Programming of enzyme specificity by substrate mimetics: investigations on the Glu-specific V8 protease reveals a novel general principle of biocatalysis

BACKGROUND: The purpose of the study was to determine the accuracy and role of the sentinel node technique in patients with non-small cell lung cancer. METHODS: This study was carried out on 36 consecutive patients undergoing lung resection. Peritumoral tissue was infiltrated with isosulfan blue dye and the first lymph node to stain was identified as a sentinel node. Sensitivity and specificity of the sentinel node in predicting the status of other lymph node stations were determined. RESULTS: Seventeen patients had sentinel lymph nodes. In 9 of these 17 cases neither the sentinel node nor any other lymph node contained metastatic carcinoma. In 5 cases the sentinel node was in the mediastinum and documented unexpected N2 disease. In 19 patients no sentinel node was found. Final lymph node statuses were N0 in 13 patients, N1 in 5, and N2 in 1. CONCLUSIONS: The use of isosulfan blue for intraoperative lymphatic mapping is feasible. The specificity in our experience was good; 9 of 9 patients with negative sentinel nodes were found to be N0 on the final pathology report. Unexpected N2 disease was found in 5 patients. The accumulation of further experience will determine the role of the sentinel node technique in patients with non-small cell lung cancer.     

Decreased paralysis and better motor coordination with microspinal versus PE10 intrathecal catheters in pain study rats

BACKGROUND: The sentinel lymph node is the first node or nodes to drain a cutaneous melanoma. Sentinel lymph node biopsy is performed to determine whether regional metastases are present. The authors' experience with the new technique of sentinel lymph node biopsy for melanoma of the head and neck is reported. PATIENTS AND METHODS: During the period of January of 1992 to December of 1995, 58 consecutive patients were identified from the melanoma database who had localization of the sentinel lymph node for primary cutaneous melanoma of the head and neck. Techniques for identification of the sentinel node(s) include preoperative lymphoscintigraphy and intraoperative Lymphazurin dye (vital blue dye) and technetium-99m-labeled sulfur colloid injection around the primary tumor site with Neoprobe mapping. RESULTS: Fifty-eight patients (13 female, 45 male), mean age 61 years, with melanoma of the head and neck with a mean Breslow thickness of 2.21 mm. (range, 0.82-6.87 mm.) and no regional lymphadenopathy underwent sentinel node mapping. The sentinel node was successfully identified in 55 patients (95 percent). Blue dye was visualized in 85 of 126 sentinel nodes excised (67 percent), whereas the remainder of the sentinel nodes were localized with the Neoprobe. Forty-nine patients who had successful mapping and sentinel node biopsy had no evidence of metastatic disease in the sentinel node or other nodes in the basin. Six of the fifty-five patients (11 percent) had evidence of micrometastatic disease, and all six had the sentinel node as the only site of metastasis. Five of six patients with micrometastases had a subsequent neck dissection and/or superficial parotidectomy. None of these patients had evidence of "skip metastases" with a negative sentinel node and higher level nodes positive for metastases. In total, 6 of the 18 sentinel nodes (33 percent) identified in these six patients contained micrometastatic disease, whereas none of the 139 other nodes sampled had any evidence of metastases. The exact probability that all six unpaired observations would consist of involvement of only the sentinel nodes is p = 0.0312. CONCLUSIONS: By combining the two mapping techniques in patients with melanoma of the head and neck, the sentinel node(s) can be mapped and identified individually, similar to melanoma in other locations. The sentinel nodes have been shown to contain the first evidence of regional metastatic melanoma. This staging information can be used to plan therapeutic node dissections and adjuvant therapy that may have a survival benefit in patients with stage III melanoma of the head and neck. Lymphatic mapping can be used to make the surgical care of the melanoma patient more conservative, so that only those patients with solid evidence of regional node metastases are subjected to the morbidity and expense of a complete node dissection and the toxicities of adjuvant therapy.     

