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

Variability of Sentinel Lymph Node Location in Patients with Trunk Melanoma

(1) Background: Melanoma is one of the most aggressive types of neoplasia, and the management of this pathology requires a correct staging, as well as a personalized modern oncological treatment. The main objective of the study is to determine the variability of the lymphatic drainage for patients with melanomas located on the trunk and, secondarily, to determine the features of individuals who underwent sentinel lymph node biopsy (SLNB) depending on the exact location on the trunk. (2) Methods: This retrospective, observational, single-center study included 62 cases of trunk melanoma operated between July 2019 and March 2023, in which SLNB was performed and a total of 84 lymph nodes were excised. (3) Results: Patients had a median age of 54.5 (33-78) years, with 58.1% being male; the melanomas had a median Breslow index of 2.3 (0.5-12.5) mm. Approximately 64.3% of the cohort had melanoma on the upper part of the trunk (54 cases) and 35.7% had it on the lower part (30 cases). The type of anesthesia chosen was general anesthesia in 53 cases and spinal anesthesia in 9 cases (85.5% vs. 14.5%, p < 0.001). The number of sentinel lymph nodes excised was 54 for melanomas located on the upper part of the trunk (8 cervical and 46 axillary) and 30 sentinel lymph nodes for melanomas of the lower part of the trunk (16 at the axillary level and 14 at the inguinal level). Out of the 54 LNs identified in patients with melanoma on the upper part of the trunk, 13 were positive, with a total of 12 positive lymph nodes (LNs) from the axillar basin, and only one from the cervical region. Additionally, the incidence of patients with a minimum of two identified sentinel lymph nodes was 32.2%, with a total of seven having LN involvement in two basins, and only one of these cases showed positivity for malignancy. (4) Conclusions: SLNBs were more frequent in the axillary region overall, and had more positive SLNs. Moreover, melanoma on the upper part of the trunk had a higher rate of positive SLNs compared to the lower part. Tumors located on the lower part of the truck had more positive SLNs in the axillary region than in the inguinal one.

The Utility of Indocyanine Green Dye Fluorescence Lymphography and Angiography During Wide Excision of Cutaneous Melanoma

Background and Objectives. Lymph node status is the most important prognostic factor in cutaneous melanoma patients. Recent studies showed that indocyanine green (ICG) fluorescence lymphography helps locating sentinel nodes better. Sometimes, flap reconstruction is needed after wide excision of tumor. Indocyanine green fluorescence also simplifies the intraoperative design of flaps. This study investigates the use of ICG fluorescence in patients with cutaneous melanoma during operation. Methods. We performed a single-center, retrospective study of subjects with cutaneous melanoma using ICG lymphograhy and/or angiography during wide excision of tumor between 2015 and 2019. Patients received a dermal injection of ICG and patent blue (PB) dye. The positive node was excised. Indocyanine green angiography was utilized to visualize better skin paddle during flap reconstruction if needed. Results. A total of 37 sentinel lymph nodes (SLNs) were removed in 12 patients. Indocyanine green successful localization was found in 10 of the 12 patients (83%). Three patients were found with 6 metastatic nodes on final pathology. 100% of these 6 nodes were identified by ICG, while 83% (5/6) were positive PB. Three of the 12 patients received flap reconstruction after operation, and no major complications occurred. Conclusions. ICG dye lymphangiography is a good alternative for locating SLNs in patients with melanoma. It could also visualize well perfusion skin paddle during reconstruction. We reported a reproducible and simple method to utilize ICG fluorescence in cutaneous melanoma patients.

Methods of Sentinel Lymph Node Detection and Management in Urinary Bladder Cancer—A Narrative Review

