Cervical sentinel lymph node biopsy for melanomas of the head and neck and upper thorax

Melanoma in the head and neck region: the value of preoperative imaging in melanoma stage I-II

The management of head and neck melanoma (HNM) is constantly being fine-tuned in the era of immunotherapy. HNM have different metastatic patterns and a worse prognosis than melanoma of the trunk, asking for a more fine-tuned managing strategy. In clinically node-negative HNM patients, the ultrasound (US) with fine needle aspiration cytology (FNAC) and chest X-ray (CXR) are optional modalities in the preoperative staging workup. The contribution of imaging seems limited in this stage of disease. This study aims to research the value of the US-FNAC and CXR in clinically node-negative HNM patients. Clinical stage I-II HNM patients from 2016 to 2021 were retrospectively reviewed. A total of 373 patients were analyzed. Patient characteristics, surgery and follow-up details, recurrences, tumor characteristics, staging, imaging, sentinel node procedure (SNP) details, and lab results were collected from the patient files. All patients received preoperative US. A total of 65 FNACs were performed, which found metastatic lymph nodes in two patients (0.54%). The CXR was performed in 336/373 patients and did not find any pulmonary metastases. The SNP was performed in 242 patients and demonstrated 40 positive patients, with 86% having micrometastases, isolated tumor cells, or submicrometastases. This study demonstrated a low number of relevant findings by both the US and CXR. We can conclude that both imaging modalities do not have a significant contribution to the routine staging procedure of clinical stage I-II HNM in our study group, with our results being in line with current general melanoma guidelines.

Prognostic nomogram for external ear melanoma patients in the elderly: a SEER-based study

AIM

The aim of this study was to construct and validate a nomogram to predict the 1-, 3- and 5-year overall survival (OS) in external ear melanoma (EEM) patients in the elderly based on the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

The information of patients diagnosed with EEM in the elderly between 2010 and 2014 was downloaded from the SEER database. Univariable and multivariable Cox analyses were carried out to identify the independent characteristics, and the independent factors were further included to construct a nomogram. The discriminative ability and calibration of the nomogram to predict OS were tested using C-index value, and calibration plots. Based on the risk score of the nomogram, the patients were divided into high- and low-risk subgroup. Finally, the survival differences of different subgroups were explored by Kaplan-Meier curves. All statistical analyses were performed by R 4.2.0.

RESULTS

A total of 710 elderly EMM patients were included and randomly divided into training cohort and validation cohort. Univariable Cox regression were used to identify age, race, sex, American Joint Committee on Cancer (AJCC), T, surgery, radiation, chemotherapy, and tumor size as independent risk factors. Then, multivariable Cox model to determine significant risk factors was used to establish the selected factors. A nomogram for predicting the 1-, 3- and 5-year OS was constructed using the independent variables including age, AJCC, T, surgery and chemotherapy. The C-index values were 0.78 (95% CI 0.75-0.81) in training set and 0.72 (95% CI 0.66-0.78) in validation set. The calibration curves were closer to ideal curves indicated the accurate predictive ability of this nomogram. The elderly patients with EEM in the low-risk group showed a longer OS than patients in the high-risk group in both training and validation cohorts.

CONCLUSIONS

Our study established and validated a novel model to predict 1-, 3- and 5-year OS for EEM. The individualized nomogram has a good prognostic ability and can be used as a new survival prediction tool for the elderly patients with EMM.

Analysis of the Different Lymphatic Drainage Patterns during Sentinel Lymph Node Biopsy for Skin Melanoma

In the last two decades, studies of lymphoscintigraphy imaging in lymphatic mapping reported an extreme heterogeneity of skin lymphatic drainage of some skin area, in contrast with the previous scientific literature. The aim of this study was to investigate the presence of any correlations between the topographical location of cutaneous melanoma and the topographical location of sentinel lymph nodes. Data from 165 patients undergoing sentinel lymph node biopsy between January 2013 and May 2021 were analyzed, demonstrating that melanomas in the Lumbar region presented a significant more heterogeneous drainage by site than those in the Scapular region (p < 0.01) and that melanomas in the Subscapular region were significantly more heterogeneous by laterality (unilateral vs. bilateral) than those in the Scapular region (p < 0.05). Results of this study supported the evidence of multiple lymphatic drainage as regards the sentinel node biopsy performed in skin melanoma located on the dorsal subscapular region and lumbar region. For this reason, the association of preoperative lymphoscintigraphy with another imaging evaluation is needed in these critical cutaneous areas. Recent technical developments enabling fluorescence lymphography together with indocyanine green have significantly improved the visualization of lymphatic drainage patterns at a microscopic level. In the preoperative phase, any doubt can be resolved by associating the SPET-CT scan to lymphoscintigraphy, while during the intraoperative phase, an additional evaluation with indocyanine green can be performed in doubtful cases. The aim of the duplex lymphatic mapping (pre and/or intraoperative) is an accurate search of sentinel nodes, in order to reduce the rate of false negatives.

Determining the number and distribution of intraparotid lymph nodes according to parotidectomy classification of European Salivary Gland Society: Cadaveric study

BACKGROUND

To investigate the distribution of the parotid gland's intraglandular lymph nodes using the parotidectomy zones determined by the parotidectomy classification of the European Salivary Gland Society (ESGS).

MATERIALS AND METHODS

A total of 128 parotid glands were dissected from 64 fresh cadavers, by bilateral parotidectomy without additional incision within the standard autopsy procedure, and categorized.

