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Preoperative and Intraoperative Lymphatic Mapping for Radioguided Sentinel Lymph Node Biopsy in Cutaneous Melanoma

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Atlas of Lymphoscintigraphy and Sentinel Node Mapping

Abstract

Regional lymph nodes are often the initial landing site for metastases, and lymphatic mapping is currently a routine procedure in patients with intermediate-risk melanoma. Lymphatic drainage of the skin is unpredictable in many regions, and the sentinel lymph nodes (draining lymph nodes in the direct lymphatic pathway from the tumour) can be found in unexpected positions. Lymphoscintigraphy depicts the migration sequence of the radiotracer from the primary lesion site and its subsequent uptake by the lymph nodes—thus indicating the area to be explored during surgery. Various studies have demonstrated a wide variability in lymphatic drainage of the skin, and preoperative lymphatic mapping is an essential component to personalize the sentinel lymph node approach. Tumour status of the sentinel lymph node is the most important prognostic factor in the early stages of melanoma, and sentinel lymph node biopsy has been widely adopted by surgical oncologists as an alternative to elective lymphadenectomy. Radioguided sentinel lymph node biopsy requires an accurate methodology in terms of radiocolloid injection, activity to be injected, image timing, and patient positioning. To improve results, new technologies and new tracers have been integrated in the original scenario, allowing better identification of sentinel lymph nodes in an anatomical environment (SPECT/CT) as well as in the intraoperative setting (portable gamma cameras and fluorescence cameras).

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Author information

Authors and Affiliations

  1. Nuclear Medicine Department, Hospital Clinic Barcelona, Barcelona, Catalonia, Spain

    Sergi Vidal-Sicart & Andrés Perissinotti

  2. Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Catalonia, Spain

    Sergi Vidal-Sicart

  3. Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Barcelona, Catalonia, Spain

    Andrés Perissinotti

  4. Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Centre, Leiden, Netherlands

    Daphne D. D. Rietbergen

  5. Department of Radiology, Section of Nuclear Medicine and Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands

    Renato A. Valdés Olmos

Authors
  1. Sergi Vidal-Sicart
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  2. Andrés Perissinotti
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  3. Daphne D. D. Rietbergen
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  4. Renato A. Valdés Olmos
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Corresponding author

Correspondence to Sergi Vidal-Sicart .

Editor information

Editors and Affiliations

  1. Regional Center of Nuclear Medicine Department of Translational Research and Advanced Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy

    Giuliano Mariani

  2. Nuclear Medicine Department, Hospital Clinic Barcelona, Barcelona, Catalonia, Spain

    Sergi Vidal-Sicart

  3. Department of Radiology Section of Nuclear Medicine and Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands

    Renato A. Valdés Olmos

Clinical Cases

Clinical Cases

Case 10.1: SLN Mapping in Melanoma of the Upper Back: Exclusive Drainage to SLNs in the Supraclavicular Fossa

Sergi Vidal-Sicart Núria Sánchez Andrés Tapias Antoni Bennássar

Background Clinical Case

A 67-year-old man with a black, non-ulcerated lesion on the upper back region (near the right scapula) with dermatoscopic features compatible with nodular melanoma, underwent excisional biopsy. Pathological analysis of the mole revealed nodular melanoma (7.0 mm Breslow thickness, IV Clark). Physical and preoperative examinations (ultrasonography) did not reveal suspicious regional lymph nodes.

Lymphoscintigraphy

Lymphoscintigraphy was performed 20 h before SLNB, to define the draining lymphatic basin at risk for metastatic disease and to identify the corresponding SLN. Four aliquots of 0.1 mL containing 27.5 MBq of ICG-99mTc-albumin nanocolloid were injected intradermally around the margins of the surgical scar, since the primary lesion had already been excised for biopsy. A dual-detector SPECT/CT gamma camera (Infinia Hawkeye GE Healthcare, Milwaukee, WI) equipped with low-energy general-purpose (LEGP) collimators was used to obtain planar images of the abdominal region by early dynamic imaging (2 frames/min for 10 min, 128 × 128 matrix, zoom 1.0) and 180-s delayed static imaging in anterior, and lateral views (256 × 256 matrix, zoom 1.00) at 15 min and 2 h after injection. SPECT/CT imaging was recorded after acquiring the delayed images (2 h). Image reconstruction was performed using a Xeleris (GE Healthcare) Workstation and 3D volume-rendering images were generated with a dedicated software (OsiriX MD, Pixmeo, Geneva, Switzerland).

