Patterns of recurrence following sentinel lymph node biopsy for cutaneous melanoma: outcome after 37 months of follow-up

BACKGROUND: Sentinel node biopsy (SNB) has been considered as an advance in surgical oncology for microstading melanoma. We report our experience with this procedure focusing on recurrence. METHODS: SNB was performed in 133 cutaneous melanoma patients submitted to preoperative lymphoscintigraphy, lymphatic mapping and gamma probe detection. Histologycal samples were analysed by HE and immunohistochemistry (IHC). RESULTS: The sentinel node was detected in 126 patients (96.2%). Micrometastasis were diagnosed in 20 patients (15.6%). There were nine recurrence, four in negative sentinel node group (108 patients). In this group, there was one systemic recurrence and three (2.8%) on lymphatic drainage region (false negative). In positive sentinel node group (20 patients) there were five recurrences. The recurrence was lower among negative sentinel node patients (p=0.0048). Ulceration (p=0.029) and positivity of the sentinel node (p=0.003) were considered significant risk factor by logistic analisys. Only sentinel node positivity maintained significance on multivariate analysis (p=0.024). The median follow up was 37 months. CONCLUSION: Patients with positive sentinel node presented more recurrence than negative sentinel node patients. The false negative rate was 2.8% and patients didn't have long-term sequelae ,allowing us to consider SNB as a secure and accurate procedure for melanoma staging.OBJETIVO: A biópsia de linfonodo sentinela (BLS) representa um avanço na cirurgia oncológica para o microestadiamento do melanoma. Apresentamos nossa experiência dando ênfase para a recorrência. MÉTODO: A BLS foi realizada em 133 pacientes portadores de melanoma cutâneo localizado envolvendo linfocintilografia, mapeamento linfático e detecção gama intra-operatórios em todos os pacientes. O exame histopatológico foi realizado por HE e imunohistoquímica (IHC). RESULTADOS: Encontrou-se LS em 128 pacientes (96,2%). Micrometástase foi diagnosticada em 20 pacientes (15,6%). Houve nove recorrências, sendo quatro no grupo com LS negativo (108 pacientes). Neste grupo, houve uma recorrência sistêmica e três (2,8%) na região linfática de drenagem (falso negativo). No grupo com LS positivo (20 pacientes) ocorreram cinco recorrências. Houve diferença significativa de recorrência entre os grupos, tendo sido menor no grupo LS negativo (p=0,0048). Através de análise de regressão logística univariada a ulceração (p=0,029) e a positividade do LS (p=0,003) apresentaram significância estatística como fatores de risco. Porém, apenas a positividade do LS manteve singificância na análise multivariada (p=0,024). O seguimento mediano foi de 37 meses. CONCLUSÕES: Pacientes com LS positivo apresentam recorrência significativamente maior que pacientes com LS negativo. O índice de falso negativo foi de 2,8% e os pacientes não apresentaram seqüelas o que permite considerar a BLS como procedimento seguro para o microestadiamento do melanoma cutâneo.UNIFESP-EPMCentro Avançado de Prevenção e Tratamento de CâncerHospital Israelita Albert EinsteinUniversidade de São PauloUNIFESP, EPMSciEL

