Valuable Staging Information Research Articles

Diagnostic and Prognostic Evaluation Value of 18f-FDG PET-CT for Bone Marrow Infiltration in Primary Treated Follicular Lymphoma

Objective ：The purpose of this paper is to evaluate the value of 18F-FDG PET-CT in the diagnosis of bone marrow infiltration in patients with primary treated follicular lymphoma and whether it provides valuable information for staging and prognosis. Methods ：This is a retrospective analysis of 199 hospitalized patients with primary 1-3a follicular lymphoma diagnosed by pathological examination from January 01, 2014 to September 31, 2022 in Fujian Medical University's Union Hospital. The recorded clinical characteristics, bone marrow examination, the result of 18F-FDG PET-CT for bone marrow involvement, treatment regimen, efficacy, and survival status were analyzed. univariate analysis and multivariate analysis were performed for clinical features, laboratory results. Results ： 1.Among the 199 patients with FL , the median age was 54.1 years old, including 88 males and 111 females Stage III-IV patients accounted for 82.9%.The Number in high-risk groups was 70（35.2%）according to FLIPI score and was 33（16.6%）according to FLIPI-2 score. The median OS in all cases was not reached. The cumulative OS rates at 1, 3, and 5 years were 93.5%90.0% and 88.8%,respectively The median PFS in all cases was not reached. The cumulative PFS rates at 1, 3, and 5 years were 87.3%72.0% and 67.8%,respectively. PET-CT images showed increased bone marrow uptake FDG in a total of 42 patients (21.1%), of which 17 patients (8.54%) had focal increased bone marrow uptake FDG (6 unifocal; 3 bifocal; 8 multifocal), 6 patients (3.02%) had focal with diffuse increased bone marrow uptake FDG, and 19 patients (9.55%) had diffuse bone marrow FDG uptake was elevated in 19 patients (9.55%).Bone marrow infiltration was detected by PET-CT alone in 16 patients (8.04%),and by BMB alone in 19 patients (9.54%), and by both PET-CT and BMB in 26 patients (13.63%), Bone marrow infiltration was detected by PET-CT and BMB in a total of 26 patients (13.61%). 45 patients (22.6%) had bone marrow infiltration detected by BMB and 42 patients (21.1%) had bone marrow infiltration detected by PET-CT. Using BMB results as the gold standard for bone marrow infiltration, the paired chi-square design corrected chi-square test yielded c 2=0.11， P=0.735, so it can be considered that the results of the two methods for testing bone marrow infiltration were consistent, and the difference was not statistically significant, and the agreement between PET-CT and BMB diagnostic results was general (Kappa=0.485, P<0.05), using BMB as the gold standard , the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of PET-CT for detecting bone marrow infiltration were 57.78%, 89.61%, 82.41%, 61.90%, and 87.90%, respectively.The initial staging of 199 patients with FL was based on PET-CT findings of lesions outside of the bone marrow, and 22 patients with initial stage III were up-staged to stage IV by restaging with PET-CT findings of bone marrow lesions; similarly, 1 patient with initial stage II was up-staged to stage IV by restaging with BMB findings of bone marrow lesions, and 23 patients with initial stage III were up-staged to stage IV by BMB. Eight patients with stage III were upstaged to stage IV by PET-CT alone, one patient with stage II and nine patients with stage III were upstaged to stage IV by BMB alone, and 14 patients were upstaged to stage IV by BMB and PET-CT together, making a total of 32 patients upstaged to stage IV by BMB or PET-CT. 5 patients were upstaged to stage IV by BMB and PET-CT. Five patients changed their treatment plan due to up-staging of BMB bone marrow infiltration, and five patients had up-staging of BMB bone marrow infiltration but were unable to change their standard treatment due to symptoms or high tumor load.The result of univariate analysis showed that BMB positivity, PET-CT detection of bone marrow infiltration, Ann Arbor staging based on PET-CT, PET-CT combined with Ann Arbor staging of BMB,were factors associated with OS ( P < 0.05)Multifactorial results showed thatPET-CT detection of bone marrow infiltration were risk factors for OS (P<0.05) Conclusion ： Combined PET-CT and marrow biopsy has higher accuracy than bone marrow biopsy alone.PET-CT detection of bone marrow infiltration were risk factors for OS and was associated with poor prognosis. Keywords: bone marrow biopsy, positron emission tomography/computed tomography，follicular lymphoma, prognostic factor

