITB in a medical center from 1997 to 2006 were identified and their medical records reviewed. A number of 4,567 patients with culture or histology-proven tuberculosis were identified, and 30 (0.66%) were diagnosed with LGITB. Principal co-morbidities were type II diabetes mellitus (23%) and alcoholism (23%). Twenty-two (73%) had radiographic findings suggestive of pulmonary tuberculosis, which was culture-proven in 13. Mycobacterial cultures from stool or sputum had diagnostic yields of about 50%, comparable to that of histological studies of colonoscopic or surgical biopsies. Multidrug-resistant tuberculosis (MDRTB) was identified in four patients, including two alcoholics. Fourteen underwent surgery; two (14%) received right hemicolectomy under the diagnosis of colon cancer without pre- or intraoperative histological study. The 1-year mortality was 20% but was 50% in patients with MDRTB. A high rate of alcoholism and diabetes mellitus and a high percentage of MDRTB among alcoholics were observed in our patients with LGITB. The diagnostic yields of stool or sputum mycobacterial culture (50%) were similar to that of intestinal histological study. Pre- or intraoperative histological examination could prevent unnecessarily extensive surgery.

A new histological classification for intra‐operative histological examination of the ductal resection margin in cholangiocarcinoma

The purpose of this study was to establish a standard histological classification for intra-operative histological examination of ductal resection margins in cholangiocarcinoma to distinguish between epithelial and intramural lesions and to clarify correlations between the new classification and clinical outcomes. Intra-operative diagnosis of ductal margins was performed for 357 stumps from 216 patients undergoing surgical resection of cholangiocarcinoma at the National Cancer Center, Japan. Three expert pathologists reviewed the materials and established a histological classification defined by grade of atypia. The new classification comprised four categories: 'insufficient', insufficient for diagnosis due to distortion of specimen; 'negative for malignancy', no atypia suggestive of neoplasia; 'undetermined lesion', specimen showing either cellular or structural atypia; and 'positive for malignancy', specimen showing both cellular and structural atypia. Each category was defined to distinguish between epithelial and intramural lesions. Validity and reproducibility of the proposed classification were found to be moderate to substantial. Multivariate analyses using the clinicopathological factors identified to be associated with overall survival by univariate analyses indicated that patients diagnosed with 'positive for malignancy' in intramural lesions of the proximal margin displayed significant poor prognosis. Meanwhile, in patients diagnosed with 'positive for malignancy' or 'undetermined lesion' in epithelial lesions of the proximal margin, no difference in overall survival was apparent compared to patients diagnosed with 'negative for malignancy'. We propose new histological classification for intra-operative histological examination of ductal resection margins in cholangiocarcinoma that shows a correlation with patients' prognosis and should facilitate the determination of ductal resection margin status for cholangiocarcinoma.

Méningiome rachidien extradural. À propos d’un cas et revue de la littérature

Objectives We report a case of purely extradural spinal meningioma and discuss the potential pitfalls in differential diagnosis. Background Spinal meningiomas account for 20–30% of all spinal neoplasms. Epidural meningiomas are infrequent intraspinal tumors that can be easily confused with malignant neoplasms or spinal schwannomas. Case A 62-year-old man with a previous history of malignant disease presented with back pain and weakness of the lower limbs. Magnetic resonance imaging revealed a well-enhanced T4 intraspinal lesion. The intraoperative histological examination showed a meningioma (confirmed by postoperative examination). Opening the dura mater confirmed the purely epidural location of the lesion. The postoperative course was uneventful with no recurrence 12 months after surgery. Conclusion Purely extradural spinal meningiomas can mimic metastatic tumors or schwannomas. Intraoperative histology is mandatory for optimal surgical decision making.

Mitral annuloplasty in an infant with Barth syndrome and severe mitral insufficiency: First case report and determination of annular diameter

DISCUSSION The diagnosis of PA sarcoma is often not correctly established before surgery, as described in our case. Even though magnetic resonance imaging and positron emission tomography did not demonstrate any signs of malignancy, intraoperative and postoperative histologic examination showed relapse of the sarcoma. It is without doubt that even advanced and unique diagnostics, such as magnetic resonance imaging and positron emission tomography scanning once, again failed to distinguish pulmonary embolism from intravascular sarcoma. A definitive diagnosis of PA sarcoma requires the pathologic examination of tissue obtained by intravascular, percutaneous, or surgical biopsies. In this emergency situation, we were able to resect a sarcoma of the PA, which was mimicking fulminant acute pulmonary embolism with tumor-free resection margins, and to solve the acute problem. Improvements are required to establish the diagnosis of this disease correctly. Nevertheless, this case is rare and it shows the feasibility of resection of recurrent sarcomas in areas such as the great vessels even after extensive previous resection.

