Annals of Surgical Oncology

, Volume 19, Issue 4, pp 1100–1106 | Cite as

Preoperative Ultrasound is Not Useful for Identifying Nodal Metastasis in Melanoma Patients Undergoing Sentinel Node Biopsy: Preoperative Ultrasound in Clinically Node-Negative Melanoma

  • Christy Y. Chai
  • Jonathan S. Zager
  • Margaret M. Szabunio
  • Suroosh S. Marzban
  • Alec Chau
  • Robert M. Rossi
  • Vernon K. Sondak



Sentinel lymph node biopsy (SLNB) is widely used in melanoma. Identifying nodal involvement preoperatively by high-resolution ultrasound may offer less invasive staging. This study assessed feasibility and staging results of clinically targeted ultrasound (before lymphoscintigraphy) compared to SLNB.


From 2005 to 2009, a total of 325 patients with melanoma underwent ultrasound before SLNB. We reviewed demographics and histopathologic characteristics, then compared ultrasound and SLNB results. Sensitivity, specificity, and positive and negative predictive value were determined.


A total of 325 patients were included, 58% men and 42% women with a median age of 58 (range 18–86) years. A total of 471 basins were examined with ultrasound. Only six patients (1.8%) avoided SLNB by undergoing ultrasound-guided fine-needle aspiration of involved nodes, then therapeutic lymphadenectomy. Sixty-five patients (20.4%) had 69 SLNB positive nodal basins; 17 nodal basins from 15 patients with positive ultrasounds were considered truly positive. Forty-five SLNB positive basins had negative ultrasounds (falsely negative). Seven node-positive basins did not undergo ultrasound because of unpredicted drainage. A total of 253 patients with negative SLNBs had negative ultrasounds in 240 nodal basins (truly negative) but falsely positive ultrasounds occurred in 40 basins. Overall, sensitivity of ultrasound was 33.8%, specificity 85.7%, positive predictive value 36.5%, and negative predictive value 84.2%. Sensitivity and specificity improved somewhat with increasing Breslow depth. Sensitivity was highest for the neck, but specificity was highest for the groin.


Routine preoperative ultrasound in clinically node-negative melanoma is impractical because of its low sensitivity. Selected patients with thick or ulcerated lesions may benefit. Because of variable lymphatic drainage patterns, preoperative ultrasound without lymphoscintigraphic localization will provide incomplete evaluation in many cases.