Limited benefit of additional contrast-enhanced CT to end-of-treatment PET/CT evaluation in patients with follicular lymphoma

Despite follicular lymphoma (FL) is frequently characterized by a moderate increase of glucose metabolism, PET/CT examinations provides valuable information for staging and response assessment of the disease. The aim of the study was to assess and compare the diagnostic performance of PET/ldCT and PET/ceCT, respectively, in evaluating FL patients at the end of treatment. Fifty FL consecutive patients who underwent end-of-therapy PET/CT with both ldCT and ceCT were analyzed. Two blinded observers independently assessed PET/ldCT and PET/ceCT applying the Deauville score (DS) and Lugano classification criteria. PET imaging obtained after the end-of-treatment (EoT) was classified as showing PET and ce-CT matched response (concordant imaging group, CIG) or PET and ce-CT unmatched response (discordant imaging group, DIG). Relapse rate and Event-Free Survival (EFS) were compared between CIG and DIG patients. Overall, no differences in metabolic response classification were observed between PET/ldCT and PET/ceCT. In 13 (26%) patients PET/ceCT identified additional FDG-negative nodal lesions in mesenteric, retroperitoneal and iliac regions. However, in all cases, final DS remained unchanged and the additional results did not modify the following therapeutic decision. Among patients, who obtained complete metabolic response a comparable rate of relapse was registered in DIG 3/13 (23%) and CIG subgroups 5/20 (25%) [p = 0.899]. In all 3 DIG cohort patients who relapsed the recurrent disease involved also, but not exclusively, PET negative lymph nodes detected by ceCT. In overall population metabolic response defined by PET/ldCT predicted EFS [76% (group of patients with metabolic response) vs 35% (group of patients with residual disease), p = 0.0013] significantly better than ceCT-Based response assessment [75% (group of patients with complete response) vs 53% (group of patients with residual disease), p = 0.06]. Our study demonstrates a negligible diagnostic and predictive value of ceCT performed in addition to standard 18FDG PET/ldCT for EoT response evaluation in FLs. PET/ldCT should be performed as first-line imaging procedure, also in patients with prevalent abdominal and pelvic involvement, limiting the acquisition of ceCT in selected cases. This tailored approach would contribute to avoid useless radiation exposure and preserve renal function of patients.

Integration of 18-FDG PET/CT in the Initial Work-Up to Stage Head and Neck Cancer: Prognostic Significance and Impact on Therapeutic Decision Making.

Background: The objective of this study was to assess the therapeutic and prognostic impact of integrating18F-fluorodeoxyglucose (18-FDG) positron emission tomography (PET)/computed tomography (CT) into work-up (WU) at initial staging of patients with head and neck squamous cell carcinoma (HNSCC).Method: 477 consecutive patients (414M/63F, mean age 62.3 ± 9.7 years) with newly diagnosed HNSCC who underwent pre-treatment 18-FDG PET/CT were retrospectively included. The 18-FDG PET/CT stage (sPET) was compared to the conventional work-up stage (sCWU). A group of cancer specialists determined whether integrating PET/CT into WU at initial staging had an impact on the therapeutic decision, classifying the clinical impact as high (change in therapeutic modality), medium (change in the radiotherapy or surgical procedure), or low (modification of TNM staging and/or detection of synchronous cancer without high or medium impact). Three-year overall survival (OS) was considered as primary endpoint of the prognostic analysis.Results: 18-FDG PET/CT had a clinical impact in 221 patients (46.3%) with a medium or high impact on management in 94 (19.5%) patients. Medium and high impact of 18-FDG PET/CT was statistically equivalent between sCWU-stage I/II and III/IV subgroups (p = 0.02). 42 patients were PET/CT-upstaged from early stage I/II to advanced stage III/IV and had a significantly lower 3-year OS than those with concordant CWU and 18-FDG PET/CT early stage (54.8 vs. 82.6%, p = 0.001).Conclusion: This study demonstrated that implementing 18-FDG PET/CT in the initial WU of HNSCC provides valuable staging information with a better prognostic stratification. Patient management was modified for any disease stage, even for early stage I-II, with consequences on survival.

