Influence of fast lymphatic drainage on metastatic spread in cutaneous malignant melanoma: a prospective feasibility study

  • Sofiane Maza
  • Ray Valencia
  • Lilli Geworski
  • Dirk Sandrock
  • Andreas Zander
  • Heike Audring
  • Erik Dräger
  • Helmut Winter
  • Wolfram Sterry
  • Dieter L. Munz
Original Article


The concept of sentinel lymph node biopsy in cutaneous malignant melanoma is widely established. Preoperative cutaneous lymphoscintigraphic mapping is a reliable method for identifying the nodal basins at risk of metastases in melanomas. In this prospective study we investigated the correlation between the scintigraphic appearance time and the metastatic involvement of sentinel lymph nodes. In 276 malignant melanoma patients (137 women, 139 men; age 16–93 years), dynamic and static lymphoscintigraphy was performed after strict intracutaneous application of technetium-99m nanocolloid (40–150 MBq; 0.05 ml/deposit) around the tumour or biopsy scar. Analysis of dynamic scans primarily focussed on the appearance time of sentinel lymph nodes. Sentinel lymph node visualisation ≤20 min post injection was defined as fast drainage, and visualisation >20 min as slow drainage. Fast lymphatic drainage was found in 236 patients, of whom 34 (14.4%) had sentinel lymph node metastases. Twenty-two patients showed hybrid (fast and slow) lymphatic drainage, and eight (36.4%) of them had sentinel lymph node metastases. Seven of the latter demonstrated fast lymphatic drainage, while one showed one positive sentinel lymph node with fast and another with slow drainage. The melanomas of 18 patients demonstrated exclusively slow lymphatic drainage, in all cases without sentinel lymph node metastases. This prospective study indicates that the scintigraphic appearance time of sentinel lymph nodes seems to be a clinically relevant factor for prediction of metastatic spread of cutaneous malignant melanoma. Larger numbers of patients need to be examined to truly assess the benefit of the scintigraphic appearance time compared with other predictors of sentinel lymph node tumour positivity.


