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Open Access 01-05-2013 | Melanomas

Individualized Surgery: Gamma-Probe-Guided Lymphadenectomy in Patients with Clinically Enlarged Lymph Node Metastases from Melanomas

Authors: Lutz Kretschmer, MD, Carsten-Oliver Sahlmann, MD, Pavel Bardzik, Christina Mitteldorf, MD, Hans-Joachim Helms, Johannes Meller, MD, Michael Peter Schön, MD, Hans Peter Bertsch, MD

Published in: Annals of Surgical Oncology | Issue 5/2013

Abstract

Background

The value of a preoperative lymphoscintigraphy in melanoma patients with clinically evident regional lymph node metastases has not been studied. Therapeutic lymph node dissection (TLND) is regarded as the clinical standard, but the appropriate extent of TLND is controversial in all lymphatic basins.

Patients and Methods

Of the 115 consecutive patients with surgery on palpable lymph node metastases, 34 received a pre-operative lymphoscintigraphy. Lymphatic drainage to a second nodal basin outside the clinically involved basin was found in 15 cases. In 13 patients, the ectopic tumor-draining lymph nodes were excised as in a sentinel node biopsy. The lymph nodes from the TLND specimens were postoperatively separated and classified as either radioactive or non-radioactive.

Results

A total of 493 lymph nodes were examined pathologically. The largest macrometastasis maintained the ability to take up radiotracer in 77% of cases. Radioactively labeled lymph nodes carried a higher risk of being involved with metastasis. The proportions of tumor involvement for radioactive and non-radioactive lymph nodes were 44.5 and 16.9%, respectively (P=0.00002). Of the 13 ectopic nodal basins surgically explored, six harbored clinically occult metastases.

Conclusion

In patients undergoing TLND for palpable metastases, tumor-draining lymph nodes in a second, ectopic nodal basin should be excised, because they could be affected by occult metastasis. With respect to radioactive lymph nodes situated within the nodal basin of the macrometastasis but beyond the borders of a less-radical lymphadenectomy, further studies are needed.

Meier F, Will S, Ellwanger U, Schlagenhauff B, Schittek B, Rassner G, et al. Metastatic pathways and time courses in the orderly progression of cutaneous melanoma. Br J Dermatol. 2002;147:62–70.PubMedCrossRef

McHugh JB, Su L, Griffith KA, Schwartz JL, Wong SL, Cimmino V, et al. Significance of multiple lymphatic basin drainage in truncal melanoma patients undergoing sentinel lymph node biopsy. Ann Surg Oncol. 2006;13:1216–23.PubMedCrossRef

Federico AC, Chagpar AB, Ross MI, Martin RC, Noyes RD, Goydos JS, et al. Effect of multiple-nodal basin drainage on cutaneous melanoma. Arch Surg. 2008;143:632–7.PubMedCrossRef

Lyo V, Jaigirdar AA, Thummala S, Morita ET, Treseler PA, Kashani-Sabet M, et al. In-transit intramammary sentinel lymph nodes from malignant melanoma of the trunk. Ann Surg. 2012;255:122–7.PubMedCrossRef

Kretschmer L, Altenvoerde G, Meller J, Zutt M, Funke M, Neumann C, et al. Dynamic lymphoscintigraphy and image fusion of SPECT and pelvic CT-scans allow mapping of aberrant pelvic sentinel lymph nodes in malignant melanoma. Eur J Cancer. 2003;39:175–83.PubMedCrossRef

Kretschmer L, Sahlmann CO, Bardzik P, Thoms KM, Bertsch HP, Meller J. The popliteal fossa - a problem zone for sentinel lymphonodectomy. J Dtsch Dermatol Ges. 2011;9:123–7.PubMed

Aydin MA, Okudan B, Nasir S, Ozbek M, Karagöz A, Altuntaş S. Lymphoscintigraphic drainage of acral limb skin to interval sentinel lymph nodes in healthy subjects. J Surg Oncol. 2006;93:286–93.PubMedCrossRef

Kretschmer L, Neumann C, Preusser KP, Marsch WC. Superficial inguinal and radical ilioinguinal lymph node dissection in patients with palpable melanoma metastases to the groin–an analysis of survival and local recurrence. Acta Oncol. 2001;40:72–8.PubMedCrossRef

Kretschmer L, Preusser KP. Standardized axillary lymphadenectomy improves local control but not survival in patients with palpable lymph node metastases of cutaneous malignant melanoma. Langenbecks Arch Surg. 2001;386:418–25.PubMedCrossRef

10.

Mitteldorf C, Bertsch HP, Zapf A, Neumann C, Kretschmer L. Cutting a sentinel lymph node into slices is the optimal first step for examination of sentinel lymph nodes in melanoma patients. Mod Pathol. 2009;22:1622–7.PubMedCrossRef

11.

Reintgen D, Cruse CW, Wells K, Berman C, Fenske N, Glass F, et al. The orderly progression of melanoma nodal metastases. Ann Surg. 1994;220:759–67.PubMedCrossRef

12.

Kamath D, Brobeil A, Stall A, Lyman G, Cruse CW, Glass F, et al. Cutaneous lymphatic drainage in patients with grossly involved nodal basins. Ann Surg Oncol. 1999;6:345–9.PubMedCrossRef

13.

Ariyan C, Brady MS, Gönen M, Busam K, Coit D. Positive nonsentinel node status predicts mortality in patients with cutaneous melanoma. Ann Surg Oncol. 2009;16:186–90.PubMedCrossRef

14.

