Neck Sentinel Lymph Node Biopsy Research Articles

Virtual reality-based training and pre-operative planning for head and neck sentinel lymph node biopsy

ObjectiveSentinel lymph node biopsy (SLNB) is crucial for managing head and neck skin cancer. However, variable lymphatic drainage can complicate SLN detection when using Single-Photon Emission Computed Tomography (SPECT) or lymphoscintigraphy. Virtual Reality (VR) can contribute to pre-operative planning by simulating a realistic 3D model, which improves orientation. VR can also facilitate real-patient training outside the operating room. This study explored using a VR platform for pre-operative planning in head and neck skin cancer patients undergoing SLNBs and assessed its value for residential training. Materials and methodsIn this prospective technology pilot study, attending surgeons and residents who performed 21 SLNB operations on patients with head and neck skin cancers (81% males, mean age 69.2 ± 11.3) used a VR simulation model based on each patient's pre-operative SPECT scan to examine patient-specific anatomy. After surgery, they completed a questionnaire on the efficiency of the VR simulation as a pre-operative planning tool and training device for residents. ResultsThe attending surgeons rated the VR model's accuracy at 8.3 ± 1.6 out of 10. Three-quarters (76%) of residents reported increased confidence after using VR. The physicians rated the platform's contribution to residents' training at 7.4 ± 2.1 to 8.9 ± 1.3 out of 10. ConclusionA VR SLNB simulation can accurately portray marked sentinel lymph nodes. It was rated high as a surgical planning and teaching tool among attending surgeons and residents alike and may play a role in pre-operative planning and resident training. Further studies are needed to explore its applications in practice.

Post-operative follow-up of 150 patients with sentinel lymph node biopsy under tumescence local anesthesia.

Sentinel lymph node biopsy (SLNB) is useful for staging of patients with melanoma. Although SLNB is mostly performed under general anesthesia (GA), tumescence local anesthesia (TLA) can also be used. However, less data are available regarding feasibility of SLNB under TLA. Here we present a post-operative follow-up of 150 patients. We prospectively analyzed data from 150 patients with primary cutaneous malignant melanoma. We assessed pain, post-operative complications and patients' satisfaction after SLNB under TLA. 32% of the patients reported post-operative pain within the first 48h after SLNB. Seroma was the most frequent complication, as 29 seromas after SLNB were observed. Wound infection was observed in 3.3% of the patients. 98.7% of the patients were satisfied with SLNB under TLA. SLNB under TLA is a safe and feasible option and should be considered for patients with melanoma. Especially with multimorbid or elderly patients, the risks of GA can be avoided.

Lateral neck sentinel lymph node biopsy in papillary thyroid carcinoma, is it really necessary? A randomized, controlled study

Although occult metastasis to lymph node in the lateral neck compartment is common in papillary thyroid carcinoma (PTC), the clinical impact of these metastasis is unknown. We hypothesized that sentinel lymph node biopsy (SLNB) of the lateral neck compartment with radioisotopes may detect occult metastasis, which could prevent recurrence. This randomized, controlled study was conducted from June 2009 to January 2011 and included 283 patients with PTC who were receiving treatment at the Samsung Medical Center. Of the 283 patients enrolled in the study, 141 were randomized to a lateral SLNB (LSLNB) group and 142 patients were to the control group. Lateral sentinel lymph nodes (LSLNs) were identified in 80 of the 127 patients (63.0%) for whom stimulated thyroglobulin (sTg) levels were available. Among the 80 patients with LSLNs, 24 (30.0%) had metastases and underwent an ipsilateral modified radical neck dissection. Among the 191 patients for whom repeated sTg test results were available, the first median level of sTg in the LSLNB study group was less compared with the control group (P=.012, adjusted for duration). However, the second sTg level (after the first radioactive iodine ablation) was not different between the 2 groups. Moreover, the sTg levels were not significantly different between the LSLN-positive (n=23) and other patients (n=168) after the first and second ablations. During patient follow-up (median, 39months; range, 7-55), 3 cases of recurrence were observed in the control group and 1 case in the study group (a LSLN had not been detected in this case). Although LSLNB was able to remove occult metastasis in PTC, this procedure had no effect on either sTg levels or on recurrence rates at a mean follow-up of 39months. Additional long-term studies are needed to explore fully the clinical usefulness of LSLNB in the prevention of PTC recurrence.

