Review of the role of sentinel node biopsy in cutaneous head and neck melanoma

Sentinel node biopsy (SNB) is recommended for selected melanoma patients in many parts of the world. This review examines the evidence surrounding the accuracy and prognostic value of SNB and completion neck dissection in head and neck melanoma. Sentinel nodes were identified in an average of 94.7% of head and neck cases compared with 95.3–100% in all melanoma cases. More false‐negative sentinel nodes were found in head and neck cases. A positive sentinel node was associated with both lower disease‐free survival (53.4 versus 83.2%) and overall survival (40 versus 84%). We conclude that SNB should be offered to all patients with intermediate and high‐risk melanomas in the head and neck area. To date, evidence does not exist to demonstrate the safety of avoiding completion lymph node dissection in sentinel node‐positive patients with head and neck melanoma.     

Lymphatic drainage patterns of head and neck cutaneous melanoma observed on lymphoscintigraphy and sentinel lymph node biopsy

BACKGROUND: The purpose of this study was to evaluate lymphatic drainage patterns of head and neck cutaneous melanoma observed on preoperative lymphoscintigraphy and sentinel lymph node biopsy (SLNB) and determine discordancy from clinically predicted lymphatic drainage patterns. METHODS: We conducted a retrospective chart review of 114 patients with head and neck cutaneous melanomas evaluated with preoperative lymphoscintigraphy and SLNB from January 2001 through July 2004. RESULTS: At least one sentinel lymph node (SLN) was identified in 97% of cases. On preoperative lymphoscintigraphy, an SLN was identified in an area not clinically predicted in 49 cases (43%). The most common sites of discordancy were in areas not typically dissected in standard neck dissections, such as the postauricular region, or in areas of more distant drainage than described previously, such as the inferior or posterior neck. Their percentages of discordant cases were 51%, 27%, and 22%, respectively. The sites of regional recurrence occurred in two cases not predicted on preoperative lymphoscintigraphy and in two cases of failed SLNB. CONCLUSIONS: On the basis of preoperative lymphoscintigraphy and the results of SLNB, head and neck cutaneous melanomas do have expected lymphatic drainage patterns despite perceived discordancy with previously clinically predicted drainage patterns that are based on standard neck dissection specimens. These "discordant" sites can still harbor melanoma, and all sites predicted on preoperative lymphoscintigraphy still need to be explored. The four cases of recurrences underscore the importance of close follow-up for all patients regardless of the SLNB result.     

Dilemma of clinically node-negative head and neck melanoma: outcome of "watch and wait" policy, elective lymph node dissection, and sentinel node biopsy--a systematic review

The management of patients with clinically node-negative melanoma of the head and neck remains controversial. This is a systematic review of management strategies for stage I head and neck melanoma. Subgroup analysis of 1 randomized controlled trial (RCT) and most available cohort studies do not reveal a significant impact of elective neck dissection on survival. For 1.2- to 3.5-mm-thick melanoma at all anatomical sites, 1 RCT does not show an overall significant melanoma-specific survival benefit of sentinel node biopsy, but subgroup analysis suggests a survival benefit for lymph node-positive patients, confirming findings from 3 retrospective series. Sentinel node biopsy in the head and neck region can be technically demanding, with lower identification rates and higher false-negative rates. There is no conclusive survival advantage of either elective neck dissection or sentinel node biopsy in patients with clinically node-negative head and neck melanoma of intermediate thickness.     