Surgical management of aberrant sentinel lymph node drainage in cutaneous melanoma

BACKGROUND: Sentinel lymph node (SLN) mapping by lymphoscintigraphy has changed the surgical management of regional lymph node metastases for melanoma. SLNs lying outside of traditional nodal basins are now being identified. Our hypothesis is that when preoperative lymphoscintigraphy identifies aberrant SLNs, these nodes should be excised and, if histologically positive, lymphadenectomy of the aberrant nodal basin should be performed. METHODS: Patients with melanomas 1 mm or larger Breslow thickness and clinical stage N0M0 underwent lymphoscintigraphy and excision with SLN biopsy. Preoperative lymphoscintigraphy, intraoperative gamma probe, and intraoperative injection of isosulfan blue were performed to identify the SLN. Aberrant SLNs were defined as epitrochlear, supraclavicular, or popliteal nodes for extremity lesions and intramuscular nodes for truncal and head and neck lesions. RESULTS: Thirty-two patients were entered into the protocol. Seven (22%) were found to have aberrant nodes. Five of 19 patients with extremity melanoma had an aberrant SLN; 2 of 13 patients with truncal and head and neck melanoma had an aberrant SLN. CONCLUSIONS: This study demonstrates that (1) aberrant SLNs are encountered with similar frequency for extremity and truncal lesions, (2) biopsy should be performed on aberrant SLNs with intraoperative lymph node mapping with the gamma probe and blue dye, and (3) lymphadenectomy of the aberrant region should be considered if the aberrant SLN is positive.     

The carry-through of residues of maleic hydrazide from treated potatoes, following manufacture into potato crisps and ''jacket'' potato crisps

Primary nodal drainage basins in melanoma of the head and neck are often unpredictable. The ear is a notorious example of an anatomic site with ambiguous patterns of lymphatic drainage. Preoperative lymphoscintigraphy has recently emerged as one modality to assist in identifying clinically relevant nodes. We propose that the addition of intraoperative lymph node mapping techniques that utilize radioactive tracers ("intraoperative lymphoscintigraphy") can increase the accuracy of identifying sentinel nodes and help to determine which patients may benefit from a complete neck dissection. This report demonstrates the ambiguity in identifying drainage patterns in melanoma of the ear and offers a reliable method of sentinel lymph node mapping. This report also addresses current issues regarding treatment protocols of patients with micrometastatic disease in the periauricular region.     

Effect of various forms of metastatic lymph node involvement on prognosis of squamous epithelial carcinomas of the upper aerodigestive tract

BACKGROUND: Based on a new histo-morphological rating scheme, we assessed the impact on patient prognosis of lymph node metastasis of squamous cell carcinoma (SCC) in the head/neck area. Special attention was given to possible capsular rupture. METHOD: In a retrospective study, 111 patients with squamous cell carcinoma of the head and neck with concomitant cervical lymph node metastases were evaluated to determine the importance of lymph node capsular rupture on the occurrence of disseminated disease, loco-regional recurrence as well as survival rate. To cover the broad morphological spectrum of cervical metastatic disease, a newly developed scheme (differentiating seven different histo-morphological types of lymph node metastasis) was applied. On the basis of this scheme, every single metastatic lymph node received a score from one to seven. These single scores were then added to obtain a total score for every individual patient. These total scores were then divided into four groups. RESULTS: Synthesis of histo-morphological pattern of metastasis in combination with the number of metastatic lymph nodes showed highest concordance/significance in respect of disseminated disease (p = 0.0029), local recurrence (p = 0.0008) and regional lymph node metastasis (p = 0.0000) as well as survival rate (p = 0.0000). CONCLUSION: The newly introduced histological scheme seems to provide more accuiate and detailed information on the prognosis of SCC in the head and neck area.     

A pivotal role for glutamate in the pathogenesis of schizophrenia, and its cognitive dysfunction

PURPOSE: To compare the outcome for patients with squamous cell carcinoma of cervical lymph nodes metastatic from an unknown primary site who were irradiated to both sides of the neck and potential mucosal sites with opposed photon beams, and for those irradiated to the ipsilateral side of the neck alone with an electron beam. METHODS AND MATERIALS: Fifty-two patients with squamous cell carcinoma metastatic to cervical lymph nodes from an unknown primary site were irradiated by two different methods. Thirty-six were irradiated with a bilateral technique (BT), i.e., to both sides of the neck, including the naso-oro-hypopharyngeal mucosa, and 16 were irradiated with an electron beam (EB) to the ipsilateral side of the neck alone. Twenty patients of the BT group and 11 of the EB group had cervical lymph node dissections, and the remaining 21 patients had lymph node biopsies, prior to radiotherapy. RESULTS: Tumor control in the ipsilateral side of the neck did not differ for either radiation technique, but was significantly higher after lymph node dissection than after biopsy (90 vs. 48%; p = 0.0004). Control of subclinical metastases in the contralateral cervical lymph nodes was higher for patients irradiated with BT than for patients irradiated with EB (86 vs. 56%; p = 0.03). The occult primary was later discovered in 8% of the patients in the BT group and 44% of the EB group (p = 0.0005). The disease-free survival rate at 5 years for patients who had lymph node dissection prior to irradiation was 61%, and was 37% for those who had biopsy (p = 0.05). Only 20% of patients who subsequently developed an occult primary were salvaged and survived for 5 years after salvage treatment. CONCLUSION: Bilateral neck and mucosal irradiation is superior to ipsilateral neck irradiation in preventing contralateral cervical lymph node metastases and the subsequent appearance of an occult primary cancer. Both techniques combined with cervical lymph node dissection were equally effective in controlling the ipsilateral neck disease.     