RESULTS

Eighty-six percent of the IGLNs were located in the superficial lobe and 14% in the deep lobe. An average of 7.09 ± 3.55 IGLNs were found for each of the gland; there were 6.11 ± 3.28 in the superficial lobe and 0.98 ± 1.46 in the deep lobe. While the most common lymph nodes were found in level 2 with 47.7%, only 5% of IGLNs were at level 4. According to the proposed modification, the most common lymph nodes (35.24%) were located at level 2B.

CONCLUSION

Level 2B was found to contain significantly more lymph nodes than other levels, which has not been evaluated before in literature.

Sentinel lymph node biopsy in cutaneous head and neck melanoma

PURPOSE

Sentinel lymph node biopsy (SLNB) is now a standard of care for cutaneous melanoma, but it is still controversial for cutaneous head and neck melanoma (CHNM). This study aims to confirm the feasibility, accuracy and low morbidity of SLNB in CHNM and evaluate its prognostic value.

METHODS

A monocentric and retrospective study on patients with CHNM treated in our tertiary care center (Gustave Roussy) between January 2008 and December 2012 was performed. The feasibility, morbidity and prognostic value of this technique were analysed.

RESULTS

One hundred and twenty-four consecutive patients were included. SLNB was realized in 97.6% of the cases. No significant post-operative morbidity was observed. Nineteen percents of patients had a positive SN while only 14.3% of complete lymph node dissections (CLND) had additional nodal metastasis. The risk of recurrence after positive SN was significantly higher (69.2 vs 30.8%, p = 0.043). The false omission rate was low with 7.1%. Overall survival and disease-free survival were better in the negative SN group (82 vs 49%, p < 0.001 and 69.3 vs 41.8%, p = 0.0131). The risk of recurrence was significantly higher in the positive SN group (p = 0.043) and when primary tumour was ulcerated (p = 0.031). Only the mitotic rate of the primary tumour was associated with SN positivity (p = 0.049).

CONCLUSION

As in other sites, SLNB status is a strong prognostic factor with comparable false omission rate and no superior morbidity.

Sentinel lymph node biopsy for melanoma of the head and neck

Since its first description nearly two centuries ago, melanoma has been a difficult disease to diagnose and treat. With the incidence and mortality rates slowly increasing, understanding this disease is more important than ever. Herein, the current diagnostic and treatment recommendations for melanoma of the head and neck are reviewed, with special emphasis on the use of sentinel lymph node biopsy (SLNB). For the past decade, SLNB has been a well-accepted procedure in the treatment of truncal and extremity melanoma, providing useful information for both treatment and prognosis. Still, despite its clear role in the rest of the body, the role of SLNB has not yet been fully defined in the management of melanoma of the head and neck. The complexity of lymphatic drainage patterns and the frequent need to remove sentinel lymph nodes from the parotid gland, thus placing the facial nerve at risk, have made head and neck surgical oncologists slow to adopt this method. However, current data from several trials indicate that in the head and neck, sentinel lymph nodes can be identified reliably approximately 98% of the time using intraoperative lymphatic mapping. In addition, the false-negative and complication rates are appropriately low. SLNB allows for accurate staging of patients, informed discussions of prognosis and the use of adjuvant therapies, including radiation and interferon-alpha2b. For these reasons, the authors believe that SLNB will become the standard-of-care for head and neck melanoma as well as for other body sites.

Incidence and location of positive nonsentinel lymph nodes in head and neck melanoma

BACKGROUND

The complex lymphatic drainage in the head and neck makes sentinel lymph node biopsy (SLNB) for melanomas in this region challenging. This study describes the incidence, and location of additional positive nonsentinel lymph nodes (NSLN) in patients with cutaneous head and neck melanoma following a positive SLNB.

METHODS

A retrospective review was performed using a single institution prospective database. Patients with a primary melanoma in the head or neck with a positive cervical SLNB were identified. The lymphadenectomy specimen was divided intraoperatively into lymph node levels I-V, and NSLN status determined for each level.

RESULTS

Of 387 patients with melanoma of the head and neck who underwent cervical SLNB, 54 had a positive SLN identified (14%). Thirty six patients (67%) underwent immediate completion lymph node dissection (CLND) of whom eight patients (22%) had a positive NSLN. The remaining 18 patients (33%) did not undergo CLND and were observed. Half of positive NSLNs (50%) were in the same lymph node level as the SLN and 33% were in an immediately adjacent level; only two patients were found to have NSLNs in non-adjacent levels. The only factor predictive of NSLN involvement was the size of the tumor deposit in the SLN>0.2 mm (p = 0.05). Superficial parotidectomy at CLND revealed metastatic melanoma only in patients with a positive parotid SLN.

CONCLUSIONS

A positive NLSN was identified in 22% of patients undergoing CLND after a positive SLNB. The majority of positive NSLNs are found within or immediately adjacent to the nodal level containing the SLN.

Cervical lymph node evaluation and diagnosis

This article discusses the rationale for imaging cervical lymph nodes and reviews nodal anatomy and common drainage patterns, imaging features of pathologic lymph nodes, and the advantages of various imaging modalities available for evaluation and diagnosis of the lymph nodes.

Is complete lymph node dissection after a positive sentinel lymph node biopsy for cutaneous melanoma always necessary? A meta-analysis

BACKGROUND

The current recommendation for patients with cutaneous melanoma and a positive sentinel lymph node (SLN) biopsy is a complete lymph node dissection (CLND). However, metastatic melanoma is not present in approximately 80% of CLND specimens. A meta-analysis was performed to identify the clinicopathological variables most predictive of non-sentinel node (NSN) metastases when the sentinel node is positive in patients with melanoma.

