Abstract
The management of clinically negative regional lymph nodes in early-stage melanoma has been controversial for at least a century. While some surgeons offer elective lymph node dissection (ELND), others recommend treatment of the primary alone and only perform a therapeutic dissection (TLND) for cases of recurrence in the nodal basin. The rationale for ELND is based on the concept that metastases occur via the sequential passage of tumor from the primary site to the regional lymph nodes and then to more distant sites. If this theory is correct then early dissection of the regional lymph nodes will disrupt the metastatic cascade and prevent further spread of disease. On the other hand, advocates of the “wait and watch” approach suggest that metastases to the regional lymph node basin are only a marker of disease progression and that distant disease can occur in the absence of lymph node metastases. Four randomized prospective studies have examined the efficacy of ELND versus TLND. While all four studies have failed to demonstrate a survival advantage of ELND, there is some suggestion that patients with metastases in the regional basin may benefit from ELND.
As an alternative approach to this controversy, Morton and associates at the John Wayne Cancer Institute devised the technique of intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL). This minimally invasive operative procedure allows the surgeon to identify the first or sentinel lymph (SN) in the regional basin. The technique is predicated on accurate mapping of the cutaneous lymphatics by lymphoscintigraphy and the intraoperative use of a vital blue dye to lead the surgeon to the SN and allow the pathologists to identify metastases in the lymph nodes. Patients with tumor-positive dissections would undergo complete lymph node dissection (CLND), and for those without metastases the complications and costs associated with CLND could be avoided. The success of the procedure depends on the completion of the learning phase and the cooperation of the nuclear medicine physicians, surgeons, and pathologists. While this technique has become almost standard practice in the United States and around the world, we await the results of several important clinical trials to determine whether LM/SL will replace ELND or the wait and watch approach in the management of early-stage melanoma.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Preview
Unable to display preview. Download preview PDF.
References
Albertini JJ, Cruse CW, Rapaport D, et al. (1996) Intraoperative radiolymphoscintigraphy improves sentinel lymph node identification for patients with melanoma. Ann Surg 223:217–224.
Balch CM, Soong S-J, Murad TM, et al. (1981) A multifactorial analysis of melanoma. III. Prognostic factors in melanoma patients with lymph node metastases (stage III). Ann Surg 193:377–388.
Balch CM, Milton GW, Cascinelli N, Sim FH (1992) Elective lymph node dissection: pros and cons. In: Balch CM, Houghton AN, Milton GW, Sober AJ, Soong S-J (eds) Cutaneous melanoma, 2nd edn. Lippincott, Philadelphia, pp 345–366.
Balch CM, Soong SJ, Bartolucci AA, Urist MM, Karakousis CP, Smith TJ, et al. (1996) Efficacy of an elective regional lymph node dissection of 1 to 4 mm thick melanomas for patients 60 years of age and younger. Ann Surg 224:255–266.
Belli F, Lenisa L, Clemente C, Tragni G, Mascheroni L, Gallino G, Cascinelli N (1998) Sentinel node biopsy and selective dissection for melanoma nodal metastases. Tumori 84:24–28.
Bennett LR, Lago G (1983) Cutaneous lymphoscintigraphy in malignant melanoma. Semin Nucl Med 13:61–69.
Bilchik AJ, Giuliano AE, Essner R, et al. (1998) Universal application of intraoperative mapping and sentinel lymphadenectomy in solid neoplasms. Cancer J Sci Am 4:351–358.
Bostick P, Essner R, Santarou T, Kelley M, Glass E, Foshag L, Stern S, Morton DL (1997) Intraoperative lymphatic mapping for early-stage melanoma of the head and neck. Am J Surg 174:536–539.
Bostick PJ, Essner R, Glass E, Kelley M, Sarantou T, Foshag L, et al. (1999 a) Comparison of blue dye and probe-assisted intraoperative lymphatic mapping in melanoma to identify sentinel nodes in 100 lymphatic basins. Arch Surg 134:43–49.
Bostick PJ, Morton DL, Turner RR, et al. (1999 b) Prognostic significance of occult metastases detected by sentinel lymphadenectomy and reverse transcriptase-polymerase chain reaction in early-stage melanoma patients. J Clin Oncol 17:3238–3244.
Cabanas RM (1977) An approach to the treatment of penile carcinoma. Cancer 39:456–466.
Carson KF, Wen D-R, Li P-X, Lana AM, Bailly C, Morton DL, Cochran AJ (1996) Nodal nevi and cutaneous melanomas. Am J Surg Pathol 20:834–840.