Role of dynamic thermography in diagnosis of nodal involvement in patients with breast cancer: A pilot study

BackgroundThe existing standard method of axillary nodal staging in breast cancer is sentinel lymph node biopsy using tracing agents such as blue dye or radioisotope. However, there are some drawbacks to using these agents such as skin tattooing and adverse reactions caused by blue dye and radiation risk posed by radioisotopes. Considering tumor biology, digital infrared thermal imaging may aid in detecting metastatic lymph nodes and staging axillary nodal disease while refraining from these disadvantages. Patients and methodsIn this pilot study, 26 patients with invasive ductal carcinoma of breast were enrolled. Prior to surgical intervention, axillary region was evaluated by digital infrared thermal imaging after 2 min of cold stress. Diagnostic potential of dynamic thermography was assessed. ResultsDynamic thermography achieved sensitivity of 83% and the false negative rate was 16%. Thermal analysis was superior to ultrasound, mammography and magnetic resonance imaging in terms of detecting metastatic lymph nodes. ConclusionThe proposed research protocol of dynamic thermography was found to be workable. Digital infrared thermal imaging of axillary region seems promising and can render valuable staging information in the era of minimally invasive surgery.

Transoral robotic retropharyngeal node dissection in oropharyngeal squamous cell carcinoma: Patterns of metastasis and functional outcomes.

Assessment of the retropharyngeal lymph nodes is essential in the treatment for oropharyngeal squamous cell carcinoma (SCC). Transoral robotic retropharyngeal lymph node dissection (RPLND) may provide valuable staging information and guide selection of adjuvant therapy in a transoral robotic surgery (TORS) treatment paradigm. Outcomes were compared between 30 patients with oropharyngeal SCC with tonsillar primaries undergoing RPLND and 37 stage-matched cases without RPLND. Retropharyngeal metastasis was confirmed in 6 patients undergoing RPLND. Compared with 37 stage-matched controls, there were no differences in length of stay, length of feeding tube dependence, net change in perioperative weight, or rates of hemorrhage and postoperative complications. RPLND altered adjuvant treatment recommendations in 1 of 30 patients. RPLND is technically feasible by a purely transoral robotic approach. Its performance is not associated with worse swallowing outcomes or rates of complication. In select patients, RPLND may provide valuable staging information and guide the selection of adjuvant therapy.

Testicular Seminoma and Its Mimics: From the Radiologic Pathology Archives.