METHODS

A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google scholar, Science Direct, and Web of Science. The search identified 54 relevant articles reporting the frequency of NSN metastases in melanoma. Original data was abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI).

FINDINGS

The pooled estimates that were found to be significantly associated with the high likelihood of NSN metastases were: ulceration (OR: 1.88, 95% CI: 1.53-2.31), satellitosis (OR: 3.25, 95% CI: 1.86-5.66), neurotropism (OR: 2.51, 95% CI: 1.39-4.53), >1 positive SLN (OR: 1.77, 95% CI: 1.2-2.62), Starz 3 (old) (OR: 1.83, 95% CI: 0.89-3.76), Angiolymphatic invasion (OR: 2.46, 95% CI: 1.34-4.54), extensive location (OR: 2.22, 95% CI: 1.74-2.81), macrometastases >2 mm (OR: 1.95, 95% CI: 1.61-2.35), extranodal extension (OR: 3.38, 95% CI: 1.79-6.40) and capsular involvement (OR: 3.16, 95% CI: 1.37-7.27). There were 3 characteristics not associated with NSN metastases: subcapsular location (OR: 0.51, 95% CI: 0.38-0.67), Rotterdam Criteria <0.1 mm (OR: 0.29, 95% CI: 0.17-0.50) and Starz I (new) (OR: 0.44, 95% CI: 0.22-0.91). Other variables including gender, Breslow thickness 2-4 mm and extremity as primary site were found to be equivocal.

INTERPRETATION

This meta-analysis provides evidence that patients with low SLN tumor burden could probably be spared the morbidity associated with CLND. We identified 9 factors predictive of non-SLN metastases that should be recorded and evaluated routinely in SLN databases. However, further studies are needed to confirm the standard criteria for not performing CLND.

Lymphatic drainage patterns from melanomas on the shoulder or upper trunk to cervical lymph nodes and implications for the extent of neck dissection

Purpose

To determine the incidence and pattern of cervical lymphatic drainage in patients with melanomas located on the upper limb or trunk, and to evaluate our current neck dissection protocol for those patients with a N+ neck.

Methods

Of 1192 melanoma patients who underwent sentinel node biopsy, 631 were selected with a primary tumor on the upper limb or trunk. All lymphoscintigrams, SPECT/CT images and operative reports were reviewed to determine the exact locations of sentinel nodes visualized preoperatively and dissected during operation.

Results

Thirty-nine (6.2 %) of 631 patients with a melanoma on the upper limb or trunk showing cervical lymph node drainage were identified. In 34 (87 %) of 39 patients, sentinel nodes were excised from level IV or Vb, and in 30 of those 39 patients simultaneous from the axilla. In the remaining five patients (13 %), sentinel nodes were collected from level IIb, level III or the suboccipital region. All collected sentinel nodes were located in the intended dissection area for N+ patients. Thirteen patients (33 %) had a total of 22 tumor-positive sentinel nodes in either the axilla (n = 10), level IV (n = 2), Vb (n = 9) or suboccipital (n = 1).

Conclusions

Only a minority of the patients with upper limb or trunk melanomas demonstrated lymphatic drainage to cervical lymph node basins, with preferential drainage to levels IV and Vb. Our current dissection protocol of levels II–V, with or without extension to the suboccipital region, in those patients with involved cervical sentinel nodes seems sufficient.

Long-term prognosis and significance of the sentinel lymph node in head and neck melanoma

OBJECTIVE

To report the long-term significance of sentinel lymph node (SLN) biopsy on prognosis, determine false-negative SLN occurrences, and determine risk factors for death and recurrence in a large series of patients with head and neck melanoma.

STUDY DESIGN

Case series with tumor registry review.

SETTING

Academic tertiary care medical center.

SUBJECTS AND METHODS

A database review was performed of all patients who underwent SLN biopsy for head and neck melanoma from 1994 to 2009. End points assessed were SLN status, recurrence, false-negative SLN results, and survival comparing SLN-positive and SLN-negative patients and different locations. Survival curves and multivariate analyses were performed.

RESULTS

SLN biopsy was performed in 365 patients. SLNs were identified in 98.6% of patients with a mean of 3.7 nodes removed from 1.6 nodal basins per patient. Median follow-up was 8 years. The SLN was positive in 40 (11%) patients. SLN-positive patients had significantly thicker melanomas, higher recurrence (P < .0001), and a significant decrease in overall survival compared with SLN-negative patients (P < .002). Scalp melanoma patients had significantly thicker melanomas and an elevated risk of SLN positivity, recurrence, and death compared with other sites. Seventeen of 365 SLN-negative patients developed regional nodal disease for a false-omission rate of 5.2% and a negative predictive value of a negative SLN to be 94.8%. Risks for false negative-SLN occurrences included thick melanomas and scalp melanomas.

CONCLUSION

SLN biopsy is accurate in head and neck melanoma and provides significant prognostic data. Scalp melanoma patients present with thicker tumors with an increase in SLN positivity and false-negative SLN occurrences.

