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ORIGINAL ARTICLES |
From the Department of Surgery, Division General Surgery, Section of Surgical Oncology, The University of Alabama at Birmingham, Birmingham, Alabama.
Correspondence: Address correspondence and reprint requests to: Marshall M. Urist, MD, 321 Kracke Building, 1922 Seventh Avenue South, Birmingham, AL 35233-1924; Fax: 205-975-5971.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Methods: We performed a retrospective analysis of patients who underwent selective sentinel lymphadenectomy for cutaneous melanoma of the head and neck at the University of Alabama at Birmingham from 1997 through 2000, by using a standard technique of preoperative lymphoscintigram and biopsy guided with blue dye injection and a handheld gamma probe. Complete lymph node dissection was recommended only for tumor-positive sentinel lymph nodes (SLNs). Survival curves were constructed with the Kaplan-Meier method. Fisher’s exact test was used for comparisons. Significance was defined as P < .05.
Results: Thirty-eight patients underwent selective sentinel lymphadenectomy with the standard technique during the study period. A majority (82%) of patients were men with a median age of 55 years. The most common site of the primary tumor was the face (44%), followed by the scalp (24%). Mean tumor thickness was 2.5 mm. The sentinel node was identified during surgery in 35 patients (92%). Before the use of the handheld gamma probe, the identification rate of the SLN was only 56%. A single SLN was identified in 53% of cases. The incidence of metastases in SLN was 11.4%. With a mean follow-up of 17 months, the actuarial 3-year overall survival was 92%. The accuracy of the selective sentinel lymphadenectomy in this series was 80%.
Conclusions: Selective sentinel lymphadenectomy in the head and neck region is a technically demanding procedure, but the combined use of blue dye and gamma-probe radiolocalization can be a reliable method of staging regional lymph nodes and determining the need for elective lymphadenectomy.
Key Words: Melanoma • Sentinel node • Head and neck • Lymphadenectomy
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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In 1992 Morton et al.8 described their original experience with the sentinel lymph node (SLN) technique. They found that the SLN could be identified in 82% of cases, and the accuracy rate increased with the experience of the surgeon. Since then, other authors have reported their experience with this technique, and with a combined use of vital dye injected at the primary lesion site and a gamma detection probe, the SLN can be identified in up to 98% of patients with cutaneous melanoma.9 Most of the lymphatic mapping studies have concentrated on melanomas of the trunk and extremities rather than of the head and neck, where the localization of SLN has been reported to be a more demanding procedure.10 In this review, we describe the experience of a single institution in lymphatic mapping in the head and neck cutaneous melanoma and discuss the factors associated with the success of localization of the SLN and the accuracy of the technique.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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From October 1994 through November 2000, 54 patients with cutaneous melanoma in the head and neck area underwent SLN biopsy. Starting in November 1997, all patients underwent lymphoscintigram, and the node biopsy was guided with the blue dye injection and a handheld gamma probe (C-TrakTM, Care Wise Medical Products, Morgan Hill, CA). We reported the experience with those 38 patients who underwent this procedure with this standard method. All procedures were performed by one of the senior authors (M.M.U.). The radioactive tracer was 99mTc-labeled sulfur colloid (CIS-US, Inc, Bedford, MA). The tracer, 1.0 to 2.7 mCi, was injected intradermally around the circumference of the primary melanoma or the scar from the previous biopsy. From 20 to 120 minutes after the radionuclide injections, planar gamma camera images were obtained to identify a focal area of accumulation (a hot spot). A mark corresponding to the imaged hot spot was placed on the skin for reference. All patients had an intradermal injection of 1% isosulfan blue (LymphazurinTM, Ben Veneu Labs, Inc., Bedford, OH) around the tumor or the surgical scar of the previous biopsy immediately before surgical resection.
The SLNs were submitted separately for routine histopathologic evaluation by using hematoxylin and eosin staining and immunohistochemical techniques with antibodies to S-100 protein and HMB-45. If the final histopathologic interpretation of the SLN was negative for micrometastases, no further intervention was performed. If the SLN was positive for metastatic melanoma, then a complete regional node dissection was recommended to the patient.
Follow-up of the patients was performed through clinical notes or telephone contact with the patient, his or her family, or his or her primary doctors. No patient was lost to follow-up. The mean and median follow-up were 17 and 15 months, respectively (range, 1 to 36 months). The date of the last follow-up was November 30, 2000. Recurrence and survival curves were constructed with the Kaplan-Meier method. The 
2 or Fisher’s exact tests were used for comparisons when appropriate. Significance was defined as P < .05.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Preoperative lymphoscintigram identified one or more hot spots in 33 patients (87%). In two patients the tracer did not move from the site of injection, and in three patients the site identified did not corresponded to the SLN site. The SLN was identified during surgery in 35 patients (92.1%). For comparison, during the same time period, 222 SLN biopsies were performed for cutaneous melanomas in the trunk and extremities. The success rate for localization of the SLN in these sites was 96.8%, which was not significantly different from the identification rate in the head and neck area (P = .2). In 25 (65.8%) patients, the SLN was located both by dye and gamma probe, in 9 patients (23.7%) with the gamma probe only, and in 1 patient (2.6%) with blue dye only. In three patients, SLN was not identified, and no further dissection was performed.