Melanoma Metastasis Sentinel lymph node Lymphatic mapping Lymphoscintigraphy 


  1. 1.
    Morton DL, Wen D-R, Wong JH, Economou JS, Cagle LA, Storm FK, Foshg LJ, Cochran AJ. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 1992; 127:392–399.Google Scholar
  2. 2.
    Munz DL, ed. The sentinel lymph node concept in oncology – facts and fiction. Munich: Zuckschwerdt, 2001.Google Scholar
  3. 3.
    Morton DL, Bostick PJ. Will the true sentinel node please stand? Ann Surg Oncol 1999; 6:12–14.Google Scholar
  4. 4.
    Uren RF, Howman-Giles R, Thompson JF. Lymphoscintigraphy to identify sentinel lymph nodes in patients with melanoma. Melanoma Res 1994; 4:395–399.Google Scholar
  5. 5.
    Gershenwald JE, Thompson W, Mansfield PF, Lee JE, Colome MI, Tseng C, Lee JJ, Balch CM, Reintgen DS, Ross MI. 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; 17:976–983.Google Scholar
  6. 6.
    Jansen L, Nieweg OE, Peterse JL, Hoefnagel CA, Olmos RA, Kroon BB. Reliability of sentinel lymph node biopsy for staging melanoma. Br J Surg 2000; 87:484–489.Google Scholar
  7. 7.
    McMasters KM, Reintgen DS, Ross MI, Gershenwald JE, Edwards MJ, Sober A, Fenske N, Glass F, Balch CM, Coit DG. Sentinel lymph node biopsy for melanoma: controversy despite widespread agreement. J Clin Oncol 2001; 19:2851–2855.Google Scholar
  8. 8.
    Statius Muller MG, van Leeuwen PA, de Lange-de Klerk ES, van Diest PJ, Pijpers R, Ferwerda CC, Vuylsteke RJ, Meijer S. The sentinel lymph node status is an important factor for predicting clinical outcome in patients with stage I or II cutaneous melanoma. Cancer 2001; 91:2401–2408.Google Scholar
  9. 9.
    Krag D, Moffat F. Nuclear medicine and the surgeon. Lancet 1999; 354:1019–1022.Google Scholar
  10. 10.
    Munz DL, Altmeyer P, Sessler MJ, Hör G. Axillary lymph node groups—the center in lymphatic drainage from the truncal skin in man. Clinical significance for management of malignant melanoma. Lymphology 1982; 15:143–147.Google Scholar
  11. 11.
    Valdes Olmos RA, Tanis PJ, Hoefnagel CA, Nieweg OE, Muller SH, Rutgers EJT, Jansen L, Kroon BBR. Improved sentinel node visualization in breast cancer by optimizing the tracer dosage and particle concentration [abstract]. Eur J Nucl Med 2000; 27:1134.Google Scholar
  12. 12.
    UICC. TNM Supplement 2001. A commentary on uniform use, 2nd edn. Wittekind C, Henson DE, Hutter RVP, Sobin LH, eds. New York: Wiley, 2001.Google Scholar
  13. 13.
    Fee HJ, Robinson DS, Sample WF, Graham LS, Holmes EC, Morton DL. The determination of lymph shed by colloidal gold scanning in patients with malignant melanoma: a preliminary study. Surgery 1978; 84:626–632.Google Scholar
  14. 14.
    Robinson DS, Sample WF, Fee HJ, Holmes EC, Morton DL. Regional lymphatic drainage in primary malignant melanoma of the trunk determined by colloidal gold scanning. Surg Forum 1977; 28:147–148.Google Scholar
  15. 15.
    Thompson JF, McCarthy WH, Bosch CM, O'Brien CJ, Quinn MJ, Paramaesvaran S, Crotty K, McCarthy SW, Uren RF, Howman-Giles R. Sentinel lymph node status as an indicator of the presence of metastatic melanoma in regional lymph nodes. Melanoma Res 1995; 5:255–260.Google Scholar
  16. 16.
    Albertini JJ, Cruse CW, Rapaport D, Wells K, Ross M, DeConti R, Berman CG, Jared K, Messina J, Lyman G, Glass F, Fenske N, Reintgen DS. Intraoperative radiolymphoscintigraphy improves sentinel lymph node identification for patients with melanoma. Ann Surg 1996; 223:217–224.Google Scholar
  17. 17.
    Kapteijn BA, Nieweg OE, Muller SH, Liem IH, Hoefnagel CA, Rutgers EJ, Kroon BB. Validation of gamma probe detection of the sentinel node in melanoma. J Nucl Med 1997; 38:362–366.Google Scholar
  18. 18.
    Pijpers R, Borgstein PJ, Meijer S, Hoekstra OS, van Hattum LH, Teule GJ. Sentinel node biopsy in melanoma patients: dynamic lymphoscintigraphy followed by intraoperative gamma probe and vital dye guidance. World J Surg 1997; 21:788–792.Google Scholar
  19. 19.
    Mraz-Gernhard S, Sagebiel RW, Kashani-Sabet M, Miller JR 3rd, Leong SP. Prediction of sentinel lymph node micrometastasis by histological features in primary cutaneous malignant melanoma. Arch Dermatol 1998; 134:983–987.Google Scholar
  20. 20.
    Birdwell RL, Smith KL, Betts BJ, Ikeda DM, Strauss HW, Jeffrey SS. Breast cancer: variables affecting sentinel lymph node visualization at preoperative lymphoscintigraphy. Radiology 2001; 220:47–53.Google Scholar
  21. 21.
    Haigh PI, Hansen NM, Giuliano AE, Edwards GK, Ye W, Glass EC. Factors affecting sentinel node localization during preoperative breast lymphoscintigraphy. J Nucl Med 2000; 41:1682–1688.Google Scholar
  22. 22.
    Földi M, Kubik S, eds. Lehrbuch der Lymphologie. Stuttgart: Gustav Fischer, 1993.Google Scholar
  23. 23.
    Kapteijn BAE, Nieweg OE, Valdes Olmos RA, Liem ICH, Baidjnath Panday RKL, Hoefnagel CA, Kroon BB. Reproducibility of lymphoscintigraphy for lymphatic mapping in patients with cutaneous melanoma. J Nucl Med 1996; 37:972–975.Google Scholar
  24. 24.
    Mudun A, Murray DR, Herda SC, Eshima D, Shattuck LA, Vansant JP, Taylor AT, Alazraki NP. Early stage melanoma: lymphoscintigraphy, reproducibility of sentinel node detection, and effectiveness of the intraoperative gamma probe. Radiology 1996; 199:171–175.Google Scholar
  25. 25.
    Martinez-Escribano JA, Navarro JL, Pinero A, Nicolas F, Frias JF, Sanchez-Pedreno P, Parrilla P. Does injection distance of the radiocolloid modify lymphatic mapping in melanoma? Dermatol Surg 2001; 27:881–884.Google Scholar
  26. 26.
    Rettenbacher L, Koller J, Kässmann H, Holzmannhofer J, Rettenbacher T, Galvan G. Reproducibility of lymphoscintigraphy in cutaneous melanoma: can we accurately detect the sentinel lymph node by expanding the tracer injection distance from the tumor site? J Nucl Med 2001; 42:424–429.Google Scholar
  27. 27.
    Ivancevic V, Munz DL. Radiopharmaceuticals and dyes. In: Munz DL, ed. The sentinel lymph node concept in oncology—facts and fiction. Munich: Zuckschwerdt; 2001:37–54.Google Scholar

Copyright information

© Springer-Verlag 2003

Authors and Affiliations

  • Sofiane Maza
    • 1
  • Ray Valencia
    • 1
  • Lilli Geworski
    • 1
  • Dirk Sandrock
    • 1
  • Andreas Zander
    • 1
  • Heike Audring
    • 2
  • Erik Dräger
    • 3
  • Helmut Winter
    • 3
  • Wolfram Sterry
    • 3
  • Dieter L. Munz
    • 1
  1. 1.Clinic for Nuclear MedicineUniversity Hospital Charité, Humboldt University of BerlinBerlinGermany
  2. 2.Division of DermatopathologyUniversity Hospital Charité, Humboldt University of BerlinBerlinGermany
  3. 3.Clinic for Dermatology, Venereology and AllergologyUniversity Hospital Charité, Humboldt University of BerlinBerlinGermany

Personalised recommendations