Primary pulmonary meningioma: Report of a case and review of the literature

Primary pulmonary meningioma (PPM) is a rare disease and usually presents as a solitary pulmonary nodule (SPN). These lesions are mostly benign, but malignant PPMs have been reported, and primary lung cancer or metastasis may be suspected on imaging. We report one case of benign PPM, with a review of 37 cases published in the literature. Diagnostic work-up included radiological chest study and in 3 cases positron emission tomography (PET) showing increased uptake, highly suspicious for malignancy. After exclusion of 13 cases lacking radiological studies of the central nervous system (CNS), 25 patients with radiological data and histological assessment confirming PPM were considered in the analysis. All patients underwent surgical resection except for 1 case with diagnosis at autopsy. Histological assessment revealed benign PPMs in 23 cases (including all 3 cases with positive PET) and malignant PPMs in 2 cases. No recurrence was observed in long-term follow-up of patients with benign PPMs, but the two malignant PPMs relapsed. PPM is an uncommon SPN, so that it can be misdiagnosed and its management unsuited. Indeed, 8 patients (32%) were overtreated with major thoracic surgical resection or with chemotherapy. When feasible, pulmonary wedge resection by video-assisted thoracic surgery (VATS) including intra-operative histological examination is the most suitable approach to determine the diagnosis and the volume of pulmonary resection.

Prolonged Survival of a Patient Affected by Pancreatic Adenocarcinoma with Massive Lymphocyte and Dendritic Cell Infiltration after Interleukin-2 Immunotherapy. Report of a Case

Several studies have shown that there is a paucity of immune cells within the stroma of pancreatic adenocarcinoma, a very aggressive cancer with a median survival of about 18 months. A 65-year-old man presented with jaundice. Abdominal ultrasound revealed intra- and extrahepatic bile duct dilatation and a 45-mm diameter hypoechoic solid mass within the pancreatic head; a computed tomography scan excluded vascular infiltration and metastatic lesions. The patient received immunotherapy consisting of 6,000,000 IU human recombinant interleukin-2 administered subcutaneously twice a day for 3 consecutive days. Thirty-six hours after the last dose, he underwent a pylorus-preserving pancreatoduodenectomy. Because of the presence of high-grade dysplasia detected by intraoperative histological examination of a distal section, a spleen preserving total pancreatectomy was performed. The postoperative course was uneventful. The patient died 32 months after surgery because of local recurrence. Histopathology showed G3 pancreatic ductal adenocarcinoma infiltrating the anterior and posterior peripancreatic tissue, duodenal wall and intrapancreatic common bile duct, with sarcoma-like foci and a component of intraductal tumor involving the common bile duct. In the distal pancreas, widespread foci of pancreatic intraepithelial neoplasia (PanI2-3) were found. The Ki-67 proliferation index was 16%. TNM staging was pT3 pN1 R1. Sections were immunostained for the T-lymphocyte marker CD3 and for the dendritic cell marker CD1a. Intratumoral infiltration was high for CD1a+ cells and mild for CD3+ cells. Preoperative immunotherapy with interleukin-2 may contribute to massive stromal infiltration of immune cells in pancreatic adenocarcinoma. This may prolong the survival even in the presence of negative prognostic factors (age >65 years, tumor diameter >20 mm, R1, tumor grade G3).

Rare ileal localisation of angiolipoma presenting as chronic haemorrhage and severe anaemia: a case report

IntroductionAngiolipomas are frequently observed benign tumours. They have a typical vascular component and are often located in subcutaneous tissues, and more rarely, in the gastrointestinal tract.Case presentationWe report an uncommon case of an angiolipoma found in the lower portion of the small bowel of an 80-year-old man who was undergoing evaluation for chronic anaemia. A standardised diagnostic pathway was followed. Endoscopic and radiological findings were negative. The diagnosis was finally established with the aid of capsule endoscopy. The case we report is the first in the literature of an angiolipoma without specific painful symptoms. In fact, the patient did not complain of abdominal pain or alvus changes, and abdominal examination did not suggest an expansive process. The endoscopic study performed with the capsule identified the lesion as the cause of the ingravescent anaemia. Intra-operative histological examination of the lesion made it possible to avoid a major surgical procedure and assured a short postoperative course for the patient.ConclusionThis report focuses on the importance of correct pre- and/or intra-operative histological diagnosis in order to offer the best therapeutic choice. An angiolipoma was suspected in this case, even though they are rarely located in the ileum.

