Routine Elective Lymph Node Dissection Research Articles

Controversies in the Management of Regional Nodes in Melanoma

The surgical management of the regional lymph node basin of melanoma has undergone significant changes in the past 2 decades, most of which have been guided by prospective randomized trials. Historically, routine elective lymph node dissection was recommended for the management of melanoma regardless of clinical nodal involvement. Subsequent randomized trials failed to show a clear benefit for all patients, and sentinel lymph node (SLN) biopsy emerged as an alternative. Although the prognostic value of SLN biopsy in intermediate-thickness melanoma is well accepted, its value for patients with thin and thick lesions is debated. The therapeutic advantage of removing an involved SLN, and the need for a completion lymph node dissection after the identification of a positive SLN, are areas of continued controversy. This article discusses these issues in the management of the regional lymph node basin in patients with melanoma.

Nail apparatus melanoma.

Nail apparatus melanoma is a relatively rare variant of melanoma with a disproportionately high mortality when compared with melanoma elsewhere. The aetiology and natural history remain poorly understood. There is no clear epidemiological association with race, skin type or sun exposure. Universally accepted clinical and histological criteria for the diagnosis of early nail apparatus melanoma have not been defined. The two cardinal clinical signs are melanonychia striata and Hutchinson's sign. These are useful but not pathognomonic of melanoma. Diagnostic delay is frequent and patients commonly have advanced disease at the time of diagnosis. Surgical excision is advocated for treatment of stage I disease; however, the most appropriate re-excision margins, including the level of amputation where required, have not been determined. Early diagnosis and excision of the tumour is the only treatment known to increase survival. Adjuvant systemic chemotherapy, isolated limb perfusion, and routine elective lymph node dissection have been used, but no survival benefit has been demonstrated.

Clinical Significance of Micrometastatic Disease in the Era of Sentinel Node

The 1990’s ushered in a new era of staging the regional lymph node basin for patients with cutaneous melanoma and invasive breast cancer. At the 1990 meeting of the Society of Surgical Oncology [1], intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL) with isosulfan blue dye (Lymphazurin 1%, Hirsch Industries, Inc., Richmond, VA) was proposed as an accurate alternative to routine elective lymph node dissection for staging the regional lymphatics in patients with cutaneous melanoma [2]. At the 1994 meeting of the American Surgical Association (Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Presented at The American Surgical Association, San Antonio, TX, April 7-9 1994), LM/SL with isosulfan blue dye was proposed as an accurate alternative to routine level I and II axillary lymph node dissection (ALND) in patients with invasive breast cancer [3]. Other investigators [4–7] have proposed using radioactive technetium-labeled sulfur colloid to identify the sentinel node for melanoma [8] and breast cancer patients [9,10]. A mounting body of evidence suggests that a combination of the two methods maximizes the accuracy rate for identifying the sentinel node [11–14]. This paper does

Critical review of the sentinel node hypothesis

Initially presented at the 1990 meeting of the Society of Surgical Oncology1 and first reported in the literature in 1992,2 intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL) was proposed as an accurate alternative to routine elective lymph node dissection for staging regional lymphatics in patients with cutaneous melanoma. Since that time, the intense interest in LM/SL has generated more than 250 peer-reviewed studies in the literature. The technique has been described not only for patients with melanoma3-6 and for those with breast cancer,7-11 but also for those with thyroid carcinoma,12 colon cancer,13 oropharyngeal carcinoma,14,15 and vulvar carcinoma.

Role of elective lymph node dissection in melanoma.

In the last several years, much debate has centered on the management of the regional lymph nodes in malignant melanoma. The regional lymph nodes are the most common site of melanoma metastases and surgical excision of these involved nodes is the most effective treatment for either cure or local disease control. The issue still in question is the approach to the clinically negative regional lymph node basin. Retrospective studies have yielded conflicting results regarding the value of routine elective lymph node dissection (ELND) when nodes are clinically negative. Four prospective randomized clinical trials have been completed which have indicated that routine ELND is not worthwhile for the majority of melanoma patients. However, ELND may be associated with improved outcome in certain subgroups of patients: those <60 years age with 1 to 2 mm thick melanomas with or without ulceration. In addition, lymphatic mapping with sentinel lymph node biopsy has become increasingly available and has allowed clinicians an alternative to ELND. In the absence of sentinel lymph node biopsy, the role for ELND in these subgroups of patients is one of the remaining unresolved issues.

Scintillation probe guided sentinel lymphadenectomy in malignant melanoma

In cutaneous melanoma, biopsy of the first tumor-draining lymph node (Sentinel node, SLN) may replace routine elective lymph node dissection (ELND). The SLN has been shown to contain the first micrometastasis in early lymphatic tumor dissemination. As micrometastases were identified in 10-30% of stage I (AJCC/UICC) patients, sentinel lymphonodectomy (SLND) should enable us to select patients clinically in stages I and II, but histopathologically in stage III. This optimization of patient selection is mandatory as only this subgroup profits from ELND. Since the beginning of 1995 we was scintillation detector (gamma probe)-guided sentinel biopsy in patients with a melanoma > 1.0 mm and clinically negative lymph nodes. After injecting colloidal 99m-Tc-labelled tin(II)-sulfide solution around the tumor (or the biopsy scar), the SLN can be localized exactly. The technique is minimally invasive and easy to handle. If the SLN contains tumor, a standard en bloc lymphonodectomy is performed. Long-term follow-up, however, is needed to delineate the role of this procedure in melanoma treatment.

The impact of dynamic lymphoscintigraphy and gamma probe guidance on sentinel node biopsy in melanoma.

In cutaneous melanoma, biopsy of the first tumour-draining lymph node (sentinel node, SN) may replace routine elective lymph node dissection (ELND). Even in experienced hands the original technique using vital dyes fails to localise the SN in 20% of cases. In this study we investigated whether the procedure benefits from lymphoscintigraphy and the use of a gamma probe. In 41 patients technetium-99m-colloidal albumin was injected intracutaneously around the scar of the excised tumour. This was followed by dynamic and late static imaging. The first focal accumulation was assumed to be the SN. In all patients at least one SN was found, in 95% within the first 20 min. By showing multiple or ramifying lymphatic channels, dynamic lymphoscintigraphy differentiated between spill and multiple SNs. In all cases the initial focus retained the highest fraction of radioactivity for at least 18 h. The gamma probe was especially useful in the axilla and neck, where it accurately showed the optimal incision site and facilitated the search for deep-seated nodes. Gamma probe-localised SNs were dye-positive in 93% of cases. The SN contained metastases in 20% of the patients. Only in these patients was ELND performed, which revealed that the SN had been the only metastatic node in four of eight cases. We conclude that dynamic lymphoscintigraphy is essential for SN localisation, that tracer kinetics allow flexible timing of surgery, and that the surgical procedure benefits from use of the gamma probe.