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The surgical treatment of a melanoma patient with macroscopic metastasis in peri and retrocaval lymph nodes and with a positive sentinel lymph node in the groin
No full textINTRODUZIONE: Lâestensione della linfadenectomia in pazienti affetti da melanoma con linfonodo sentinella inguinale metastatico à ̈ molto dibattuta. Gli studi piÃ1 recenti â in accordo con le linee guida per il trattamento chirurgico di carcinomi del tratto uro-genitale â suggeriscono lâestensione della dissezione chirurgica ai linfonodi iliaco-otturatori. Attualmente, perÃ2, i limiti anatomici e lâindicazione allâallargamento pelvico della linfadenectomia inguinale non sono ancora definiti.CASE REPORT: Un uomo di 46 anni con un melanoma nodulare cutaneo sulla faccia antero-mediale della gamba destra à ̈ stato sottoposto a biopsia del linfonodo sentinella dellâinguine, risultato positiva per macrometastasi. Dopo 2 settimane à ̈ stata eseguita la linfadenectomia inguinale con completamento con dissezione pelvica estesa; ma durante lâintervento à ̈ stata notata la presenza di metastasi macroscopicamente visibili anche in sede peri e retro cavale. Si à ̈ optato pertanto per passare alla linfadenectomia pelvica super-estesa, rimuovendo anche questi linfonodi. In totale sono stati rimossi 56 linfonodi, 54 sono risultati macrometastatici e di questi ultimi 9 erano peri-cavali e 2 retro-cavali. Dopo 49 mesi il paziente à ̈ giunto alla nostra attenzione per metastasi scrotali multiple, in assenza di ulteriori localizzazioni secondarie.DISCUSSIONE: Attualmente non ci sono linee guida per i pazienti affetti da melanoma a riguardo di indicazioni e limiti anatomici dellâestensione iliaco-otturatoria. La dissezione pelvica estesa à ̈ la procedura chirurgica di elezione nei pazienti affetti da carcinoma uro-genitali. In caso di riscontro intraoperatorio di macrometastasi in regione peri/retro cavale, lâapproccio da seguire risulta ancora piÃ1 incerto. Noi abbiamo eseguito una dissezione super-estesa pelvica con una buona prognosi per il paziente.CONCLUSIONI: Questo case-report testimonia la necessità di analizzare accuratamente lâeventuale presenza di metastasi linfatiche macroscopicamente visibili in regione peri/retro cavale, mettendo in evidenza la necessità di ulteriori studi per valutare la frequenza di metastasi in tale localizzazione nonché di sviluppare linee guida specifiche su indicazione ed estensione della dissezione pelvica nei pazienti affetti da melanoma con metastasi linfonodali inguinali.BACKGROUND: The extension of iliac-obturator dissection in melanoma patient with metastatic sentinel node of the groin is very debated. More recent studies - in accord with guidelines for urogenital cancers - suggest the extension to pelvic lymph nodes. At present, however, anatomical limits and indications to pelvic dissection are not defined in melanoma patients with metastatic lymph nodes of groin.CASE REPORT: A 46-year-old man affected by nodular cutaneous melanoma (Breslow-thickness 10 mm, Clark-level V) on the anterior-medial surface of the right leg underwent sentinel node biopsy of groin. Three macro-metastatic sentinel lymph nodes were removed in right inguinal field and, after 2 weeks, an ipsi-lateral inguinal lymphadenectomy with an extended pelvic dissection was performed. During the surgery, we reported the presence of macrometastases also in retro/peri caval lymph nodes. As a result of these findings, we decided to perform the super-extended pelvic lymphadenectomy. Overall we removed 56 lymph nodes with 9 peri-caval and 2 retro-caval macro metastatic lymph nodes. After a period of 49 months, the patients came to our attention with multiple scrotal metastases. The imagining restaging of the patient was already negative for other melanoma localizations.DISCUSSION: Currently there are no guidelines about indications and anatomical limits of iliac-obturator extension in melanoma patients. The extended pelvic dissection is the gold-standard procedure used in urogenital carcinomas. In case of finding of macro-metastases during the surgical procedure, the approach to follow is even more uncertain. We perform a super-extended pelvic dissection with a good prognosis for the patient.KEY WORDS: Caval-metastasis, Extended-pelvic-lymphadenectomy, Metastatic-melanoma
Cutaneous metastases of melanoma affecting exclusively skin graft donorand receiving sites: A novel clinical presentation
No full textA large metastatic intramammary lesion of an occult melanoma
No full textOBJECTIVE: Malignant melanomas presenting with unknown primaries are uncommon. In the majority of cases metastases of occult melanoma were detected in skin or in lymph nodes. Melanoma can rarely occur as a primary or metastatic intramammary tumor. CASE REPORT: We report the case of a 58-year-old Caucasian woman who came to our department with a voluminous mass in her right breast. Histopathological examination found metastasis of epithelioid melanoma with unknown primary lesion. Our patient underwent a radical enlarged mastectomy, but due to the extension a radical removal was not possible. DISCUSSION: In 2.2% of cases, melanoma may present with a metastasis without an identifiable primary lesion; this case should be considered a stage IV melanoma (Tx; Nl; Ml) due to the extension of the lesion and the infiltration of adjacent structures. CONCLUSIONS: In literature, the presence of a breast metastasis of melanoma with unknown primary origin was reported just in one case. The execution of histopathological analysis is mandatory for a correct differential diagnosis with primary carcinoma of the breast. Palliative metastasectomy should be discussed with multidisciplinary melanoma board
