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Giornale Italiano di Dermatologia e Venereologia 2000 April;135(2):161-9


language: English

Sentinel lymphonodectomy and micromorphometric S-staging, a successful new strategy in the management of cutaneous malignancies

Starz H., Balda B. R.

From the Department of Dermatology and Allergology Augsburg, Germany


The sentinel lymph node (SLN) concept has its theoretical roots concerning lymphatic tumor progression in the ideas of the eighteenth and nineteenth century brought up by Valsalva, Virchow and Halsted. Technical prerequisites like lymphoscintigraphy, lymphatic mapping and immunohistochemistry were introduced several decades ago in the twentieth century. The current SLN technology, however, which combines all these procedures, is not older than eight years. In melanoma patients it quickly achieved rates higher than 90% in the detection and removal of exactly those regional lymph nodes which are the initial target of lymphogenous tumor cell spread. Thanks to semi-serial paraffin-section histology and adequate immunolabelling, clinically still occult nodal metastases are discovered in an average of 20% of intermediate and high risk melanoma cases. In contrast tumor involved SLNs of thin melanomas below 0.76 mm have not been reported until now. Therefore SLNE is dispensable in these cases. Since 1992, two further methodical improvements essentially refined the surgical and the diagnostic precision: 1. The intraoperative application of gamma-probes, and 2. standardized micromorphometry permitting routine staging of SLN metastases (S-staging). In melanoma patients S-stage proved to be the best predictor not only of non-sentinel node metastases in the respective lymph node region, but also of primarily inapparent hematogenous dissemination. Preliminary data of other solid skin malignancies show the same trend. Therefore S-stage will probably be the most important governor of therapeutic decisions in consequence of sentinel lymphonodectomy (SLNE). For example there is growing evidence, that in most cases of stage S1, perhaps also S2, SLNE has already a regionally curative effect per se. If this hypothesis is confirmed by future multicenter studies, then completion lymphadenectomy implying considerable morbidity might be restricted to patients of stage S3. A similar selectivity and stratification will be indispensable for the design of new adjuvant therapy studies. Furthermore, the SLN concept opens a promising gate to study tumor-host interactions like immune response and immune escape. At this point, cancer might loose a further piece of its unpredictability and provide us with new targets for specific therapies.

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