Uncommon co-localization of pituitary adenoma and parasellar cavernous angioma

We encountered a 49-year-old female presenting with left oculomotor palsy who was found to be co-localized cavernous sinus cavernous angioma (CA) and pituitary adenoma. Although CA originated from parasellar regions are not so rare, on neuroimaging studies, the characteristics of CA may be difficult to differentiate from those of pituitary adenomas. The co-localization of these two tumors was identified by preoperative dynamic MRI study. As intraoperative histological examination confirmed our preoperative diagnosis, we performed biopsy of the CA only to avoid uncontrollable intraoperative hemorrhage.

Ischemic stroke due to dissection of intracranial internal carotid artery: implications for early surgical treatment

Background Intracranial ICA dissection is a rare pathology that frequently results in severe morbidity or mortality in young patients. This study examined the suitability of early surgical treatment. Methods We present and analyze 6 of our own cases and 39 other cases reported after 1980. The clinical courses were classified into 3 types: A, single attack and severe outcome; B, single attack and mild to moderate outcome; and C, recurrent attacks and various outcomes. Results Type A patients (n = 11) usually deteriorated quickly and severely so that early surgical treatment was not possible. Most type B patients (n = 12) did not require surgical intervention because of relatively stable courses. Only some type C patients (n = 10) are candidates for early surgery to prevent progressive deterioration. Twelve cases were unclassified because of insufficient information. We encountered 3 cases of type C, and emergency bypass surgery with parent ICA occlusion was planned in 2 patients. The surgery was successful with good prognosis in 1 patient; but the ICA and its branches were already occluded in the other patient, which precluded completion of bypass surgery and resulted in severe hemiparesis. Intraoperative findings and histologic examination of the MCA confirmed arterial dissection. Conclusion Young patients with intracranial ICA dissection manifesting as mild ischemic stroke should be considered for early bypass surgery with occlusion of the dissected ICA if any sign of progression or recurrence occurs after the onset.

Intra-operative testing for parathyroid hormone: the Central Laboratory option

Intra-operative PTH testing in the operating theatre has proven to be an accurate way to verify the removal of all pathological parathyroid tissue in primary hyperparathyroidism. Its limitation is the high cost. An alternative, more cost-effective procedure is proposed: intra-operative PTH dosage at the Central Laboratory. Fifty-four patients underwent parathyroidectomy with intraoperative dosage of PTH at the Central Laboratory. Three blood samples were taken from each patient: just after the induction of anesthesia, 5 and 10 min after parathyroidectomy. The samples were sent to the Central Laboratory and analysed simultaneously. The results were phoned back to the theatre. The procedure was considered effective when PTH drop was >/=50% from basal value, 10 min after parathyroidectomy. 98.1% of patients proved recovered (average follow- up 31.1 months). The procedure had 3 false negatives, 1 false positive, with sensitivity, specificity, accuracy, positive predictive value and negative predictive value of 94.0%, 75.0%, 92.6%, 97.9%, and 50.0%, respectively. The main disadvantage of the presented procedure is the long waiting time. Nevertheless this time is the same as that required for results from intra-operative histological examination, the only alternative to determine surgery effectiveness in centres where portable instrumentation for intra-operative PTH dosage in the operating theatre is not available. The advantage of intra-operative PTH at the Central Laboratory is the very low cost. If results in terms of sensitivity, specificity, accuracy, and cost are taken into consideration, intra-operative dosage of PTH at the Central Laboratory may be deemed a viable alternative to the operating theatre.

Benign osteoblastoma of the odontoid process of the axis with secondary aneurysmal bone cyst component: a case report

The authors report their experience on one patient with osteoblatoma of the odontoid process of the axis with secondary aneurysmal bone cyst. According to their knowledge, this is the first case, reported in the literature, of this kind of lesion in that particular anatomical region. Because of the rarity of this lesion, it was difficult to have a certain preoperative diagnosis. Therefore, the patient underwent a biopsy via a transoral route. The biopsy was performed over the noncalcified component of the lesion. The intraoperative histological examination showed the benign nature of the lesion. Thereafter, the lesion was totally removed, succeeding in preserving the remaining part of the odontoid process and the anterior arch of C1. In the follow-up, there was no evidence of cranio-vertebral instability. The histological examination revealed an osteoblastoma of the odontoid process of the axis with a secondary aneurysmal bone cyst. To the best of our knowledge, this is the first case reported in the literature.