Merkel cell carcinoma: identification of prognostic factors unique to tumors located in the head and neck based on analysis of SEER data

OBJECTIVES/HYPOTHESIS

Merkel cell carcinoma (MCC) is an aggressive cutaneous neoplasm that occurs most frequently in the head and neck region. Because of its rarity, prognostic factors are poorly characterized. Head and neck MCC (HN-MCC) may require separate consideration from MCC that occurs in other anatomic regions. Our objective was to determine the relevance of clinicopathologic parameters as prognostic factors in a large series of patients with HN-MCC and to compare these to a series of patients with non-head and neck MCC (NHN-MCC).

STUDY DESIGN

Retrospective analysis of large population database.

METHODS

Patients with MCC were identified using the Surveillance, Epidemiology, and End Results database and categorized according to tumor location either 1) within or 2) outside of the head and neck region. Clinicopathologic data were compared between groups. Retrospective univariable and multivariable analyses of factors associated with disease-specific survival (DSS) were performed.

RESULTS

We identified 2,104 patients with HN-MCC and 2,272 with NHN-MCC. DSS was similar between groups. Independent prognostic factors in HN-MCC are male sex (P < .001), lip primary site (P = .005), tumor extension beyond the dermis (P = .03), histologically confirmed nodal disease (P < .001), absence of histologic lymph node evaluation (P = .01), and distant metastasis (P = .001). Male sex and tumor extension limited to the subcutis are prognostic factors that are unique to HN-MCC.

CONCLUSIONS

Because independent markers of aggressive disease appear to be unique in HN-MCC, it is important that future studies provide separate consideration for HN-MCC to allow for the most accurate identification of prognostic indicators and assessment of treatment outcomes accordingly.

Role of selective sentinel lymph node dissection in head and neck melanoma

Selective sentinel lymph node dissection (SLND) plays an important role in the staging of the regional nodal basins for head and neck (H&N) melanoma. Preoperative lymphoscintigraphy is mandatory to identify the regional nodal basin(s) accurately for a newly diagnosed H&N primary melanoma of at least 1mm or greater. A wide local excision should be delayed if SLN mapping is indicated, to minimize watershed effect and maximize accuracy in identifying the "true" SLN because of the complex lymphatic network in the H&N region. An experienced multidisciplinary team is required for optimal identification of H&N SLNs. In general, selective SLND can replace ELND to minimize the complications of a neck dissection. Completion lymph node dissection is only indicated when the SLN is positive. A nerve stimulator should be used during selective SLND in the parotid and posterior triangle to minimize the injury to the facial and spinal accessory nerve.

Sentinel lymph node biopsy is accurate and prognostic in head and neck melanoma

BACKGROUND

Sentinel lymph node biopsy (SLNB) has emerged as a widely used staging procedure for cutaneous melanoma. However, debate remains around the accuracy and prognostic implications of SLNB for cutaneous melanoma arising in the head and neck, as previous reports have demonstrated inferior results to those in nonhead and neck regions. Through the largest single-institution series of head and neck melanoma patients, the authors set out to demonstrate that SLNB accuracy and prognostic value in the head and neck region are comparable to other sites.

METHODS

A prospectively collected database was queried for cutaneous head and neck melanoma patients who underwent SLNB at the University of Michigan between 1997 and 2007. Primary endpoints included SLNB result, time to recurrence, site of recurrence, and date and cause of death. Multivariate models were constructed for analyses.

RESULTS

Three hundred fifty-three patients were identified. A sentinel lymph node was identified in 352 of 353 patients (99.7%). Sixty-nine of the 353 (19.6%) patients had a positive SLNB. Seventeen of 68 patients (25%) undergoing completion lymphadenectomy after a positive SLNB result had at least 1 additional positive nonsentinel lymph node. Patients with local control and a negative SLNB failed regionally in 4.2% of cases. Multivariate analysis revealed positive SLNB status to be the most prognostic clinicopathologic predictor of poor outcome; hazard ratio was 4.23 for SLNB status and recurrence-free survival (P < .0001) and 3.33 for overall survival (P < .0001).

CONCLUSIONS

SLNB is accurate and its results are of prognostic importance for head and neck melanoma patients.

False-Negative Sentinel Lymph Node Biopsy in Head and Neck Melanoma

Objective. The results of sentinel lymph node biopsy (SLNB) can be useful for staging and deciding on adjuvant treatment for patients with head and neck melanoma. False-negative SLNB can result in treatment delay. This study aimed to evaluate the characteristics and outcome of patients with false-negative SLNB in cutaneous melanoma of the head and neck.

Study Design. Longitudinal cohort study using a prospective institutional tumor registry.

Setting. Academic health center.

Subjects and Methods. Data from 153 patients who underwent SLNB for melanoma of the head and neck were analyzed. False-negative biopsy was defined as recurrence of tumor in a previously identified negative nodal basin. Statistical analysis was performed on registry data.

Results. Positive sentinel lymph nodes were identified in 19 (12.4%) patients. False-negative SLNB was noted in 9 (5.9%) patients, with a false-negative SLNB rate of 32.1%. Using multivariate regression analysis, only examination of a single sentinel lymph node was a significant predictor of false-negative SLNB ( P = .01). The mean treatment delay for the false-negative SLNB group was 470 days compared with 23 days in the positive SLNB group ( P < .001). The 2-year overall survival of patients with false-negative SLNB was 75% compared with 84% and 98% in positive and negative SLNB groups, respectively ( P = .02).

Conclusions. False-negative SLNB is more likely to occur when a single sentinel lymph node is harvested. There is significant treatment delay in patients with false-negative SLNB. False-negative SLNB is associated with poor outcome in patients with melanoma of the head and neck.