The use of selective lymphadenectomy in squamous cell carcinoma of the wrist: a case report

Squamous cell carcinoma is the second most common skin cancer in humans and has a rate of metastasis of 0.5%-5.9%. Regional lymphadenectomy is generally not recommended for patients with advanced lesions and clinically node-negative disease. Selective lymphadenectomy using preoperative lymphoscintigraphy and intraoperative radiolymphoscintigraphy and vital dye injections to identify the sentinel lymph node may help in staging patients with upper-extremity squamous cell carcinoma while avoiding the complications of a complete axillary node dissection. The case of a patient with a large squamous cell carcinoma of the wrist with clinically negative findings on axillary examination who was found to have a sentinel lymph node containing metastatic tumor is presented. Although this treatment method is still considered investigational, it holds great promise for nodal staging by being able to detect occult metastatic nodal disease in otherwise clinically node-negative patients.     

Calcium and magnesium mass transfer in peritoneal dialysis patients using 1.25 mmol/L calcium, 0.25 mmol/L magnesium dialysis fluid

The percentage of melanoma patients diagnosed at an early stage is increasing. Many of these patients, particularly those with primary tumors thicker than 1.5 mm, harbor occult metastases in regional nodes and are eligible for regional lymphadenectomy as part of their primary management. Until the results of recently completed prospective randomized trials are available the role for elective lymphadenectomy in terms of survival benefit remains a controversial issue. A new technique, intraoperative lymphatic mapping and sentinel node biopsy, has emerged as a simple way to determine whether or not metastatic disease is present. An intradermal injection of a vital blue dye at the site of the primary tumor allows identification of a "sentinel" node in the regional basin. A study of 237 patients was recently reported by Morton et al. (Arch Surg 127:392-399, 1992; Surg Oncol Clin North Am 1:247-259, 1992) demonstrating that the sentinel node can be readily identified > 80% of the time and that histologic examination of the node results in at least a 95% accuracy rate in staging the nodal basin for metastases. Our present series substantiates the results of the original study. An international multicenter trial has been proposed to further confirm the accuracy and universal feasibility of this technique. Acceptance of this technique will lead to a selective approach to regional lymphadenectomy, as only patients with proven micrometastases will undergo lymph node dissections. This approach should satisfy both the advocates and the opponents of elective regional lymphadenectomy.     

Neuralgic amyotrophy or an isolated lesion of the anterior interosseal nerve?]

OBJECTIVE: Considerable evidence exists to suggest that tumor hypoxia results in radioresistance. Historically, it has been difficult to assess tumor oxygen tension levels reliably. These levels can now be assessed in head and neck malignancies using the Eppendorf pO2 histograph, which uses a fine-needle electrode and a computerized micromanipulator. This technology was used to compare the pretreatment tumor oxygen tension level in lymph node metastases of patients with head and neck cancer to measurements taken during nonsurgical treatment after a partial response had been achieved. STUDY DESIGN: Prospective study. METHODS: Oxygen tension levels were measured in the cervical lymph nodes of 10 patients with biopsy-proven head and neck squamous cell carcinoma and cervical metastases who were being treated with nonsurgical management. These levels were obtained using the Eppendorf pO2 histograph system. Measurements were taken before the start of treatment and were repeated when the size of the cervical metastatic node had decreased by 50%. Normal subcutaneous tissue was measured during the same session. The mean and median pO2 levels, as well as the percentage of measurements with pO2 less than 5 mm Hg were determined. RESULTS: A mean of 72.6 measurements per session was taken from each lymph node. The median tumor pO2 measurement fell from a mean (+/-SD) of 13.9+/-8.0 mm Hg to 7.3+/-9.9 mm Hg. Even more dramatic, however, was the substantial increase in the percentage of values less than 5 mm Hg, a rise from 29% to 52%. CONCLUSIONS: While there is variability both in the pretreatment oxygenation of head and neck cervical metastases and in the change in tumor oxygen tension during treatment, there appears to be a decrease in the overall oxygenation of the tumors. The dramatic increase in very low oxygen measurements may reflect selective survival of radioresistant or chemoresistant hypoxic tumor cells. Cells at the very low level would be expected to be radiobiologically hypoxic (resistant to radiation-induced cell kill).     

