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Objective: To assess whether preoperative ultrasound (US) assessment of regional lymph nodes in patients who present with primary cutaneous melanoma provides accurate staging. Background: It has been suggested that preoperative US could avoid the need for sentinel node (SN) biopsy, but in most single-institution reports, the sensitivity of preoperative US has been low. Methods: Preoperative US data and SNB results were analyzed for patients enrolled at 20 centers participating in the screening phase of the second Multicenter Selective Lymphadenectomy Trial. Excised SNs were histopathologically assessed and considered positive if any melanoma was seen. Results: SNs were identified and removed from 2859 patients who had preoperative US evaluation. Among those patients, 548 had SN metastases. US was positive (abnormal) in 87 patients (3.0%). Among SN-positive patients, 39 (7.1%) had an abnormal US. When analyzed by lymph node basin, 3302 basins were evaluated, and 38 were true positive (1.2%). By basin, the sensitivity of US was 6.6% (95% confidence interval: 4.6–8.7) and the specificity 98.0% (95% CI: 97.5–98.5). Median cross-sectional area of all SN metastases was 0.13 mm2; in US true-positive nodes, it was 6.8 mm2. US sensitivity increased with increasing Breslow thickness of the primary melanoma (0% for ≤1 mm thickness, 11.9% for >4 mm thickness). US sensitivity was not significantly greater with higher trial center volume or with pre-US lymphoscintigraphy. Conclusion: In the MSLT-II screening phase population, SN tumor volume was usually too small to be reliably detected by US. For accurate nodal staging to guide the management of melanoma patients, US is not an effective substitute for SN biopsy. [ABSTRACT FROM AUTHOR]

Abstract Background Although sentinel lymph node (SLN) biopsy is a standard of care for the evaluation of the axillary lymph nodes during breast cancer surgery, a substantial degree of variation exists among individual surgeons as to what represents an adequate assessment. The aim of the current study was to assess when metastatic disease was first identified within consecutively harvested SLN candidates for invasive breast cancers demonstrating a positive SLN. Methods We retrospectively analyzed a series of 400 breast cancers from a recently published prospective randomized clinical trial. A combined radiocolloid and blue dye technique was used. All potential SLN candidates, containing counts of at least 10% of the hottest SLN and/or containing blue dye, were harvested and were consecutively numbered in the order of the decreasing level of counts (with the hottest SLN representing SLN #1). Results Among 371 invasive breast cancers, a SLN was identified within 353 cases (95%). Mean number of SLNs identified was 2.5 (range, 1 to 9), with a single SLN identified in 104 (29%) cases, two identified in 110 (31%), three identified in 73 (21%), four identified in 35 (10%), five identified in 16 (5%), and six or more identified in 15 (4%). A positive SLN was found in 104 (29%) cases. SLN #1 was the first positive SLN in 86 (83%). SLN #2 was the first positive SLN in 15 (14%). SLN #3, SLN #4, and SLN #5 were the first positive SLN in one case (1%) each. A positive SLN was found in 18% (19/104) of cases when a single SLN was identified, as compared to in 34% (85/249) when two or more SLNs were identified (P = 0.003). Conclusion The accurate and optimal assessment of the axilla during breast cancer surgery requires persistence and diligence for attempting to identify all potential SLN candidates in order to avoid failing to recognize a positive SLN. The scenario in which only a single negative SLN candidate is intraoperatively identified is one that should raise some concern to the operating surgeon.

Increased use of neo‐adjuvant chemotherapy (NAC) for breast cancer has raised uncertainty regarding staging of the axilla, particularly for patients with a clinically negative axillary physical examination (PE). We sought to determine whether axillary ultrasound (AUS) prior to NAC to identify occult nodal disease is beneficial in patients with a clinically negative examination by evaluating the difference in nodal burden on final pathology in those with abnormal vs normal AUS. A retrospective review of an institutional cancer registry identified patients who underwent NAC for breast cancer and had a pretreatment AUS. Differences in the number of positive lymph nodes (PLN) in patients with a normal axillary PE and abnormal vs normal AUS prior to NAC were determined. A total of 120 patients who received NAC had a negative axillary PE prior to treatment. Fifty‐three had an abnormal AUS and biopsy‐proven lymph node (LN) involvement. In patients with an abnormal AUS, median number of PLNs at surgery was 1 vs 0 for those with a normal AUS (mean difference of 2.12, P <.0001). Of those patients with an abnormal AUS and biopsy‐proven LN involvement, 87% underwent axillary lymph node dissection (ALND) and nearly half had no PLN on final pathology (N = 23, 43%). Patients with a clinically negative axilla and an abnormal AUS were more likely to have PLN at the time of surgery. However, almost half of those patients had no residual LN involvement. Routine AUS prior to NAC may lead to more extensive surgical management of the axilla. [ABSTRACT FROM AUTHOR]

Case studies for 67‐year‐old female with a pimple‐like lesion on scalp for 3 years, and a 77‐year‐old female with a right axillary skin lesion for less than one year. Differential diagnosis for both included primary eccrine carcinoma versus metastasis from a mucinous adenocarcinoma. Given the absence of breast abnormalities, a diagnosis of eccrine carcinoma was favored in both.

A 45 year old woman presented approximately 1 year after initial therapy for a T1N0M0 left breast cancer (estrogen receptor [ER] negative, progesterone receptor [PR] positive, Her-2/neu negative) with a palpable left supraclavicular mass without associated axillary adenopathy. Previous therapy consisted of lumpectomy and axillary sentinel lymph node biopsy followed by adjuvant Adriamycin and cyclophosphamide, radiation therapy (5040 cGy to the breast with a 1000 cGy boost to the lumpectomy site), and tamoxifen. A computed tomography (CT) scan of the neck was performed which demonstrated left supraclavicular lymphadenopathy extending into the posterior triangle of the left neck. Fine-needle aspiration biopsy showed poorly differentiated metastatic adenocarcinoma consistent with the breast primary. A full staging examination showed no evidence of additional metastases. Breast magnetic resonance imaging was negative.