Sentinel Node Biopsy for Head and Neck Melanoma

Objective. This systematic review was conducted to examine the test performance of sentinel node biopsy in head and neck melanoma, including the identification rate and false-negative rate.

Data Sources. PubMed, EMBASE, ASCO, and SSO database searches were conducted to identify studies fulfilling the following inclusion criteria: sentinel node biopsy was performed, lesions were located on the head and neck, and recurrence data for both metastatic and nonmetastatic patients were reported.

Review Methods. Dual-blind data extraction was conducted. Primary outcomes included identification rate and test performance based on completion neck dissection or nodal recurrence.

Results. A total of 3442 patients from 32 studies published between 1990 and 2009 were reviewed. Seventy-eight percent of studies were retrospective and 22% were prospective. Trials varied from 9 to 755 patients (median 55). Mean Breslow depth was 2.53 mm. Median sentinel node biopsy identification rate was 95.2%. More than 1 basin was reported in 33.1% of patients. A median of 2.56 sentinel nodes per patient were excised. Sentinel node biopsy was positive in 15% of patients. Subsequent completion neck dissection was performed in almost all of these patients and revealed additional positive nodes in 13.67%. Median follow-up was 31 months. Across all studies, predictive value positive for nodal recurrence was 13.1% and posttest probability negative was 5%. Median false-negative rate for nodal recurrence was 20.4%.

Conclusion. Sentinel node biopsy of head and neck melanoma is associated with an increased false-negative rate compared with studies of non–head and neck lesions. Positive sentinel node status is highly predictive of recurrence.

Invasive melanoma of the face: Management, outcomes, and the role of sentinel lymph node biopsy in 260 patients at a single institution

BACKGROUND AND OBJECTIVES

The face is a common site of melanoma occurrence. The purpose of this study was to examine the management and outcomes of patients with invasive melanoma of the face.

METHODS

Patients with invasive melanoma of the face managed at our institution from 1997 to 2008 were retrospectively reviewed. Details of sentinel lymph node biopsy (SNB), disease recurrence, and deaths were recorded.

RESULTS

Two hundred sixty patients were reviewed (mean age 68, mean tumor thickness 0.87 mm). Of 100 patients eligible for SNB (tumor thickness ≥ 1 mm, Clark level ≥ IV, or ulceration) this was performed in only 29 (29%), and those who underwent SNB were younger than those who did not (mean age 59 vs. 79 years, P < 0.0001). SNB was successful in 28 (97%), and no complications occurred. SNB was positive in 3 (11%). After mean follow-up of 30 months, nodal recurrence occurred in 9 (3.5%) and distant recurrence in 20 (7.7%). There were 60 deaths (overall mortality 23%); attributed to melanoma in only 16 cases (disease specific mortality 6.2%).

CONCLUSIONS

Facial melanoma is associated with low rates of regional recurrence despite underutilization of SNB. Older patients are less likely to undergo SNB. Due to the advanced age of patients with facial melanoma, most deaths occurring are from unrelated causes.

Follow-up after intraoperative sentinel node biopsy of N0 neck oral cancer patients

The objective of the study was to evaluate the validity of sentinel node (SN) biopsy in early oral cancer patients focusing on the accuracy of intraoperative diagnoses of SN status, recurrences in follow-up and impact on patient survival. Previously untreated N0 oral cancer patients were candidates for the study. Using a radioisotope method, an intraoperative SN biopsy was performed. Patients with a positive frozen section of SN underwent immediate neck dissection as a single-stage procedure; they were followed in our outpatient clinic. Forty-five cT1-2N0 patients with squamous cell carcinoma were analyzed. There were seven patients with positive SN, five of whom were detected by intraoperative frozen section analysis. The sensitivity, specificity and accuracy of the intraoperative frozen section analysis of SN were 71.4, 100 and 95.6%, respectively. There were 13 recurrences in the course of all patients treated. Those with positive SN showed a tendency toward recurrence. Three patients with negative SN suffered from delayed ipsilateral neck recurrence. These were considered false negatives at a rate of 7.9%. The 5-year overall survival rate of all patients was 91.1%. SN-positive patient survival was significantly poorer than that of SN-negative patients. Positive SN had a negative impact on the survival. SN biopsy was shown to be a valuable method for determining the neck status of early oral cancer patients. The concordance rate of intraoperative multislice frozen section analysis of SN and patient neck status at the time of operation was 95.6%. SN-positive patients exhibited a tendency toward cancer recurrence. There were three cases of false negatives not conforming to the SN concept and their rate was 7.9%. Positive SN had a negative impact on patient survival.

Regional recurrence after negative sentinel lymph node biopsy for melanoma

OBJECTIVE

Sentinel lymph node (SLN) biopsy has shown great utility in the management of melanoma. An analysis of regional recurrence in previously mapped negative SLN basins as the first site of relapse is performed.

METHODS

A retrospective query of a prospective melanoma database from 1994 to 2006 identified 1287 patients who underwent successful SLN biopsy. One thousand sixty patients (82.4%) were SLN negative and 227 (17.6%) patients SLN positive. Clinical variables were examined for the impact on regional recurrence by multivariate analysis.

