Multi-institutional melanoma lymphatic mapping experience: the prognostic value of sentinel lymph node status in 612 stage I or II melanoma patients.
(1/67)
PURPOSE: To compare the effect of pathologic sentinel lymph node (SLN) status with that of other known prognostic factors on recurrence and survival in patients with stage I or II cutaneous melanoma. PATIENTS AND METHODS: We reviewed the records of 612 patients with primary cutaneous melanoma who underwent lymphatic mapping and SLN biopsy between January 1991 and May 1995 to determine the effects of tumor thickness, ulceration, Clark level, location, sex, and SLN pathologic status on disease-free and disease-specific survival. RESULTS: In the 580 patients in whom lymphatic mapping and SLN biopsy were successful, the SLN was positive by conventional histology in 85 patients (15%) but negative in 495 patients (85%). SLN status was the most significant prognostic factor with respect to disease-free and disease-specific survival by univariate and multiple covariate analyses. Although tumor thickness and ulceration influenced survival in SLN-negative patients, they provided no additional prognostic information in SLN-positive patients. CONCLUSION: Lymphatic mapping and SLN biopsy is highly accurate in staging nodal basins at risk for regional metastases in primary melanoma patients and identifies those who may benefit from earlier lymphadenectomy. Furthermore, pathologic status of the SLN in these patients with clinically negative nodes is the most important prognostic factor for recurrence. The information from SLN biopsy is particularly helpful in establishing stratification criteria for future adjuvant trials. (+info)
Lymphoscintigraphy in tumors of the head and neck using double tracer technique.
(2/67)
Knowledge of possible lymphatic drainage may facilitate planning of surgery for patients with head and neck tumors. Therefore, the aim of this study was to present a method of lymphoscintigraphy with special attention to an accurate correlation of lymphatic drainage to anatomic regions. METHODS: Lymphoscintigraphy was performed using a double tracer technique before surgery in a total of 75 patients with squamous cell carcinoma of the head and neck. All patients received 100 MBq 99mTc-colloid at three to four peritumoral sites. A perchlorate solution (2 mL) was given orally to block salivary glands and the thyroid gland. Patients received 50 MBq 99mTc-pertechnetate intravenously for body contouring 20 min postinjection. Planar images were obtained over 5 min each, at 30 min and 4 h postinjection from anterior, right lateral and left lateral views with a large-field-of-view gamma camera. Lymphatic drainage was assessed by visual inspection and assigned to six cervical compartments. RESULTS: Neither the salivary glands nor the thyroid gland were seen in any of the patients. In 22 of 75 patients (29.3%), the injection site was the only focal tracer uptake seen. In contrast, lymphatic drainage was identified in the remaining 53 patients (70.7%), and lymph nodes could be assigned easily to the six cervical compartments. Of 75 patients, 36 (48%) exhibited ipsilateral lymphatic drainage. In addition, 17 patients (22.7%) with unilateral tumor showed bilateral (n = 12), contralateral (n = 2) or retropharyngeal (n = 3) lymphatic drainage. In 3 of these 17 patients, bilateral lymph node metastases were proven. A subgroup of 12 patients (16%) exhibited N2c nodal status, despite a unilateral localized primary tumor. In 3 of these 12 patients, surgery was extended as a result of scintigraphic findings from unilateral toward bilateral neck dissection, and histology confirmed nodal involvement in these patients. CONCLUSION: Lymphoscintigraphy using the double tracer technique allows an accurate correlation of lymphatic drainage to the six cervical compartments. This may provide the basis for a re-evaluation of its impact in treatment planning of patients with head and neck tumors. (+info)
Lymphoscintigraphy using (99m)Tc filtered sulfur colloid in chylothorax: a case report.
(3/67)
OBJECTIVE: A 66-y-old man was diagnosed with esophageal carcinoma and underwent a right thoracotomy and esophagectomy. Postoperatively, a recurring right pleural effusion developed. Because an attempt at lymphangiography failed, lymphoscintigraphy was suggested. Because of the inability to obtain radiolabeled albumin, dextran, or nanocolloid, we used filtered sulfur colloid. (0.1 um). The study confirmed the diagnosis of chylothorax. (+info)
Reversal of abnormal lymphoscintigraphy after placement of venous stents for correction of associated venous obstruction.