Objective: Observe patient-clinician communication to gain insight about the reasons underlying the choice of patients with unilateral breast cancer to undergo contralateral prophylactic mastectomy (CPM), despite lack of survival benefit, risk of harms, and cautions expressed by surgical guidelines and clinicians., Methods & Measures: WORDS is a prospective study that explored patient-clinician communication and patient decision making. Participants recorded clinical visits through a downloadable mobile application. We analyzed 44 recordings from 22 patients: 9 who chose CPM, 8 who considered CPM but decided against it, and 5 who never considered CPM. We used abductive analysis combined with constructivist grounded theory methods., Results: Decisions to undergo CPM are patient-driven and motivated by perceptions that CPM is the most aggressive, and therefore safest, treatment option available. These decisions are shaped not primarily by the content of conversations with clinicians, but by the history of cancer in patients' families, their own first-hand experiences with cancers among loved ones, fear for their children, and anxiety about cancer recurrence., Conclusion: The perception that CPM is the safest, most aggressive option strongly influences patients, despite scientific evidence to the contrary. Future efforts to address high CPM rates should focus on patient-driven decision making and cancer-related fears.

Objective: To determine whether, in the era of sentinel lymph node (SLN) biopsy, head and neck melanoma (HNM) has a poorer outcome than melanomas at other sites (OMS)., Design: Prospective database, 1994 to 2004. Characteristics and outcomes of patients with HNM vs those with OMS were analyzed by Fisher test, paired t test, and chi(2) test., Setting: Tertiary referral center., Patients: A total of 755 patients with melanoma who had undergone SLN biopsy., Main Outcome Measures: Differences between patients with HNM and those with OMS., Results: A total of 17.4% of patients had HNM vs 82.6% with OMS. There was a male HNM preponderance: 68.7% vs 50.3% for females (P < .01). Patients with HNM were older (mean [SD] age, 57.1 [16.6] years vs 53.3 [16.2] years; P < .01). There were fewer cases of superficial spreading melanoma in patients with HNM (29.0% vs 53.7%; P < .01). There were more diagnoses of lentigo maligna in patients with HNM (26.0% vs 1.9%; P < .01). The mean thickness of the primary lesion was 2.32 (1.9) mm vs 2.31 (2.9) mm; P = .49. Fewer patients with HNM had Clark level involvement lower than level IV (13.3% vs 24.0%; P < .01). More SLNs were harvested from patients with HNM (3.72 [3.2] vs 2.89 [2.6]; P < .01), but a lower percentage of positive SLNs was found (9.2% vs 16.0%; P < .05). There was no difference in local, regional, or distant recurrence (5.3%, 6.9%, and 5.3%, respectively, in patients with HNM and 3.4%, 5.5%, and 6.7%, respectively, in patients with OMS). The 2- and 5-year survival rates for patients with HNM were 96.2% and 72.6%, respectively, vs 93.6% and 79.0%, respectively, in patients with OMS (P = .40)., Conclusions: Most patients with HNM are older males with more SLNs harvested. They do not seem to have poorer outcome than patients with OMS.

Although mammography remains the most widely used tool for the early detection of breast cancers and evaluation of palpable abnormalities, a number of other imaging tools are being developed and used. Ultrasonography (US) is an excellent adjunct to conventional mammography. In addition to identifying solid and cystic abnormalities, US can often distinguish benign and malignant solid nodules. Magnetic resonance imaging (MRI) also is useful in assessing the extent of disease within the breast, particularly in women with dense breasts. MRI may be a more sensitive screening tool in women at elevated breast cancer risk. Newer techniques based on the metabolic activity of breast tumors also have been developed. One such technique is scintimammography, which uses radiolabeled tracers to detect breast malignancies. Positron emission tomography (PET), which relies on the high metabolic rate of tumors, also has been described as a method to evaluate breast disease. Other techniques, such as optical tomography and thermography, rely on angiogenesis and generated heat to identify cancers. These and other tools may help to improve both the sensitivity and specificity of cancer detection. Ideally, this improved detection results in improved outcomes in those who have breast cancer and avoidance of unnecessary procedures in those who do not.

Background: Tumor necrosis factor-alpha (TNF-alpha) is a well-documented central inflammatory mediator in sepsis. Specific polymorphisms of the TNF-alpha and TNF-beta genes (TNF2 and LTA + 250, respectively) have been suggested to correlate with higher mortality in septic shock. This study sought to determine whether these polymorphisms of the TNF-alpha and -beta genes are associated with an increased risk of infection in an at-risk surgical intensive care population., Materials and Methods: Forty-four consecutive patients with systemic inflammatory response syndrome were enrolled prospectively in the study. Genomic DNA was isolated from whole blood samples using standard phenol/chloroform extraction techniques. Specific fragments including the polymorphic sites of each gene were amplified by polymerase chain reaction, and restriction enzyme digestions were performed. Genotypes were determined by gel electrophoresis and confirmed by direct sequencing., Results: Eighty-six percent of the patients were TNF1 homozygotes (G:G at -308 of the TNF-alpha promoter region), whereas 9% of the patients were homozygous for TNF2 (A:A). There was no difference in the incidence of sepsis, septic shock, or mortality between patients bearing the various alleles. Only 13.6% of the patients exhibited the G:G alleles for TNF-beta, whereas the homozygous A:A was present in 45.4% of the patients., Conclusion: The presence of the A allele at these polymorphic sites did not predispose critically ill surgical patients to either infection or septic shock.