In 20 cases (52.6%) there was one SLN, and in 8 patients (21.1%) there were two SLNs. Three and four SLNs were identified in two and five patients, respectively. At least one SLN was positive for metastatic melanoma by hematoxylin and eosin staining in two patients (5.7% of those who had SLNs located). Two additional patients had metastatic disease in the SLN detected only by immunohistochemistry. Thus, the incidence of metastases in SLN was 11.4% (4 of 35). One patient with metastasis to the SLN detected only by immunohistochemistry refused to have additional surgery; at the 27-month follow-up he was alive with no evidence of recurrence. The other patient underwent modified radical neck dissection: no further positive nodes were identified, and the patient was alive with no evidence of disease 5 months after his initial operation. In the two additional patients who underwent neck dissection, one patient was found to have five additional positive nodes, and in the second patient the SLN was the only positive node.
Eleven patients had SLN identified around the parotid gland. In two cases, the SLN was positive for metastatic disease, and those patients underwent superficial parotidectomy in addition to modified neck dissection.
Before the use of the handheld gamma probe, the identification rate of the SLN was only 56%; this is significantly different from the 92% success rate with the use of the standard technique (P = .02). Patient age or sex, primary site, thickness of the tumor, and type of previous biopsy were not associated with the success in identification of SLNs.
Two patients received immunotherapy and chemotherapy with interleukin-2 and dacarbazine. Both patients had unsuccessful localization of the SLN. During follow-up, three patients had a recurrence (8%). Two patients had locoregional recurrence only. One additional patient developed central nervous system metastasis 17 months after the diagnosis and died from melanoma. The mean time to recurrence was 15 months (range, 5 to 23 months). One patient had a regional recurrence in the same nodal basin where the SLN was biopsied (false-negative SLN), and one patient had in-transit metastases, which were excised. The accuracy of the technique was 80%. Both patients with locoregional recurrence were alive with no evidence of disease at the last follow-up.
Actuarial 3-year survival for the whole group was 92.3%. At last follow-up, 37 patients (97.4%) were alive with no evidence of disease, and 1 patient (2.6%) had died because of disease.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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In the head and neck area, often a large number of SLNs and nonsentinel nodes are visualized. In this series, more than 40% of patients had two or more SLNs identified, and possibly not all of them represented true SLNs. Jansen et al.10 have proposed the use of tracers with a greater particle size, which will accumulate predominantly in the first-echelon node so that fewer will pass through to depict higher-echelon nodes.
The false-negative rate of SLN biopsy has been calculated on the basis of the recurrence of melanoma in the same nodal basin where the node was biopsied. Most series, including this study, have reported a low rate of this event, and several studies have reported no locoregional recurrence, with a median follow-up from 11 to 46 months.11,12,13 However, the technique has not been validated with a complete lymph node dissection as it has in melanoma of other anatomical sites.14
In conclusion, SLN biopsy for melanoma of the head and neck is a technically demanding procedure, but with experience it accurately predicts the status of the lymph nodes similar to other anatomical sites. The combined use of blue dye and gamma-probe radiolocalization is essential for optimal SLN localization.
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Footnotes |
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Received for publication March 17, 2001. Accepted for publication June 25, 2001.
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REFERENCES |
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  V. H. Ho, M. I. Ross, V. G. Prieto, A. Khaleeq, S. Kim, and B. Esmaeli Sentinel Lymph Node Biopsy for Sebaceous Cell Carcinoma and Melanoma of the Ocular Adnexa Arch Otolaryngol Head Neck Surg, August 1, 2007; 133(8): 820 - 826. [Abstract] [Full Text] [PDF]
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 B. Esmaeli, D. Reifler, V. G. Prieto, M. Amir Ahmadi, L. Hidaji, E. Delpassand, and M. I. Ross Conjunctival Melanoma With a Positive Sentinel Lymph Node Arch Ophthalmol, December 1, 2003; 121(12): 1779 - 1783. [Full Text] [PDF]
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 R. Simmons, S. Thevarajah, M. B. Brennan, P. Christos, and M. Osborne Methylene Blue Dye as an Alternative to Isosulfan Blue Dye for Sentinel Lymph Node Localization Ann. Surg. Oncol., April 1, 2003; 10(3): 242 - 247. [Abstract] [Full Text] [PDF]
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