Testicular seminoma is the most common malignant tumor of the testis. It classically manifests as a painless mass. Radiologic evaluation with high-frequency ultrasonography (US) is critical for diagnosis. Seminomas are usually homogeneously hypoechoic masses at US. In challenging cases, magnetic resonance (MR) imaging may help confirm that a mass is intratesticular and provide data for local staging. Computed tomography (CT) provides valuable information for staging, including the presence and size of retroperitoneal lymph nodes. Testicular seminoma is treated with radical inguinal orchiectomy and is highly curable even at advanced stages of disease. Several neoplastic and nonneoplastic conditions may mimic testicular seminoma at imaging. Benign mimics include segmental infarction, hematoma, infection, epidermoid cyst, adrenal rests, sarcoidosis, splenogonadal fusion, and sex cord-stromal tumors. Malignant mimics include nonseminomatous germ cell tumors, lymphoma, and metastases. These conditions are individually reviewed with emphasis on features that allow differentiation from seminoma. Spermatocytic tumor, formerly known as spermatocytic seminoma, accounts for only 1% of testicular tumors. It is distinct from classic seminoma, with unique histologic, molecular, and genetic features. It affects an older patient population than classic seminoma and demonstrates indolent clinical behavior. Radiologists serve a key role in diagnosis, staging, and surveillance of patients with seminoma. A thorough knowledge of related clinical, radiologic, and pathologic findings will help the radiologist contribute to high-quality interdisciplinary care of affected patients.

Troubleshooting Sentinel Lymph Node Biopsy in Breast Cancer Surgery.

Performing a sentinel lymph node biopsy (SLNB) is the standard of care for axillary nodal staging in patients with invasive breast cancer and clinically negative nodes. The procedure provides valuable staging information with few complications when performed by experienced surgeons. However, variation in proficiency exists for this procedure, and a great amount of experience is required to master the technique, especially when faced with challenging cases. The purpose of this paper was to provide a troubleshooting guide for commonly encountered technical difficulties in SLNB, and offer potential solutions so that surgeons can improve their own technical performance from the collective knowledge of experienced specialists in the field. Information was obtained from a convenience sample of six experienced breast cancer specialists, each actively involved in training surgeons and residents/fellows in SLNB. Each surgeon responded to a structured interview in order to provide salient points of the SLNB procedure. Four of the key opinion surgical specialists provided their perspective using technetium-99m sulfur colloid, and two shared their experience using blue dye only. Distinct categories of commonly encountered problem scenarios were presented and agreed upon by the panel of surgeons. The responses to each of these scenarios were collected and organized into a troubleshooting guide. We present a compilation of 'tips' organized as a troubleshooting guide to be used to guide surgeons of varying levels of experience when encountering technical difficulties with SLNB.

Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography evaluation of subcutaneous panniculitis-like T cell lymphoma and treatment response

Subcutaneous panniculitis-like T cell lymphoma (SPTCL) is a very rare variant of non-Hodgkin’s lymphoma. Currently, there is no standard imaging method for staging of SPTCL nor for assessment of treatment response. Here, we describe our use of fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for staging and monitoring of treatment response in 3 cases of SPTCL. Primary staging by PET/CT showed that all 3 patients had multiple foci in the subcutaneous fat tissue, with SUVmax from 10.5 to 14.6. Involvement of intra-abdominal fat with high SUVmax was identified in 2 of the patients. Use of the triple drug regimen of gemcitabine, cisplatin and methylprednisolone (commonly known as “GEM-P”) as first-line therapy or second-line therapy facilitated complete metabolic response for all 3 cases. FDG PET/CT provides valuable information for staging and monitoring of treatment response and can reveal occult involvement of the intra-abdominal visceral fat. High FDG uptake on pre-treatment PET can identify patients with aggressive disease and help in selection of first-line therapy.

Anatomic Extent of Pelvic Lymph Node Dissection: Impact on Long-term Cancer-specific Outcomes in Men With Positive Lymph Nodes at Time of Radical Prostatectomy