  1. 1.
    Buzzell RA, Zitelli JA. Favorable prognostic factors in recurrent and metastatic melanoma. J Am Acad Dermatol. 1996;34:798–803.PubMedCrossRefGoogle Scholar
  2. 2.
    Estourgie SH, Nieweg OE, Valdes Olmos RA, et al. Review and evaluation of sentinel node procedures in 250 melanoma patients with a median follow-up of 6 years. Ann Surg Oncol. 2003;10:681–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Stebbins WG, Garibyan L, Sober AJ. Sentinel lymph node biopsy and melanoma: 2010 update, part II. J Am Acad Dermatol. 2010;62:737–48.PubMedCrossRefGoogle Scholar
  4. 4.
    Stebbins WG, Garibyan L, Sober AJ. Sentinel lymph node biopsy and melanoma: 2010 update, part I. J Am Acad Dermatol. 2010;62:723–34.PubMedCrossRefGoogle Scholar
  5. 5.
    Morton DL, Wen DR, Wong JH, et al. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg. 1992;127:392–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Van Akkooi AC, de Wilt JH, Verhoef C, et al. High positive sentinel node identification rate by EORTC Melanoma Group protocol. Prognostic indicators of metastatic patterns after sentinel node biopsy in melanoma. Eur J Cancer. 2006;42:372–80.PubMedCrossRefGoogle Scholar
  7. 7.
    Uren RF, Howman-Giles R, Thompson JF, et al. High-resolution ultrasound to diagnose melanoma metastases in patients with clinically palpable lymph nodes. Australas Radiol. 1999;43:148–52.PubMedCrossRefGoogle Scholar
  8. 8.
    Bafounta ML, Beauchet A, Chagnon S, Saiag P. Ultrasonography or palpation for detection of melanoma nodal invasion: a meta-analysis. Lancet Oncol. 2004;5:673–80.PubMedCrossRefGoogle Scholar
  9. 9.
    Voit C, Mayer T, Proebstle TM, et al. Ultrasound-guided fine-needle aspiration cytology in the early detection of melanoma metastases. Cancer. 2000;90:186–93.PubMedCrossRefGoogle Scholar
  10. 10.
    Blum A, Schlagenhauff B, Stroebel W, et al. Ultrasound examination of regional lymph nodes significantly improves early detection of locoregional metastases during the follow-up of patients with cutaneous melanoma: results of a prospective study of 1288 patients. Cancer. 2000;88:2534–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Voit C, Mayer T, Kron M, et al. Efficacy of ultrasound B-scan compared with physical examination in follow-up of melanoma patients. Cancer. 2001;91:2409–16.PubMedCrossRefGoogle Scholar
  12. 12.
    Rossi CR, Seno A, Vecchiato A, et al. The impact of ultrasound scanning in the staging and follow-up of patients with clinical stage I cutaneous melanoma. Eur J Cancer. 1997;33:200–3.PubMedCrossRefGoogle Scholar
  13. 13.
    Starritt EC, Uren RF, Scolyer RA, et al. Ultrasound examination of sentinel nodes in the initial assessment of patients with primary cutaneous melanoma. Ann Surg Oncol. 2005;12:18–23.PubMedCrossRefGoogle Scholar
  14. 14.
    Testori A, Lazzaro G, Baldini F, et al. The role of ultrasound of sentinel nodes in the pre- and post-operative evaluation of stage I melanoma patients. Melanoma Res. 2005;15:191–8.PubMedCrossRefGoogle Scholar
  15. 15.
    van Rijk MC, Teertstra HJ, Peterse JL, et al. Ultrasonography and fine-needle aspiration cytology in the preoperative evaluation of melanoma patients eligible for sentinel node biopsy. Ann Surg Oncol. 2006;13:1511–6.PubMedCrossRefGoogle Scholar
  16. 16.
    Voit C, Kron M, Schafer G, et al. Ultrasound-guided fine needle aspiration cytology prior to sentinel lymph node biopsy in melanoma patients. Ann Surg Oncol. 2006;13:1682–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Voit CA, van Akkooi AC, Schafer-Hesterberg G, et al. Rotterdam criteria for sentinel node (SN) tumor burden and the accuracy of ultrasound (US)-guided fine-needle aspiration cytology (FNAC): can US-guided FNAC replace SN staging in patients with melanoma? J Clin Oncol. 2009;27:4994–5000.PubMedCrossRefGoogle Scholar
  18. 18.
    Rossi CR, Mocellin S, Scagnet B, et al. The role of preoperative ultrasound scan in detecting lymph node metastasis before sentinel node biopsy in melanoma patients. J Surg Oncol. 2003;83:80–4.PubMedCrossRefGoogle Scholar
  19. 19.
    Schmid-Wendtner MH, Paerschke G, Baumert J, et al. Value of ultrasonography compared with physical examination for the detection of locoregional metastases in patients with cutaneous melanoma. Melanoma Res. 2003;13:183–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Voit C, Van Akkooi AC, Schafer-Hesterberg G, et al. Ultrasound morphology criteria predict metastatic disease of the sentinel nodes in patients with melanoma. J Clin Oncol. 2010;28:847–52.PubMedCrossRefGoogle Scholar
  21. 21.
    Puleo CA, Messina JL, Riker AI, et al. Sentinel node biopsy for thin melanomas: which patients should be considered? Cancer Control. 2005;12:230–5.PubMedGoogle Scholar
  22. 22.
    Phan GQ, Messina JL, Sondak VK, Zager JS. Sentinel lymph node biopsy for melanoma: indications and rationale. Cancer Control. 2009;16:234–9.PubMedGoogle Scholar
  23. 23.
    Leong SP, Kim J, Ross M, et al. A phase 2 study of (99 m)Tc-tilmanocept in the detection of sentinel lymph nodes in melanoma and breast cancer. Ann Surg Oncol. 2011;18:961–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Wrightson WR, Wong SL, Edwards MJ, et al. Complications associated with sentinel lymph node biopsy for melanoma. Ann Surg Oncol. 2003;10:676–80.PubMedCrossRefGoogle Scholar
