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Trivial biophysical-semeiotic manoeuvre in bed-side detecting both breast cancer, since initial stages, and sentinel lymph node
- Sergio Stagnaro (4 June 2004)
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sentinel nodes technique drawbacks
- Stefano Ciatto (7 June 2004)
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Sentinel lymph node biopsy for melanoma not yet standard of care
- J Meirion Thomas, Matthew A. Clark, Consultant Surgical Oncologist (9 June 2004)
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Sentinel node biopsy
- Ervine D Long, John R Read (10 June 2004)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8 16037 RivaTrigoso (Genova) Italy
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Sir, To assess regional lymph node status in patients with malignancy, e.g., breast cancer and melanoma (1), there is now fortunately a simple and not at all expensive “clinical” method, among others more difficult to be applied, but certainly more refined, willingly either ignored or overlooked by oncologists all around the world, WHO authorities (excluding only Competent Authorities Health Europe: website http://www.epha.org/a/355), and Public Health Ministers. I described these clinical procedures eleven years ago (2)(See my HONCode website 233736, www.semeioticabiofisica.it). Before removing only a “small number” of nodes in order to find their status, I suggest to my dear colleagues the following “trivial” manoeuvre: digital pressure of mean intensity, applied exactly on such as lymph node, brings about gastric aspecific reflex (= in the stomach, both fundus and body dilate, while antral-pyloric region contracts: See Technical page N° 1 in the above-cited site) after a latency time less than the normal (NN = 9,5 sec.), in inverse relation to the severity of underlying disease. In addition, reflex persists pathologically 4 sec. or more (NN less than 4 sec.); this time is in direct relation to disorder seriousness. Finally, rapid tonic Gastric Contraction (pathological and characteristic biophysical-semeiotic sign of malignancy) appears: it is “always” absent in healthy individuals (2, 3). Readers who want to understand patho-physiological microcirculatory mechanisms of this reflex parameters, may visit my website. Surely, sentinel lymph node biopsy is now widely available, and most cancer surgeons offer this as part of their diagnostic protocol for patients. However, not to speak of lymph node other location (e.g. pancreas carcinoma), patients must await for a long time for both surgical intervention and biopsy result, having trouble with such events, of course. What is, moreover, the percentage of benign cases, showing only a simple inflammation? In my opinion, this surgical procedure has to be applied on rationally and clinically selected individuals by means of Biophysical Semeiotics of both sexes (breast cancer does spare, perhaps, males?), affected in all cases by Oncological Terrain, conditio sine qua non of malignancy (3). 1) Kell MR., Kerin MJ. Sentinel lymph node biopsy BMJ 2004;328:1330-1331 (5 June), doi:10.1136/bmj.328.7452.1330 2) Stagnaro-Neri M., Stagnaro S., Cancro della mammella: prevenzione primaria e diagnosi precoce con la percussione ascoltata. Gazz. Med. It. – Arch. Sc. Med. 152, 447 1993 3) Stagnaro-Neri Marina, Stagnaro Sergio. Introduzione alla Semeiotica Biofisica. Il Terreno oncologico”. Travel Factory SRL., Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm Competing interests: None declared |
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Stefano Ciatto, Head Dept. Diagnostic Imaging Centro per lo Studio e la Prevenzione Oncologica, Viale Volta 171, I-50131, Florence, Italy
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Among the possible drawbacks of sentinel node biopsy (SNB) there is the risk of false positive findings due to reactive lymphnode swelling in the biopsy site. Periodic follow-up of the sampled lymphnode area has become a common practice after SNB, mostly based on palpation and untrasonography (US). Swelling of axillary or inguinal lymphnodes reactive to SNB is likely to occur, as such a reaction in this sites is a common event, even after lesser injuries. Unfortunately, both palpation and US are poorly accurate to assess enlarged nodes, and false positive reports are likely to occur: FNAC may help, if positive, but considering that in these cases a greater diagnostic aggressiveness is expected, a false positive assessment might end in further lymphnode surgical biopsy. A more aggressive surveillance regimen is expected in subjects undergoing SNB, as well as a higher frequency of false positive reports and unnecessary invasive procedures. This possible negative effect is rarely addressed in the literature, although it might substantially reduce the benefits of SNB, a technique aimed uniquely at improving quality of life. Studies aim to demonstrate SNB cost-effectinevess should mainly address the quality of life endpoint, and the frequency of invasive procedures to assess false positive findings at periodic follow-up should be a variabe carefully taken into account. Competing interests: None declared |
