Optimal extent of completion lymphadenectomy for patients with melanoma and a positive sentinel node in the groin

Background: The optimal extent of groin completion lymph node dissection (CLND) (inguinal or ilioinguinal dissection) in patients with melanoma is controversial. The aim of this study was to evaluate whether the extent of groin CLND after a positive sentinel node biopsy (SNB) is associated with improved outcome. Methods: Data from all sentinel node-positive patients who underwent gr

The value of intraoperative neurophysiological monitoring in tethered cord surgery

The value of intraoperative neurophysiological monitoring (IONM) with surgical detethering in dysraphic patients has been questioned. A retrospective analysis of our series of 65 patients is presented with special focus on technical set-up and outcome. All patients were diagnosed with a tethered cord (TC) due to spinal dysraphism. A high-risk group (HRG) was determined consisting of 40 patients with a lipomyelomeningocele and/or a split cord malformation sometimes in combination with a tight filum terminale. The surgical procedure was a detethering operation in all cases performed by a single surgeon during a 9-year period (1999-2008). A standard set-up of IONM was used in all patients consisting of motor-evoked potentials (MEP) evoked by transcranial electrical stimulation (TES) and electrical nerve root stimulation. In young patients, conditioning stimulation was applied in order to improve absent or weak MEPs. IONM responses could be obtained in all patients. Postoperative deterioration of symptoms was found in two patients of whom one patient belonged to the HRG. Mean maximal follow-up of all 65 patients was 4.6 years (median 4.1 years). Long-term deterioration of symptoms was found in 6 of 65 patients with a mean follow-up of 5 years (median 5.3 years). The use of IONM is feasible in all TC patients. The identification of functional nervous structures and continuous guarding of the integrity of sacral motor roots by IONM may contribute to the safety of surgical detethering

Implementation of the 7th edition AJCC staging system: Effects on staging and survival for pT1 melanoma. A Dutch population based study

In the 7th edition of the AJCC staging system, the mitotic rate criterion replaced Clark level to increase correct classification of high-risk thin melanoma patients (pT1B). Additionally, sentinel node biopsy (SNB) was recommended for nodal staging of pT1B melanomas. The aim of this article was to evaluate the effects on pT1 substaging and clinical implications in the national pT1 melanoma population. All pT1 melanomas diagnosed in the Netherlands between 2003 and 2014 were selected from the Netherlands Cancer Registry (IKNL). Patients were stratified by cohort according to AJCC edition: (1) 2003-2009 (6th ) and (2) 2010-2014 (7th ). Relative survival was calculated to estimate melanoma-specific survival. A total of 29.546 pT1 melanoma patients were included. The pT1b proportion increased from 10.1% in Cohort 1 to 21.5% in Cohort 2. The proportion of performed SNBs per cohort increased: for pT1b melanomas alone from 4.5% to 13.0%. SNB positivity rate decreased from 10.5% to 8.8% for the entire pT1 population, and for pT1b melanomas from 11.3% to 8.6%. At 5 years, the relative survival rate was similar for pT1a and pT1b in both cohorts, namely, pT1a 100% vs pT1b 97% (Cohort 1), and pT1a 100% vs pT1b 98% (Cohort 2). The 7th edition of the AJCC staging system has caused an increased number of patients to undergo SNB, without an increase in SNB positivity rate. Survival between pT1 subgroups remains similar. The mitotic rate criterion for pT1b classification and the recommendation to perform SNB for pT1b melanomas should be reconsidered

Gamma probe and ultrasound-guided fine needle aspiration cytology of the sentinel node (GULF) trial

PURPOSE: Sentinel lymph node biopsy (SLNB) was introduced as a minimally invasive technique for nodal staging. Since associated morbidity is not negligible, it is highly relevant to pursue a more minimally invasive alternative. The purpose of this study was to prospectively evaluate the sensitivity of fine needle aspiration cytology (FNAC) with combined gamma probe and ultrasound (US) guidance in comparison with the gold standard histology of the sentinel node (SN) after SLNB for detecting metastasis. METHODS: The study was designed as a prospective, multicentre, open-label, single-arm trial enrolling patients with newly diagnosed cutaneous melanoma or breast cancer between May 2015 and August 2017. Sample radioactivity was measured using a Mini 900 scintillation monitor. After FNAC, all patients underwent SLNB. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were estimated. RESULTS: Accrual was terminated early following an unplanned interim analysis indicating that a FNAC sensitivity of at least 80% could not be achieved. In total 58 patients of the originally planned 116 patients underwent FNAC with gamma probe and US guidance. There were no true-positive FNAC results, 14 false-negative results and one false-positive result, and thus the sensitivity, specificity, PPV and NPV of FNAC were 0%, 98%, 0% and 75%, respectively. At least 75% of the FNAC samples had a radioactivity signal higher than the background signal. CONCLUSION: FNAC with gamma probe and US guidance is not able to correctly detect metastases in the SN and is therefore not able to replace SLNB. Gamma probe-guided US is a highly accurate method for correctly identifying the SN, which offers possibilities for future research