Fig. 10.17
figure 17

Intradermal injection of four doses of ICG-99mTc-nanocolloid around the biopsy scar on right parascapular area. (a) Dynamic lymphoscintigraphy showed the progression of tracer to a “caudal” to injection site uptake (red arrow) that was considered the SLN (b)

Full size image
Fig. 10.18
figure 18

Planar anterior view (a–c), with a lead covering injection site (d), and right lateral views (e) were subsequently acquired. The uptake was located anteriorly to injection site (red arrow). The fused axial SPECT/CT image (f) and volume-rendering images (g and h), precisely located two different foci of tracer uptake in the right supraclavicular fossa. This information was crucial to plan the optimal surgical approach

Full size image

Case 10.2: SLN Mapping in Melanoma of the Perianal Area: Drainage to Inguinal and Iliac Lymph Nodes

Sergi Vidal-Sicart Antonio Seva Antoni Bennássar

Background Clinical Case

A 56-year-old man with a black- and brown-pigmented area in the left gluteus underwent excisional biopsy. Histology revealed a heavily pigmented dermal, asymmetric superficial spread melanoma, involving the dermo-epidermal junction (Breslow 1.5 mm, Clark’s level IV). Preoperative computed tomography (CT) of chest and abdomen was normal.

Lymphoscintigraphy

Lymphoscintigraphic delayed images were acquired 16 h before SLNB, to define the draining lymphatic basin at risk for metastatic disease and to identify the corresponding SLN. Four aliquots of 0.1 mL each, containing in total 111 MBq of ICG-99mTc-albumin nanocolloid, were injected intradermally around the margins of the surgical scar, since the primary lesion had already been excised for biopsy. A one-detector gamma camera (E-Cam, Siemens, Erlangen, Germany) equipped with low-energy high-resolution (LEHR) collimators was used to obtain planar images of the abdominal and chest regions by early dynamic imaging (1 frame/30 s for 10 min) and delayed static imaging (anterior and lateral views), with a 256 × 256 matrix and zoom factor 1.00.

Fig. 10.19
figure 19

Pigmented lesion located on the inner part of the left buttock, near the anal margin (a). Same location after excisional biopsy of the lesion (b). Schematic representation of the area of injection, around the biopsy scar (c). Anterior static acquisition of the thorax 30 min after radiotracer injections showing no drainage to potential in-transit or axillary nodes. Although very infrequent drainage has been observed coming from gluteal area, acquisition of one scan is recommended in order to rule out any uptake (d). A lymphatic duct, connecting inguinal and iliac lymph nodes, is clearly depicted in the anterior abdominal view (e). Left (f) and right (g) lateral views showing the different depth of these foci of uptake. Right lateral view showed the activity coming from the left nodes, but no right nodes appeared

Full size image

Case 10.3: SLN Mapping in Melanoma of the Back: Drainage to In-Transit Paravertebral, Flank Lymph Nodes and Bilateral Inguinal Basins

Sergi Vidal-Sicart Antoni Bennássar Antonio Seva

Background Clinical Case

A 38-year-old woman with a lesion of the central lumbar region (L3 level) underwent excisional biopsy. Histology showed that the melanoma was in vertical growth phase, with epithelioid cells, and extended to the reticular dermis (Breslow 0.8 mm; Clark’s level III). No axillary or groin lymphadenopathy was detected at ultrasonography examination.

Lymphoscintigraphy

Lymphoscintigraphy was performed 17 h before SLNB, to assess the lymphatic drainage and identify the basins at risk for metastatic disease and to identify the corresponding SLN. Aliquots of 0.4 mL containing in total 111 MBq of 99mTc-albumin nanocolloid were injected intradermally around the margins of the surgical scar located in lumbar zone. Dynamic study and delayed planar images were obtained with a single-headed gamma camera (E-Cam, Siemens, Erlangen, Germany) immediately after tracer injection (dynamic study lasting for 10 min and planar static images at 15 min and 2 h after injection). After the 2-h delayed images, a dual-detector SPECT gamma camera (Infinia Hawkeye GE Healthcare, Milwaukee, WI) equipped with low-energy general-purpose (LEGP) collimators was used to acquire SPECT/CT imaging (SPECT acquisition: 120 3° frames, and 30 s/frame in a 128 × 128 matrix, zoom 1.0).