(4/67)
PURPOSE: The purpose of this study was to report improvement or normalization of abnormal lymphoscintigraphy in swollen lower limbs after correction of associated venous stenosis by balloon dilatation and placement of venous stent of the iliac veins. MATERIAL: Twenty-six patients with lower-limb swelling underwent balloon dilatation and placement of venous stent of the iliac veins for correction of venous stenosis. Technetium 99M-sulfur colloid lymphoscintigraphy was also abnormal (8 absent, 18 reduced) before stent placement in all 26 limbs, suggesting combined venous/lymphatic etiology for the limb swelling. Median age was 53 years. Male-to-female ratio was 1:8 and left-to-right ratio, 3:1. Fifteen patients had limb pain associated with the swelling. Severity of venous stenosis was generally underestimated by preoperative transfemoral venography as compared with intravascular ultrasound, (mean, 50% versus 77%); in five limbs (19%), transfemoral venography altogether failed to identify the venous lesion evident on intravascular ultrasound. The etiology of venous obstruction was post-thrombotic in nine limbs and nonthrombotic (web, stricture, or May-Thurner syndrome) in 17 limbs. RESULTS: Poststent lymphoscintigraphy completely normalized in 10 limbs, improved but remained abnormal in 9, and remained unchanged in 7. Clinical follow-up (mean, 1 year) showed improvement in swelling in 16 of 26 limbs (P <.022), with complete resolution of swelling in six; degree of pain also improved (P <.02), with total relief of pain in 9 of 15 patients. There was also significant improvement in all categories of a quality of life questionnaire. CONCLUSION: These findings suggest that patients with a diagnosis of lymphedema made on the basis of lymphoscintigraphy alone and consigned to conservative therapy on that basis may benefit from additional venous investigations regardless of clinical presentation suggestive of lymphedema. This report supports the practice of aggressively searching for a venous basis of edema in these patients. Correction of the venous lesion may result in normalization or improvement of the lymphoscintigraphic abnormality and in any case may yield significant symptom relief, even in some limbs where the lymphoscintigraphic abnormality failed to improve after placement of venous stent. (+info)
Treatment of symptomatic primary chylous disorders.
(5/67)
PURPOSE: Primary chylous disorders (PCDs) are rare. Rupture of dilated lymph vessels (lymphangiectasia) may result in chylous ascites, chylothorax, or leakage of chyle through chylocutanous fistulas in the lower limbs or genitalia. Chyle may reflux through incompetent lymphatics, causing lymphedema. To assess the efficacy of surgical treatment, we reviewed our experience. METHODS: The clinical data of 35 patients with PCDs treated between January 1, 1976, and August 31, 2000, were reviewed retrospectively. RESULTS: Fifteen men and 20 women (mean age, 29 years; range, 1 day-81 years) presented with PCDs. Sixteen (46%) patients had chylous ascites, and 19 (54%) had chylothorax (20 patients), and of these, 10 (29%) had both. In 16 patients, reflux of chyle into the pelvic or lower limb lymphatics caused lymphedema (14, 88%) or lymphatic leak through cutaneous fistulae (11, 69%). Presenting symptoms included lower-limb edema (19, 54%), dyspnea (17, 49%), scrotal or labial edema (15, 43%), or abdominal distention (13, 37%). Primary lymphangiectasia presented alone in 23 patients (66%), and it was associated with clinical syndromes or additional pathologic findings in 12 (yellow nail syndrome in 4, lymphangiomyomatosis in 3, unknown in 3, Prasad syndrome (hypogammaglobulinemia, lymphadenopathy, and pulmonary insufficiency) in 1, and thoracic duct cyst in 1). Twenty-one (60%) patients underwent 26 surgical procedures. Preoperative imaging included computed tomography scan in 15 patients, magnetic resonance imaging in 3, lymphoscintigraphy in 12, and lymphangiography in 14. Fifteen patients underwent 18 procedures for chylous ascites or pelvic reflux. Ten (56%) procedures were resection of retroperitoneal/mesenteric lymphatics with or without sclerotherapy of lymphatics, 4 (22%) were lymphovenous anastomoses or grafts, 3 (17%) were peritoneovenous shunts, and 1 (6%) patient had a hysterectomy. Six patients underwent eight procedures for chylothorax, including thoracotomy with decortication and pleurodesis (4 procedures), thoracoscopic decortication (1 patient), ligation of thoracic duct (2 procedures), and resection of thoracic duct cyst (1 patient). Postoperative mean follow-up was 54 months (range, 0.3-276). Early complications included wound infections in 3 patients, elevated liver enzymes in 1, and peritoneovenous shunt occlusion with innominate vein occlusion in 1. All patients improved initially, but four (19%) had recurrence of symptoms at a mean of 25 months (range, 1-43). Three patients had postoperative lymphoscintigraphy confirming improved lymphatic transport and diminished reflux. One patient died 12 years postoperatively, from causes unrelated to PCD. CONCLUSIONS: More than half of the patients with PCDs require surgical treatment, and surgery should be considered in patients with significant symptoms of PCD. Lymphangiography is recommended to determine anatomy and the site of the lymphatic leak, especially if lymphovenous grafting is planned. All patients had initial benefit postoperatively and two thirds of patients demonstrated durable clinical improvement after surgical treatment. (+info)
Quantification of lymphatic function for investigation of lymphedema: depot clearance and rate of appearance of soluble macromolecules in blood.