Cascinelli N, Morabito A, Santinami M, Mackie RM, Belli F (1998) Immediate or delayed dissection of regional nodes in patients with melanoma of the trunk: a randomised trial. Lancet 351:793–796.
Chen Y-T, Stockert E, Jungblith A, et al. (1996) Serological analysis of Melan-A (MART-1), a melanocyte-specific protein homogenously expressed in human melanomas. Proc Natl Acad Sci USA 93:5915–5919.
Cochran AJ, Wen D-R, Herschman HR, Gaynor RB (1982) Detection of S-100 protein as an aid to the identification of melanocytic tumors. Int J Cancer 30:295–297.
Cochran AJ, Holland G, Wen D-R, Herschman HR, Lee WR, Straatsma BR (1983) Detection of S-100 protein in the diagnosis of primary and metastatic intraocular tumors. Invest Ophthalmol Vis Sci 24:1153–1155.
Cochran AJ, Wen D-R, Morton DL (1988) Occult tumor cells in the lymph nodes of patients with pathological stage I malignant melanoma: an immunohistological study. Am J Surg Pathol 12:612–618.
Cochran AJ, Wen DR, Morton DL (1992) Management of the regional lymph nodes in patients with cutaneous malignant melanoma. World J Surg 16:214–221.
Cochran AJ, Bailly C, Paul E, Remotti F (1997) Melanocytic tumors: a guide to diagnosis. Lippincott-Raven, Philadelphia.
Essner R (1997) The role of lymphoscintigraphy and sentinel node mapping in assessing patient risk in melanoma. Semin Oncol 24:S4–S10.
Essner R, Wen DR, Cochran A, Morton DL, Ramming KP (1993) Lymphatic mapping and selective lymph node biopsy: an alternative to elective lymphadenectomy for early-stage melanomas of the trunk and lower extremity. Proc Am Soc Clin Oncol 12:396.
Essner R, Foshag L, Morton DL (1994) Intraoperative radiolymphoscintigraphy: a useful adjunct to intraoperative lymphatic mapping and selective lymphadenectomy in patients with clinical stage I melanoma. Presented at the annual meeting of the Society of Surgical Oncology, Houston, Tex., 17–20 March.
Essner R, Bostick PJ, Glass EC, et al. (2000) Standardized probe-directed sentinel node dissection in melanoma. Surgery 127:26–31.
Fetsch PA, Cromier J, Hijazi YM (1997) Immunocytochemical detections of MART-1 in fresh and paraffin embedded malignant melanomas. J Immunother 20:60–64.
Gaynor R, Irie R, Morton DL, Herschman HR (1980) S-100 protein in cultured human malignant melanomas. Nature 286:400–401.
Gaynor R, Herschman HR, Irie R, Jones PC, Morton DL, Cochran AJ (1981) S-100 protein: A marker for human malignant melanomas Lancet 1:869–871.
Glass EC, Essner R, Morton DL (1998) Kinetics of three lymphoscintigraphic agents in patients with cutaneous melanoma. J Nucl Med 39:1185–1190.
Glass EC, Basinski JE, Krasne DL, Giuliano AE (1999) Radiation safety considerations for sentinel node techniques. Ann Surg Oncol 6:10–11.
Gown AM, Vogel AM, Heak D, Gough D, McNutt MA (1986) Monoclonal antibodies specific for melanocyte tumors distinguished subpopulations of melanocytes. Am J Pathol 123:195–203.
Jansen L, Nieweg OE, Peterse JL, Hoefnagl CA, Valdes Olmos RA, Kroon BBR (2000) Reliability of sentinel lymph node biopsy for staging melanoma. Br J Surg 87:484–489.
Joseph E, Messina J, Glass FL, et al. (1997) Radioguided surgery for the ultrastaging of the patient with melanoma. CA Cancer J Sci Am 3:341–345.
Karakousis CP, Velez AF, Spellman JE Jr, Scarozza J (1996) The technique of sentinel node biopsy. Ear J Surg Oncol 22:271–275.
Kelemen PR, Essner R, Foshag LJ, Morton DL (1999) Lymphatic mapping and sentinel lymphadenectomy after wide excision of primary melanoma. J Am Coll Surg 184:247–252.