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J Meirion Thomas, Consultant Surgical Oncologist Royal Marsden Hospital Melanoma and Sarcoma Unit, London SW3 6JJ, Matthew A. Clark, Consultant Surgical Oncologist
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Dear Sir, We write concerning the Editorial “Sentinel Lymph Node Biopsy” in the BMJ on June 5th 2004. Sentinel lymph node biopsy (SLNB) is a staging procedure, with a well established role in breast cancer that reduces the need for axillary node dissection. In contrast, the indications and advantages for SLNB in melanoma are not confirmed, and it is certainly not the established treatment implied in the Editorial.[1] It is true that sentinel node (SN) status in melanoma is the best staging and prognostic indicator: SN–negative patients have a better prognosis then SN–positive patients. However, there is no evidence from randomised clinical trials that completion lymphadenectomy (sometimes known as selective lymphadenectomy) in SN–positive patients offers any survival advantage. Neither is there any adjuvant therapy which can influence the natural history and benefit patients who are SN–positive.[2] Concern has recently been raised about the possible increased incidence of local and in-transit recurrence in SN–positive patients who undergo completion lymphadenectomy.[3] This iatrogenic complication carries an ominous prognosis and is probably explained by lymphatic obstruction and entrapment of melanoma cells in- transit to the regional nodes. The final decision for or against SLNB in melanoma must await the result of the Multicenter Selective Lymphadenectomy Trial which will not be published before 2006.[4] Until then, patients deserve to be informed that SLNB in melanoma is an investigational procedure with an unknown outcome; the significance of a possibly-increased incidence of local/in-transit recurrence should be included when obtaining informed consent. Finally, a degree of editorial balance in the literature should be encouraged, rather than the present unbridled enthusiasm for an attractive but unproven concept. Yours sincerely, J. Meirion Thomas MS FRCP FRCS Matthew A. Clark MD FRACS Consultant Surgeons, Sarcoma and Melanoma Unit 1. Roberts DL, Anstey AV, Barlow RJ, et al. U.K. guidelines for the management of cutaneous melanoma. Br J Dermatol 2002;146(1):7-17. 2. Wheatley K, Ives N, Hancock B, Gore M, Eggermont A, Suciu S. Does adjuvant Interferon-alpha for high risk melanoma provide a worthwhile benefit? A meta-analysis of the randomised trails. Cancer Treat Rev 2003;29: 241-52. 3. Thomas JM, Clark MA. Does completion lymphadenectomy in sentinel node positive patients increase the risk of local and in-transit recurrence in melanoma? Eur J Surg Oncol 2004 In press;doi 10.1016/j.ejso.2004.04.004. 4. Morton DL, Thompson JF, Essner R, et al. Validation of the accuracy of intraoperative lymphatic mapping and sentinel lymphadenectomy for early- stage melanoma: a multicenter trial. Multicenter Selective Lymphadenectomy Trial Group. Ann Surg 1999;230:453-63. Competing interests: None declared |
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Ervine D Long, Consultant Histopathologist Hull Royal Infirmary HU3 2JZ, John R Read
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Sentinel lymph node biopsy EDITOR - Kell and Kerin [1] report on the current status of sentinel lymph node biopsy in the surgical treatment of breast cancer and melanoma. They suggest that the detection of occult malignancy in lymph nodes in breast cancer signifies a worse prognosis and that the rapid intra- operative detection of malignant cells by immunocytochemistry will vitalize sentinel node biopsy – both assertions may be premature. Although a number of earlier studies have suggested a worse prognosis, a more recent study using multivariate analysis [2] has indicated that occult metastases are of no independent prognostic significance. The optimum method by which lymph nodes removed in the course of breast cancer surgery should be examined, including the utility of immunocytochemistry, remains to be determined. Touch imprint cytology [3] is a reliable method for the detection of carcinoma cells, but may not reliably discriminate between macrometastases (deposits > 2mm), micrometastases (deposits < 2mm) and small numbers of individual tumour cells involving the peripheral sinus of a lymph node. Further studies, preferably with large patient numbers and adequate follow-up, will be required before these techniques enter routine practice. Ervine D Long and John R Read Consultant Histopathologists Hull Royal Infirmary, Anlaby Road, Hull HU3 2JZ ervine.long@hey.nhs.uk 1 Kell MR and Kerin MJ. Sentinel lymph node biopsy. Br Med J 2004; 7452:1330-1 2 Millis RR, Springall R, Lee AHS, Ryder K, Rytina ERC and Fentiman IS. Occult axillary lymph node metastases are of no prognostic significance in breast cancer. Br J Cancer 2002; 86: 396-401 3 Salem AA, Douglas-Jones AG, Sweetland HM, Newcombe RG and Mansel RE. Evaluation of axillary lymph nodes using touch imprint cytology and immunohistochemistry. Br J Surg 2002; 89:1386-1389 Competing interests: None declared |
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