Overexpression of the p53 gene in primary and metastatic head and neck carcinomas

The p53 gene has been correlated with disease progression in a number of human malignancies, and p53 abnormalities are found in a high percentage of head and neck squamous cell carcinomas. The objectives of this study were 1. to correlate p53 expression with disease progression in squamous cell carcinoma of the head and neck (SCCHN), and 2. to determine whether there are site-specific differences in p53 expression. Primary lesions and/or lymph node metastases from 147 patients with invasive SCCHN were immunostained for p53 overexpression. Expression of p53 was similar (42% versus 43%) in primary lesions and lymph node metastases. Expression also did not vary significantly by site in the head and neck. In conclusion, increased p53 expression did not correlate with disease progression in our series of patients with invasive SCCHN. The finding of a lack of increased expression with disease spread to lymph nodes supports the belief that p53 alterations occur early in head and neck carcinogenesis.     

Clinicopathological study on patterns of cervical lymph node metastases from squamous cell carcinomas (SCC) of the head and neck

In order to investigate the patterns of cervical lymph node metastases from head and neck SCC, serial sections were performed on 384 radical neck dissection (RND) specimens. Positive lymph node was found in 60.4% RNDs. The cervical lymph node spread from SCC in the head and neck regions including oral cavity, oropharynx, hypopharynx and larynx has some predictable patterns, i.e., for primary SCC of the oral cavity, the majority of cervical lymph node metastases were clustered at levels I, II and III; and for primary carcinoma of the oropharynx, hypopharynx and larynx, a majority of node metastases were located at levels II, III and IV. The positive lymph nodes mainly distributed at only one level or consecutive levels. The rates of pathologically positive lymph node and extranodal spread grew with the increase of the clinical N-staging. It is suggested that supraomohyoid neck dissection (levels I, II and III) is particularly applicable to carcinomas of the oral cavity, and lateral neck dissction (levels II, III and IV) is applicable to carcinomas of the oropharynx, hypopharynx and larynx in patients with limited (N0 and N1) neck nodules, but for patients with N2 and N3 nodules, RND is neccessary to eradicate the nodal metastases. Moreover, the postoperative radiotherapy is indispensable for ruling out the occult cervical lymph node metastaese in selective neck dissection.     

MR imaging in squamous cell carcinoma of the head and neck with no palpable lymph nodes

PURPOSE: To assess the efficacy of MR imaging in the detection of lymph node metastasis in patients with no palpable lymph nodes ("N0 neck") who have squamous cell carcinoma of the head and neck region. MATERIAL AND METHODS: MR neck imagings in 18 patients who underwent neck dissection (bilaterally in 2) for squamous cell carcinoma of the head and neck region were examined preoperatively for the purpose of detecting lymph node metastases. The imaging features taken into consideration were: size (cutoff point 10 mm), grouping, presence of central necrosis, and appearance of extracapsular spread. The MR examinations comprised spin-echo T1- and T2-weighted sequences. The MR findings were compared with those of surgery and histopathological examination. RESULTS: MR suggested metastatic lymph node involvement in 5 necks. In 2 of these, central necrosis was seen in the enlarged lymph nodes. In a third, a grouping of the lymph nodes was noted. Extracapsular spread was not present. Histopathological examination revealed metastatic lymph nodes in 7 of the 20 necks, the rate of clinically occult disease being 35%, and 4 of them had been accurately graded by MR. There was one false-positive MR examination. The MR sensitivity was 57.1% and specificity 92.3%. CONCLUSION: MR may reveal metastatic lymph nodes in patients with no clinical evidence of metastasis. However, conventional MR techniques are not always sufficient for decision-making on surgery in cases of "N0 neck".     

Lymphatic mapping and sentinel node biopsy in breast cancer

BACKGROUND: Sentinel lymph node biopsy is a recently developed, minimally invasive technique for staging the axilla in patients with breast cancer. It has been suggested that this technique will avoid the morbidity associated with more extensive axillary dissection. A wide range of different methods and materials has been employed for lymphatic mapping, but there has been little consensus on the most reliable and reproducible technique. METHODS: This is a comprehensive review of all published literature on sentinel node biopsy in breast cancer, using the Medline and Embase databases and cross-referencing of major articles on the subject. RESULTS AND CONCLUSION: Sentinel node biopsy is a valid technique in breast cancer management, providing valuable axillary staging information. The optimal technique of lymphatic mapping utilizes a combination of vital blue dye and radiolabelled colloid. However, there remain controversial issues which require to be resolved before sentinel node biopsy becomes a widely accepted part of breast cancer care.     