Kirkwood JM, Strawderman MH, Ernstoff MS, Smith TJ, Borden EC, Blum RH (1996) Interferon alfa-2b adjuvant therapy of high-risk resected cutaneous melanoma: the Eastern Cooperative Group trial EST 1684. J Clin Oncol 14:7–17.
Krag DN, Meijer SJ, Weaver DL, et al. (1995) Minimal-access surgery for staging of malignant melanoma. Arch Surg 130:954–657.
Leong SPL, Steinmetz I, Habib FA, McMillan A, Gans JZ, Allen RE Jr, et al. (1997) Optimal selective sentinel lymph node dissection in primary malignant melanoma. Arch Surg 132:666–673.
Lingam MK, Mackie RM, McKay AJ (1997) Intraoperative identification of SLN in patients with malignant melanoma. Br J Cancer 75:1505–1508.
Lock-Andersen J, Rossing N, Drzewiecki KT (1989) Preoperative cutaneous lymphoscintigraphy in malignant melanoma. Cancer 63:77–82.
Loggie BW, Hosseinian AA, Watson NE (1997) Prospective evaluation of selective lymph node biopsy for cutaneous malignant melanoma. Presented at the 65th annual scientific meeting and postgraduate course program, Southeastern Surgical Congress, Nashville, Tennessee, 1–5 February.
McCarthy WH, Shaw HM, Milton GW (1985) Efficacy of elective lymph node dissection in 2,347 patients with clinical stage I malignant melanoma. Surg Gynecol Obstet 161:575–580.
Miliotes G, Albertini J, Berman C, et al. (1996) The tumor biology of melanoma nodal metastases. Am Surg 62:81–88.
Moore BW (1965) Chemistry and biology of two proteins, S-100 and 14–3–2, specific to the nervous system. Biochem Biophys Res Commun 19:739–744.
Morton DL (1997) Intraoperative lymphatic mapping and sentinel lymphadenectomy: community standard care or clinical investigation CA Cancer J Sci Am 3:328–330.
Morton DL, Barth A (1996) Vaccine therapy for malignant melanoma. CA Cancer J Clin 46:225–244.
Morton DL, Wanek L, Nizze JA, Elashoff RM, Wong JH (1991) Improved long-term survival after lymphadenectomy of melanoma metastatic to regional nodes: analysis of prognostic factors in 1134 patients from the John Wayne Cancer Institute. Ann Surg 214:491–501.
Morton DL, Wen D-R, Wong JH, et al. (1992 a) Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 127:392–399.
Morton DL, Wen DR, Cochran AJ (1992 b) Management of early-stage melanoma by intraoperative lymphatic mapping and selective lymphadenectomy. Surg Oncol Clin North Am 1:247–259.
Morton DL, Wen DR, Foshag LJ, Essner R, Cochran A (1993) Intraoperative lymphatic mapping and selective cervical lymphadenectomy for early-stage melanoma of the head and neck. J Clin Oncol 11:1751–1156.
Morton DL, Thompson JF, Essner, et al. (1999) Validation of the accuracy of intraoperative lymphatic mapping and sentinel lymphadenectomy for early-stage melanoma: a multi-center trial. Ann Surg 230:453–465.
Mudun A, Murray DR, Herda SC, et al. (1996) Early stage melanoma: Lymphoscintigraphy, reproducibility of sentinel node detection, and effectiveness of the intraoperative gamma probe. Radiology 199:171–175.
Murray DF, Carlson GW, Greenlee R, Alazrki N, Fry-spray C, Hestley A, Poole R, Blais M, Timbert DS, Vansant J (2000) Surgical management of malignant melanoma using dynamic lymphoscintigraphy and gamma probe-guided sentinel lymph node biopsy: the emory experience. Am Surg 66:763–767.
Nathanson SD, Avery M, Anaya P, Sarantou T, Hetzel FW (1997) Lymphatic diameters and radionuclide clearance in a murine melanoma model. Arch Surg 132:311–315.
Nieweg OE, Kapteijn BAE, Thompson JF, Kroon BBR (1997) Lymphatic mapping and selective lymphadenectomy for melanoma: not yet standard therapy. Eur J Surg Oncol 23:397–398.
Norman J, Cruse CW, Espinosa C, et al. (1991) Redefinition of cutaneous lymphatic drainage with the use of lymphoscintigraphy for malignant melanoma. Am J Surg 162:432.
Pijpers R, Collet GJ, Meijer S, Hoekstr OS (1995) The impact of dynamic lymphoscintigraphy and gamma probe guidance on sentinel node biopsy in melanoma. Eur J Nucl Med 22:1238–1241.