To evaluate the impact of an extended pelvic lymph node (LN) dissection (EPLND) on the oncologic outcomes of men with LN-positive prostate cancer. Patients were identified who underwent an open radical prostatectomy by one of two surgeons at the Johns Hopkins Hospital between 1992 and 2003. The first surgeon routinely performed a limited pelvic LN dissection (LPLND), whereas the second performed an EPLND. Men with positive LNs from each cohort were compared for differences in oncologic outcomes. Positive LNs were found in 94 men (2.2%), 21 (22.3%) with an LPLND and 73 (77.7%) with an EPLND. On average, LPLND and EPLND yielded 11.4 and 14.6 nodes, respectively (P = .022). The two groups were similar in terms of the number of positive LNs (1.4 vs 1.8, P = .223) and the proportion of patients with <15% positive nodes (57.1% vs 69.9%, P = .300). At a median follow-up of 10.5 years, patients who underwent an EPLND had superior oncologic outcomes compared with the LPLND group: 5-year biochemical recurrence-free survival of 30.1% vs 7.1% (P = .018), 10-year metastasis-free survival of 62.2% vs 22.2% (P = .035), and 10-year cancer-specific survival of 83.6% vs 52.6% (P = .199). This analysis demonstrated an augmented improvement in biochemical recurrence-free survival in men with <15% positive nodes. In addition to affording valuable staging information, an EPLND may confer a therapeutic benefit to patients found to have positive LNs at the time of radical prostatectomy.

Utility of diffusion-weighted imaging in the evaluation of liver fibrosis

To evaluate the usefulness of diffusion- weighted MRI (DWI) in the detection and staging of liver fibrosis and inflammation. DWI was performed with b-factors of 0, 500 and 1000 s/mm². ADC values were obtained by placing circular regions of interest in four segments of the liver. Differences between the study (n = 34) and control groups' (n = 25) ADC values were examined. Further, this study investigated if and how ADC values were related to fibrosis stages and histological activity index (HAI) scores. The mean ADC value of the liver was smaller in the study group compared with the control group (P < 0.001). Spearman rho correlation analyses showed lower ADC values were associated with higher fibrosis and HAI scores (P < 0.01). There were statistically significant differences in liver ADC values between each combination of fibrosis stages (e.g. stages 0 and 1, 0 and 2) except for stages 1 and 2. ADC values prove to be a valuable technique for the diagnosis of liver fibrosis and inflammation. They can also be useful in fibrosis staging, particularly in distinguishing later stages of fibrosis from intermediate and early stages. Diffusion Weighted MRI is a promising technique for diagnosis of liver fibrosis. Apparent Diffusion Coefficients provide valuable information for staging of liver fibrosis. DWI may offer alternative to biopsy for assessing liver fibrosis.