The Efficacy of Lateral Neck Sentinel Lymph Node Biopsy in Papillary Thyroid Carcinoma

Although occult lymph node metastasis to the lateral neck compartment is common in papillary thyroid carcinoma, the incidence and patterns of lateral neck node metastasis in papillary carcinoma are not known. We hypothesized that sentinel lymph node biopsy (SLNB) with radioisotope in the detection of occult lateral neck node metastasis would be useful in characterizing metastasis in papillary carcinoma. Ninety-four patients with papillary thyroid carcinoma were included from June 2009 to March 2010 for lateral neck SLNB. Preoperative lymphoscintigraphy was obtained after intratumoral injection of a (99m)Tc-tin colloid under ultrasound guidance. Total thyroidectomy or lobectomy preceded SLN detection to avoid radioactivity interference with the primary tumor, after which SLNB was performed in the lateral neck nodes. In the cases where metastasis was detected in SLNs upon frozen biopsy, an immediate modified radical neck node dissection was performed. A total of 174 SLNs were identified in 60 patients (63.8%). The identification rate of the SLNs with isotope increased with time. Sentinel lymph node metastasis was found in 19 patients (31.7%). This clinically occult metastasis was only related to the total number of metastatic LNs in the central compartment. Patient age, gender, tumor size, location, extent of tumor invasion, multiplicity, and presence of thyroiditis were not related to metastasis in the lateral compartment. Detection of lateral neck SLNs upon biopsy with radioisotope was also feasible in level II and contralateral neck. Sentinel lymph node biopsy is a useful method for evaluating the occult lateral neck lymph node status in patients with papillary thyroid carcinoma, especially in the cases of central neck node metastasis.

Sentinel Lymph Node Biopsy for Papillary Thyroid Cancer: Commentary on the efficacy of Lateral Neck Sentinel Lymph Node Biopsy in Papillary Thyroid Carcinoma by Se Kyung Lee et al.

In their article on the efficacy of lateral neck sentinel lymph node (SLN) biopsy in papillary thyroid carcinoma, Dr. Kim’s group has detailed an impressive series of lateral neck SLN assessments for papillary thyroid cancer [1]. In their 94 patients, they were able to identify sentinel nodes in 60 (64%). In 19 of these patients, the sentinel node contained papillary thyroid cancer, leading the surgeons to perform a compartment-oriented neck dissection. They did not perform lateral neck dissection on the patients with negative sentinel node biopsies, and so sensitivity estimates are not available. Sentinel node biopsy has been a marked advance in the management of patients with breast cancer and melanoma, because it allows accurate staging of patients with minimal morbidity. This technique has resolved the morbidity of routine axillary dissection for breast cancer, and the controversy of whether or not to perform prophylactic dissections for melanoma. However, this has not yet found a place in the therapy for thyroid cancer. In my opinion, there are several reasons for this: (1) sentinel node biopsy in the confined area of the neck is technically challenging; (2) the most common node basin for papillary thyroid cancer metastasis is the level 6 nodes, an area that has already been exposed during thyroidectomy and can be dissected with limited additional morbidity; (3) ultrasound evaluation of the lateral neck is sensitive for identification of nonpalpable node metastases; and (4) lateral neck recurrence is uncommon after effective adjuvant treatment with radioiodine. The contribution by this group has effectively answered some of these issues. Using the sentinel node biopsy after thyroidectomy to assess the lateral neck, rather than just the first sentinel node that is usually in the central neck, they have resolved some of the technical issues caused by the proximity of the radiotracer injection to the nodes in question. In addition, assessing only the lateral neck nodes focused the procedure on the nodes that would not otherwise be directly accessible during the thyroidectomy. A remaining question in this area is the comparison of preoperative ultrasound evaluation of the lateral neck to the intraoperative sentinel node biopsy assessment. Unfortunately, it does not appear that this series of patients had preoperative ultrasound node mapping in order to delineate this. However, this should be a part of any further reports on this subject. Finally, the issue of whether it is important to remove these small amounts of disease, or whether they can be effectively managed by radioiodine therapy, will require careful clinical study.