RESULTS

Mean follow-up was 44.3 months (range 3-155 months). Thirty-five patients (3.3%) presented with false-negative (FN) SLN biopsy. Pathologic review of the SLNs harvested from these basins found 7 (20.0%) samples positive for metastatic melanoma. Multivariate analysis found head and neck site [hazard ratio 3.67; 95% confidence interval (CI), 1.77-7.60, P < 0.001] and tumor thickness (hazard ratio 1.16; 95% CI, 1.04-1.30, P = 0.01) to be predictive of FN SLN biopsy. The 5-year melanoma specific survival calculated from the date of the SLN biopsy was 57.6% (95%CI, 35.7-41.9) in the FN group, which was not statistically different than the SLN positive group 60.0% (95% CI, 29.6-40.1; P = 0.14).

CONCLUSIONS

Head and neck tumor site and tumor thickness are predictors of a FN SLN biopsy. Mechanisms other than pathologic SLN sampling error may contribute to the failure of the SLN biopsy in some patients. Patients with regional recurrence after negative SLN biopsy have a similar 5-year survival compared with patients with positive SLNs.

Cutaneous lesions of the external ear

Skin diseases on the external aspect of the ear are seen in a variety of medical disciplines. Dermatologists, othorhinolaryngologists, general practitioners, general and plastic surgeons are regularly consulted regarding cutaneous lesions on the ear.

This article will focus on those diseases wherefore surgery or laser therapy is considered as a possible treatment option or which are potentially subject to surgical evaluation.

Use of Sentinel Lymph Node Biopsy for Melanoma of the Head and Neck

Sentinel lymph node biopsy (SLN) is a well-accepted procedure for truncal and extremity melanoma (T&E). However, its role in melanoma of the head and neck (H&N) remains controversial. Complex lymphatic and vascular drainage make SLN more challenging in this region. This study was done to evaluate the results of SLN for H&N versus T&E melanoma. Three hundred sixteen patients who underwent SLN for melanoma using a double indicator technique were identified from a prospective database. Records were analyzed retrospectively. Statistical analysis was performed using χ2, t test, or Mann-Whitney U test to evaluate the results, as appropriate. H&N was found in 87 cases (27.5%). The mean age was 63.2 and 53.2 years for H&N and T&E melanoma (P < 0.001), respectively. 99Technetium positivity (89.7% H&N versus 99.6% T&E, P < 0.001) and isosulfan blue positivity (85.1% H&N versus 91.7% T&E, P = 0.08) were more likely in T&E melanoma. There was a significant difference between H&N and T&E melanoma with respect to the incidence of failed SLN, defined as no sentinel nodes identified intraoperatively (8.0% versus 0%, P < 0.001). Both groups had similar rates of positive intraoperative imprint cytologic examination (4.6% H&N versus 6.1% T&E, P > 0.5). There was a trend suggesting a higher mean number of sentinel lymph nodes found (3.1 versus 2.7, P = 0.1) in H&N melanoma. The total number of lymph nodes found in dissection specimens (20.9 versus 21.9, P = 0.45), the total number of positive lymph nodes (3.5 versus 1.6, P = 0.32), the incidence of any recurrence (19.5% versus 12.7%, P = 0.2), and time to recurrence (14.2 versus 20.6 months, P = 0.18) were similar between H&N and T&E melanoma. SLN mapping of H&N lesions is more difficult than at other sites. However, rates of nodal positivity are similar to melanoma of the trunk and extremities. Therefore, despite being more demanding, SLN is useful in diagnosis and treatment of melanomas of the head and neck.

Optimal management and challenges in treatment of upper facial melanoma

This study's purpose was to evaluate clinical and surgical outcomes in patients with upper facial melanoma. A sentinel lymph node (SLN) biopsy database review identified 43 patients receiving a diagnosis of upper facial melanoma between February 1997 and April 2005 at Mayo Clinic Arizona in Scottsdale. Patients underwent wide local excision (n = 40) or Mohs excision (n = 3) and SLN biopsy. Nine patients (21%) had positive margins requiring reexcision. SLN mapping identified the SLN in 39 patients (91%) and drainage to bilateral lymph node basins in 8 (21%). The SLN was positive for melanoma in 2 patients (5%). Recurrence in 33 patients with more than 1 year of follow-up (local in 5 [15%] and regional in 1 [3%]) was treated with salvage surgery; 1 patient developed metastatic disease. Two patients (5%) died, one of an unknown cause and the other of metastatic melanoma. We concluded that oncologic surgery can result in good local disease control in patients with upper facial melanoma.

Sentinel Lymph Node Biopsy for Cutaneous Head and Neck Melanoma: Mapping the Parotid Gland

BACKGROUND

Sentinel lymph node biopsy (SLNB) for primary cutaneous head and neck melanoma (CHNM) has been shown to be successful and is the current standard of care for intermediate-thickness melanoma. We evaluated our experience with CHNM associated with SLNB mapping to the region of the parotid gland.

METHODS

Retrospective review of a prospectively collected melanoma database identified 1014 CHNMs. Two-hundred twenty-three patients underwent SLNB, and 72 (32%) had mapping in the region of the parotid gland between May 1995 and June 2003.

RESULTS

The mean number of SLNs per patient was 2.5. A sentinel lymph node (SLN) was successfully identified in 94% of patients, and in 12%, the SLN was positive for metastatic disease. Biopsy of intraparotid SLNs was performed in 51.4% and of periparotid SLNs in 26.4%, and a superficial parotidectomy was performed in 22.2%. Ten patients were found to have lymph nodes in the parotid region with metastatic disease (eight identified by SLNB), and two (20%) patients developed intraparotid lymph node recurrence in the setting of a negative SLNB. Same-basin recurrence in SLN-negative patients was 3.3% with a median follow-up of 26 months. Facial nerve dysfunction was identified in seven (10%) patients. Facial nerve function returned to preoperative status in all patients.