289 ANATOMICAL EXTENT OF LYMPH NODE DISSECTION: IMPACT ON MEN WITH POSITIVE LYMPH NODES AT TIME OF RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Staging1 Apr 2011289 ANATOMICAL EXTENT OF LYMPH NODE DISSECTION: IMPACT ON MEN WITH POSITIVE LYMPH NODES AT TIME OF RADICAL PROSTATECTOMY Trinity Bivalacqua, Philip Pierorazio, Ashley Ross, mohamad allaf, H. Ballentine Carter, and Patrick Walsh Trinity BivalacquaTrinity Bivalacqua Baltimore, MD More articles by this author , Philip PierorazioPhilip Pierorazio Baltimore, MD More articles by this author , Ashley RossAshley Ross Baltimore, MD More articles by this author , mohamad allafmohamad allaf Baltimore, MD More articles by this author , H. Ballentine CarterH. Ballentine Carter Baltimore, MD More articles by this author , and Patrick WalshPatrick Walsh Baltimore, MD More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.382AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The therapeutic benefit of a limited and extended pelvic lymph node dissection (PLND) in prostate cancer management is currently under debate. We have previously demonstrated a benefit of extended PLND on biochemical recurrence-free survival (BFS). This study evaluates the influence of the anatomical extent of PLND performed in men with positive LN at time of radical prostatectomy (RP) on LN yield, BFS, metastases free survival (MFS), and prostate cancer specific survival (CSS). METHODS Between 1992 and 2003, two surgeons at one hospital performed 2,279 (PCW) and 1,986 (HBC) RP with PLND, respectively. One surgeon routinely performed an extended PLND (EPLND; superior: bifurcation of common iliac artery; inferior: femoral canal to pelvic side wall; posterior: obturator and internal iliac vessels) while the second surgeon performed a limited PLND (LPLND, differed by posterior extent termination at obturator nerve). Men with positive LN from each cohort were analyzed and compared between the two surgeons using appropriate comparative tests. BFS, MFS (demonstrated by radiography or positive bone scan), and CSS were calculated using the Kaplan-Meier method and log-rank test. RESULTS Of 94 men with positive LN at RP, 73 and 21 men underwent EPLND and LPLND respectively. There was no difference in age, pre-operative PSA, clinical stage, biopsy or pathological Gleason sum among groups. There was no difference in the proportion of men with extraprostatic extension, seminal vesicle invasion and positive surgical margins among groups. The mean follow-up was 10.5 years, 8 (4–16) for LPLND and 12 (1–17) for EPLND (p=0.13). On average, EPLND and LPLND yielded 14.3 (6–29) and 11.4 (4–20) nodes respectively (p=0.02). There was no difference in the number of positive LN (1.66 vs. 1.38, p=0.3) or the proportion of patients with <15% positive LN (28.8% vs. 42.9%, p=0.3) among groups. 5-year BFS was 30.1% and 8.3% for EPLND and LPLND respectively (p=0.05); 10-year MFS was 62.2% vs. 22.2% (p=0.035) and 10-year CSS was 83.6% vs. 52.6% (p=0.2). The magnitude of the difference in BFS and MFS were accentuated in those patients with <15% positive LN (n=30, 31.9%). CONCLUSIONS In a cohort analysis matched for preoperative and pathological prostate cancer characteristics, patients who underwent EPLND had more LN dissected on average and experienced animproved BFS and MFS. Therefore, in addition to affording valuable staging information, an EPLND at RP may provide a therapeutic benefit to patients with LN positive prostate cancer. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e117-e118 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Trinity Bivalacqua Baltimore, MD More articles by this author Philip Pierorazio Baltimore, MD More articles by this author Ashley Ross Baltimore, MD More articles by this author mohamad allaf Baltimore, MD More articles by this author H. Ballentine Carter Baltimore, MD More articles by this author Patrick Walsh Baltimore, MD More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Role of lymphadenectomy in the staging of endometrial cancer

Pelvic lymphadenectomy offers no therapeutic benefit to women diagnosed with early-stage endometrial cancer according to a new study. Lymphadenectomy can only be recommended as part of a clinical trial in this disease setting; however, it can offer valuable staging information in those with advanced disease.

Inguinal lymphadenectomy combined with staging endoscopic pelvic node sampling for stage III melanoma

Elective pelvic lymphadenectomy is one of the enduring controversies in the management of Stage III melanoma of the groin. It can provide valuable staging information but concerns remain over the possibility of increased morbidity without the benefit of increased survival. Endoscopic lymphadenectomy of the pelvic nodes is an established procedure in the management of urological and gynaecological malignancy but is relatively novel in the management of metastatic melanoma. An endoscopic approach reduces the risks suggested to be associated with the open procedure while still providing the clinician with the benefit of improved staging information. The authors present their experience of a combined procedure in a series of eight patients undertaken between January 2005 and May 2006 at the Exeter Melanoma Unit. One patient was discovered to harbour occult pelvic nodal metastases, despite a negative pre-operative CT scan. While no complications were directly attributable to the endoscopic procedure, the only major complication was post-operative lymphoedema which occurred in one case. The authors' experience suggests a combined procedure is both feasible and safe in the Plastic Surgery Department setting for the management of Stage III melanoma of the groin. This is the first documented UK experience of this technique.

Sentinel lymph node status in melanoma: a valuable prognostic factor?

