Non-Sentinel Lymph Node Detection during Sentinel Lymph Node Biopsy in Not-Complete-Lymph-Node-Dissection Era: A New Technique for Better Staging and Treating Melanoma Patients.

Franco Picciotto,Federico Castellengo,Rebecca Senetta,Gianluca Avallone,Adriana Lesca,Simone Ribero,Désirée Deandreis,Martina Merli,Maria Teresa Fierro,Pietro Quaglino,Virginia Caliendo

doi:10.3390/jcm10194319

Abstract

Sentinel lymph node biopsy has been demonstrated to be an effective staging procedure since its introduction in 1992. The new American Joint Committee on Cancer (AJCC) classification did not consider the lack of information that would result from the less usage of the complete lymph node dissection as for a diagnostic purpose. Thus, this makes it difficult the correct staging and would leave about 20% of the further positive non-sentinel lymph nodes in the lymph node basin. In this paper, we aim to describe a new surgical technique that, combined with single-photon emission computed tomography-computed tomography (SPECT-CT), allows for better staging of melanoma patients. This is a prospective study that includes 104 patients with cutaneous melanoma. Sentinel lymph node biopsy was offered according to the AJCC guideline. Planar lymphoscintigraphy was performed in association with SPECT-CT, identifying and removing all non-biologically “excluded” lymph nodes, guiding the surgeon’s hand in detection and removal of lymph nodes. Even if identification and removal of non-sentinel lymph nodes is unable to increase overall survival, it definitely gives better disease control in the basin. With a “classic” setting, the risk of leaving further lymph nodes out of the sentinel lymph node procedure is around 20%, thus, basically, the surgical sentinel lymph node of first and second lymph nodes would have therapeutic value and complete lymph node dissection classically performed.

Highlights

Sentinel lymph node biopsy was offered according to the American Joint Committee on Cancer (AJCC) guideline for all patients with a melanoma thicker than 0.8 mm [6], who accepted the diagnostic procedure and signed a proper consent form
non-sentinel lymph nodes (NSLNs) were in the same basin for all the patients; a part of the 5 cases were the only sentinel lymph nodes (SLN) in transit in the thoracic area and the NSLN in axilla, 1 case of a popliteal SLN and NSLN
In inguinal basin, and in 1 case the SLN was in mastoid area and the NSLN in parotids

Summary

Introduction

For the Sentinel lymph node biopsy (SLNB) procedure to be accurate, it is of critical importance that all true sentinel nodes are identified and harvested for examination. Seeing the lymphatic collectors enter the nodes by mean of dynamic phase of lymphoscintigraphy is vital to identify true sentinel node(s); singlephoton emission computed tomography – computed tomography (SPECT-CT) enhanced lymphoscintigraphy can identify other unseen locations at planar lymphoscintigraphy 4.0/). Sentinel lymph node biopsy (SLNB) has been demonstrated to be an effective staging procedure since its introduction in 1992 [1]. The CLND carries a considerable burden of complications that is not a negligible aspect [5]. This has made SLNB the last surgical diagnostic procedure before the adjuvant therapy [4]

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