Cascinelli N, Bombardieri E, Bufalino R, Camerini T, Carbone A, Clemente C, et al. Sentinel and nonsentinel node status in stage IB and II melanoma patients: two-step prognostic indicators of survival. J Clin Oncol. 2006;24:4464–71.PubMedCrossRef

15.

Govindarajan A, Ghazarian DM, McCready DR, Leong WL. Histological features of melanoma sentinel lymph node metastases associated with status of the completion lymphadenectomy and rate of subsequent relapse. Ann Surg Oncol. 2007;14:906–12.PubMedCrossRef

16.

Kane M, McClay E, Bellet RE. Frequency of occult residual melanoma after excision of a clinically positive regional lymph node. Ann Surg. 1987;205:88–9.PubMedCrossRef

17.

Karakousis CP, Rizos S, Driscoll DL. Residual nodal disease after excisional biopsy of a palpable, positive node in melanoma. Am J Surg. 1994;168:69–70.PubMedCrossRef

18.

Meyer T, Merkel S, Gohl J, Hohenberger W. Lymph node dissection for clinically evident lymph node metastases of malignant melanoma. Eur J Surg Oncol. 2002;28:424–30.PubMedCrossRef

19.

Kretschmer L, Hilgers R, Möhrle M, Balda BR, Breuninger H, Konz B, et al. Patients with lymphatic metastasis of cutaneous malignant melanoma benefit from sentinel lymphonodectomy and early excision of their nodal disease. Eur J Cancer 2004;40:212–8.PubMedCrossRef

20.

Morton DL, Thompson JF, Cochran AJ, Mozzillo N, Elashoff R, Essner R, et al.; MSLT Group. Sentinel-node biopsy or nodal observation in melanoma. N Engl J Med. 2006;355:1307–17.PubMedCrossRef

21.

Pidhorecky I, Lee RJ, Proulx G, Kollmorgen DR, Jia C, Driscoll DL, et al. Risk factors for nodal recurrence after lymphadenectomy for melanoma. Ann Surg Oncol. 2001;8:109–15.PubMedCrossRef

22.

Wevers KP, Bastiaannet E, Poos HP, van Ginkel RJ, Plukker JT, Hoekstra HJ. Therapeutic lymph node dissection in melanoma: different prognosis for different macrometastasis sites? Ann Surg Oncol. 2012;19:3913–8.PubMedCrossRef

23.

Multicenter Selective Lymphadenectomy Trial II (MSLT-II). http://clinicaltrial.gov/ct2/show/NCT00297895?term=MSLT?2&rank=2. Accessed 29 Jan 2012.

24.

Solá M, Alberro JA, Fraile M, Santesteban P, Ramos M, Fabregas R, et al. Complete axillary lymph node dissection versus clinical follow-up in breast cancer patients with sentinel node micrometastasis: final results from the multicenter clinical trial AATRM 048/13/2000. Ann Surg Oncol. 2013;20:120–7.PubMedCrossRef

25.

Mack LA, McKinnon JG. Controversies in the management of metastatic melanoma to regional lymphatic basins. J Surg Oncol. 2004;86:189–99.PubMedCrossRef

26.

Pasquali S, Spillane AJ, de Wilt JH, McCaffery K, Rossi CR, Quinn MJ, et al. Surgeons’ opinions on lymphadenectomy in melanoma patients with positive sentinel nodes: a worldwide web-based survey. Ann Surg Oncol. 2012; 18 Jul. Epub ahead of print.

27.

Klop WM, Veenstra HJ, Vermeeren L, Nieweg OE, Balm AJ, Lohuis PJ. Assessment of lymphatic drainage patterns and implications for the extent of neck dissection in head and neck melanoma patients. J Surg Oncol. 2011;103:756–60.PubMedCrossRef

28.

Pratsch AL, Kretschmer L. Leg swelling following inguinal and Ilioinguinal dissection of melanoma metastases. Zentralbl Chir. 2012; 17 Apr. Epub ahead of print German.

29.

Mann GB, Coit DG. Does the extent of operation influence the prognosis in patients with melanoma metastatic to the inguinal nodes. Ann Surg Oncol 1999;6:263–71.PubMedCrossRef

30.

Kelemen PR, Essner R, Foshag LJ, Morton DL. Lymphatic mapping and sentinel lymphadenectomy after wide local excision of primary melanoma. J Am Coll Surg. 1999;189:247–52.PubMedCrossRef

Title: Individualized Surgery: Gamma-Probe-Guided Lymphadenectomy in Patients with Clinically Enlarged Lymph Node Metastases from Melanomas
Authors: Lutz Kretschmer, MD
Carsten-Oliver Sahlmann, MD
Pavel Bardzik
Christina Mitteldorf, MD
Hans-Joachim Helms
Johannes Meller, MD
Michael Peter Schön, MD
Hans Peter Bertsch, MD
Publication date: 01-05-2013
Publisher: Springer-Verlag
Published in: Annals of Surgical Oncology / Issue 5/2013
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-012-2841-1

At a glance: The STEP trials

Springer Medicine

Individualized Surgery: Gamma-Probe-Guided Lymphadenectomy in Patients with Clinically Enlarged Lymph Node Metastases from Melanomas

Abstract

Background

Patients and Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Patients and Methods

Results

Conclusion

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