Sentinel lymph node (SLN) biopsy is advocated as the standard of care for patients with primary melanoma. It is a procedure with few side-effects and provides valuable staging information about the regional lymphatics. To investigate the prognostic value of SLN biopsy and to compare it with that of other known risk factors in primary melanoma. One hundred and forty-nine patients with primary melanomas (tumour thickness >1.0 mm) underwent SLN biopsy between May 1998 and April 2004 at our department. This report summarizes the follow-up data of this cohort until October 2004. SLN biopsies of 49 of 149 patients (33%) revealed micrometastatic disease. Of all clinical and histological criteria, only the clinical type of primary melanoma (11 of 19 patients with acrolentiginous melanomas) and the Clark level were predictive for SLN positivity. Progression was observed in 22 patients (15%). It was significantly associated with ulceration of the primary tumour, tumour thickness, clinical type and localization of the primary tumour, female sex and older age. In contrast, SLN positivity was not significantly associated with a higher risk of progression (eight of 49 SLN-positive vs. 14 of 100 SLN-negative patients; P = 0.807). Twelve of 149 patients (8%) died because of melanoma in the follow-up period. Significant criteria for death were ulceration of the tumour, clinical type and localization of the primary tumour, but not SLN positivity. A high percentage of positive SLNs was observed in the patients with melanoma in our study (33%). The fractions of patients both with progressive disease and with tumour-related death were not significantly higher in patients with positive SLN than in those with negative SLN. We therefore conclude that the SLN status is not a reliable prognostic factor for progression of melanoma.

Sentinel lymph node biopsy in children and adolescents with malignant melanoma

Background/purpose Sentinel lymph node biopsy (SLNB) provides valuable staging information for adult patients presenting with clinically localized cutaneous melanoma. There are little data pertaining to the use of SLNB in the pediatric melanoma population. The objective of this study is to investigate the use of SLNB in the pediatric population, focusing on its diagnostic and therapeutic implications. Methods Retrospective identification was made of patients 18 years or younger who underwent sentinel lymph node biopsy for clinically localized melanoma at Indiana University Medical Center between 1994 and 2001. Patient demographics, primary tumor thickness, location of primary tumor, presence of tumor ulceration, number of lymph nodes removed, pathology of examined nodes, and number of lymph nodes involved with tumor were recorded. Disease status and dates of last clinical contact were determined. Results Twelve patients, 18 years or younger, were identified. Mean age of the study population was 14.1 years (range, 4 to 18). Mean tumor thickness was 1.65 mm (range, 0.36 to 4.7 mm). Three patients (25%) had positive sentinel lymph node biopsies. All 3 patients underwent completion lymph node dissection (CLND). One patient had micrometastatic disease detected on CLND; he had recurrence 6.1 months later and died 7.5 months after his SLND/CLND. At a median follow-up of 11.7 months, the remaining 11 patients had not experienced recurrence. There were no complications related to the SLNB procedure. Conclusions The minimally invasive surgical approach and limited complications associated with SLNB make this procedure a useful aid in assisting the physician in making therapeutic decisions in the pediatric melanoma patient.

Delayed harvesting of sentinel lymph nodes after previous wide local excision of extremity melanoma.

Harvesting the sentinel lymph node (SLN) is important in the management of patients with primary cutaneous melanoma. Selective sentinel lymphadenectomy (SSL) is generally performed at the time of wide local excision (WLE). The aim of our study was to determine whether delayed SSL is useful in detecting micrometastasis to the regional basin in patients with previous WLE of an extremity melanoma. Of 203 patients with a primary melanoma site located on the upper or lower extremity seen at the University of California, San Francisco/Mount Zion Melanoma Center from May 17, 1994, to March 23, 1999, 24 patients had a WLE of their extremity melanoma with adequate margins before referral. SSL was performed to assess micrometastasis in the regional lymph node basin after preoperative lymphoscintigraphy. At least 1 SLN was identified in all 24 patients. At a median follow-up of 3 years, two patients showed micrometastasis in the SLNs. One of these two patients developed recurrence, and all remaining patients showed no evidence of disease. Although it is generally advised that WLE should be performed simultaneously with SSL, delayed SSL after WLE of an extremity melanoma can still provide valuable staging information, which is critical for management of the patient.