(6/67)
The object of this study was to develop a new technique for the quantitative measurement of lymphatic function. The rate of clearance of radiolabeled protein from a subcutaneous depot is supplemented by measurement of the appearance of the protein in venous blood. This initial study was performed on normal arms, with a view to subsequent clinical application such as in the investigation of women with breast cancer--related lymphedema (BCRL). METHODS: Fourteen healthy volunteers (12 women, 2 men) and 8 women awaiting surgery for breast cancer were recruited for the study. Each received subcutaneous depot injection of protein solution in the second dorsal web space of each hand, labeled with (111)In on one side and with (99m)Tc on the other side. Human serum albumin (HSA) was the protein used in the first 8 subjects and human polyclonal immunoglobulin G (HIgG) was used thereafter. The activity at each depot was measured at regular intervals using a collimated sodium iodide scintillation detector, and the activity in venous blood sampled from both arms was measured in an automatic sample counter. RESULTS: (99m)Tc-HSA cleared from the depot consistently faster than (111)In-HSA (P = 0.001). The proportions of radionuclide remaining bound to protein in venous blood were higher for (99m)Tc than for (111)In. HIgG displayed improved labeling stability for both nuclides, reflected in equal rates of clearance. Blood activity rose steadily after an early latent phase and for HIgG correlated strongly with the rate of clearance from the depot (P < 0.001). Marked variation between individuals was observed. CONCLUSION: A dual-isotope technique relies on identical behavior of the 2 radiopharmaceuticals used. This study shows that this is the case with respect to HIgG but not HSA. (99m)Tc-HSA cleared faster than (111)In-HSA and yet displayed better in vivo labeling stability. We conclude that (111)In dissociates from HSA in the depot but then becomes locally bound. Using HIgG, a close correlation was observed between the rates of clearance from the depot and the appearance in venous blood. This finding suggests that HIgG would be a suitable marker for subsequent dual-isotope studies on women with BCRL. (+info)
Whole-body lymphoscintigraphy using transmission scans.
(7/67)
OBJECTIVE: Our objective was to show the advantages of performing whole-body lymphoscintigraphy using transmission sources. This technique should decrease scanning time, help locate the sentinel lymph node, and decrease radiation exposure to the technologist. METHODS: Twenty patients with proven melanoma received 18.5 MBq (0.5 mCi) filtered (0.22 microm) (99m)Tc-sulfur colloid in a 0.2-mL volume, administered as multiple intradermal or subcutaneous injections around the known melanoma lesion or scar. All 20 patients underwent serial static imaging immediately after the injection, along with whole-body scanning after the static imaging. The static emission images were acquired for 5 min and the transmission images for 1 min using a 256 x 256 matrix. The whole-body transmission scans were acquired after the whole-body emission scans. The transmission scans were obtained with the same parameters as the emission scans, with the addition of placement of a (57)Co sheet source on one of the detectors of the large-field-of-view dual-head camera. The planar static axial images (transmission, emission) were compared with the whole-body images (transmission, emission) to determine whether the same number of lymph nodes was visualized with each technique. Posterior outlines were obtained through computer manipulation of anterior transmission images. RESULTS: In all 20 patients, the number of lymph nodes seen on the static images was the same as that seen on the whole-body emission and transmission images. The whole-body emission and transmission scanning time was an average of 30 min less than the time required to acquire the serial static images. CONCLUSION: The anatomic location of the sentinel lymph node is seen more easily on whole-body images, both anterior transmission and posterior transmission, than on planar static images. Whole-body emission and transmission imaging decreased scanning time and thus improved patient comfort and throughput. Technologists received less radiation exposure when handling the (57)Co source only twice during whole-body imaging, as opposed to several times during static imaging. (+info)
Contamination problem with sentinel node localization procedure: a case study.
(8/67)
Lymphoscintigraphy for sentinel node (SN) localization was performed on a 60-y-old man with a melanoma on his back. Skin contamination occurred as a result of the radiopharmaceutical dose administration. Skin contamination could result in a misinterpretation of the SN location. Careful observation of the procedure avoided a misinterpretation with this study. (+info)