Autologous bone grafting with platelet-rich plasma for alveolar cleft repair in patient with cleft and palate
No full textBone grafting of the alveolus has become an essential part of the contemporary surgical management of the oral cleft. The aim of this retrospective study was to evaluate the results of bone grafting in association with PRP (plateletrich plasma) to enhance osteogenesis and osteointegration.
PATIENTS AND METHODS:
The study included 16 patients, aged between 9 and 11, affected with unilateral residual alveolar clefts, who underwent bone grafting using secondary alveoplasty. The eight patients belonging to the control group were administered autologous bone graft alone while the study group, consisting of 8 patients, underwent autologous bone grafting in association with PRP. All patients had pre and post surgery orthodontic treatment. The statistical analyses included Student's t test, 2 test and Kaplan-Meir time to event analysis. The p-value was considered significant if p<0.05. All statistical analyses were performed using SAS Software release 9.3 (SAS Institute, Cary, Nc).
RESULTS:
The control group (M 50%, mean age 10.2±2.3) underwent simple autologous bone graft while the study group (M 62.5%, mean age 9.9±2.2) was treated with a combination of autologous bone and PRP. No statistically significant differences were found between the two groups as regards age, gender and labial-palatal cleft clinical characteristics. 6, 12, 24 month follow-ups were performed by means of clinical and radiographic investigations. None of the study group developed oronasal fistulas or experienced bone height, bone bridging and bone quality loss; only two patients developed mild periodontal problems. The study group was able to undergo a significantly (p<0.001) earlier and shorter orthodontic treatment.
CONCLUSIONS:
In our experience, the use of PRP enhances the quality of osteoplasty, accelerates "creeping substitution" and bone healing and favours earlier orthodontic treatment
Multiple lymphatic-venous anastomoses in reducing the risk of lymphedema in melanoma patients undergoing complete lymph node dissection. A retrospective case-control study
No full textSentinel lymph node biopsy (SLNB) is an indispensable surgical procedure in staging and management of intermediate-to-thick melanomas. Although recent studies have demonstrated that complete lymph node dissection (CLND) does not improve 3-year specific survival, its utility in increasing the disease-free period and the control of local disease remains confirmed. The most frequent complication related to CLND is lymphedema, which may affect up to 20% of patients undergoing CLND. The preventive use of lymphatic-venous micro-anastomoses could avoid this complication
Optimizing the staging of melanoma patients for their best surgical management
No full textInterval nodes (IN) are defined as lymph nodes that lie along the course of lymphatic collecting vessels between a primary tumor site and a draining node field. Sometimes INs contain metastases and a consensus on their surgical management is needed. Therefore, to optimize the surgical management of melanoma patients with metastatic lymphatic involvement, especially when the sentinel lymph node biopsy identifies an unusual drainage field, we identified patients treated at the Department of Plastic and Reconstruction Surgery of Bari between July 1994 and December 2012 identified with a primary-cutaneous melanoma who underwent lymphoscintigraphy and subsequent positive-IN the lymphadenectomy to evaluate the impact of this procedure on overall survival and disease-free-period. 51 patients presented INs, and lymphadenectomy (LA) of the subsequent lymphatic field was performed in 13 subjects with positive-IN. In 4 cases additional lymphatic metastases were detected in the usual basin beyond the IN+. Recurrence-free period and survival rate at 5 years were higher in patients with positive-IN who underwent LA than in subjects who underwent LA due to positive lymph nodes in the usual field. Immediate lymphadenectomy of the subsequent lymphatic field in patients with positive-INs may afford patients earlier stage treatment of their disease and improved prognosis
Interval sentinel lymph nodes in melanoma: a digital pathology analysis of Ki67 expression and microvascular density
No full textThe presence of interval sentinel lymph nodes
in melanoma is documented in several studies, but controversies
still exist about the management of these lymph
nodes. In this study, an immunohistochemical evaluation
of tumor cell proliferation and neo-angiogenesis has been
performed with the aim of establishing a correlation
between these two parameters between positive and
negative interval sentinel lymph nodes. This retrospective
study reviewed data of 23 patients diagnosed with melanoma.
