ARTICLE
Auteur(s) : Roberto Cecchi1,
Lauro Buralli2, Cataldo de Gaudio3
1UO di Dermatologia Ospedale di Pistoia, V. Matteotti
1, 51100 Pistoia, ItalyFax: (+39) 0573/352290.
2UO di Chirurga Generale Ospedale di Pistoia, Italy
3UO di Medicina Nucleare Ospedale di Lucca, Italy
accepté le 5 Juillet 2005
Although cutaneous squamous cell carcinomas (SCCs) are generally
associated with a low metastatic potential, there are defined
subsets of tumours, that have a higher risk for both local
recurrence and metastasis [1]. The majority of metastases from
cutaneous SCC typically occur in the regional lymph nodes, whereas
distant involvement is uncommon [2, 3]. Nodal metastases carry a
poor prognosis, with a reported overall 5-year survival rate of
34.4% or less [1].Therefore, the early detection of regional lymph
node metastases is particularly crucial for staging and treatment
planning [3]. Recent studies suggest that the lymphatic mapping
(LM) and sentinel lymphonodectomy (SLNE), widely used to detect
nodal micrometastases in malignant melanoma, breast carcinoma, and
other select tumours, may also be successfully employed to screen
nodal basins in patients with high-risk cutaneous SCCs and
clinically negative regional lymph nodes [4-10].We report our
experience with this procedure in five selected patients affected
with recurrent cutaneous SCCs.
Materials and methods
Since July 2001, five patients (3 men and 2 women with an average
age of 75 years; range: 72-80 years) with recurrent cutaneous SCCs
and non-palpable regional lymph nodes underwent LM and SLNE.
Previous treatments included liquid nitrogen cryotherapy,
electrocoagulation, and surgical excision. Recurrent tumours had
been present for an average period of approximately 14 months, and
no immunodeficiency status was apparent.
Intradermal injection of Tc 99m-labelled nanocolloids around the
tumour was performed on the morning of surgery, followed by
lymphoscintigraphy to obtain dynamic flow and static images. At
surgery, perilesional injection of vital blue dye (Blue Patent V)
was also made. Patients then underwent surgical excision of their
tumours (4 patients by micrographic surgery, 1 patient by
amputation of the big toe), followed by gamma probe SLNE (Neoprobe
2000; Ethicon). Harvested sentinel lymph nodes (SLNs), after
formalin fixation, were serially sectioned and stained with
hematoxylin and eosin, and then with immunohistochemical staining
for AE1, AE3, and PCK26 keratins (Anti Pan keratin primary
antibody; Ventana Medical Systems).
Complete lymph node dissection (LND) was performed only in
patients with positive SLN.
Results
The characteristics of the patients and tumours are listed in table
1( Table 1 ). SLNs were identified in
all cases. During SLNE a total of 8 SLNs were harvested and results
are shown in table 2( Table 2 ). A SLN
metastasis, corresponding to stage S3, according the
micromorphometric S-classification proposed by Starz and Balda
[11], was found in 1 of the 5 cases. This patient had a recurrent
SCC on the dorsal aspect of his left hand. No metastasis was found
in the remaining non-SLNs, after complete axillary LND. The 4
patients with negative SLNs showed no evidence of tumour spread
after a median follow-up of 24 months (range: 18-40 months). The
patient with positive SLN was disease-free 18 months after LND. No
local or systemic complication related to the SLNE procedure was
observed.
Table 1 Clinical and histological features of the 5
patients with recurrent cutaneous squamous cell carcinomas
|
Patient
|
Age/Sex
|
Tumour
|
Size (cm)
|
Clark
|
Breslow
|
Treatment of the recurrent tumour
|
SLN site
|
|
No
|
location
|
level
|
thickness (mm)
|
|
1
|
72/F
|
Big toe
|
2 × 1.8
|
V
|
8.5
|
Amputation
|
Inguinal
|
|
2
|
76/F
|
Arm
|
2.5 × 2
|
IV
|
7.2
|
Micrographic surgery
|
Axillary
|
|
3
|
73/M
|
Lower lip
|
2.2 × 1.8
|
IV
|
4
|
Micrographic surgery
|
Neck
|
|
4
|
74/M
|
Face
|
2.1 × 2.0
|
V
|
7.8
|
Micrographic surgery
|
Neck
|
|
5
|
80/M
|
Hand
|
2.3 × 2.0
|
V
|
6.5
|
Micrographic surgery
|
Axillary
|
Table 2 Sentinel lymphodectomy findings
|
Patient No
|
SLN No
|
Histological result
|
Positive LNs in LND
|
Follow-up (months)
|
|
1
|
2
|
Negative
|
–
|
40
|
|
2
|
1
|
Negative
|
–
|
32
|
|
3
|
3
|
Negative
|
–
|
24
|
|
4
|
1
|
Negative
|
–
|
20
|
|
5
|
1
|
Positive
|
None (of 12)
|
18
|
Discussion
Recent studies have identified many variables associated with a
more aggressive behaviour and metastasis in patients with cutaneous
SCCs [1, 12, 13]. They include tumour size greater than 2 cm;
depth of lesion greater than 4 mm and Clark level IV or V;
poor histological differentiation; perineural, vascular or
lymphatic invasion; localization (lip, ear, or over burn scars);
recurrent tumours, and immunosuppression [1, 12]. In particular,
recurrent SCCs show a metastatic rate ranging approximately from
25% to 45%, if the re-treatment is by conventional surgery [1].
Micrographic surgery is the treatment of choice for these patients
[2, 12].
The management of high-risk cutaneous SCCs is still
controversial, and no consensus exists on the adequate staging of
these tumours, as well as on the appropriate therapeutic approach
[8, 12]. Radical LND with or without radiotherapy is usually
performed when there is evidence of lymph node involvement.
Conversely, there is no consensus on prophylactic or elective LND
in patients with clinically negative lymph nodes. This procedure is
not routinely performed and there is not sufficient evidence of
benefit over morbidity [12].
LM/SLNE have shown an accuracy and sensitivity in detecting
nodal micrometastases, superior to any other staging procedure in
melanoma and other malignancies at clinical stage N0. The use of
LM/SLNE in cutaneous SCCs has been up to now reported in only small
trials or anecdotal cases, but the results are encouraging [4-10].
The incidence of nodal metastases, detected by SLNE is quite
variable, ranging from 12% to 44% in different surveys [7, 10]. In
the largest series, reported by Wagner et al. [9] a positive SLN
was detected in 29.4% of cases, while 1 false negative result (12%)
was observed after LND in a patient with recurrent SCC of the
scalp, previously treated with surgical excision and radiation
therapy.
In conclusion, these studies and our results provide evidence
that SLNE is a feasible, sensitive, and minimally invasive staging
procedure in patients with high-risk, cutaneous SCCs. It may select
patients with occult metastases in the regional nodal basins, who
can be submitted to therapeutic LND, avoiding the morbidity of a
prophylactic LND in patients without metastases in SLNs.
Further prospective studies on larger series and longer
follow-up are necessary to better verify the advantages of this
technique in the treatment of patients with high-risk cutaneous
SCCs.
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