Lymphatic Mapping and Sentinel Node Biopsy in Melanoma
Invited Commentary
Invited Commentary
Lymphatic Mapping and Sentinel Node Biopsy in Melanoma Charles M. Balch, MD; Merrick I. Ross, MD
Lymphatic mapping is essential in performing sentinel lymph node biopsy (SLNB) procedures accurately because it allows for the complete visualization of nodal groups at risk for metastases.1 While the use of Tc 99–labeled agents has been Related article the gold standard method for lymphatic mapping in patients with melanoma, alternative visualization techniques have been explored. Most notably, indocyanine green (ICG) has been widely used for the staging of breast and gastrointestinal cancers where lymphatic drainage patterns are fairly predictable. Results using ICG dye in patients with melanoma have been mixed in retrospective studies, most likely because there is ambiguous lymphatic drainage in 25% to 40% of melanomas arising in the trunk or head and neck areas.2 In a prospective study of patients with melanomas of the trunk or extremities, Stoffels and colleagues3 found that ICG dye was inferior to Tc 99 in defining lymphatic basins containing metastases. The fluorescence signal was simply not strong enough, especially in obese patients. We agree entirely with their conclusions that Tc 99 radiocolloid remains the gold standard for lymphoscintigraphy in patients with melanoma and that single-photon emission computed tomography/computed tomography should also be used in patients with head and neck cancer. Not discussed in the article was the possibility that the 95% concordance data reported are likely to be artificially inflated. The intraoperative localization of the SLN using the Tc 99 label probably enhanced the ability to visualize the ICG dye. A more critical determination of the ICG dye concordance would have been to blind the lymphoscintigraphy results to the surgeons in the beginning of the procedure and ARTICLE INFORMATION Author Affiliations: University of Texas Southwestern Medical Center, Dallas (Balch); University of Texas MD Anderson Cancer Center, Houston (Ross). Corresponding Author: Charles M. Balch, MD, Division of Surgical Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Mail Code 8548, Dallas, TX 75390-8548 ([email protected]). Published Online: May 27, 2015. doi:10.1001/jamasurg.2015.0712. Conflict of Interest Disclosures: None reported. REFERENCES
restrict the use of the Tc 99–guided intraoperative SLN localization until the SLNB procedure was initially attempted using the ICG dye alone. There is now convincing evidence demonstrating the staging value of SLNB for cohorts of patients with melanoma.4 Thus, the SLNB procedure (including preoperative lymphoscintigraphy and intraoperative and Tc 99–guided SLN localization) has enabled clinicians to identify patients with occult nodal metastases that would otherwise take months or years to become clinically palpable. The results of Multicenter Selective Lymphadenectomy Trial 1 clearly demonstrate the important role of SLNB in a defined group of patients, with staging value for those with intermediate thickness (1.0-4.0 mm) and thicker melanomas, as well as a survival benefit for those patients with a positive SLN with intermediatethickness melanomas.5 These results reinforce guideline recommendations for SLNB made by the American Society of Clinical Oncology and the Society of Surgical Oncology.6 In our practice, the SLNB procedure is offered to patients with melanomas greater than or equal to 1.0 mm in thickness and clinically normal regional lymph nodes when the morbidity and risks of SLNB are acceptable. It may also be offered to patients with primary melanomas less than 1.0 mm in thickness, if there are adverse pathologic features such as a mitotic rate of greater than or equal to 1 per square millimeter or ulceration.5 We should not understage, and therefore undertreat, patients with melanoma because we may miss the opportunity to prevent the progression to stage IV disease and the even more expensive and potentially toxic series of treatments required when managing patients with advanced disease.
2. Uren RF, Thompson JF, Coventry BJ, Chatterton BF. Lymphoscintigraphy in patients with melanoma. In: Balch CM, Houghton AN, Sober AJ, et al. Cutaneous Melanoma. 5th ed. St Louis, MO: Quality Medical Press; 2009. 3. Stoffels I, Dissemond J, Pöppel T, Schadendorf D, Klode J. Intraoperative fluorescence imaging for sentinel lymph node detection: prospective clinical trial to compare the usefulness of indocyanine green vs technetium Tc 99m for identification of sentinel lymph nodes [published online May 27, 2015]. JAMA Surg. doi:10.1001/jamasurg.2014.3502.
5. Morton DL, Thompson JF, Cochran AJ, et al; MSLT Group. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med. 2014;370(7):599-609. 6. Wong SL, Balch CM, Hurley P, et al; American Society of Clinical Oncology; Society of Surgical Oncology. Sentinel lymph node biopsy for melanoma: American Society of Clinical Oncology and Society of Surgical Oncology joint clinical practice guideline. Ann Surg Oncol. 2012;19(11): 3313-3324.
4. Balch CM, Gershenwald JE. Clinical value of the sentinel-node biopsy in primary cutaneous melanoma. N Engl J Med. 2014;370(7):663-664.
1. Thompson JF, Uren RF. Lymphatic mapping in management of patients with primary cutaneous melanoma. Lancet Oncol. 2005;6(11):877-885.