Dynamic sentinel node biopsy for penile cancer: reliability of a staging technique

PURPOSE: We determine the value of dynamic sentinel node biopsy for staging squamous cell carcinoma of the penis. MATERIALS AND METHODS: A total of 90 patients with clinically node negative penile cancer were prospectively entered in this study. Preoperative lymphoscintigraphy was performed after intradermal injection of 99mtechnetium nanocolloid around the primary tumor. The sentinel node was intraoperatively identified with the aid of intradermal administered patent blue dye and a gamma ray detection probe. Histopathological examination of sentinel nodes included serial sectioning and immunohistochemical staining. Regional lymph node dissection was performed only if metastasis was found in a sentinel node. Median followup was 36 months (range 5 to 95). RESULTS: Lymphoscintigraphy visualized 217 sentinel nodes in 159 inguinal regions of 88 patients. A total of 208 sentinel nodes were intraoperatively identified in 149 inguinal regions of 88 patients. Sentinel node metastasis was found in 19 inguinal regions of 18 patients. Four of 8 patients with unilateral clinical stage N1 disease had a tumor positive sentinel node on the opposite site. Regional recurrence after excision of a tumor negative sentinel node or after nonvisualization was seen in 5 patients, resulting in a false-negative rate of 22% (5 of 23). The 3-year disease specific survival was 98% and 71% for patients with a tumor negative or tumor positive sentinel node, respectively (p = 0.0018). CONCLUSIONS: Occult lymph node metastases in penile cancer can be detected with a sensitivity of about 80% by dynamic sentinel node biopsy, including preoperative lymphoscintigraphy, vital dye and a gamma ray detection probe.     

Dynamic MR lymphangiography and carbon dye for sentinel lymph node detection: a solution for sentinel lymph node biopsy in mucosal head and neck cancer

BACKGROUND: The practical application of sentinel lymph node biopsy in squamous cell carcinoma of the head and neck is restricted by the time sensitivity of blue dye and lack of spatial resolution and nonspecific node enhancement with radiocolloid. This study evaluates the use of magnetic resonance (MR) lymphangiography and carbon dye labeling to circumvent these limitations. METHODS: Gadomer/carbon dye mixture was injected into the tongue and stifle of adult swine (n = 4). MR lymphatic mapping was followed by intraoperative mapping with isosulfan blue dye. Sentinel lymph node biopsy and completion node dissection were performed 60 minutes after injection in four nodal basins and at 7 days after injection in eight. RESULTS: The technique was successful in all 12 nodal basins. The sentinel lymph nodes were stained black at the time of the immediate and delayed dissections. CONCLUSIONS: MR lymphangiography provides temporal and anatomic localization of the sentinel lymph node with a single investigation. Carbon dye is a sensitive and persistent visual marker of MRI-targeted sentinel lymph nodes.     

Alternative sites of injection for sentinel lymph node biopsy in breast cancer

Background: Sentinel node biopsy is rapidly gaining popularity as a less invasive approach to nodal staging in breast cancer. The optimal route of injection of radiocolloids and dye is controversial. The purpose of the present paper was to review and assess the literature. Methods: A MEDLINE search for reports of studies involving different injection sites of colloid and/or dye was performed. Results: Although controversial, current evidence suggests that subareolar (SA) or intradermal/subdermal (ID/SD) injection will map the same axillary sentinel nodes (SN) as peritumoral (PT) injection in the vast majority of cases, is at least as successful, and is better logistically. Peritumoral, but not alternative routes, identify extra‐axillary sentinel nodes, which are important in a minority of patients. Conclusions: It is recommended that at least some of the radiocolloid be injected peritumorally to avoid missing those SN not located in the ipsilateral axilla. Injection of the dye and a portion of radiocolloid in an ID/SA location is reasonable to take advantage of the general ease and accuracy of ID/SA injections in identifying axillary SN.     

Axillary staging using positron emission tomography in breast cancer patients qualifying for sentinel lymph node biopsy