Technical outcomes of sentinel-lymph-node resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial

The goals of axillary-lymph-node dissection (ALND) are to maximise survival, provide regional control, and stage the patient. However, this technique has substantial side-effects. The purpose of the B-32 trial is to establish whether sentinel-lymph-node (SLN) resection can achieve the same therapeutic goals as conventional ALND but with decreased side-effects. The aim of this paper is to report the technical success and accuracy of SLN resection plus ALND versus SLN resection alone. 5611 women with invasive breast cancer were randomly assigned to receive either SLN resection followed by immediate conventional ALND (n=2807; group 1) or SLN resection without ALND if SLNs were negative on intraoperative cytology and histological examination (n=2804; group 2) in the B-32 trial. Patients in group 2 underwent ALND if no SLNs were identified or if one or more SLNs were positive on intraoperative cytology or subsequent histological examination. Primary endpoints, including survival, regional control, and morbidity, will be reported later. Secondary endpoints are accuracy and technical success and are reported here. This trial is registered with the Clinical Trial registry, number NCT00003830. Data for technical success were available for 5536 of 5611 patients; 75 declined protocol treatment, had no SLNs removed, or had no SLN resection done. SLNs were successfully removed in 97.2% of patients (5379 of 5536) in both groups combined. Identification of a preincision hot spot was associated with greater SLN removal (98.9% [5072 of 5128]). Only 1.4% (189 of 13171) of SLN specimens were outside of axillary levels I and II. 65.1% (8571 of 13 171) of SLN specimens were both radioactive and blue; a small percentage was identified by palpation only (3.9% [515 of 13 171]). The overall accuracy of SLN resection in patients in group 1 was 97.1% (2544 of 2619; 95% CI 96.4-97.7), with a false-negative rate of 9.8% (75 of 766; 95% CI 7.8-12.2). Differences in tumour location, type of biopsy, and number of SLNs removed significantly affected the false-negative rate. Allergic reactions related to blue dye occurred in 0.7% (37 of 5588) of patients with data on toxic effects. The findings reported here indicate excellent balance in clinical patient characteristics between the two randomised groups and that the success of SLN resection was high. These findings are important because the B-32 trial is the only trial of sufficient size to provide definitive information related to the primary outcome measures of survival and regional control. Removal of more than one SLN and avoidance of excisional biopsy are important variables in reducing the false-negative rate.

Warthin's Tumor of the Hard Palate

Warthin's Tumor (WT) or papillary cystadenoma lymphomatosum is typically located in parotid gland. Extraparotid localization of WTs (EPWT) was rarely described in ectopic salivary tissue in the latero-cervical and para-parotid lymph nodes. Localization in the hard palate is exceptional. This paper describes pre-surgical diagnostic work up and surgical management of a solitary WT localized in the hard palate as found in a 27-year-old Caucasian woman. With consideration of uncertain pre-surgical diagnosis obtained with FNAC, intraoperative histologic examination of frozen sections was planned. Conservative surgical approach was performed. After WT was diagnosed with histology, a local bone curettage was made. Clinical and radiographic follow-up at 12th month was negative for relapse.

Occult Breast Lesion Localization plus Sentinel Node Biopsy (SNOLL): Experience with 959 Patients at the European Institute of Oncology

Non-palpable breast lesions are diagnosed frequently posing the problem of localization and removal. When such lesions are malignant, axillary node status must be determined. We report our experience using radio-guided occult lesion localization (ROLL) for locating and removing non-palpable breast lesions together with sentinel node biopsy (SNB) to assess axillary status. We call the technique SNOLL. From March 1997 to April 2004, 1046 consecutive patients presented suspicious non-palpable breast lesions and were programmed for conservative surgery and SNB. In 87 patients intraoperative histological examination revealed a benign lesion and SNB was not performed. The remaining 959 patients, with cytologically or histologically proven cancer, underwent SNOLL with immobile radiotracer injected under mammographic or ultrasound (US) guidance into the lesion, and subsequent injection of mobile tracer subdermally to localize the sentinel node (SN). Patients then underwent breast surgery and SNB. Breast lesions were localized by ROLL in 99.6% of cases and were removed radically with negative margins in 91.9% of cases. Sentinel nodes were detected in all but one case. Intraoperative or definitive histological examination revealed 776 invasive/microinvasive carcinomas and 182 with in situ disease. Sentinel nodes were positive in 154 (19.8%) of 776 invasive/microinvasive cancers and in two with ductal intraepithelial neoplasia (1.1%). In SNOLL the injection procedures are performed separately, but both lesion and SNs are removed together; axillary dissection is performed if the SN is positive, thus definitive treatment of malignant non-palpable lesions occurs in a single surgical session.

