Is intra-operative gamma probe detection really necessary for inguinal sentinel lymph node biopsy?
Keywords:
Sentinel node, Lymphoscintigraphy, Gamma detection, Lymphatic mappingAbstract
CONTEXT: Sentinel node (SN) biopsy has changed the surgical treatment of malignant melanoma. The literature has emphasized the importance of gamma probe detection (GPD) of the SN. OBJECTIVE: Our objective was to evaluate the efficacy of patent blue dye (PBD) and GPD for SN biopsy in different lymphatic basins. DESIGN: Patients with cutaneous malignant melanoma in stages I and II were submitted to biopsy of the SN, identified by PBD and GPD, as part of a research project. SETTING: Patients were seen at Hospital São Paulo by a multidisciplinary group (Plastic Surgery Tumor Branch, Nuclear Medicine and Pathology). PATIENTS: 64 patients with localized malignant melanoma were studied. The median age was 46.5 years. The primary tumor was located in the neck, trunk or extremities. INTERVENTIONS: Preoperative lymphoscintigraphy, lymphatic mapping with PBD and intraoperative GPD was performed on all patients. The SN was examined by conventional and immunohistochemical staining. If the SN was not found or contained micrometastases, only complete lymphadenectomy was performed. MAIN MEASUREMENTS: The SN was identified by PBD if it was blue-stained, and by GPD if demonstrated activity five times greater than the adipose tissue of the neighborhood. RESULTS: Seventy lymphatic basins were explored. Lymphoscintigraphy showed ambiguous drainage in 7 patients. GPD identified the SN in 68 basins (97%) and PBD in 53 (76%). PBD and GPD identified SN in 100% of the inguinal basins. For the remaining basins both techniques were complementary. A metastatic SN was found in 10 basins. Three patients with negative SN had recurrence (median follow-up = 11 months). CONCLUSION: Although both GPD and PBD are useful and complementary, PBD alone identified the SN in 100% of the inguinal lymphatic basins.
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References
Kroon BB, Jonk A. Elective lymph node dissection in melanoma: still a controversial issue. Neth J Surg 1991;43:129-32.
Cascinelli N, Morabito A, Santinami M, Mackie RM, Belli F. Immediate or delayed dissection of regional nodes in patients with melanoma of the trunk: a randomized trial. WHO Melanoma Program. Lancet 1998;351:793-6.
Balch CM. The role of elective lymph node dissection in melanoma: rationale, results, and controversies. J Clin Oncol 1988;6:163-72.
McNeer G, Das Gupta TK. Prognosis in malignant melanoma. Surgery 1964;56:512-8.
Balch CM, Milton GW, Cascinelli N, Sim FH. Elective lymph node dissection: Pros and Cons. In: Balch CM, Houghton NA, Milton GW, Sober AJ, Soong SJ, Editors. Cutaneous melanoma. 2nd edition. Philadelphia: Lippincott; 1992:345-66.
Milton GW, Shaw HM, McCarthy WH, et al. Prophylactic lymph node dissection in clinical stage I cutaneous malignant melanoma: results of surgical treatment in 1319 patients. Br J Surg 1982;69:108-11.
Veronesi U, Adamus J, Bandiera DC, et al. Inefficacy of immediate node dissection in stage l melanoma of the limbs. N Engl J Med 1977;297:627-30.
Veronesi U, Adamus J, Bandiera DC, et al. Delayed regional lymph node dissection in stage l melanoma of the skin of the lower extremities. Cancer 1982;49:2420-30.
McCarthy WH, Shaw HM, Milton GW. Efficacy of elective lymph node dissection in 2347 patients with clinical stage l melanoma. Surg Gynecol Obstet 1985;161:575-80.
Baas PC, Schraffordt Koops H, Hoefkstra JH, Van Bruggen JJ, Van der Weele LT, Oldhoff J. Groin dissection in the treatment of lower-extremity melanoma: short-term and long term morbidity. Ach Surg 1992;127:281-6.
