Sentinel lymph node biopsy (SLNB)

Considerations

• • History 

  • 2009: Head and neck sentinel lymph node biopsy: current state of the art

  • 2015: The history of sentinel node biopsy in head and neck cancer: From visualization of lymphatic vessels to sentinel nodes

  • Cutaneous melanoma

    • Indications 

      • All patients with clinically negative nodal basin and a primary melanoma greater than 1 mm in depth

        • The National Comprehensive Cancer Network (NCCN) currently recommends against SLND for melanoma in situ or melanoma less than 1.0 mm in thickness

      • May be considered for melanoma 0.76-1.0 mm in thickness if adverse features (ulceration, increased mitotic rate, positive deep margins, lymphovascular invasion, age < 40 years, significant vertical growth phase, Clark level ≥IV) are present

    • May be considered for melanoma that exhibits regression (controversial)

  • 2009: Sentinel lymph node biopsy for melanoma: indications and rationale

    • • "In our opinion, SLNB should be performed on most patients (with acceptable surgical and anesthesia risk) who have melanomas with a Breslow depth >or= 0.76 mm"

  • 2011: Sentinel node biopsy for head and neck melanoma: a systematic review

  • 2014: Sentinel lymph node biopsy in head and neck melanoma

  • 2014: Sentinel Lymph Node Biopsy in Head and Neck Melanoma: A Review

  • 2015: Is sentinel lymph node biopsy the standard of care for cutaneous head and neck melanoma?

  • Squamous cell carcinoma

  • 2009: Sentinel node biopsy in head and neck squamous cell carcinoma

  • 2014: Sentinel lymph node biopsy for oral cancer: supporting evidence and recent novel developments

  • 2015: Sentinel lymph node biopsy in oral and oropharyngeal squamous cell carcinoma: current status and unresolved challenges

  • Merkel cell carcinoma

  • 2012: Role of Sentinel Lymph Node Biopsy in the Management of Merkel Cell Carcinoma

  • 2012: Sentinel lymph node biopsy in patients with Merkel cell carcinoma: an emerging role and the Westmead hospital experience

  • 2016: Sentinel lymph node biopsy in Merkel cell carcinoma: a 15-year institutional experience and statistical analysis of 721 reported cases

  • Other readings

  • 2017: Management Controversies in Head and Neck Melanoma: A Systematic Review

Preparation

• • Nuclear Medicine suite for lymphoscintigraphy

  • Meet the technician, NM physician, and patient on the morning of the day of surgery

  • For dosing, see Dr. Rasgon's recommendations ***

  • 2009: Lymphoscintigraphy in cutaneous melanoma: an updated total body atlas of sentinel node mapping

  • 2015: EANM practice guidelines for lymphoscintigraphy and sentinel lymph node biopsy in melanoma

  • Equipment 

    • Ultrasound 

    • Methylene blue 

    • TB syringe and *** needle 

    • Neoprobe Gamma Detection System (GTS) with collimator (YouTube 0:21 - Neoprobe In-Service Video: Technician Focus - Collimator)

    • Tray ***

  • Inspect, palpate, and mark the primary tumor 

  • Inspect, palpate, scan with Neoprobe, ultrasound, and mark suspect sentinel lymph nodes(s) 

Procedure

• • Infiltrate Methylene blue intradermally at 4 points around the gross margin of the primary tumor 

  • Infiltrate local anesthesia 

  • Prep and drape

  • Complete wide local excision of the primary tumor 

    • Orient for permanent pathology 

  • Scan the wound bed

  • Identify the potential SLN with the highest gamma count 

  • Dissect and remove the first SLN

    • Measure the gamma count of the first SLN ex vivo and record this value 

  • Repeat scan the wound bed

  • If the background gamma count is less than 10% of the "hottest" (highest count) SLN ex vivo then cease the dissection 

    • If not, then continue to dissect and remove additional SLNs 

Sample operative report

Post-op

Pearls & Pitfalls

• • Plan all SLNB incisions being mindful that a completion neck dissection or parotidectomy may be necessary in the future 

High-Yield

Links

• eMedicine - Sentinel Lymph Node Biopsy in Patients With Melanoma

• eMedicine - Sentinel Lymph Node Biopsy for Squamous Cell Carcinoma

• YouTube (24:24) - Sentinel Lymph Node Biopsy in the Surgical Management of Melanoma

• YouTube (25:35) - Malignant Melanoma State of the Art – Sentinel Lymph Node Biopsy