Role of intraoperative cytology combined with histology in detecting continuous and skip type intraductal cancer existence for intraductal papillary mucinous carcinoma of the pancreas

Intraductal papillary mucinous neoplasm (IPMN) is a recently discovered pancreatic tumor that has continuous or discontinuous (skip) lesions. Recent reports suggest a higher frequency of cancer recurrence in the remnant pancreas after surgical resection of IPMN. It is therefore important to precisely detect intraductal cancer extension and skip lesions when resecting IPMN. Both intraoperative histologic examination of the surgical margin and cytologic examination of the pancreatic juice from each pancreatic segment (head, body, or tail) were performed on 43 IPMN patients. In addition to the preoperatively planned resection, 1 or 2 pancreatic segment(s) were additionally resected if the pancreatic juice tested positive in cytology. When a surgical margin was positive but the cytology in the remaining segment was negative, a subsegment (2-cm slice in width) was additionally resected until a negative margin was confirmed. Twenty-five patients (58%) demonstrated negative results in both histology and cytology obtained from the segment(s) that were not initially intended to be removed. In contrast to the preoperative estimation, 5 patients were found to have a positive surgical margin and negative cytology, 5 patients demonstrated a negative surgical margin and positive cytology, and 8 patients demonstrated a positive surgical margin and positive cytology. Investigations of the resected specimens revealed that 8 patients (19%) had skip lesions in addition to the main lesion. Logistic regression analysis revealed that patients with a dilated main pancreatic duct, or those with cancerous lesions in the main tumors, were at high risk for positive histology and/or cytology. Using intraoperative frozen-section histology and pancreatic juice cytology, 18 out of 43 patients in the current study (42%) required additional resection of the pancreas. A necessary and sufficient range of resection should be determined by intraoperative examination.

Incidental Small Ampullary Somatostatinoma Treated with Ampullectomy 2 Years After Diagnosis

Somatostatinomas are rare tumors; ampullary somatostatinomas are very rare. We report a case of a small pure somatostatin-producing neuroendocrine tumor of ampulla of Vater in a 54-year-old woman with neither neurofibromatosis nor somatostatinoma syndrome, "incidentally" discovered during an abdominal computed tomography. The patient initially refused other adjunctive exams but after 2 years she was admitted, presenting with itch, night sweats, severe fatigue, and unintentional weight loss. The size of the tumor (1.5 cm) and the other radiologic findings had not changed since the abdominal CT scan 2 years before. The somatostatin, gastrin, glucagons, serotonin, vasoactive intestinal peptide, dopamine, norepinephrine, epinephrine, and calcitonin plasma levels were normal. ERCP-obtained biopsies revealed a neuroendocrine tumor with psammoma bodies; immunohistochemical profile was positive for chromogranin and somatostatin. The patient underwent surgery; intraoperative histologic examination of lymph nodes sampling of perihepatic and periduodenal lymph nodes was negative for metastasis. We performed, therefore, a transduodenal ampullectomy. The patient continues to do well at 3 years' follow-up with no evidence of local or distance recurrence of disease.

An Icteric Type Hepatocellular Carcinoma with No Detectable Tumor in the Liver: Report of a Case

A 70-year-old man was admitted to our hospital with obstructive jaundice. Computed tomography revealed a tumor in the left intrahepatic bile duct extending to the common bile duct without any significant lesions in the liver. Cholangiography showed a filling defect due to an intraductal tumor. Cytology of the bile juice was negative and tumor markers were carcinoembryonic antigen 5.7 ng/ml, carbohydrate antigen 19-9 49 U/ml, alpha-fetoprotein 9 ng/dl, and PIVKA-II 19 200 AU/ml. With a preoperative diagnosis of hilar bile duct carcinoma, a laparotomy was performed. The common bile duct was filled with a tumor and it extended into the bilateral intrahepatic bile ducts. The intraductal tumor was removed together with the extrahepatic bile ducts. An intraoperative histological examination of the tumor showed a well-differentiated hepatocellular carcinoma. No lesions were detected in the liver by ultrasonography, palpation during the operation, or a computed tomography scan after the operation. At 1 year postoperatively, no recurrence has been seen in this patient.