Browsher WG, Taylor BA, Hughes LE. Morbidity, mortality and local recurrence following regional node dissection for melanoma. Br J Surg 1986;73:906-8.
Balch CM, Soong SJ, Bartolucci AA, et al. Efficacy of an elective regional lymph node dissection of 1 to 4 mm thick melanomas for patients 60 years of age and younger. Ann Surg 1996;224:255-63.
Dreeper H, Kohler CO, Bastian B, et al. Benefit of elective lymph node dissection in subgroups of melanoma patients. Cancer 1993;72:741-9.
Morton DL, Wen DR, Wong JH, et al. Technical details of intraoperative lymphatic mapping for early-stage melanoma. Arch Surg 1992;127:392-9.
Wong JK, Cagle LA, Morton DL. Lymphatic drainage of skin to a sentinel lymph node feline model. Ann Surg 1991;214:637-41.
Krag DN, Sybren JM, Weaver DL, et al. Minimal access surgery for staging of malignant melanoma. Arch Surg 1995;130:654-8.
Oliveira Filho RS, Tovo-Filho R, Eto CM, Bortoletto MCC. Mapeamento linfático intra-operatório para melanoma estádio clínico I - uma técnica promissora. Anais Bras Dermatol 1994;69:477-81.
Oliveira Filho RS, Lima EN. Selective lymphadenectomy and sentinel node biopsy in cutaneous melanoma stage I and II. Acta Oncológica Brasileira 1997;17:74-7.
Thompson FJ, McCarthy WH, Bosch CMJ, et al. Sentinel lymph node as an indicator of the presence of metastatic melanoma in regional lymph nodes. Mel Res 1995;5:255-60.
Reintgen D, Wayne Cruse C, Wells K, Berman C, et al. The orderly progression of melanoma nodal metastases. Ann Surg 1994;220:759-67.
Reintgen D, Balch CM, Kirkwood J, Ross M. Recent advances in the care of the patient with malignant melanoma. Ann Surgery 1997;225:1-14.
Ross MI. Surgical management of stage I and II melanoma patients: approach to the regional lymph node basin. Sem Surg Oncol 1996;12:394-401.
Leong SP, Steinmetz I, Habib FA, et al. Optimal selective lymph node dissection in primary malignant melanoma. Arch Surg 1997;132:666-72.
Emmanuella J, Brobeil A, Glass F, et al. Results of complete lymph node dissection in 83 melanoma patients with positive sentinel nodes. Ann Surg Oncol 1998;5:119-25.
Gershenwald JE, Thompson W, Mansfield PF, et al. Multi-institutional melanoma lymphatic mapping experience: the prognostic value of Sentinel lymph node status in 612 stage I or II melanoma patients. J Clin Oncol 1999;17:976-83.
Ross MI, Reintgen D, Balch CM. Selective lymphadenectomy: emerging role for lymphatic mapping and sentinel node biopsy in the management of early stage melanoma. Sem Surg Oncol 1993;9:219-23
Kapteijn BAE, Nieweg OE, Liem IL, et al. Localizing the sentinel node in cutaneous melanoma: gamma probe detection versus blue dye. An Surg Oncol 1997;4:156-60.
Bostick P, Essner R, Glass E, et al. Comparison of blue dye and probe-assisted intraoperative lymphatic mapping in melanoma to identify sentinel nodes in 100 lymphatic basins. Arch Surg 1999 Jan;134:43-9.
Belli F, Lenisa L, Clemente C, et al. Sentinel node biopsy and selective dissection for melanoma nodal metastases. Tumori 1998; 84:24-8.
Bongers V, Borel Rinkes IHM, Barneveld PC, et al. Towards quality assurance of the sentinel node procedure in malignant melanoma patients: a single institution evaluation and a European survey. Eur J Nucl Med 1999;26:84-90.