Fig. 10.20
figure 20

Upper row: Early planar images acquired 15 min after tracer injection (a). Anterior thoracic view showing the injection site (left image, bottom) and a tiny focus of uptake left to injection site, but no axillary drainage at all. Abdominal and inguinal area scan showed bilateral inguinal drainage through two well-defined lymphatic channels. A hot spot was clearly observed in both inguinal areas (central image). Right and left lateral views nicely demonstrated the lymphatic channels to inguinal area (right images). Lower row: Delayed planar images at 2 h after tracer injection (b). Anterior thoracic view showing no changes to the early image (left image). Abdominal and inguinal area scan showing bilateral inguinal drainage and the appearance of second-echelon nodes in every inguinal basin. A well-defined focus of uptake is now clearly identified in left flank at the same level of injection site. It was considered an in-transit SLN (central image). Right and left lateral views nicely demonstrated the corresponding SLNs in every area and the in-transit left flank (right images)

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Fig. 10.21
figure 21

SPECT/CT reconstruction with axial slices, 3D volume-rendering and MIP images showing the complex drainage from the injection site. The images demonstrate the importance of SPECT/CT in this case. Two subcutaneous in-transit left flank hot spots were clearly seen in the volume-rendering image and in the corresponding axial slice (c left and right, respectively). Two different faint hot spots were observed in dorsal paravertebral area (d left and right) that were unnoticed in planar images. Volume-rendering and MIP images depicted all different tracer hot spots. A right paravertebral uptake (L3 level, near injection site) was discovered (e and f). During surgery, the in-transit left flank SLNs were intraoperatively imaged with a portable gamma camera equipped with an optical camera (g). Paravertebral nodes were not surgically pursued, although activity was demonstrated both with a portable gamma camera and with a handheld gamma probe

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Case 10.4: SLN Mapping in Melanoma of the Neck: Bilateral Drainage to Right Submandibular and Right Axillary Lymph Nodes

Sergi Vidal-Sicart Antoni Bennássar Núria Sánchez Erika Padilla-Morales John Orozco

Background Clinical Case

A 50-year-old woman with desmoplastic melanoma of the right-central neck, already surgically removed for biopsy. Histology showed that the melanoma was in radial growth stage and extended to the reticular dermis (Breslow 3.0 mm; Clark’s level IV, no mitosis per mm2 was present).

Lymphoscintigraphy

Lymphoscintigraphy was performed 17 h before SLNB, to define the draining lymphatic basin at risk for metastatic disease and to identify the corresponding SLN. Four aliquots of 0.1 mL each, containing a total activity of 111 MBq of 99mTc-albumin nanocolloid, were intradermally injected around the margins of the surgical scar. Dynamic study and delayed planar images were obtained with a single-headed gamma camera (E-Cam, Siemens, Erlangen, Germany) immediately after tracer administration (dynamic study lasting for 10 min and planar static images at 15 min and 2 h after injection). After acquiring the 2-h delayed images, a dual-detector SPECT gamma camera (Infinia Hawkeye GE Healthcare, Milwaukee, WI) equipped with low-energy general-purpose (LEGP) collimators was used to obtain tomographic images (SPECT/CT). SPECT acquisition: 120 3° frames, 30 s/frame in a 128 × 128 matrix and zoom 1.0.

Preoperative assessment was also performed with the Declipse freehand SPECT (SurgicEye, Munich, Germany) and a portable gamma camera (Sentinella, Oncovision, Valencia, Spain) in order to precisely mark the SLN localization on the patient’s skin.

Fig. 10.22
figure 22

Upper row: Early planar images performed at 15 min after tracer injection (a, b). Anterior and right lateral thoracic views showing the injection site and two lymphatic channels going cranially and caudally to different lymphatic basins (neck and axilla). Lower row: Delayed planar images at 2 h after tracer injection (c, d). Anterior and right lateral thoracic views showing two hot spots in right cervical area (cranially to injection site). A faint uptake is depicted on the left-hand side, at similar level, corresponding to a new SLN (arrow). A right hot spot, caudally to injection site, is well depicted as axillary SLN. Volume-rendering images showing the precise anatomical location of these SLNs (e, f)