Lymphoscintigraphy with double tracer technique in carcinomas of the head-neck region

BACKGROUND: Lymphoscintigraphy has been used since the early 1960s to demonstrate lymphatic drainage of head and neck tumors, but did not prove satisfactory. With the increasing importance of highly sophisticated neck dissection procedures, lymphoscintigraphy may have greater diagnostic impact. This assumes that lymphoscintigraphy will allow an accurate correlation of lymphatic drainage with anatomic structures. In this paper, we report on a method of lymphoscintigraphy with simultaneous body contouring. METHODS: Double-tracer lymphoscintigraphy was performed in 78 patients with squamous cell carcinoma. Patients received 100 MBq 99mTc-colloid in 0.1-0.2 ml in 3-4 peritumoral localizations. Ten patients were injected during surgery. Two milliliters of perchlorate solution were given orally in order to block the thyroid. Twenty minutes later patients received 50 MBq 99mTc-pertechnetate i.v. for body contouring. Planar images were obtained over 5 min each at 30 min and 4-6 h after injection from anterior, right lateral and left lateral using a LFOV-gamma camera. RESULTS: The thyroid was not visualized in any of the patients. In 28 of 78 patients (36%), the injection site was the only focal activity seen. In 50 of 78 patients (64%), lymph drainage was observed. Thirty-six of 78 patients (46%) showed unilateral lymphatic drainage, and 14 of 78 (18%) showed bilateral drainage. In all 50 patients showing lymphatic drainage, lymph nodes could be easily assigned to the six cervical lymph node compartments described. CONCLUSIONS: Double-tracer lymphoscintigraphy enables an accurate correlation of cervical lymph nodes and anatomic structures of the head and neck region. These findings suggest that the impact of these studies on the preoperative planning for neck dissection should be reevaluated.     

Sentinel node localization in patients with breast cancer

BACKGROUND: Intraoperative lymphatic mapping and identification of the first draining lymph node (the sentinel node) may allow some patients with breast cancer to avoid the morbidity of formal axillary clearance. The aim of this pilot study was to establish the reliability of the technique in predicting axillary node status. METHODS: Sixty-eight consecutive patients with breast cancer, 38 undergoing mastectomy and 30 wide local excision, were included. Some 2-4 ml of 2.5 per cent Patent Blue dye was injected into adjacent breast tissue on the axillary side of the primary tumour. After 5-10 min, the axilla was explored. Blue-stained lymphatics were dissected to the sentinel node, which was removed for frozen-section examination, followed by routine histology. Formal axillary dissection was then completed. RESULTS: A sentinel lymph node was identified successfully in 56 (82 per cent) of 68 patients. Histology of the sentinel node accurately predicted axillary node status in 53 (95 per cent). There were three false negatives (5 per cent). In each case, only a single non-sentinel node was tumour positive. Sensitivity and specificity were 83 and 100 per cent respectively. CONCLUSION: This technique would allow a selective policy of formal axillary dissection in only node-positive patients; however, further experience and refinement are needed.     

Prospective comparison of 18F-FDG PET with conventional imaging modalities (CT, MRI, US) in lymph node staging of head and neck cancer