  25. 25.
    Schafer-Hesterberg G, Voit C. Ultrasound pre sentinel node dissection. Melanoma Res. 2008;18:68–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Morton DL, Thompson JF, Cochran AJ, et al. Sentinel-node biopsy or nodal observation in melanoma. N Engl J Med. 2006;355:1307–17.PubMedCrossRefGoogle Scholar
  27. 27.
    van Akkooi AC, Voit CA, Verhoef C, Eggermont AM. Potential cost-effectiveness of US-guided FNAC in melanoma patients as a primary procedure and in follow-up. Ann Surg Oncol. 2010;17:660–2.PubMedCrossRefGoogle Scholar
  28. 28.
    Aukema TS, Valdes Olmos RA, Wouters MW, et al. Utility of preoperative 18F-FDG PET/CT and brain MRI in melanoma patients with palpable lymph node metastases. Ann Surg Oncol. 2010;17:2773–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Whitman GJ, Strom EA. Workup and staging of locally advanced breast cancer. Semin Radiat Oncol. 2009;19:211–21.PubMedCrossRefGoogle Scholar
  30. 30.
    Sarvanan K, Bapuraj JR, Sharma SC, et al. Computed tomography and ultrasonographic evaluation of metastatic cervical lymph nodes with surgicoclinicopathologic correlation. J Laryngol Otol. 2002;116:194–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Kell MR, Ridge JA, Joseph N, Sigurdson ER. PET CT imaging in patients undergoing sentinel node biopsy for melanoma. Eur J Surg Oncol. 2007;33:911–3.PubMedCrossRefGoogle Scholar
  32. 32.
    Lam TK, Uren RF, Scolyer RA, et al. False-negative sentinel node biopsy because of obstruction of lymphatics by metastatic melanoma: the value of ultrasound in conjunction with preoperative lymphoscintigraphy. Melanoma Res. 2009;19:94–9.PubMedCrossRefGoogle Scholar
  33. 33.
    van Akkooi AC, Voit CA, Verhoef C, Eggermont AM. New developments in sentinel node staging in melanoma: controversies and alternatives. Curr Opin Oncol. 2010;22:169–77.PubMedCrossRefGoogle Scholar
  34. 34.
    Thompson JF, Stretch JR, Uren RF, et al. Sentinel node biopsy for melanoma: where have we been and where are we going? Ann Surg Oncol. 2004;11:147S–151S.PubMedCrossRefGoogle Scholar
  35. 35.
    Voit C, Van Akkooi AC, Schafer-Hesterberg G, et al. Ultrasound morphology criteria predict metastatic disease of the sentinel nodes in patients with melanoma. J Clin Oncol. 2010; 28:847–52.PubMedCrossRefGoogle Scholar
  36. 36.
    van Akkooi AC, de Wilt JH, Verhoef C, et al. Clinical relevance of melanoma micrometastases (<0.1 mm) in sentinel nodes: are these nodes to be considered negative? Ann Oncol. 2006;17:1578–85.PubMedCrossRefGoogle Scholar
  37. 37.
    van Akkooi AC, Nowecki ZI, Voit C, et al. Sentinel node tumor burden according to the Rotterdam criteria is the most important prognostic factor for survival in melanoma patients: a multicenter study in 388 patients with positive sentinel nodes. Ann Surg. 2008;248:949–55.PubMedCrossRefGoogle Scholar
  38. 38.
    Hocevar M, Bracko M, Pogacnik A, et al. The role of preoperative ultrasonography in reducing the number of sentinel lymph node procedures in melanoma. Melanoma Res. 2004;14:533–6.PubMedCrossRefGoogle Scholar
  39. 39.
    Sibon C, Chagnon S, Tchakerian A, et al. The contribution of high-resolution ultrasonography in preoperatively detecting sentinel-node metastases in melanoma patients. Melanoma Res. 2007;17:233–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Sanki A, Uren RF, Moncrieff M, et al. Targeted high-resolution ultrasound is not an effective substitute for sentinel lymph node biopsy in patients with primary cutaneous melanoma. J Clin Oncol. 2009;27:5614–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Thompson JF, Haydu LE, Uren RF, et al. Preoperative ultrasound assessment of sentinel nodes in melanoma patients does not provide reliable staging: results from a large multicenter trial. Ann Surg Oncol. 2011;18: S21, 46.Google Scholar
  42. 42.
    Lee MC, Eatrides J, Chau A, et al. Consequences of axillary ultrasound in patients with T2 or greater invasive breast cancers. Ann Surg Oncol. 2011;18:72–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Reynolds HM, Dunbar PR, Uren RF, et al. Three-dimensional visualisation of lymphatic drainage patterns in patients with cutaneous melanoma. Lancet Oncol. 2007;8:806–12.PubMedCrossRefGoogle Scholar
  44. 44.
    Thompson JF, Uren RF, Shaw HM, et al. Location of sentinel lymph nodes in patients with cutaneous melanoma: new insights into lymphatic anatomy. J Am Coll Surg. 1999;189:195–204.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2011

Authors and Affiliations

  • Christy Y. Chai
    • 1
  • Jonathan S. Zager
    • 2
    • 3
  • Margaret M. Szabunio
    • 4
  • Suroosh S. Marzban
    • 2
  • Alec Chau
    • 5
  • Robert M. Rossi
    • 2
  • Vernon K. Sondak
    • 2
    • 3
  1. 1.Department of SurgerySan Antonio Military Medical CenterSan AntonioUSA
  2. 2.Department of Cutaneous OncologyMoffitt Cancer CenterTampaUSA
  3. 3.Departments of Oncologic Sciences and SurgeryUniversity of South Florida College of MedicineTampaUSA
  4. 4.Division of Women’s RadiologyUniversity of Kentucky College of MedicineLexingtonUSA
  5. 5.Department of RadiologyMoffitt Cancer CenterTampaUSA

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