Prediction of potential metastatic sites in cutaneous head and neck melanoma using lymphoscintigraphy

doi:10.1016/S0002-9610(99)80330-4

The American Journal of Surgery

Volume 170, Issue 5, November 1995, Pages 461-466

https://doi.org/10.1016/S0002-9610(99)80330-4 Get rights and content

Background: The technique of lymphoscintigraphy may allow a more selective approach to the management of clinically negative neck nodes among patients with cutaneous head and neck melanoma.

Patients and methods: A group of 97 patients with cutaneous head and neck melanoma had preoperative lymphoscintigraphy using intradermal injections of technetium 99m antimony trisulfide colloid to identify sentinel nodes. Fifty-one patients were eligible for clinical analysis after initial definitive treatment by wide excision only (n = 11), wide excision and elective dissection of the neck (n = 19) or axilla (n = 1), or wide excision and a sentinel node biopsy procedure (n = 20).

Results: Sentinel nodes were identified in 95 of 97 lymphoscintigrams, and 85% of patients had multiple sentinel nodes. In 21 patients (22%), sentinel nodes were identified outside the parotid region and the 5 main neck levels, mostly in postauricular nodes (n = 13). Lymphoscintigrams were discordant with clinical predictions in 33 patients (34%). Lymph nodes were positive in 4 elective dissections and 4 sentinel node biopsies. Among 16 patients evaluable after wide excision and a negative sentinel node biopsy, 4 patients subsequently developed metastatic nodes; however, confident identification of all nodes marked as sentinel nodes on lymphoscintigraphy was not achieved at the original biopsy procedure in 3 of these patients.

Conclusions: Lymphoscintigraphy and sentinel node biopsy are more difficult to perform in the head and neck than in other parts of the body. The reliability of sentinel node biopsy based on lymphoscintigraphy may be improved by identifying and marking all nodes that are considered to receive direct lymphatic drainage from the primary melanoma, and by use of a gamma probe intraoperatively.