Head and Neck Sentinel Lymph Node Biopsy: Current State of the Art

Sentinel node biopsy is an alternative to elective neck dissection for the management of T1/T2 oral and oro-pharyngeal squamous cell carcinomas and is also finding application to head and neck cancer at other sites. The main clinical aim of sentinel node biopsy is to achieve better staging and there is now evidence that the procedure reduces morbidity. Reported detection rates for sentinel neck nodes are greater than 95% and there is also a negative predictive value of 95% for negative sentinel nodes. Current histopathological protocols have been developed for use in the research setting and are designed to identify all micrometastatic disease. However the use of step serial sectioning at 150 micron intervals with pan-cytokeratin immunohistochemistry is currently advised and appears to upstage nodes by approximately 20% over the initial single routine stained section. Adoption of the UICC/TNM definitions is recommended for future sentinel node studies, but further refinements and descriptions are required. The SENT trial has recruited over 300 cases from 10 European centres and a quality control study of the pathological material is in progress. At the first consensus meeting of the SENT pathology group there were excellent levels of agreement on the diagnosis of positive and negative nodes, and a number of potential pitfalls such as non-malignant inclusions and staining artefacts were identified.

Sentinel lymph node biopsy for malignant melanoma as day surgery

Sentinel lymph node biopsy for malignant melanoma has been performed as day surgery at our hospital since August 2002. The aim of this retrospective study was to assess its feasibility compared to the inpatient procedure. A telephone survey and review of medical records was carried out for patients who had daycase, nonhead and neck sentinel lymph node biopsy for malignant melanoma over an 18-month period. A similar matched number of inpatients were reviewed, comparing waiting times, prolonged hospital stay, complication rates and overall satisfaction. There were no significant differences between the two groups in terms of time from diagnosis to surgery, prolonged hospital stay and complication rates. However, in terms of overall satisfaction, 86.3% of daycase patients preferred their mode of admission whereas 52.9% of inpatients preferred their mode of admission (P=0.0003). Sentinel lymph node biopsy (nonhead and neck) for malignant melanoma as day surgery is feasible and confers greater patient satisfaction, increased availability of inpatient beds and cost savings without compromising patient care.

Sentinel-lymph-node biopsy (SLNB) for melanoma is not complication-free

Background and aim Sentinel lymph node biopsy (SLNB) is reportedly associated with insignificant morbidity. The study aims at documenting SLNB-related complications and identifying possible risk factors. Method Data of all melanoma patients who underwent SLNB in our medical center (1994–2002) were analysed. Procedure-related complications were recorded. Results Three hundred and nine lymphatic basins of 250 patients were explored for SLNB. Overall complication rate was 20%. Sensory morbidity was significantly associated with axillary SLNB ( p=0.04) and was more prevalent in younger patients. The use of blue dye alone or combined with a hand-held gamma probe had no statistically significant impact on the identification rate. There were six false-negatives (2.3%), for an overall false-negative rate of 18%. A positive sentinel node was significantly associated with shortened overall survival ( p=0.04). Conclusion Wound complications are more frequent than usually reported. Sensory morbidity occurs mostly in the axilla. Neck SLNB is associated with the highest rate of identification failure. Patient age, basin location, and number of excised nodes may serve as prognostic factors of morbidity.