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Technical Details of Intraoperative Lymphatic Mapping for Early Stage Melanoma

Technical Details of Intraoperative Lymphatic Mapping for Early Stage Melanoma Abstract • The initial route of metastases in most patients with melanoma is via the lymphatics to the regional nodes. However, routine lymphadenectomy for patients with clinical stage I melanoma remains controversial because most of these patients do not have nodal metastases, are unlikely to benefit from the operation, and may suffer troublesome postoperative edema of the limbs. A new procedure was developed using vital dyes that permits intraoperative identification of the sentinel lymph node, the lymph node nearest the site of the primary melanoma, on the direct drainage pathway. The most likely site of early metastases, the sentinel node can be removed for immediate intraoperative study to identify clinically occult melanoma cells. We successfully identified the sentinel node(s) in 194 of 237 lymphatic basins and detected metastases in 40 specimens (21%) on examination of routine hematoxylin-eosin—stained slides (12%) or exclusively in immunohistochemically stained preparations (9%). Metastases were present in 47 (18%) of 259 sentinel nodes, while nonsentinel nodes were the sole site of metastasis in only two of 3079 nodes from 194 lymphadenectomy specimens that had an identifiable sentinel node, a false-negative rate of less than 1%. Thus, this technique identifies, with a high degree of accuracy, patients with early stage melanoma who have nodal metastases and are likely to benefit from radical lymphadenectomy. (Arch Surg. 1992;127:392-399) References 1. Cox KR, Hare WSC, Bruce PT. Lymphography in melanoma: correlation of radiology with pathology . Cancer . 1966;19:637-647.Crossref 2. Balch CM, Murad TM, Soong SJ, Ingalls AL, Richards PC, Maddox WA. Tumor thickness as a guide to surgical management of clinical stage I melanoma patients . Cancer . 1979;43:883-888.Crossref 3. Balch CM, Soong SJ, Milton GW, et al. A comparison of prognostic factors and surgical results in 1,786 patients with localized (stage I) melanoma treated in Alabama, USA, and New South Wales, Australia . Ann Surg . 1982;196:677-684.Crossref 4. Milton GW, Shaw HM, McCarthy WH, Pearson L, Balch CM, Soong S-J. Prophylactic lymph node dissection in clinical stage I cutaneous malignant melanoma: results of surgical treatment in 1,319 patients . Br J Surg . 1982;69:108-111.Crossref 5. Reintgen DS, Cox EB, McCarty KS Jr, Vollmer RT, Seigler HF. Efficacy of elective lymph node dissection in patients with intermediate thickness primary melanoma . Ann Surg . 1983;198:379-385.Crossref 6. Clark WH Jr, From L, Bernardino EA, Mihm MC. The histogenesis and biologic behavior of primary malignant melanomas of the skin . Cancer Res . 1969;29:705-727. 7. Breslow A. Thickness, cross sectional area, and depth of invasion in the prognosis of cutaneous melanoma . Ann Surg . 1970;172:902-908.Crossref 8. Das Gupta TK. Results of treatment of 269 patients with primary cutaneous melanoma: a five-year prospective study . Ann Surg . 1977;186:201-209.Crossref 9. Balch CM, Soong SJ, Murad TM, Ingalls AL, Maddox WA. A multifactorial analysis of melanoma, III: prognostic factors in melanoma patients with lymph node metastases (stage II) . Ann Surg . 1981; 193:337-388.Crossref 10. Cohen MH, Ketcham AS, Felix EL, et al. Prognostic factors in patients undergoing lymphadenectomy for malignant melanoma . Ann Surg . 1977;186:635-642.Crossref 11. McNeer G, Das Gupta TK. Prognosis in malignant melanoma . Surgery . 1964;56:512-518. 12. Roses DF, Provet JA, Harris MN, Gumport SL, Dubin N. Prognosis of patients with pathologic stage II cutaneous malignant melanoma . Ann Surg . 1985;201:103-107. 13. Callery C, Cochran AJ, Roe DJ, et al. Factors prognostic for survival in patients with malignant melanoma spread to the regional lymph nodes . Ann Surg . 1982;196:69-75.Crossref 14. Sim FH, Taylor WF, Ivins JC, Pritchard DJ, Soule EH. A prospective randomized study of the efficacy of routine elective lymphadenectomy in management of malignant melanoma: preliminary results . Cancer . 1978;41:948-956.Crossref 15. Veronesi U, Adamus J, Bandiera DC, et al. Inefficacy of immediate node dissection in stage I melanoma of the limbs . N Engl J Med . 