Invited commentary on “Decorative sentinel lymph node – a new entity?” by Vandeweyer and Van De Casseye

Invited commentary on “Decorative sentinel lymph node – a new entity?” by Vandeweyer and... Eur J Plast Surg (2005) 28: 357 DOI 10.1007/s00238-005-0781-8 INVITED COMMENTARY Alistair J. Cochran Invited commentary on ‘‘Decorative sentinel lymph node – a new entity?’’ by Vandeweyer and Van De Casseye Accepted: 6 June 2005 / Published online: 19 July 2005 Springer-Verlag 2005 tattoo artist in the case of peripheral nodes and cigarette All that glitters....!’’ smoke, the coal mine and the polluted urban environ- ment in the case of pulmonary and mediastinal nodes. In an age of super-specialization we are all most com- Carbon pigment is now used to confirm the ‘‘sentinel’’ fortable in our own areas of expertise. status of a lymph node [1]. To the operating surgeon an unexpected black-hued Thus, the intriguing clinical dilemma presented by lymph node is a surprising and disturbing finding that Vandeweyer et al. in this issue is readily resolved by appropriately raises concern that the node may harbor careful pathologic evaluation of the tissues. Note that melanoma, even in the absence of a history of prior this requires fixed tissues and special stains and is thus melanoma. not a matter that can readily or certainly be resolved by To pathologists pigments in tissues are relatively intraoperative frozen-section analysis. A node that is commonplace, but can be challenging. A dark-colored dark-colored on clinical inspection may be the site of node may contain melanin pigment, in melanoma cells metastatic melanoma, but it would seem inappropriate or in macrophages, hemosiderin or, as in the case re- to undertake further and substantial surgery purely on ported in this issue, particulate carbon. Rarer possibili- the basis of gross inspection, without detailed and ties include lipofuscin or homogentisic acid in patients thoughtful histological analysis. Close consultation be- with alkaptonuria. In interpreting the nature and sig- tween the operating room and the surgical pathology nificance of tissue pigmentation pathologists follow well- laboratory provides a solid basis for optimal clinical established algorithms. Iron-based pigments, such as management. hemosiderin react precisely in the Prussian blue histo- chemical reaction and turn a striking blue color. Mela- nins turn darker with silver stains and are removed by References bleaching agents such as potassium permanganate (iron and carbon are not bleachable). The cytology and his- 1. Morton DL, Hoon DS, Cochran AJ et al (2003) Lymphatic tology of a melanized lymph node are remarkably easier mapping and sentinel lymphadenectomy for early-stage mela- to interpret in a hematoxylin and eosin-stained section noma: therapeutic utility and implications of nodal microanat- omy and molecular staging for improving the accuracy of after removal of the masking melanin by bleaching. detection of nodal micrometastases. Ann Surg 238(4):538–549 Nodal carbon is relatively common: deriving from the A. J. Cochran Department of Pathology and Laboratory Medicine Room 13-145C CHS, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095-1732, USA E-mail: European Journal of Plastic Surgery Springer Journals

Invited commentary on “Decorative sentinel lymph node – a new entity?” by Vandeweyer and Van De Casseye

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