These data support the fact that cutaneous lymphatic drainage patterns are maintained in patients with grossly involved basins, thus buttressing the idea that the SLN is the node most likely to develop metastatic disease. Gross disease in the basin does not significantly alter cutaneous lymphatic flow into the regional basin, as the sentinel lymph node identified under these circumstances is the same as with the grossly involved node. Preoperative lymphoscintigraphy in patients who present with grossly involved nodes in one basin may identify other regional basins with micrometastatic disease and deserves further study in this setting.

Lymphatic mapping and sentinel lymph node biopsy is a new technique used in the surgical treatment of patients with malignant melanoma. The purpose of this study was to evaluate the results of this approach for patients with melanoma of the lower extremity. Between May of 1994 and June of 1997 at the H. Lee Moffitt Cancer Center and Research Institute, 85 consecutive patients with clinical stage I and II melanoma of the lower extremity underwent lymphatic mapping and sentinel lymph node biopsy. These nodes were identified in all 85 patients by intraoperative lymphatic mapping with both radiolymphoscintigraphy and a vital blue dye injection. Eleven patients (12.9 percent) had histologically positive sentinel lymph nodes, and 10 patients underwent inguinal complete lymph node dissections. All 10 patients had no further histologically positive lymph nodes confirmed by subsequent complete dissection. Among 74 patients with histologically negative sentinel lymph nodes, only 2 patients (2.7 percent) developed inguinal nodal metastases during a mean follow-up period of 21.8 months (range, 13.5 to 58.3 months). The sensitivity of lymphatic mapping and sentinel lymph node biopsy in this series was 100 percent and the specificity was 97.3 percent. Therefore, we conclude that the use of lymphatic mapping and sentinel lymph node biopsy can accurately stage patients with melanoma of the lower extremity and provide a rational surgical approach for these patients.

A 28-year-old white man complained of the progressive development of lesions affecting the glans penis. He claimed he was treated for condylomata acuminata affecting the penile shaft 4 years previously. At the same time, he noticed a "roughened area" on the corona. This area did not enhance with 5% acetic acid and thus was not treated by his local dermatologist.Over the next 4 years, the affected area grew, encompassing the entire dorsal and lateral glans penis. Four months prior to the patient's presentation at our institution, a shave biopsy was performed and interpreted as showing changes consistent with condyloma acuminatum. The patient was referred to an urologist who ruled out urethral involvement. He was then unsuccessfully treated by a second dermatologist with podophyllin prior to referral.At the time of presentation at our institution, the patient and his wife were distressed about the resistant and progressive nature of his lesions. In addition, they desired children, yet were concerned about transmission of venereal warts.Gross examination showed a coarse "velvety" appearance of the glans penis with the exception of the previous biopsy site (Fig. 1). Stretching the skin of the glans laterally revealed uniform rows of soft flesh-colored filiform papules running radially from the urethral meatus to the corona. There were a few papules affecting the sulcus of the glans penis but there were no papules on the penile shaft.Histopathologic examination of tissue obtained at our institution from the glans penis disclosed compact orthokeratosis overlying an acanthotic epidermis. Hypergranulosis and focally elongated rete ridges were noted. Within an expanded papillary dermis, there was a proliferation of ectatic capillaries lined by variably thin to plump endothelium, as well as increased numbers of plump, stellate-shaped fibroblasts with occasional multinucleation (Fig. 2). The background collagen demonstrated Increased, thickened fibers, and there was an infiltrate of lymphocytes and mast From the