1977;297:627-630.Crossref 16. Veronesi U, Adamus J, Bandiera DC, et al. Delayed regional lymph node dissection in stage I melanoma of the skin of the lower extremities . Cancer . 1982;49:2420-2430.Crossref 17. Day CL, Lew RA. Malignant melanoma prognostic factors: elective lymph node dissection . J Dermatol Surg Oncol . 1985;11:233-239.Crossref 18. Day CL, Mihm MC, Lew RA, et al. Prognostic factors for patients with clinical stage I melanoma of intermediate thickness (1.51-3.99 mm) . Ann Surg . 1982;195:35-43.Crossref 19. Cady B. 'Prophylactic' lymph node dissection in melanoma: does it help? J Clin Oncol . 1988;6:2-4. 20. Balch CM. The role of elective lymph node dissection in melanoma: rationale, results and controversies . J Clin Oncol . 1988;6:163-172. 21. Robinson DS, Sample WF, Fee HJ, Holmes EC, Morton DL. Regional lymphatic drainage in primary malignant melanoma of the trunk determined by colloidal gold scanning . Surg Forum . 1977;28:147-148. 22. Fee HJ, Robinson DS, Sample WF, Graham LS, Holmes EC, Morton DL. The determination of lymph shed by colloidal gold scanning patients with malignant melanoma: a preliminary study . Surgery . 1978;84:626-632. 23. Holmes EC, Moseley HS, Morton DL, Clark W, Robinson D, Urist MM. A rational approach to the surgical management of melanoma . Ann Surg . 1977;186:481-490.Crossref 24. Bennett LR, Lago G. Cutaneous lymphoscintigraphy in malignant melanoma . Semin Nucl Med . 1983;13:61-69.Crossref 25. Rees WV, Robinson DS, Holmes EC, Morton DL. Altered lymphatic drainage following lymphadenectomy . Cancer . 1980;45:3045-3059.Crossref 26. Morton DL. Surgical treatment for malignant melanoma . Clin Oncol . 1984;3:517-529. 27. Finck SJ, Giuliano AE, Mann BD, Morton DL. Results of ilioinguinal dissection for stage II melanoma . Ann Surg . 1982;196:180-186.Crossref 28. Storm FK, Eilber FR, Morton DL, Clark WH Jr. Malignant melanoma of the head and neck . Head Neck Surg . 1978;1:123-128.Crossref 29. Cochran AJ, Wen D-R, Morton DL. Occult tumor cells in the lymph nodes of patients with pathological stage I malignant melanoma . Am J Surg Pathol . 1988;12:612-618.Crossref 30. Cochran AJ, Wen D-R, Herschman JR. Occult melanoma in lymph nodes detected by antiserum to S-100 proteins . Int J Cancer . 1984;34:159-163.Crossref 31. Goldsmith HS, Shah JP, Kim DH. Prognostic significance of lymph node dissection in the treatment of malignant melanoma . Cancer . 1970;26:606-609.Crossref 32. Naruns PL, Nizze JA, Cochran AJ, Lee MB, Morton DL. Recurrence potential of thin primary melanomas . Cancer . 1986;57:545-548.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Technical Details of Intraoperative Lymphatic Mapping for Early Stage Melanoma

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References (35)

Publisher
American Medical Association
Copyright
Copyright © 1992 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1992.01420040034005
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Abstract

Abstract • The initial route of metastases in most patients with melanoma is via the lymphatics to the regional nodes. However, routine lymphadenectomy for patients with clinical stage I melanoma remains controversial because most of these patients do not have nodal metastases, are unlikely to benefit from the operation, and may suffer troublesome postoperative edema of the limbs. A new procedure was developed using vital dyes that permits intraoperative identification of the sentinel lymph node, the lymph node nearest the site of the primary melanoma, on the direct drainage pathway. The most likely site of early metastases, the sentinel node can be removed for immediate intraoperative study to identify clinically occult melanoma cells. We successfully identified the sentinel node(s) in 194 of 237 lymphatic basins and detected metastases in 40 specimens (21%) on examination of routine hematoxylin-eosin—stained slides (12%) or exclusively in immunohistochemically stained preparations (9%). Metastases were present in 47 (18%) of 259 sentinel nodes, while nonsentinel nodes were the sole site of metastasis in only two of 3079 nodes from 194 lymphadenectomy specimens that had an identifiable sentinel node, a false-negative rate of less than 1%. Thus, this technique identifies, with a high degree of accuracy, patients with early stage melanoma who have nodal metastases and are likely to benefit from radical lymphadenectomy. (Arch Surg. 1992;127:392-399) References 1. Cox KR, Hare WSC, Bruce PT. Lymphography in melanoma: correlation of radiology with pathology . Cancer . 