Reintgen DS, Cox EB, McCarty KS Jr, Vollmer RT, Seigler HF (1983) Efficacy of elective lymph node dissection in patients with intermediate thickness primary melanoma. Ann Surg 198:379–385.
Reintgen D, Cruse CW, Wells K, et al. (1994) The orderly progression of melanoma nodal metastases. Ann Surg 220:759–767.
Reintgen D, Balch CM, Kirkwood J, Ross M (1997) Recent advances in the care of the patient with malignant melanoma. Ann Surg 225:1–14.
Robinson DS, Sample WF, Fee HJ, et al. (1977) Regional lymphatic drainage in primary malignant melanoma of the trunk determined by colloidal gold scanning. Surg Forum 28:147.
Roses DF, Provet JA, Harris MN, et al. (1985) Prognosis of patients with pathologic stage II cutaneous melanoma. Ann Surg 201:103–107.
Shah JP, Kraus DH, Dubner S, Sarkar S (1991) Patterns of regional lymph node metastases from cutaneous melanoma of the head and neck. Am J Surg 162:320–323.
Shivers SC, Wang X, Li W, et al. (1998) Molecular staging of malignant melanoma: correlation with clinical outcome. JAMA 280:1410–1415.
Sim FH, Taylor WF, Pritchard DJ, Soule EH (1986) Lymphadenectomy in the management of stage I malignant melanoma: a prospective randomized study. Mayo Clin Proc 61:697–705.
Snow H (1892) Melanotic cancerous disease. Lancet 2:872.
Sullivan DC, Croker BP, Harris CC, Deery P, Seigler HF (1981) Lymphoscintigraphy in malignant melanoma: Tc-99m antimony sulfur colloid. AJR Am J Roentgenol 137:847–851.
Thompson J, McCarthy WH, Bosch CMJ, O’Brien CJ, Quinn MJ, Paramaesvaran S, et al. (1995) Sentinel lymph node status as an indicator of the presence of metastatic melanoma in regional lymph nodes. Melanoma Res 5:255–260.
Thompson JF, Niewind P, Uren RF, Bosch CMJ, Howman-Giles R, Vrouenraets BC (1997) Single-dose isotope injection for both preoperative lymphoscintigraphy and intraoperative sentinel lymph node identification in melanoma patients. Melanoma Res 7:500–506.
Van der Veen H, Hoekstra OS, Cuesta MA, Meijer S (1994) Gamma probe-guided sentinel node biopsy to select patients with melanoma for lymphadenectomy. Br J Surg 81:1769–1770.
Veronesi U, Adamus J, Bandiera DC, Brennhoud 10, Caceres E, Caseinell N, et al. (1982) Delayed regional lymph node dissection in stage I melanoma of the skin of the lower extremities. Cancer 49:2420–2430.
Veronesi U, Adamus J, Bandiera DC, et al. (1977) Inefficacy of immediate node dissection in stage I melanoma of the limbs. N Engl J Med 297:627–630.
Wanebo HJ, Harpole D, Teates CD (1985) Radionuclide lymphoscintigraphy with technetium 99m antimony sulfide colloid to identify lymphatic drainage of cutaneous melanoma of ambiguous sites in the head and neck and trunk. Cancer 55:1403–1413.
Wen D-R, Gaynor RB, Cochran AJ (1983) S-100 protein: a marker for melanocytic tumors. Ann NY Acad Sci 420:261–266.
Wong JH, Cagle LA, Morton DL (1991) Lymphatic drainage of skin to a sentinel lymph in a feline model. Ann Surg 214:637–641.
Wong JH, Terada K, Ko P, Coel MN (1997) Lack of effect of particle size on the identification of the sentinel node in cutaneous malignancies. Ann Surg Oncol 5:77–80.
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2002 Springer-Verlag Berlin Heidelberg
About this paper
Cite this paper
Essner, R., Cochran, A.J. (2002). Sentinel Node Biopsy: Not Only a Staging Tool?. In: Dummer, R., Nestle, F.O., Burg, G. (eds) Cancers of the Skin. Recent Results in Cancer Research, vol 160. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-59410-6_17
Download citation
DOI: https://doi.org/10.1007/978-3-642-59410-6_17
Publisher Name: Springer, Berlin, Heidelberg
Print ISBN: 978-3-642-63969-2
Online ISBN: 978-3-642-59410-6
eBook Packages: Springer Book Archive