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Fig. 10.23
figure 23

Upper row: Declipse freehand SPECT in cervical area (g). 3D SPECT/CT data overlay showing the position of every SLN (left). Data collection with freehand technique using a handheld gamma probe (central). SLN depiction (arrows) after data reconstruction (right). Lower row: Sentinella portable gamma camera in cervical area (h). Right lateral cervical view demonstrating the uptake (arrow) cranially to the injection site corresponding to the SLNs (right). A tiny uptake (arrow) is depicted on the left-hand side, at similar level, corresponding to the left cervical level II SLN (central). Intraoperative activity (arrow) corresponding to the right cervical level II SLNs after the wide local excision of the lesion. A handheld gamma probe is used (as well as the portable gamma camera) to assess that activity (left)

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Case 10.5: SLN Mapping in Melanoma of the Head and Neck: Drainage to Ipsilateral Preauricular (Parotid) and Cervical Nodes

Andrés Tapias Agustí Toll Carles Martí Andrés Perissinotti Sergi Vidal-Sicart

Background Clinical Case

A 59-year-old man with melanoma in the right frontal region (superficial spread melanoma, 1.8 Breslow thickness, IV Clark, 2 mitoses per mm2) was submitted to lymphoscintigraphy for radioguided SLNB.

Lymphoscintigraphy

Lymphoscintigraphy was performed 18 h before SLNB, to define the draining lymphatic basin at risk for metastasis and to locate the corresponding SLN. Four aliquots of 0.1 mL each containing 18.5 MBq of 99mTc-Tilmanocept were intradermally injected around the margins of the surgical scar, since the primary lesion had already been excised for biopsy. A single-detector gamma camera (E-Cam, Siemens, Erlangen, Germany) equipped with low-energy high-resolution (LEHR) collimators was used to obtain head-neck planar images, by early dynamic imaging (1 frame/30 s for 10 min) and delayed static imaging (anterior and lateral views at 15 min and 2 h p.i.). SPECT/CT acquisition was performed with a dual-detector gamma camera (Symbia Intevo Bold, Siemens Healthcare, Erlangen, Germany) using a step-and-shoot protocol of 30 s/3° for a total of 60 views per camera head, 128 × 128 matrix, zoom factor 1.45. CT parameters included a current of 40 mA, a voltage of 130 kV and a slice thickness of 2.75 mm slice.

Fig. 10.24
figure 24

Intradermal injections around biopsy scar located in right frontal area. In this part of the body it is not always easy to raise a wheal in the skin when injecting the radiotracer. (a–d) Early (15 min, e) planar imaging (right lateral view) shows two separate lymphatic channels leading to two separate areas of focal uptake of the tracer corresponding to two right cervical SLNs (red arrows), without specifying their topographic location. Two subsequent-tier nodes caudally to SLNs were also depicted (yellow arrow). Delayed (2 h, f) planar right lateral view showed the same SLNs and two more active nodes near the most caudal SLN

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Fig. 10.25
figure 25

3D volume-rendering images and SPECT/CT fused images in axial plane show that were actually two cranial SLNs, one located in right preauricular zone (upper row) and the other within the right parotid gland (lower row)

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Fig. 10.26
figure 26

Intraoperative images. A portable gamma camera (Sentinella, Oncovision, Valencia, Spain) was used to preoperatively demonstrate the activity of the tracer just before surgical procedure and to refine the skin marks done the day before (a, b). One millilitre of indocyanine green (25 mg/5 mL sterile water dilution) was preoperatively injected. A fluorescence camera (Hamamatsu FIS-00, Hamamatsu Photonics K.K., Shizuoka, Japan) was used to visualize lymphatic mapping, showing two separate lymphatic ducts confluent to right preauricular area (c, d). After careful dissection, a preauricular node was clearly seen (e, f)

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Fig. 10.27
figure 27

Cervical SLNs in level IIa (green arrows) were easily located with the combination of radioactive signal and fluorescence signal

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Vidal-Sicart, S., Perissinotti, A., Rietbergen, D.D.D., Valdés Olmos, R.A. (2020). Preoperative and Intraoperative Lymphatic Mapping for Radioguided Sentinel Lymph Node Biopsy in Cutaneous Melanoma. In: Mariani, G., Vidal-Sicart, S., Valdés Olmos, R. (eds) Atlas of Lymphoscintigraphy and Sentinel Node Mapping. Springer, Cham. https://doi.org/10.1007/978-3-030-45296-4_10

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