The incidence of the therapist’ s style in the psychotherapeutic process

El objetivo de este trabajo es puntuar la incidencia del estilo del terapeuta en el proceso de la psicoterapia. Definimos el concepto de estilo del terapeuta como los patrones habituales, únicos de cada persona , que se relacionan con la visión que tiene de sí mismo y del mundo, sus creencias, experiencias de vida, momento evolutivo que atraviesa, posición socioeconómica, y estilo afectivo.Una alta similitud en el sistema de creencias entre el paciente y el terapeuta puede provocar un estancamiento en el tratamiento, como así también, una alta disonancia puede conducir al abandono del mismo.Es fundamental que el terapeuta cuente con un espacio de supervisión y entrenamiento con el fin de abordar los siguientes items: 1-  Aumentar sus conocimientos teóricos, adquirir y fortalecer un marco teórico de referencia necesario para identificar y guiar el proceso terapéutico. 2-  Adquirir un amplio abanico de técnicas posibles de implementar en la psicoterapia. 3-Desarrollar habilidades internas que le permitan utilizar su experiencia personal, y desafiar las creencias disfuncionales que actúan como obstáculo en su labor.4-  Capacidad de interactuar y coordinar esfuerzos terapéuticos propios y con otros profesionales-médicos, abogados, psicopedagogos - de modo de tener una visión amplia e integral del paciente. El poder trabajar adecuadamente estos puntos brinda al terapeuta un mayor repertorio de recursos y favorece la obtención de conductas mas flexibles y creativas. The objective of this work is to stress the incidence of the therapist’ s style in the psychotherapeutic process. We define the concept of the therapist’s style as the particular habitual patterns of each person, that are in relation with the view he has of himself and of the world, his beliefs, life experience, stage of development, socioeconomic position and emotional style. A great similarity between the therapist’ s beliefs system and the patient’ s beliefs system can cause a block in the treatment and a big difference between them can lead the patient to abandon treatment. It is essential for the therapist to have supervision and training to tackle the following issues:1-  To increase his theoretical knowledge, to acquire and strengthen the theoretical frame of reference needed to identify and lead the therapeutic process. 2-  To acquire a wide range of possible techniques to be used in psychotherapy. 3-  To develop internal abilities that allow him to use his personal experience, and challenge the dysfunctional beliefs that act like an obstacle in his work. 4-  The capacity to interact and coordinate his own therapeutic efforts and with those of other professionals - doctors, lawyers, educational psychologists - to get a broader view of the patient. This will give the therapist a larger repertoire of resources and will support the achievement of more flexible and creative behaviours.

Corante vital é suficiente para biópsia de linfonodo sentinela inguinal em pacientes portadores de melanoma

PURPOSE: The importance of gamma probe detection (GPD) combined with vital dye for sentinel node (SN) biopsy is well accepted. We evaluated the efficacy of patent blue dye (PBD) in identifying inguinal SN. METHODS: Ninety-four cutaneous melanoma patients with inferior extremity lesions were submitted to SNB according to a established protocol. Patients were randomized in two groups: Blue group, where SN was identified by PPD and Probe group, where SN was identified by GPD. The median age was 44.2 years and median Breslow thickness was 2.1 mm. Preoperative lymphoscintigraphy, lymphatic mapping with PBD and intra-operative GPD was performed on all patients. Histological examination of SN consisted of hematoxylin-eosin and immunohistochemical staining. If micrometastases were present complete lymphadenectomy was performed. The SN was considered as identified by PBD if it was blue and identified by GPD if it demonstrated at least ten times greater radioactivity than background. RESULTS: It was explored 94 inguinal lymphatic basins, 145 SN were excised (70 guided primarily by blue dye and 75 guided primarily by probe). All SN identified by preoperative lymphoscintigraphy were excised. In the Blue group PPD identified all SN and all of them were hot. In the Probe group all SN were identified by probe and were blue. The coincidence of PPD and GPD was 100%. CONCLUSION: Patent blue dye is enough to identify superficial inguinal SN in cutaneous melanoma.OBJETIVO: a importância da detecção gama intra-operatória combinada com corante vital para biópsia de linfonodo sentinela é bem aceita. Nós avaliamos a eficácia do azul patente V na identificação do linfonodo sentinela inguinal. MÉTODOS: Noventa e quatro pacientes portadores de melanoma cutâneo de membro inferior foram submetidos a biópsia de linfonodo sentinela de acordo com protocolo estabelecido. Foram randomizados em dois grupos: Grupo Azul, onde o linfonodo sentinela foi identificado primariamente com o corante vital azul patente V (Guerbet) e o Grupo Sonda, onde o linfonodo sentinela foi identificado primariamente pela sonda de detecção gama (Neoprobe). A idade mediana foi de 44,2 anos e a espessura mediana de Breslow foi 2,1 mm. Linfocintilografia pré-operatória, mapeamento linfático com azul patente V e detecção gama intra-opertaória foram realizados em todos os pacientes. O exame histopatológico do linfonodo sentinela consistiu de hematoxilina-eosina e imunohistoquímica. Se micrometástase estivesse presente, linfadenectomia completa era realizada. O linfonodo sentinela era considerado como identificado pelo corante vital se estivesse azul e identificado pela sonda de detecção gama se demonstrasse pelo menos 10 vezes ou mais radioatividade do que o fundo. RESULTADOS: Foram exploradas 94 regiões inguinais, 145 linfonodos sentinelas foram excisados (70 dirigidos primariamente pelo corante vital e 75 dirigidos pela sonda de detecção gama). Todos os linfonodos sentinelas identificados pela linfocintilografia foram excisados. No grupo azul, todos os linfonodos sentinela foram primariamente idenficados pelo corante vital e todos se apresentavam quentes na leitura pela sonda. No grupo sonda, todos os linfonodos sentinelas foram primariamente identificados pela sonda e estavam corados pelo azul. A coincidência da sonda com o corante vital foi de 100%. CONCLUSÃO: Azul patente V foi suficiente para identificar linfonodo sentinela inguinal em pacientes com melanoma cutâneo.UNIFESP-EPM Division of Plastic SurgeryUNIFESP-EPM Surgery DepartmentOncology Prevention CenterUNIFESP-EPMAlbert Einstein Hospital Nuclear Medicine ServiceUNIFESP, EPM, Division of Plastic SurgeryUNIFESP, EPM Surgery DepartmentUNIFESP, EPMSciEL