Introduction: Detection of lymph node status in bladder cancer significantly impacts clinical decisions regarding its management. There is a wide range of detection modalities for this task, including lymphoscintigraphy, computed tomography, magnetic resonance imaging, single-photon emission computed tomography, positron emission tomography, and fluoroscopy. We aimed to study the pre- and intraoperative detection modalities of sentinel lymph nodes in urinary bladder cancer. Method: This narrative review was performed by searching the PubMed and EMBASE libraries using the following search terms: (“Transitional cell carcinoma of the bladder” OR “urothelial cancer” OR “urinary bladder cancer” OR “bladder cancer”) AND ((“sentinel lymph node”) OR (“lymphatic mapping”) OR (“lymphoscintigraphy”) OR (“lymphangiography”) OR (“lymph node metastases”)). Studies analysing the effectiveness and outcomes of sentinel lymph node detection in bladder cancer were included, while non-English language, duplicates, and non-article studies were excluded. After analysing the libraries and a further manual search of bibliographies, 31 studies were included in this paper. We followed the RAMESES publication standard for narrative reviews to produce this paper. Results: Of the 31 studies included, 7 studies included multiple detection methods; 5 studies included lymphoscintigraphy; 5 studies included computed tomography and/or single-photon emission computed tomography; 5 studies included fluoroscopy; 4 studies included magnetic resonance imaging; and 5 studies included positron emission tomography. Discussion: Anatomical, radioactive, and functional detection modalities have been studied independently and in combination. The consensus is that preoperative detection with imaging helps guide surgical management and intraoperative detection methods help capture any lymph nodes that may have been missed. Each of these types of detection represent their own set of benefits and drawbacks, but there is currently limited evidence to support any change in overall practice to replace conventional staging.

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.

Is skipped nodal metastasis a phenomenon of cutaneous melanoma?

BACKGROUND AND METHODS

Skipped nodal metastasis (SNM) is a recognized phenomenon of visceral cancers when metastases bypass the regional basin and skip to a distant nodal basin without evidence of distant metastases. Its occurrence is undocumented in cutaneous melanoma patients but of potential prognostic significance. We therefore assessed the frequency of SNM in a large series of patients with limb melanomas.

PATIENTS AND METHODS

We studied melanoma patients attending a tertiary oncology hospital in northwest England using two approaches. First, we systematically searched medical records of an unselected patient sample treated 2002-2015, and second, we studied lymphoscintigrams of all patients with limb melanoma who underwent sentinel node biopsy 2008-2019.

RESULTS

Of 672 melanoma patients whose clinical records were examined, 16 had regional nodal metastases without apparent visceral spread and one appeared to have SNM but further scans were uncovered that showed concurrent pulmonary metastases. Of 667 limb melanoma patients with lymphoscintigrams, 7 showed dual lymphatic drainage patterns to distal as well as regional nodal basins, but none had micro-metastases solely in the distant basin.

CONCLUSION

Occurrence of SNM in cutaneous melanoma is highly unlikely.

Increase of sentinel lymph node melanoma staging in The Netherlands; still room and need for further improvement

Aim:

To investigate implementation of the seventh American Joint Committee on Cancer melanoma staging with sentinel lymph node biopsy (SLNB) and associations with socioeconomic status (SES).

Patients & methods:

Data from The Netherlands Cancer Registry on patient and tumor characteristics were analyzed for all stage IB–II melanoma cases diagnosed 2010–2016, along with SES data from The Netherlands Institute for Social Research.

Results:

The proportion of SLNB-staged patients increased from 40% to 65% (p < 0.001). Multivariate analysis showed that being female, elderly, or having head-and-neck disease reduced the likelihood of SLNB staging.

Conclusion:

SLNB staging increased by 25% during the study period but lagged among elderly patients and those with head-and-neck melanoma. In The Netherlands, SES no longer affects SLNB staging performance.

Value of SPECT/CT for Sentinel Lymph Node Localization in the Parotid and External Jugular Chain

OBJECTIVE

Preoperative single-photon emission computed tomography/computed tomography (SPECT/CT) imaging may aid in the localization of sentinel lymph nodes (SLNs) in cutaneous head and neck malignancy and has been rigorously evaluated for deep cervical lymph nodes. The purpose of this study was to assess the sensitivity, specificity, and positive predictive value (PPV) of SPECT/CT for preoperative localization of nodal basins superficial to the sternocleidomastoid muscle, with comparison to deep nodal basins of the neck.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

SPECT/CT images obtained preoperatively for patients undergoing SLN biopsy for cutaneous head and neck malignancy between June 2015 and June 2016 were reviewed by a blinded nuclear medicine physician and head and neck surgeon. SPECT/CT imaging was compared to intraoperatively determined SLN location via gamma probe. Sensitivity, specificity, and positive and negative predictive values were determined and compared for superficial (external jugular [EJ] and parotid) nodes vs level II nodes.

RESULTS

Fifty-three patients were included in the study. Most had cutaneous melanoma (69.8%). The PPV of EJ/parotid node identification by SPECT/CT imaging was 85.7%, specificity was 88.9%, and sensitivity was 69.2%. Comparatively, the PPV for level II nodes was 76.9%, specificity was 50%, and sensitivity was 85.7%. No significant difference in SPECT/CT predictive value was identified between EJ/parotid and level II node identification ( P > .05).