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Lentigo maligna melanoma (LMM) predominantly presents in the head and neck of the elderly. The value of sentinel lymph node biopsy (SLNB) for LMM patients remains to be determined, as the reported average yield of positive lymph nodes is less than 10%. In this nationwide cohort study, we wanted to identify LMM patients with an increased risk of SLNB-positivity.
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Between 1991 and 2020, 1989 LMM patients met our inclusion criteria. SLNB was performed in 16.7% (n = 333) and was positive in 7.5% (25/333). The false-negative rate was 21.9%. Clinically detectable regional lymph node (LN) metastases were found in 1.3% (n = 25). Clinicopathological characteristics best predictive for SLNB-positivity (Odds ratio; 95% CI) were age (0.95; 0.91–0.99), ulceration 1.59 (0.44–4.83), T4-stage (1.81; 0.43–6.2), male sex (1.97; 0.79–5.27), (lymph)angioinvasion (5.07; 0.94–23.31), and microsatellites (7.23; 1.56–32.7) (C-statistic 0.75). During follow-up, regional LN recurrences were detected in 4.2% (83/1989) of patients, of which the majority (74/83) had no evidence of regional LN metastases at baseline.
Our findings confirm the limited SLNB-positivity in LMM patients. Based on the identified high-risk clinicopathological features, a nomogram was developed to predict the risk of a positive SLNB.
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The extent of surgical management of regional lymph nodes in the treatment of cutaneous head and neck melanoma on and anterior to O'Brien's watershed line is controversial. By comparing patients' cohorts of two separate melanoma expert centers we investigate the effectiveness of comprehensive versus (super-) selective neck dissection approach.
Sixty patients with macroscopic (palpable) neck node metastases (N2b) from anterior scalp and face melanoma were retrospectively studied. Forty therapeutic modified radical neck dissections (MRND; levels I–V) combined with elective parotidectomy from The Netherlands Cancer Institute (NCI) were compared with 16 (super-) selective neck dissections [(S)SND; 3–4 levels] and 4 solely MRNDs from Erasmus Medical Center (EMC). Cohorts were analyzed for site of recurrence, overall survival (OS), melanoma-specific survival (MSS), and disease-free survival (DFS).
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Citation Excerpt :
In a systematic review of 136 patients with head and neck MCC from 29 publications, SLNB positivity was 30.9% with a false-negative rate of 19.2%.34 Unique to head and neck MCC, complex lymph node drainage patterns may limit its reliability and prognostic value owing to the higher risk of false-negative results.35 However, other studies have shown SLNB in the head and neck to be very reliable, with false-negative rates of less than 5%.14,15
Risk factors for positive sentinel lymph nodes in head and neck melanoma — a survival analysis
2021, Brazilian Journal of Otorhinolaryngology
Sentinel lymph node biopsy is the gold standard procedure for head and neck cutaneous melanoma staging.
To evaluate the technical aspects, positivity and prognostic effect of the cervico-facial sentinel lymph node biopsy.
Retrospective, unicentric study. From 2009 to 2014, 49 patients with cutaneous melanoma of the head and neck underwent surgery at Instituto do Câncer do Estado de São Paulo (ICESP).
Of the 49 patients, 5 had cervical metastasis at the moment of admission. Clark, Breslow and mitotic index were predictors of death. Among the 31 patients undergoing sentinel lymph node biopsy, 3 had positive sentinel lymph nodes (9.7%). Deaths were recorded in two of the cases with positive sentinel lymph nodes (66.6%), and in 5 (17.8%) of the patients with negative lymph nodes. The mean Breslow index was 11.3 mm for primary melanomas with positive sentinel lymph nodes and 4.3 mm for those with negative sentinel lymph nodes. Positivity was associated with Clark and Breslow levels. Malar location showed a protective effect on prognosis. The mean survival for patients with a mitotic index <3.5 was 181 months and 63.4 months for those with a mitotic index >3.5.
The frequency of positive sentinel lymph node biopsy in patients with malignant melanoma of the head and neck was lower than in other studies, although the sample consisted of individuals with advanced melanomas. The mitotic index was important for prognosis prediction.
Patterns of failure in patients with cutaneous head and neck melanoma
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The incidence of head and neck melanoma is increasing. Various factors influence prognosis.
We sought to investigate the subgroup of patients with head and neck melanoma who fail primary treatment and to define the patterns of failure.
The database of a tertiary medical center was reviewed for patients diagnosed and surgically treated for cutaneous head and neck melanoma in 1995–2014. Regional disease failure was defined as disease confirmed in positive SLNB at first assessment or at recurrence.
The cohort included 141 patients followed for a median duration of 6.8 years (range 1–20 years). Median tumor thickness was 2.1 mm (range 0.5–12 mm). Ulceration was documented in 38 patients (26.9%). Sentinel lymph node biopsy (SLNB) was positive in 18 patients (12.8%). Total disease failure rate was 32.6% with similar rates of regional (n = 26, 18.4%) and distal (n = 22, 15.6%) failure. Most patients (86.3%) with systemic recurrence had a negative SNLB as did 6/26 patients (23%) with regional failure. Forty-three patients (30.4%) died during follow-up, half of them (23 patients, 16.3%) of melanoma. On multivariate analysis, Breslow thickness was the only significant predictor of outcome.
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: Presented at the 41st Annual Meeting of the Society of Head and Neck Surgeons, Boston, Massachussetts, May 1–3, 1995.

View full text

Prediction of potential metastatic sites in cutaneous head and neck melanoma using lymphoscintigraphy

Am J Surg

Am J Surg

Am J Surg

Am J Surg

Surg Oncol

Inefficacy of immediate node dissection in stage I melanoma of the limbs

NEJM

Elective lymph node dissection in patients with primary melanoma of the trunk and limbs treated at the Sydney Melanoma Unit from 1960 to 1991

J Am Coll Surg

Radical, modified and selective neck dissection for cutaneous malignant melanoma

Head Neck