CONCLUSIONS

SLNB for patients with primary CHNM mapping to the parotid gland can be performed with a high degree of accuracy and a low morbidity consisting of temporary facial nerve paresis.

Does sentinel lymph node biopsy in cutaneous head and neck melanoma alter disease outcome?

BACKGROUND AND OBJECTIVES

In the head and neck region, value, reliability, and safety of sentinel lymph node biopsy (SLNB) have not yet been determined conclusively. The aim of study was to assess impact of SLNB on disease outcome in cutaneous head and neck melanoma.

METHODS

Thirty-six patients with a clinically node-negative head and neck melanoma, > or =1.0 mm Breslow thickness, participated in a prospective study from 1995 to 2005. Sentinel lymph node (SLN) tumor-positive patients underwent completion lymphadenectomy. SLN tumor-negative patients underwent clinical monitoring. Median follow-up was 54 (range 10-114) months. Recurrence-free and overall survival curves were constructed by Kaplan-Meier.

RESULTS

SLNs could be identified in 33 patients (92%). In 7 patients (21%) the SLN was tumor-positive. In 1 patient (13%) the SLNB was false-negative. In 17 patients (47%) SLNs could be identified in the parotid region (success rate parotid region 100%). This study showed no significant difference in recurrence-free and overall survival between patients with tumor-positive and tumor-negative SLN.

CONCLUSIONS

The safety and accuracy of SLNB in the neck and parotid nodal basins were similar to those in non-head and neck sites. However, the technique is technically demanding in this region. In this small series SLNB did not alter disease outcome.

Sentinel node biopsy and head and neck tumors—Where do we stand today?

BACKGROUND

Sentinel lymph node sampling may be studied profitably in series of patients with 1 tumor type, such as breast carcinoma, in 1 anatomic locale. The present work analyzes the efficacy of sentinel node sampling in a pathologically diverse group of lesions from an anatomically diverse region such as the head and neck; however, there are risks conflating the findings in different tumors with radically different behaviors, in the process producing muddled data. This report reviews the head and neck experience with sentinel sampling and concludes that certain tumor types that have a known propensity for aggressive behavior are the best candidates for trials employing sentinel node sampling; candidates include many cutaneous melanomas of the head and neck, oropharyngeal squamous carcinomas, and selected thyroid carcinomas. Despite the growing popularity of sentinel node sampling in a variety of regions of the body, however, at this juncture this technique remains an investigational procedure, pending demonstration of a tangible improvement in patient outcome through its use. It is recommended that studies of the efficacy of this technique strive, whenever possible, to segregate results of different tumor types in different head and neck locales from one another so as to produce more focused findings for discrete types of malignancies, and not group together tumor types that may in reality exhibit different biological behaviors.

Sentinel lymph node biopsy in the management of cutaneous head and neck melanoma

Sentinel lymph node biopsy has revolutionized the surgical management of primary malignant melanoma. Most series on sentinel lymph node mapping have concentrated on extremity and truncal melanomas. The head and neck region has a rich and unpredictable lymphatic system. The use of sentinel lymph node mapping in the management of head and neck melanoma is evaluated. The authors conducted a retrospective review of patients treated for clinical stage I and stage II malignant melanoma of the head and neck with dynamic lymphoscintigraphy and gamma probe-guided sentinel lymph node biopsy. One hundred thirty-two patients (99 male patients and 33 female patients) were identified. The primary melanoma sites were the scalp (n = 54), ear (n = 14), face (n = 37), and neck (n = 27). Primary tumor staging was as follows: T1, 11; T2, 38; T3, 39; and T4, 44. Dynamic lymphoscintigraphy visualized sentinel lymph nodes in 128 patients (97 percent). In 71 cases (55 percent), a single draining nodal basin was identified, and in 57 cases there were multiple draining nodal basins (two basins, 55; three basins, two). Sentinel lymph nodes were successfully identified in 176 of 186 nodal basins (95 percent). Positive sentinel lymph nodes were identified in 22 patients (17.6 percent). Sentinel lymph node positivity by tumor staging was as follows: T2, 10.8 percent; T3, 19.4 percent; and T4, 26.8 percent. Completion lymphadenectomy revealed residual disease in seven patients (33.3 percent). Sentinel lymph node mapping for head and neck melanoma can be performed with results comparable to those of other anatomical sites.

Sentinel Node Localization in Head and Neck Tumors

Sentinel lymph node biopsy (SLNB) is a minimally invasive method that was developed to stage the regional lymphatics of patients with cutaneous melanoma. Many studies performed worldwide have shown that SLNB is a feasible method to stage the cervical lymphatics in patients with head and neck squamous cell carcinoma (HNSCC). The accuracy of SLNB in patients with HNSCC is currently under investigation in a multicenter study sponsored by the American College of Surgeons Oncology Group that compares the results of SLNB with standard elective neck dissection. Research to date has also shown that multiple SLNs and individualized drainage patterns characterize head and neck mucosal sites. These findings suggest that lymphoscintigraphy alone may be useful to delineate the lymphatic basins that require treatment in patients with HNSCC and in patients whose head and neck lymphatics are disrupted because of prior surgery or irradiation.