CONCLUSION

SPECT/CT imaging has strong specificity and positive predictability for preoperative localization of SLN superficial to the sternocleidomastoid muscle in cutaneous head and neck malignancy. SPECT/CT imaging may be a useful radiographic aid for preoperative SLN mapping in this patient population.

Radio-Guided Lymph Node Mapping in Bladder Cancer Using SPECT/CT and Intraoperative γ-Probe Methods

PURPOSE

Lymph outflow from bladder tumor differs between individuals, making the prediction of the metastatic landing sites difficult. A "blind" template of lymphadenectomy has been tested as a solution to this problem. We believe that it is feasible to find methods enabling more precise lymph nodes (LNs) evaluation. The aims of our study were to evaluate the possibility of LNs mapping in case of muscle invasive bladder cancer (MIBC) and to compare the 2 methods of their detection.

PATIENTS AND METHODS

Our study group consisted of 38 cN0 MIBC patients. Lymph nodes mapping was performed by SPECT/CT lymphoscintigraphy using Tc-nanocolloid, followed by intraoperative verification with γ-ray probe. Lymph nodes with increased radiotracer uptake (hot spots) were removed, and then pelvic LNs dissection was conducted. Lymph nodes resected as hot spots and LNs resected with lymphadenectomy were separately examined by a pathologist.

RESULTS

An average of 3 hot spots (range, 1-5) were identified in each case. For 36 of 38 patients, both preoperative SPECT/CT and intraoperative γ-probe evaluation results were obtained. Ninety-five percent of hot spots were found distally and caudally to the uretero-iliac crossing; 5% were found proximal. Lymph nodes outside the pelvic LNs dissection area did not contain metastases. In 2 patients, metastases were found in LNs without increased radiotracer uptake, and the observed hot spots contained no metastases.

CONCLUSIONS

Radio-guided LNs mapping in case of MIBC is feasible. Preoperative detection of hot spots using SPECT/CT and intraoperative γ-ray detection probe gives similar results.

Utility of hybrid SPECT/CT in primary melanoma lymphoscintigraphy: A retrospective case series

INTRODUCTION

Sentinel lymph node (SLN) biopsy is widely accepted as an important part of staging cutaneous malignant melanoma. Hybrid single photon emission computed tomography and computed tomography (SPECT/CT) may identify additional SLN and provide important information to the surgeon performing SLN biopsy. We report our experience at a major referral centre for melanoma surgery.

METHODS

Retrospective case series of pre-operative sentinel node lymphoscintigraphy for primary melanoma over a consecutive 12-month period. All patients had planar imaging and hybrid SPECT/CT.

RESULTS

At least 1 SLN was successfully identified in 82 of 86 eligible patients (95.3%). These 82 patients had 144 SLNs (mean 1.8). There were no patients where the SLN was seen only with SPECT/CT. Additional information was provided by SPECT/CT in 32 patients (39.0%). Histology reports were available for 52 patients, 9 (17.3%) had at least 1 SLN positive for metastatic disease.

CONCLUSIONS

We achieved a high rate of SLN identification. SPECT/CT was most frequently helpful when the primary melanoma was located in the head, neck and trunk. Routine use of SPECT/CT during lymphoscintigraphy provides important anatomical information and may reduce the false-negative rate.

Diffusion-weighted-preparation (D-prep) MRI as a future extension of SPECT/CT based surgical planning for sentinel node procedures in the head and neck area?

PURPOSE

Even when guided by SPECT/CT planning of nodal resection in the head-and-neck area is challenging due to the many critical anatomical structures present within the surgical field. In this study the potential of a (SPECT/)MRI-based surgical planning method was explored. Hereby MRI increases the identification of SNs within clustered lymph nodes (LNs) and vital structures located adjacent to the SN (such as cranial nerve branches).

METHOD AND PATIENTS

SPECT/CT and pathology reports from 100 head-and-neck melanoma and 40 oral cavity cancer patients were retrospectively assessed for SN locations in levels I-V and degree of nodal clustering. A diffusion-weighted-preparation magnetic resonance neurography (MRN) sequence was used in eight healthy volunteers to detect LNs and peripheral nerves.

