SPECT/CT-Guided Surgical Removal of a Positive External Iliac Sentinel Node in Primary Umbilical Melanoma: Report of a Case, and Up-to-Date Review of the Literature

Primary umbilical melanoma is rare tumor, representing about 5% of all umbilical malignancies.The lymphatic drainage from the tumor is challenging and can be to inguinal, axillary and retroperitoneal nodes. Dynamic and static lymphoscintigraphy with single-photon emission tomography/computed tomography (SPECT/CT) and sentinel lymph node biopsy (SLNB) is a widely validated technique in patients with clinically localized melanoma to search for and quantify nodal spread of cutaneous melanoma. Moreover, it offers the surgeon the preoperative information about the number and location of the sentinel lymph nodes (SLNs), which makes SLNB easier and quicker. This is the first report of an ulcerated thick melanoma of the umbilicus metastasizing only to an external iliac lymph-node without involvement of superficial inguinal SLNs. The preoperative high-resolution ultrasound (HR-US) examination of the regional lymph node field had been normal. This case-report shows how addition of SPECT/CT to planar imaging in a patient with clinically localized umbilical melanoma can help avoid incomplete SLNB when a deep SLN is not removed. A literature review of umbilical melanoma is also provided.

Curative Intent Surgery of Oral Malignant Melanoma and Regional Lymph Node Biopsy Assessment in 25 Dogs: 2006–2017

Medical records were searched for dogs that had received curative intent surgery for oral malignant melanoma and ipsilateral excisional regional lymph node biopsy. Twenty-seven dogs were operated on and 25 dogs of these dogs met the inclusion criteria of signalment, post-excision margin status, presence of metastasis for each biopsied lymphocentrum, survival time post-excision, presence of recurrence or metastasis at follow-up or at death/euthanasia, location of the primary tumor, and any postoperative adjuvant treatment. These 25 dogs had complete tumor excision with tumor-free margins and 19 (76%) had postoperative adjuvant therapy. Median survival time after excision for the dogs in this study was 335.5 days. Results of this study support previous work that documents prolonged survival time following complete excision of oral malignant melanoma with tumor-free surgical margins in dogs. Additionally, 4 dogs (16%) had histologically confirmed regional lymph node metastasis at the time of definitive surgery.

Differentiation and modulation of phagocyte activity in murine granuloma after treatment with thymulin 5cH

In previous studies, it was found that thymulin (thymic hormone), when prepared in homeopathic 5CH dilution, can modulate diseases progress and immune processes, such as virus infection in poultry and experimental tumor development. This project aims to study the immune modulatory mechanisms of thymulin 5CH in granulomatous experimental model induced by BCG in mice, with special focus on the phagocytes differentiation from peritoneal B1 stem cells and on the activity of these cells and lymphocyte cooperation at the injury site. Male adult Balb/c mice were inoculated with BCG into the footpad to induce granuloma and its cells were evaluated by histomorphometric methods (Ziehl-Neelsen staining of macrophages) and flow cytometry. The phenotypic characterization of phagocytes, T and B lymphocytes in the peritoneum and regional lymph node was done. Thus, CD11b (activated phagocytes and B1 cells), CD19 (B1 cells and B2), CD23 (B2 cells), CD5 (B1 cell subtypes and T cells), CD4, CD8 (effective T lymphocytes) and CD25 (regulatory lymphocytes) positive cells were quantified. After 21 days of infection, the differentiation of B1 peritoneal stem cells into phagocytes reached the peak, being higher in thymulin-treated mice (X2, p=0.0001). Simultaneously, the number of infected phagocytes in the lesion decreased (KW, p=0.001), indicating remission of the infection. The number of B1 derived phagocytes, CD4+ and CD8+ T lymphocytes in the local lymph node increased in thymulin-treated mice (X2, p=0.0001), at the same time. No difference was seen regarding to CD25+ cells. The results show that thymulin 5CH treatment is able to improve the granuloma inflammatory process by modulating local and systemic phagocyte differentiation, as well as T cell migration into the local lymph node.

Nodal Positive Breast Cancer and Its Regional Lymph Node Involvement

Purpose: In breast cancer, the lymph node status is of prognostic importance and a decisive factor in therapy planning. This study shows the distribution of lymph nodes metastases of node-positive breast cancer patients. Risk factors for lymph node metastases are described.Methods: 2095 patients with primary breast cancer were analyzed. Analysis included descriptive analysis (median, standard deviation, ranges) and statistical analysis (Chi², discriminant analysis).Results: The nodal stage was positive in 39.4% of all patients and negative in 60.6%. If the nodal stage was positive, only 1 lymph node was involved in 36% of the patients; more than 1 lymph node was involved in 64% of the patients. With an increasing number of lymph node metastases in level I, the probability of an involvement in level III also increases (F 437.845, p = .000). Other indicators are evidence of hemangiosis (F 247.728, p = .000) or lymphangiosis (F 167.368, P = .000). Despite <10 affected lymph nodes, 3.4% of the patients had nodal stage N3 due to level III involvement.Conclusion: Even with only a small number of lymph node metastases in level I higher lymphatic stations are often affected. The data cannot lead to a decision regarding an operation or radiation indication, but they can better substantiate the risk for certain therapy decisions.