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(Reprinted) JAMA Surgery Published online May 27, 2015
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Invited Commentary
Invited Commentary
Lymphatic Mapping and Sentinel Node Biopsy in Melanoma Charles M. Balch, MD; Merrick I. Ross, MD
Lymphatic mapping is essential in performing sentinel lymph node biopsy (SLNB) procedures accurately because it allows for the complete visualization of nodal groups at risk for metastases.1 While the use of Tc 99–labeled agents has been Related article the gold standard method for lymphatic mapping in patients with melanoma, alternative visualization techniques have been explored. Most notably, indocyanine green (ICG) has been widely used for the staging of breast and gastrointestinal cancers where lymphatic drainage patterns are fairly predictable. Results using ICG dye in patients with melanoma have been mixed in retrospective studies, most likely because there is ambiguous lymphatic drainage in 25% to 40% of melanomas arising in the trunk or head and neck areas.2 In a prospective study of patients with melanomas of the trunk or extremities, Stoffels and colleagues3 found that ICG dye was inferior to Tc 99 in defining lymphatic basins containing metastases. The fluorescence signal was simply not strong enough, especially in obese patients. We agree entirely with their conclusions that Tc 99 radiocolloid remains the gold standard for lymphoscintigraphy in patients with melanoma and that single-photon emission computed tomography/computed tomography should also be used in patients with head and neck cancer. Not discussed in the article was the possibility that the 95% concordance data reported are likely to be artificially inflated. The intraoperative localization of the SLN using the Tc 99 label probably enhanced the ability to visualize the ICG dye. A more critical determination of the ICG dye concordance would have been to blind the lymphoscintigraphy results to the surgeons in the beginning of the procedure and ARTICLE INFORMATION Author Affiliations: University of Texas Southwestern Medical Center, Dallas (Balch); University of Texas MD Anderson Cancer Center, Houston (Ross). Corresponding Author: Charles M. Balch, MD, Division of Surgical Oncology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Mail Code 8548, Dallas, TX 75390-8548 ([email protected]). Published Online: May 27, 2015. doi:10.1001/jamasurg.2015.0712. Conflict of Interest Disclosures: None reported. REFERENCES
restrict the use of the Tc 99–guided intraoperative SLN localization until the SLNB procedure was initially attempted using the ICG dye alone. There is now convincing evidence demonstrating the staging value of SLNB for cohorts of patients with melanoma.4 Thus, the SLNB procedure (including preoperative lymphoscintigraphy and intraoperative and Tc 99–guided SLN localization) has enabled clinicians to identify patients with occult nodal metastases that would otherwise take months or years to become clinically palpable. The results of Multicenter Selective Lymphadenectomy Trial 1 clearly demonstrate the important role of SLNB in a defined group of patients, with staging value for those with intermediate thickness (1.0-4.0 mm) and thicker melanomas, as well as a survival benefit for those patients with a positive SLN with intermediatethickness melanomas.5 These results reinforce guideline recommendations for SLNB made by the American Society of Clinical Oncology and the Society of Surgical Oncology.6 In our practice, the SLNB procedure is offered to patients with melanomas greater than or equal to 1.0 mm in thickness and clinically normal regional lymph nodes when the morbidity and risks of SLNB are acceptable. It may also be offered to patients with primary melanomas less than 1.0 mm in thickness, if there are adverse pathologic features such as a mitotic rate of greater than or equal to 1 per square millimeter or ulceration.5 We should not understage, and therefore undertreat, patients with melanoma because we may miss the opportunity to prevent the progression to stage IV disease and the even more expensive and potentially toxic series of treatments required when managing patients with advanced disease.
2. Uren RF, Thompson JF, Coventry BJ, Chatterton BF. Lymphoscintigraphy in patients with melanoma. In: Balch CM, Houghton AN, Sober AJ, et al. Cutaneous Melanoma. 5th ed. St Louis, MO: Quality Medical Press; 2009. 3. Stoffels I, Dissemond J, Pöppel T, Schadendorf D, Klode J. Intraoperative fluorescence imaging for sentinel lymph node detection: prospective clinical trial to compare the usefulness of indocyanine green vs technetium Tc 99m for identification of sentinel lymph nodes [published online May 27, 2015]. JAMA Surg. doi:10.1001/jamasurg.2014.3502.
5. Morton DL, Thompson JF, Cochran AJ, et al; MSLT Group. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med. 2014;370(7):599-609. 6. Wong SL, Balch CM, Hurley P, et al; American Society of Clinical Oncology; Society of Surgical Oncology. Sentinel lymph node biopsy for melanoma: American Society of Clinical Oncology and Society of Surgical Oncology joint clinical practice guideline. Ann Surg Oncol. 2012;19(11): 3313-3324.
4. Balch CM, Gershenwald JE. Clinical value of the sentinel-node biopsy in primary cutaneous melanoma. N Engl J Med. 2014;370(7):663-664.
1. Thompson JF, Uren RF. Lymphatic mapping in management of patients with primary cutaneous melanoma. Lancet Oncol. 2005;6(11):877-885.
jamasurgery.com
(Reprinted) JAMA Surgery Published online May 27, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/02/2015
E1