The incidence of the therapist’ s style in the psychotherapeutic process

The objective of this work is to stress the incidence of the therapist’ s style in the psychotherapeutic process. We define the concept of the therapist’s style as the particular habitual patterns of each person, that are in relation with the view he has of himself and of the world, his beliefs, life experience, stage of development, socioeconomic position and emotional style. A great similarity between the therapist’ s beliefs system and the patient’ s beliefs system can cause a block in the treatment and a big difference between them can lead the patient to abandon treatment. It is essential for the therapist to have supervision and training to tackle the following issues:1-  To increase his theoretical knowledge, to acquire and strengthen the theoretical frame of reference needed to identify and lead the therapeutic process. 2-  To acquire a wide range of possible techniques to be used in psychotherapy. 3-  To develop internal abilities that allow him to use his personal experience, and challenge the dysfunctional beliefs that act like an obstacle in his work. 4-  The capacity to interact and coordinate his own therapeutic efforts and with those of other professionals - doctors, lawyers, educational psychologists - to get a broader view of the patient. This will give the therapist a larger repertoire of resources and will support the achievement of more flexible and creative behaviours. </div

La incidencia del self del terapeuta en el proceso terapéutico

The objective of this work is to stress the incidence of the therapist’ s style in the psychotherapeutic process. We define the concept of the therapist’s style as the particular habitual patterns of each person, that are in relation with the view he has of himself and of the world, his beliefs, life experience, stage of development, socioeconomic position and emotional style. A great similarity between the therapist’ s beliefs system and the patient’ s beliefs system can cause a block in the treatment and a big difference between them can lead the patient to abandon treatment. It is essential for the therapist to have supervision and training to tackle the following issues:1-  To increase his theoretical knowledge, to acquire and strengthen the theoretical frame of reference needed to identify and lead the therapeutic process. 2-  To acquire a wide range of possible techniques to be used in psychotherapy. 3-  To develop internal abilities that allow him to use his personal experience, and challenge the dysfunctional beliefs that act like an obstacle in his work. 4-  The capacity to interact and coordinate his own therapeutic efforts and with those of other professionals - doctors, lawyers, educational psychologists - to get a broader view of the patient. This will give the therapist a larger repertoire of resources and will support the achievement of more flexible and creative behaviours. El objetivo de este trabajo es puntuar la incidencia del estilo del terapeuta en el proceso de la psicoterapia. Definimos el concepto de estilo del terapeuta como los patrones habituales, únicos de cada persona , que se relacionan con la visión que tiene de sí mismo y del mundo, sus creencias, experiencias de vida, momento evolutivo que atraviesa, posición socioeconómica, y estilo afectivo.Una alta similitud en el sistema de creencias entre el paciente y el terapeuta puede provocar un estancamiento en el tratamiento, como así también, una alta disonancia puede conducir al abandono del mismo.Es fundamental que el terapeuta cuente con un espacio de supervisión y entrenamiento con el fin de abordar los siguientes items: 1-  Aumentar sus conocimientos teóricos, adquirir y fortalecer un marco teórico de referencia necesario para identificar y guiar el proceso terapéutico. 2-  Adquirir un amplio abanico de técnicas posibles de implementar en la psicoterapia. 3-Desarrollar habilidades internas que le permitan utilizar su experiencia personal, y desafiar las creencias disfuncionales que actúan como obstáculo en su labor.4-  Capacidad de interactuar y coordinar esfuerzos terapéuticos propios y con otros profesionales-médicos, abogados, psicopedagogos - de modo de tener una visión amplia e integral del paciente. El poder trabajar adecuadamente estos puntos brinda al terapeuta un mayor repertorio de recursos y favorece la obtención de conductas mas flexibles y creativas.