Merkel Cell Carcinoma: Evaluation of the Clinico-Pathological Characteristics, Treatment Strategies and Prognostic Factors in a Monocentric Retrospective Series (n=143)

BackgroundMerkel cell carcinoma (MCC) is a rare neuroendocrine tumor of the skin. The incidence of the disease has undergone a significant increase in recent years, which is caused by an increase in the average age of the population and in the use of immunosuppressive therapies. MCC is an aggressive pathology, which metastasizes early to the lymph nodes. These characteristics impose an accurate diagnostic analysis of the regional lymph node district with radiography, clinical examination and sentinel node biopsy. In recent years, there has been a breakthrough in the treatment of the advanced pathology thanks to the introduction of monoclonal antibodies acting on the PD-1/PD-L1 axis. This study aimed to describe the clinico-pathological characteristics, treatment strategies and prognostic factors of MCC.MethodsA retrospective cohort study was conducted involving 143 consecutive patients who were diagnosed and/or treated for MCC. These patients were referred to the Veneto Institute of Oncology IOV-IRCCS and to the University Hospital of Padua (a third-level center) in the period between December 1991 and January 2020. In the majority of cases, diagnosis took place at the IOV. However, some patients were diagnosed elsewhere and subsequently referred to the IOV for a review of the diagnosis or to begin specific therapeutic regimens.Results143 patients, with an average age of 71 years, were affected mainly with autoimmune and neoplastic comorbidities. Our analysis has shown that age, autoimmune comorbidities and the use of therapy with immunomodulating drugs (which include corticosteroids, statins and beta-blockers) are associated with a negative prognosis. In this sense, male sex is also a negative prognostic factor.ConclusionsAutoimmune and neoplastic comorbidities were frequent in the studied population. The use of drugs with immunomodulatory effects was also found to be a common feature of the population under examination. The use of this type of medication is considered a negative prognostic factor. The relevance of a multidisciplinary approach to the patient with MCC is confirmed, with the aim of assessing the risks and benefits related to the use of immunomodulating therapy in the individual patient.

Merkel Cell Carcinoma: From Pathobiology to Clinical Management

Merkel cell carcinoma (MCC) is an infrequent, rapidly growing skin neoplasm that carries a greater probability of regional lymph node involvement, and a grim prognosis in advanced cases. While it is seen predominantly in old age in sun-exposed body parts, the prevalence varies among different races and geographical regions. Merkel cell polyomavirus and UV radiation-induced mutations contribute to its etiopathogenesis. The clinical presentation of MCC lacks pathognomonic features and is rarely considered highly at the time of presentation. Histopathological examination frequently reveals hyperchromatic nuclei with high mitotic activity, but immunohistochemistry is required to confirm the diagnosis. Sentinel lymph node biopsy (SLNB) and imaging are advised for effective staging of the disease. Multimodal management including surgery, radiation therapy, and/or immunotherapy are deployed. Traditional cytotoxic chemotherapies may result in an initial response, but do not result in a significant survival benefit. Checkpoint inhibitors have dramatically improved the prognosis of patients with metastatic MCC, and are recommended first-line in advanced cases. There is a need for well-tolerated agents with good safety profiles in patients who have failed immunotherapies.

Spindle cell variant of medullary thyroid carcinoma: a clinicopathologic study of four cases

Background Medullary thyroid carcinoma (MTC) is a malignant tumor derived from C cells. It accounts for about 10% of all thyroid malignancies. More than 14 histological variants have been described. Among them, spindle cell variant is extremely rare. Case presentation Here we describe 4 cases of spindle cell variant of MTC collected from 2012 to 2019. Ultrasound showed solid and hypoechoic nodules. Three patients underwent total thyroidectomy and regional lymph node dissection, and 1 patient underwent thyroid mass resection. Histologically, the tumors showed spindle shaped cells in bundles or interlaced arrangement, separated by hyalinised fibrous stroma that contained amyloid deposits. Immunohistochemistry showed that the tumor cells were positive for calcitonin, chromogranin A, synaptophysin, CD56, and TTF-1, but negative for other lineage-specific markers. Conclusions We report 4 rare cases of spindle cell variant of MTC. Due to its rarity and special morphology, the diagnosis of spindle cell variant MTC relies on its morphology and immunohistochemical markers to avoid misdiagnosis.