RESULTS

In 15% of patients clustered nodes were retrospectively shown to be present at the location where the SN was identified on SPECT/CT (level IIA: 37.2%, level IIB: 21.6% and level III: 15.5%). With MRN, improved LN delineation enabled discrimination of individual LNs within a cluster. Uniquely, this MRI technology also provided insight in LN distribution (23.2±4 LNs per subject) and size (range 21-372mm(3)), and enabled non-invasive assessment of anatomical variances in the location of the LNs and facial nerves.

CONCLUSION

Diffusion-weighted-preparation MRN enabled improved delineation of LNs and their surrounding delicate anatomical structures in the areas that most often harbor SNs in the head-and-neck. Based on our findings a combined SPECT/MRI approach is envisioned for future surgical planning of complex SN resections in this region.

Clinical Usefulness of a Novel Freehand 3D Imaging Device for Radio-Guided Intraoperative Sentinel Lymph Node Detection in Malignant Melanoma

INTRODUCTION

Patients with invasive malignant melanoma are commonly referred for sentinel lymph node (SLN) detection. A recently proposed 3D tomographic imaging modality is freehand SPECT (declipseSPECT). This "bedside system" was originally developed to enable minimal-invasive image-guided surgery. The aim of this retrospective analysis was to assess the clinical use of this freehand detector device for image-guided lymphatic mapping in melanoma patients.

MATERIALS AND METHODS

Thirty-nine patients (12 female and 27 male subjects) were included (age, 30-79 years). All of them had at least one location of melanoma with tumoral stage pT1b or greater in 37 and pTx in 2 patients in different sites of the body (abdomen in 4, back in 14, head and neck in 5, lower extremity in 6, and upper extremity in 10 patients). Lymphoscintigraphy was performed with 65 to 127 MBq Tc-nanocolloid. A 2-day protocol was applied with SPECT-CT acquisition (Brightview XCT, Philips) at day 1 and surgery using radio-guided freehand SPECT at day 2. SPECT-CT data were integrated into the 3D navigation system to enable fast and direct localization of the SLN by displaying the depth of the node from the skin surface and lateral margins in relation to the gamma probe.

RESULTS

Comparable preoperative imaging and intraoperative localization was observed in 18 patients. In 14 cases, more lymph nodes were resected than detected by SPECT-CT including 1 patient without evidence of an SLN because this node was located close to the primary right ear tumor. In 10 of these patients, intraoperative freehand SPECT revealed additional sites of lymph nodes. In 7 cases, more findings were detected by SPECT-CT than surgically removed. The procedure was safe and easy to perform, and the time of surgical intervention using freehand SPECT was in the range of 36 to 133 minutes (mean time, 66.56 minutes).

CONCLUSIONS

Freehand SPECT detected more SLN compared with SPECT-CT, and the tracking system provided precise anatomical localization of the radioactive-labeled SLNs.

Predictors and Survival Impact of False-Negative Sentinel Nodes in Melanoma

BACKGROUND

The status of the sentinel lymph node in melanoma is an important prognostic factor. The clinical predictors and implications of false-negative (FN) biopsy remain debatable.

METHODS

We compared patients with positive sentinel lymph node biopsy (SNB) [true positive (TP)] and negative SNB with and without regional recurrence [FN, true negative (TN)] from our prospective institutional database.

RESULTS

Among 2986 patients (84 FN, 494 TP, and 2408 TN; median follow-up 93 months), the incidence of FN-SNB was 2.8%. While calculated FN rate was 14.5% [84 FN/(494 TP + 84 FN) × 100], when we accounted for local/in-transit recurrence (LITR) this rate was 8.5% [46 FN/(494 TP + 46 FN) × 100 %]. On multivariate analysis, male gender (OR 2.0, 95% CI 1.1-3.6, p = 0.018), head/neck primaries (OR 2.5, 95% CI 1.3-4.8, p < 0.006), and LITR (OR 3.5, 95% CI 2.1-5.8, p < 0.001) were associated with FN-SNB. Melanoma-specific survival (MSS) for the FN group was similar to the TP group at 5 years (68 vs. 73%, p = 0.539). However, MSS declined more for the FN group with a longer follow up and was significantly worse at 10 years (44 vs. 64%, p < 0.001). On multivariate analysis, FN-SNB was a significant predictor of worse MSS in melanomas <4 mm in Breslow thickness (HR 1.6; 95% CI 1.1-2.5, p = 0.021).