The aims of this study were to investigate the detection of cervical lymph node metastases of head and neck cancer by positron emission tomographic (PET) imaging with fluorine-18 fluorodeoxyglucose (FDG) and to perform a prospective comparison with computed tomography (CT), magnetic resonance imaging (MRI), sonographic and histopathological findings. Sixty patients with histologically proven squamous cell carcinoma were studied by PET imaging before surgery. Preoperative endoscopy (including biopsy), CT, MRI and sonography of the cervical region were performed in all patients within 2 weeks preceding 18F-FDG whole-body PET. FDG PET images were analysed visually and quantitatively for objective assessment of regional tracer uptake. Histopathology of the resected neck specimens revealed a total of 1284 lymph nodes, 117 of which showed metastatic involvement. Based on histopathological findings, FDG PET correctly identified lymph node metastases with a sensitivity of 90% and a specificity of 94% (P<10(-6)). CT and MRI visualized histologically proven lymph node metastases with a sensitivity of 82% (specificity 85%) and 80% (specificity 79%), respectively (P<10(-6)). Sonography revealed a sensitivity of 72% (P<10(-6)). The comparison of 18F-FDG PET with conventional imaging modalities demonstrated statistically significant correlations (PET vs CT, P = 0.017; PET vs MRI, P = 0.012; PET vs sonography, P = 0.0001). Quantitative analysis of FDG uptake in lymph node metastases using body weight-based standardized uptake values (SUVBW) showed no significant correlation between FDG uptake (3.7+/-2.0) and histological grading of tumour-involved lymph nodes (P = 0.9). Interestingly, benign lymph nodes had increased FDG uptake as a result of inflammatory reactions (SUVBW-range: 2-15.8). This prospective, histopathologically controlled study confirms FDG PET as the procedure with the highest sensitivity and specificity for detecting lymph node metastases of head and neck cancer and has become a routine method in our University Medical Center. Furthermore, the optimal diagnostic modality may be a fusion image showing the increased metabolism of the tumour and the anatomical localization.     

Oxygenation status of squamous cell carcinoma of the head and neck: comparison of primary tumors, their neck node metastases and normal tissue

AIM: Investigation of the relationship between the pO2-status of primary tumors, their cervical neck node metastases and normal tissues in squamous cell carcinomas of the head and neck. PATIENTS AND METHODS: Pretreatment oxygenation of primary tumors, their neck node metastases and of the contralateral sternocleidomastoid muscle was assessed in 16 patients with histologically proven advanced squamous cell carcinomas of head and neck. Oxygenation was measured with a polarographic microelectrode system (Eppendorf-pO-Histograph). Using CT/MRT additionally the volume of the tumors was estimated. RESULTS: A highly significant correlation existed between the median pO2 of primary tumors and their neck node metastases and between the relative proportion of hypoxic values (< 5 mm Hg) of both anatomic sites (both p = 0.0001) (Figure 1). Primary tumors were not different from their neck node metastases, neither regarding the pO2 median values nor in view of the relative frequency of hypoxic values (Table 1). No correlation was found between the volume of primary tumors and the one of their neck node metastases. For volume of tumors and the oxygenation status no relationship was found as well. Significantly different was the median pO2 in the muscles from the one of the malignant tissues (p = 0.0004). CONCLUSION: The results suggest that for to estimate the oxygenation status of squanious cell carcinomas of the head and neck pO2 measurements of primary tumors and neck node metastases are equally sufficient.     

Single-dose isotope injection for both preoperative lymphoscintigraphy and intraoperative sentinel lymph node identification in melanoma patients

For patients with melanoma the 'sentinel' lymph node biopsy technique, although simple in concept, has the potential to provide misleading information if great care is not taken to ensure accurate sentinel node (SN) identification. The method initially reported involved lymphatic mapping by injection of blue dye around the primary melanoma site. Preoperative lymphoscintigraphy was subsequently shown to improve both the speed and accuracy of SN identification. More recently, intraoperative use of a hand-held gamma probe has been recommended, and it is likely that maximum reliability of SN biopsy will be achieved if all three manoeuvres are undertaken. As originally described, use of a gamma probe intraoperatively followed injection of tracer a short time before the surgical procedure. We report a simpler method of confirming SN identity with a gamma probe, using residual activity in the node following lymphoscintigraphy the previous day. In 21 patients close concordance with preoperative lymphoscintigram results and intraoperative findings after blue dye injection confirmed the reliability of the technique. Avoiding the need for repeat isotope administration on the day of surgery simplifies logistics, reduces costs, minimizes inconvenience and radiation dose for patients, and eliminates potential health and safety problems for operating theatre staff.     

Aggressive cutaneous squamous cell carcinoma of the head and neck in patients with chronic lymphocytic leukaemia

We describe multiple cutaneous squamous cell carcinomas of the head and neck in five patients with chronic lymphocytic leukaemia (CLL). When associated with CLL, cutaneous squamous cell carcinomata behave in a much more aggressive manner than otherwise expected. Four patients developed local recurrence after primary treatment. All five patients developed lymph node metastases containing squamous cell carcinoma. Three of five patients (60 per cent) had multiple primary lesions. Whereas the increased incidence of second cancers in CLL and notably of skin cancers is documented, little has been written to describe the aggressive behaviour of these tumours. It is important, when treating these patients, to be aware of the high tendency towards local recurrence and lymph node metastasis and to consider an aggressive management plan and careful follow-up.