Bioptic specimens of interval sentinel lymph node
were retrieved, and immunohistochemical reactions on
tissue sections were performed using Ki67 as a marker of
proliferation and CD31 as a blood vessel marker for the
study of angiogenesis. The entire stained tissue sections
for each case were digitized using Aperio Scanscope Cs
whole-slide scanning platform and stored as high-resolution
images. Image analysis was carried out on three
selected fields of equal area using IHC Nuclear and Microvessel analysis algorithms to determine positive
Ki67 nuclei and vessel number. Patients were divided into
positive and negative interval sentinel lymph node groups,
and the positive interval sentinel lymph node group was
further divided into interval positive with micrometastasis
and interval positive with macrometastasis subgroups.
The analysis revealed a significant difference between
positive and negative interval sentinel lymph nodes in the
percentage of Ki67-positive nuclei and mean vessel
number suggestive of an increased cellular proliferation
and angiogenesis in positive interval sentinel lymph
nodes. Further analysis in the interval positive lymph
node group showed a significant difference between
micro- and macrometastasis subgroups in the percentage
of Ki67-positive nuclei and mean vessel number. Percentage
of Ki67-positive nuclei was increased in the
macrometastasis subgroup, while mean vessel number
was increased in the micrometastasis subgroup. The
results of this study suggest that the correlation between
tumor cell proliferation and neo-angiogenesis in interval
sentinel lymph nodes in melanoma could be used as a
good predictive marker to distinguish interval positive
sentinel lymph nodes with micrometastasis from interval
positive lymph nodes with macrometastasis subgroups
Reply to comments on “Microvascular coupler device versus handsewn venous anastomosis: A systematic review of the literature and data meta‐analysis”
No full textN/
Optimizing the staging of melanoma patients for their best surgical management
No full textInterval nodes (IN) are defined as lymph nodes that lie along the course of lymphatic collecting vessels between a primary tumor site and a draining node field. Sometimes INs contain metastases and a consensus on their surgical management is needed. Therefore, to optimize the surgical management of melanoma patients with metastatic lymphatic involvement, especially when the sentinel lymph node biopsy identifies an unusual drainage field, we identified patients treated at the Department of Plastic and Reconstruction Surgery of Bari between July 1994 and December 2012 identified with a primary-cutaneous melanoma who underwent lymphoscintigraphy and subsequent positive-IN the lymphadenectomy to evaluate the impact of this procedure on overall survival and disease-free-period. 51 patients presented INs, and lymphadenectomy (LA) of the subsequent lymphatic field was performed in 13 subjects with positive-IN. In 4 cases additional lymphatic metastases were detected in the usual basin beyond the IN+. Recurrence-free period and survival rate at 5 years were higher in patients with positive-IN who underwent LA than in subjects who underwent LA due to positive lymph nodes in the usual field. Immediate lymphadenectomy of the subsequent lymphatic field in patients with positive-INs may afford patients earlier stage treatment of their disease and improved prognosis
Letter to the editor
No full textWe read with great interest the recent article entitled “A Headto-Head Comparison Among Donor Site Morbidity After Vascularized
Lymph Node Transfer: Pearls and Pitfalls of a 6-Year Single CenterExperience” by Ciudad et al. In this article the authors did an excellent work to discuss the pearls and pitfalls for lymph node flap harvest by comparing donor site morbidity and complications following vascularized lymph node transfer with the most common lymph node flaps described. Inspired by the authors, we would like to express some opinions and offer several suggestions. In particular, we would like to comment on some benefits of the Gastroepiploic Lymph Node Flap (GE-VLN), based on our experience. We agree with the authors that the GE-VLN flap, harvested by laparoscopy, is our flap of choice for treatment of extremity lymphedema to minimize donor site morbidity but also to optimize
the aesthetic result.
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