CONCLUSIONS

Male gender, LITR, and head and neck tumors were associated with FN-SNB. FN-SNB was an independent predictor of worse MSS in melanomas <4 mm in thickness, but this survival difference did not become apparent until after 5 years of follow-up.

Indocyanine green SPY elite-assisted sentinel lymph node biopsy in cutaneous melanoma

BACKGROUND

Sentinel lymph node biopsy is the standard of care for intermediate-depth and high-risk thin melanomas. Recently, indocyanine green and near-infrared imaging have been used to aid in sentinel node biopsy. The present study aimed to determine the feasibility of sentinel lymph node biopsy with indocyanine green SPY Elite navigation and to critically evaluate the technique compared with the standard modalities.

METHODS

A retrospective review of 90 consecutive cutaneous melanoma patients who underwent sentinel lymph node biopsy was performed. Two cohorts were formed: group A, which had sentinel lymph node biopsy performed with blue dye and radioisotope; and group B, which had sentinel lymph node biopsy performed with radioisotope and indocyanine green SPY Elite navigation. The cohorts were compared to assess for differences in localization rates, sensitivity and specificity of sentinel node identification, and length of surgery.

RESULTS

The sentinel lymph node localization rate was 79.4 percent using the blue dye method, 98.0 percent using the indocyanine green fluorescence method, and 97.8 percent using the radioisotope/handheld gamma probe method. Indocyanine green fluorescence detected more sentinel lymph nodes than the vital dye method alone (p = 0.020). A trend toward a reduction in length of surgery was noted in the SPY Elite cohort.

CONCLUSIONS

Sentinel lymph node mapping and localization in cutaneous melanoma with the indocyanine green SPY Elite navigation system is technically feasible and may offer several advantages over current modalities, including higher sensitivity and specificity, decreased number of lymph nodes sampled, decreased operative time, and potentially lower false-negative rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

Utility of SPECT/CT for periparotid sentinel lymph node mapping in the surgical management of head and neck melanoma

PURPOSE

Sentinel lymph node (SLN) biopsy is instrumental in staging and treatment of cutaneous melanoma. SPECT/CT, single-photon emission computed tomography (SPECT) integrated with computed tomography (CT), increases the accuracy of SLN mapping to improve surgical planning. SPECT/CT can correct for signal scatter to prevent masking, which is especially common in the head and neck. For periparotid lymph nodes SPECT/CT may improve localization of SLNs compared to lymphoscintigraphy.

MATERIALS/METHODS

Hospital charts were reviewed for 14 patients with melanoma and suspected lymphatic drainage to the parotid region who received lymphoscintigraphy followed by SPECT/CT prior to surgical excision and SLN.

RESULTS

Overall, SPECT/CT provided data, which changed management in 57% of patients.

CONCLUSIONS

Fifty-seven percent of our patients benefited from use of SPECT/CT. The distinction between level II and parotid sentinel lymph nodes was clearly identified through SPECT/CT images. We believe that patients with melanoma draining to the parotid region would benefit from SPECT/CT SLN mapping.

Dominant lymph drainage in the upper extremity and upper trunk region: evaluation of lymph drainage in patients with skin melanomas

BACKGROUND

The objective of this study is to evaluate the lymph drainage from the primary focus to the regional lymph nodes in patients with melanomas of the upper extremity and upper trunk region.

METHOD

The study is a retrospective study of 20 patients with upper extremity melanomas and 14 patients with upper trunk melanomas treated with axillary lymph node dissection (ALND) or sentinel lymph node biopsy at the hospital. ALND was performed in 14 cases. In these cases, 12 were curative dissections and 2 were elective dissections. The dominant lymph drainage patterns from the primary regions were analyzed.

RESULTS

Among the upper extremity and upper trunk region melanomas, lymph drainage to Level I was determined in all cases. In these two regions there were no cases of lymph drainage to Level II not passing through Level I. Furthermore, there were no cases where sentinel lymph node or metastasis of the lymph nodes was clearly determined in Level III. Among the upper extremity melanomas, lymph drainages to the cubital (10 %) and mid-arm nodes (5 %) were established. Among the scapular region melanomas, lymph drainages to the supraclavicular nodes (25 %) were determined.

CONCLUSIONS

There was a dominant lymph drainage pattern of melanomas of the upper extremity and upper trunk region to Level I. No lymph node dissection of Level III in patients with melanomas of the upper extremity and upper trunk region is necessary unless preoperative examination determines a high possibility of metastasis-positive lymph nodes in level III.