Axillary lymph node dissection (ALND) is the standard of care for nodal staging of patients with invasive breast cancer. Due to significant somatic and psychological side effects, replacement of ALND with less invasive techniques is desirable. The goal of this study was to evaluate the clinical usefulness of axillary lymph node (ALN) staging by means of positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) in breast cancer patients qualifying for sentinel lymph node biopsy (SLNB). FDG-PET was performed within 1 week before surgery in 24 clinically node-negative breast cancer patients with tumors smaller than 3 cm. Sentinel lymph nodes (SLNs) were identified by preoperative lymphoscintigraphy following peritumoral technetium 99m-labeled colloid albumin injection, and by intraoperative gamma detector and blue dye localization. Following SLNB, a standard ALND was performed. Serial sectioning and immunohistochemistry of the SLN as well as standard histologic examination of the non-SLN was performed. FDG-PET detected all primary breast cancers. Staging of ALNs by PET was accurate in 15 of 24 patients (62.5%), whereas PET staging was false negative in 8 of 10 node-positive patients and false-positive in 1 patient. The sensitivity, specificity, positive predictive value, and negative predictive value of FDG-PET for nodal status was 20%, 93%, 67%, and 62%, respectively. The mean diameter of false-negative ALN metastases was 7.5 mm (range 1-15 mm). Lymph node staging using FDG-PET is not accurate enough in clinically node-negative patients with breast cancer qualifying for SLNB and should not be used for this purpose.     

Preoperative lymphoscintigraphy and dynamic sentinel node biopsy for staging penile cancer: results with pathological correlation

PURPOSE: We assessed the sensitivity of preoperative lymphoscintigraphy and dynamic sentinel node biopsy for staging the inguinal region of patients with penile cancer and no palpable inguinal adenopathy. MATERIALS AND METHODS: The records of 31 patients with invasive penile cancer and nonpalpable (29) or nonsuspicious (2) inguinal lymph nodes were reviewed. Preoperatively lymphoscintigraphy plus dynamic sentinel node biopsy with (99m)technetium labeled sulfur colloid and isosulfan blue dye was performed in 21 patients and dynamic sentinel node biopsy alone with blue dye only was done in 10. All patients underwent superficial lymph node dissection regardless of preoperative lymphoscintigraphy or dynamic sentinel node biopsy findings to establish pathological nodal status. RESULTS: Six of 32 groins that showed drainage on preoperative lymphoscintigraphy had inguinal node metastasis, as did 1 of 10 that was drainage negative. The sensitivity of preoperative lymphoscintigraphy drainage for cancer detection was 86%. Using dynamic sentinel node biopsy with blue dye plus radiotracer 5 sentinel lymph nodes were positive for cancer, although 2 false-negative results were obtained. Thus, the sensitivity of dynamic sentinel node biopsy per groin for cancer detection was 71%. CONCLUSIONS: In our experience preoperative lymphoscintigraphy and dynamic sentinel node biopsy as currently performed remain insufficient for detecting occult inguinal disease. Superficial lymph node dissection remains the gold standard for detecting inguinal microscopic metastasis in select patients.     

Intraoperative palpation for clinically suspicious axillary sentinel lymph nodes reduces the false-negative rate of sentinel lymph node biopsy in breast cancer

Axillary sentinel lymph node biopsy (SLNB) is widely used to identify the first lymph node draining breast tumors. When the sentinel lymph node is free of metastasis, axillary dissection is avoided because the rest of the nodes are expected to be negative as well. A false-negative rate of 5% is considered acceptable. In the case of a false-negative SLNB, adjuvant local and systemic treatments might be suboptimal. We assessed the effect of intraoperative axillary palpation for clinically suspicious lymph nodes that are not otherwise detected by radioactive tracer or blue dye on the false-negative rate of SLNB in breast cancer patients. Our prospective database of patients having surgery for primary invasive breast cancer and who had a SLNB from 2000 to 2004 was reviewed. Only patients with clinically negative nodes preoperatively were included. The procedure included preoperative injection of radiotracer, with dye injection as backup, and intraoperative palpation of the axilla for suspicious lymph nodes that were not radioactive or blue. Of the 290 patients, 89 (30.7%) had sentinel node involvement by tumor. Seven patients had clinically suspicious nodes identified solely by palpation and not by tracer, in addition to sentinel lymph nodes detected by tracer. In five of the seven patients, the nodes harbored metastasis. In four of these five patients (4.5% of the 89 patients with axillary involvement), the palpable nodes were the only ones involved. A generous axillary incision and systematic palpation of the axilla reduces the false-negative rate and should be a part of the SLNB procedure.