Sentinel-Node-Biopsie

Sentinel node biopsy (SNB) is increasingly being used as a minimally invasive staging procedure in patients with malignant melanoma. For decades elective lymph node dissection (ELND) was performed in many centers on patients at risk for lymph node metastasis but without clinically detectable lymph node involvement. Today, selective lymph node dissection (SLND) is offered only to patients with histologically proven metastasis in a SN (10-29%). A positive SN is one of the most important prognostic parameters. Ten years after the introduction of the technique, the role of SNB in the treatment of cutaneous melanoma still remains controversial. Issues include the usefulness of highly sensitive evaluation of SN using molecular biology or cytology techniques, as well as the therapeutic impact of the SNB per se and the associated combined surgical or medical adjuvant therapies.

Impact of sentinel node navigation technique for carcinoma of tongue with cervical node metastases

We attempted lymph node mapping for clinically positive neck using sentinel node navigation technique. Technetium labeled rhenium sulfide was injected as a radiotracer in 11 patients with squamous cell carcinoma of the tongue. After surgery, the radioactivity and the ratio of metastatic area (RMA) of the removed nodes were measured. Average RMA (57%) of 18 high radioactive metastatic nodes was significantly lower than the RMA (90%) of 16 low radioactive metastatic nodes. Average number of metastatic nodes (4.7 nodes) in the five cases with low radioactive metastatic nodes was significantly larger than that (1.8 nodes) in the six cases with only high radioactive metastatic nodes. There is no accumulation of radioactive tracer if a lymph node is totally or predominantly occupied by metastatic cells. When the sentinel node was mostly occupied by malignant cells, the injected colloid could not flow to the sentinel node and flowed to a different lymph node through another basin. Sentinel node navigation technique can show the actual time of lymphatic flow at the operation of positive neck cases.

Lymphoscintigraphic drainage patterns of the auricle in healthy subjects

BACKGROUND

In lymphoscintigraphies of the head and neck, multiple injections around a tumor result in variable drainage to multiple nodal basins. We undertook this study in healthy subjects to test whether single injections at specified points in the auricle display single predictable pathways and predict visualization of parotid sentinel lymph nodes (SLNs).

METHODS

Twenty-five healthy subjects were classified according to their injection points in the auricle. Each was injected bilaterally with 99mTc nanocolloid. Parotid and extraparotid lymph nodes were topographically differentiated. The procedure was repeated 1 week later.

RESULTS

Lymphoscintigraphy was reproducible. Each injection revealed a single SLN. Injection site predicted parotid SLN visualization. Two lymphatic territories with parotid or extraparotid drainage were identified.

CONCLUSIONS

Lymphatic territories in the auricle coincide with the vascular territories and branchial origins. Our findings contradict the notion that lymphatic drainage of the head and neck is unpredictable and variably involves multiple nodal basins.

Micrometastasis of a sentinel lymph node in cutaneous melanoma is a significant prognostic factor for disease-free survival, distant-metastasis-free survival, and overall survival

OBJECTIVE

Sentinel lymph node biopsy (SLNB) has been proposed as a minimally invasive procedure for the histopathologic staging of the regional lymph node basin. The aim of this work was to investigate the prognostic value of detection of micrometastasis by SLNB.

METHODS

In the period from January 1996 to March 2000, a sentinel lymph node (SLN) was identified in 283 patients at the Department Dermatology, University of Tuebingen. In the case of 38 patients (13.4%) histopathologic examination led to the detection of micrometastasis in at least one SLN. The median follow-up period was 29 months.

RESULTS

Thirty-one of 245 patients (12.7%) suffered a tumor recurrence following a negative SLNB, and 19 of 38 patients (50%) following positive SLNB. In the case of disease-free survival the remaining significant independent prognostic factors of the multivariate analysis were tumor thickness (p=0.011), ulceration (p=0.026), and the detection of micrometastasis in SLNB (p=0.021). With respect to distant-metastasis-free survival the significant independent prognostic factors of the multivariate analysis were tumor thickness (p=0.0022) and the SLNB results (p=0.0068). For overall survival the tumor thickness (p=0.013) and the SLNB results (p=0.034) were significant independent prognostic parameters in the multivariate analysis.

CONCLUSION

The study examined patients with melanomas of all tumor thicknesses and SLNB for which the prognostic significance of SLNB was tested. Recurrences were more frequent in patients with a micrometastatic SLN. Patients with a negative SNLB are still at risk for tumor recurrence. The histopathologic result of SLNB is, after tumor thickness, the most significant prognostic factor for disease-free survival, distant-metastasis-free survival, and overall survival.

Lymphatic mapping for staging of head and neck cancer

Lymphatic mapping with sentinel lymph node (SLN) biopsy can accurately stage the nodal basins in patients with melanoma of the trunk and extremities and has become a routine, well-accepted diagnostic method for melanoma at these anatomic locations. Melanoma of the head and neck (16% of all cases of melanoma) is complex and difficult to manage because of the rich abundant interlacing lymphatic drainage patterns, as well as watershed areas, which can lead to unusual and unexpected drainage patterns. Radioguided surgery in combination with blue dye facilitates localization of the SLN in the head and neck; however, this type of radioguided surgery is an evolving technique of some difficulty and thus requires careful coordination among the surgeon, nuclear medicine physician, and pathologist. Applications of this technique to other sites in the head and neck are currently being investigated for conditions including squamous cell carcinoma (SCC) of the oral cavity, thyroid cancer, and Merkel cell cancer. More studies of patients with head and neck cancer are needed--and technical issues must be resolved--before radioguided surgery can be recommended as the standard of care for these patients.