A prospective trial for avoiding cervical lymph node dissection for thoracic esophageal cancers, based on intra-operative genetic diagnosis of micrometastasis in recurrent laryngeal nerve chain nodes

The aim of this study was to evaluate the usefulness of intra-operative genetic diagnosis of RN node micrometastasis in the decision-making of 3FL for thoracic esophageal cancers. Eighty-nine patients with middle and lower thoracic esophageal cancer were enrolled in a prospective study, in which 3FL was performed when RN node metastasis was revealed by intra-operative histological examination and/or genetic analysis using real-time RT-PCR assay. For other cases, 2FL was performed. Of the 89 patients, 3FL was performed for 33 patients and 2FL for 56 patients. In the 3FL group, RN node metastasis was both histologically and genetically positive in 19 patients, histologically negative and genetically positive in 11, and histologically positive and genetically negative in 3, with cervical node metastasis being detected in 7, 3, and 0 patients, respectively. In the 2FL group, only one patient had cervical node recurrence during the follow-up period. The post-operative survival in this study was equivalent to that of the historical controls (3-year survival rates 63.9% vs. 52.3%, P = 0.1513) of 66 3FL patients when 3FL was the first choice for thoracic esophageal cancers. Intra-operative histological and genetic diagnosis of RN node metastasis may help avoid unnecessary cervical node resection. A Phase III trial should be done.

Ungewöhnlicher Kombinationsbefund eines zystischen Ovarialtumors mit einer Leiomyomatosis peritonealis disseminata

Leiomyomatosis peritonealis disseminata (LPD) is a rare disease, which is most often found in women in reproductive age - seldom pre- and postmenaupausal. LPD has been described in women taking oral contraceptives or during pregnancy. LPD is mostly asymptomatic and discovered during operations like section caesarea, etc. Because of the macroscopic aspect (multiple small nodules <2 cm) a metastasing tumour is suspected during operation. These nodules consist of smooth muscle fibres and show benign histologic features. An increased level of cases with similar endometriosis (10%), myoms of uterus or functional ovarian tumours have been reported. Few cases of malignant transformation have also been described. In the pathogenesis of LPD a metaplastic change of submesothelial multipotential mesenchymal cells as an abnormal response on hormonal stimulation is debated. A regression of LPD after delivery or after stopping oral contraceptives is possible. Another therapeutic option is the application of GnRH-agonists. We present a case of a 35-year old female patient with sudden abdominal pain and suspicious findings in abominal ultrasound and CT-abdomen. The intraoperative aspect shows diffuse intraabdominal nodules consisting of smooth muscle fibres and a cystic left ovary. LPD, endometriosis and a borderline lesion of the left ovary were diagnosed by intraoperative histological examination. A bilateral salpingo-oophorectomy and omentectomy were performed.

The prognostic role of the sentinel lymph node in clinically node-negative patients with cutaneous melanoma: experience of the Genoa group

Aim To define the benefit of intraoperative frozen section examination of the sentinel lymph node (sN), and to assess its prognostic value in clinically node-negative melanoma patients. Materials and methods Between July 1993 and December 2001, 214 patients with Stage I–II cutaneous melanoma underwent sN biopsy; complete follow-up data are available in 169 of 175 patients who underwent preoperative lymphoscintigraphy, lymphatic mapping with Patent Blue-V and radio-guided surgery (RGS). Results In an initial subset, the sN was identified in 35 out of 39 patients; in the principal group of 169 patients, the sN was detected in all patients. The benefit of frozen section examination, that is the proportion of all patients having intraoperative histologic examination who tested positive, was 17.2% (29/169); notably, in patients with pT 1–2 vs pT 3–4 melanoma the corresponding values were 2.3 and 33.3%, respectively, ( P=0.000). Cox regression analysis for overall survival indicated that sN-positive patients had a two-fold increased risk of death; the most significant predictors of relapse-free survival were sN status ( P=0.004), age ( P=0.015), and T stage grouping ( P=0.033). Conclusions The sN is a reliable predictor of regional lymph node status in patients with cutaneous melanoma. Frozen section examination can be useful in avoiding a ‘two-stage’ operative procedure in patients with tumour-positive sN, but its greatest benefit seems to be restricted to patients with pT 3–pT 4 primary melanoma.