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Past
For patients with melanoma, the frequency and clinical relevance of metastasis to sentinel lymph nodes (SLNs) in minor lymph node fields is controversial. The triangular intermuscular space (TIS) on the upper lateral back contains one such minor node field and is often overlooked.1 Usually containing one to three lymph nodes, it is bounded by teres major, teres minor and the long head of triceps, and efferent lymphatics pass anteriorly from nodes in the TIS into the posterior axilla. Unless lateral lymphoscintigram views are obtained, preferably with SPECT-CT also,2 nodes in the TIS are likely to be misidentified as axillary nodes. This probably explains why the largest hitherto reported series of patients with TIS SLNs contained only 14 patients.3
Present
We assessed the frequency and management of SLNs in the TIS and outcomes following biopsy of these SLNs using information from a large institutional database.4 Preoperative lymphoscintigraphy revealed SLNs in the TIS of 266 patients, constituting 14% of 2,296 patients with melanomas on the upper back. SLN biopsy was performed in 53% of these patients, and 12% were found to be SLN-positive, resulting in upstaging of the majority of them. Recurrence in the TIS occurred only in patients who had not had a SLN biopsy, indicating that relapse in the TIS can be prevented by a SNB.
Future
Our study demonstrated the importance of high-quality, preoperative lymphoscintigraphy with lateral views, preferably with SPECT/CT, for patients with melanomas on the upper back. Biopsy of SLNs identified in the TIS is necessary to ensure accurate staging, and without this, eligible patients may not be offered potentially effective, adjuvant, systemic therapy.5 The SNB procedure will also result in better regional disease control and improved disease-free survival. The same principles are likely to apply to SNBs in other minor lymph node fields in patients with melanoma.
References
Uren RF, Howman-Giles R, Thompson JF, et al. Lymphatic drainage to triangular intermuscular space lymph nodes in melanoma on the back. J Nucl Med. 1996;37:964–6.
Moncrieff M, Pywell S, Snelling A, et al. Effectiveness of SPECT/CT imaging for sentinel node biopsy staging of primary cutaneous melanoma and patient outcomes. Ann Surg Oncol. 2022;29:767–75.
Hennessy SA, Dengel LT, Hranjec T, Slingluff CL Jr. A triangular intermuscular space sentinel node in melanoma: association with axillary lymphatic drainage. Ann Surg Oncol. 2010;17:2465–70.
Schoenfeldt T, Thompson JF, Lo S, et al. Prognostic significance and management of sentinel nodes in the triangular intermuscular space of patients with melanoma. Ann Surg Oncol. 2023;30:2354–61. https://doi.org/10.1245/s10434-022-12840-2.
Lao CD, Khushalani NI, Angeles C, Petrella TM. Current state of adjuvant therapy for melanoma: Less is more, or more is better? Am Soc Clin Oncol Educ Book. 2022;42:1–7.
Acknowledgment
Our study was funded by the Danish Cancer Society, Reinholdt W. Jorck og Hustrus Fond, and Knud Højgaard Fonden. We also thank Melanoma Institute Australia and Alfred Nuclear Medicine and Ultrasound, Sydney for support.
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DISCLOSURE
JFT has received honoraria for advisory board participation from BMS Australia, MSD Australia, GSK, and Provectus Inc., and travel and conference support from GSK, Provectus Inc., and Novartis. The other authors have no disclosures.
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Schoenfeldt, T., Chakera, A.H., Nieweg, O.E. et al. ASO Author Reflections: The Clinical Relevance of Sentinel Nodes in Minor Lymph Node Fields Such as the Triangular Intermuscular Space in Patients with Melanoma. Ann Surg Oncol 30, 5770–5771 (2023). https://doi.org/10.1245/s10434-023-13443-1
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DOI: https://doi.org/10.1245/s10434-023-13443-1