Peritoneal Washings Are Not Predictive of Occult Peritoneal Disease in Patients with Hilar Cholangiocarcinoma

Evaluation of peritoneal cytology provides valuable staging information in patients with gastric and pancreatic adenocarcinoma, but its usefulness in patients with extrahepatic cholangiocarcinoma is unclear. The aim of this study was to evaluate the predictive value of peritoneal cytology in patients with potentially resectable hilar cholangiocarcinoma. This study evaluated a possible association between positive peritoneal cytology and percutaneous transhepatic biliary drainage, which is commonly used in these patients and may result in peritoneal biliary leakage and peritoneal seeding. From October 1997 through June 2000 26 patients with hilar cholangiocarcinoma underwent staging laparoscopy immediately before planned open exploration and resection. Peritoneal washings were obtained during laparoscopic examination before any biopsies were taken. Cytologic analysis was performed using the Papanicolau technique. There were 18 men and 8 women, with a median age of 69 years (range 42 to 81 years). The most common presenting symptom was jaundice (n = 19). Previous biliary drainage was performed in 23 patients: 9 percutaneous and 14 endoscopic. Metastatic disease was suspected preoperatively in six patients, three to the liver, two to the peritoneum, and one to regional lymph nodes, all of which were confirmed at laparoscopy. Laparoscopy identified five additional patients with metastatic disease. Peritoneal cytology was positive for malignant cells in two patients, both of whom had gross peritoneal metastases. Nine other patients had metastatic disease to distant sites within the abdomen, but none had positive cytology. Overall, six patients had metastatic disease to the peritoneal cavity, only one of whom had undergone earlier percutaneous biliary drainage. Peritoneal cytology was not predictive of occult metastatic disease. Laparoscopic staging identified some patients with unresectable hilar cholangiocarcinoma, but analysis of peritoneal cytology provided no additional information. There was no association between percutaneous transhepatic biliary drainage and peritoneal tumor seeding.

MR IMAGING OF BONE LESIONS OF THE ANKLE AND FOOT

MR imaging is frequently used to evaluate patients with ankle and foot pain, with or without a relationship to trauma or other known clinical outcomes. Abnormal signal intensity of the bone marrow is the common denominator of all entities described in this article, including bone contusion, fractures, osteonecrosis, transient osteoporosis, and reflex sympathetic dystrophy. Specific MR imaging features in association with the available clinical and radiographic findings can be helpful not only to supply an accurate diagnosis but also to provide valuable information for staging and proper management of the condition.

Lymphatic mapping and sentinel node biopsy in the management of high-risk melanoma

We review sentinel lymph node biopsy in patients with high-risk melanoma. This method of selective lymphadenectomy provides valuable staging information about the regional lymphatics without the need of prophylactic complete lymph node dissection. Only patients with micrometastases are candidates for complete lymph node dissection. This avoids, in nearly 85% of patients, the morbidity of the more extensive procedure. In addition, sentinel lymph node–positive patients may qualify for adjuvant therapy protocols. Whether this surgical approach ultimately results in a survival advantage awaits the results of a National Cancer Institute–sponsored national multicenter trial. (J Am Acad Dermatol 1998;39:603-10.)

Mediastinoscopy, Thoracoscopy, and Video-Assisted Thoracic Surgery in the Diagnosis and Staging of Lung Cancer

The intrathoracic staging of lung cancer involves assessment of the primary tumor and potential sites of metastases. Imaging studies of the chest are sensitive in detecting intrathoracic abnormalities, but specific staging information generally requires a tissue biopsy. The instruments used to obtain this information include the bronchoscope, mediastinoscope, and thoracoscope. The complementary application of these instruments can provide valuable staging information while limiting the morbidity of surgical staging.