1966;19:637-647.Crossref 2. Balch CM, Murad TM, Soong SJ, Ingalls AL, Richards PC, Maddox WA. Tumor thickness as a guide to surgical management of clinical stage I melanoma patients . Cancer . 1979;43:883-888.Crossref 3. Balch CM, Soong SJ, Milton GW, et al. A comparison of prognostic factors and surgical results in 1,786 patients with localized (stage I) melanoma treated in Alabama, USA, and New South Wales, Australia . Ann Surg . 1982;196:677-684.Crossref 4. Milton GW, Shaw HM, McCarthy WH, Pearson L, Balch CM, Soong S-J. Prophylactic lymph node dissection in clinical stage I cutaneous malignant melanoma: results of surgical treatment in 1,319 patients . Br J Surg . 1982;69:108-111.Crossref 5. Reintgen DS, Cox EB, McCarty KS Jr, Vollmer RT, Seigler HF. Efficacy of elective lymph node dissection in patients with intermediate thickness primary melanoma . Ann Surg . 1983;198:379-385.Crossref 6. Clark WH Jr, From L, Bernardino EA, Mihm MC. The histogenesis and biologic behavior of primary malignant melanomas of the skin . Cancer Res . 1969;29:705-727. 7. Breslow A. Thickness, cross sectional area, and depth of invasion in the prognosis of cutaneous melanoma . Ann Surg . 1970;172:902-908.Crossref 8. Das Gupta TK. Results of treatment of 269 patients with primary cutaneous melanoma: a five-year prospective study . Ann Surg . 1977;186:201-209.Crossref 9. Balch CM, Soong SJ, Murad TM, Ingalls AL, Maddox WA. A multifactorial analysis of melanoma, III: prognostic factors in melanoma patients with lymph node metastases (stage II) . Ann Surg . 1981; 193:337-388.Crossref 10. Cohen MH, Ketcham AS, Felix EL, et al. Prognostic factors in patients undergoing lymphadenectomy for malignant melanoma . Ann Surg . 1977;186:635-642.Crossref 11. McNeer G, Das Gupta TK. Prognosis in malignant melanoma . Surgery . 1964;56:512-518. 12. Roses DF, Provet JA, Harris MN, Gumport SL, Dubin N. Prognosis of patients with pathologic stage II cutaneous malignant melanoma . Ann Surg . 1985;201:103-107. 13. Callery C, Cochran AJ, Roe DJ, et al. Factors prognostic for survival in patients with malignant melanoma spread to the regional lymph nodes . Ann Surg . 1982;196:69-75.Crossref 14. Sim FH, Taylor WF, Ivins JC, Pritchard DJ, Soule EH. A prospective randomized study of the efficacy of routine elective lymphadenectomy in management of malignant melanoma: preliminary results . Cancer . 1978;41:948-956.Crossref 15. Veronesi U, Adamus J, Bandiera DC, et al. Inefficacy of immediate node dissection in stage I melanoma of the limbs . N Engl J Med . 1977;297:627-630.Crossref 16. Veronesi U, Adamus J, Bandiera DC, et al. Delayed regional lymph node dissection in stage I melanoma of the skin of the lower extremities . Cancer . 1982;49:2420-2430.Crossref 17. Day CL, Lew RA. Malignant melanoma prognostic factors: elective lymph node dissection . J Dermatol Surg Oncol . 1985;11:233-239.Crossref 18. Day CL, Mihm MC, Lew RA, et al. Prognostic factors for patients with clinical stage I melanoma of intermediate thickness (1.51-3.99 mm) . Ann Surg . 1982;195:35-43.Crossref 19. Cady B. 'Prophylactic' lymph node dissection in melanoma: does it help? J Clin Oncol . 1988;6:2-4. 20. Balch CM. The role of elective lymph node dissection in melanoma: rationale, results and controversies . J Clin Oncol . 1988;6:163-172. 21. Robinson DS, Sample WF, Fee HJ, Holmes EC, Morton DL. Regional lymphatic drainage in primary malignant melanoma of the trunk determined by colloidal gold scanning . Surg Forum . 1977;28:147-148. 22. Fee HJ, Robinson DS, Sample WF, Graham LS, Holmes EC, Morton DL. The determination of lymph shed by colloidal gold scanning patients with malignant melanoma: a preliminary study . Surgery . 1978;84:626-632. 23. Holmes EC, Moseley HS, Morton DL, Clark W, Robinson D, Urist MM. A rational approach to the surgical management of melanoma . Ann Surg . 1977;186:481-490.Crossref 24. Bennett LR, Lago G. Cutaneous lymphoscintigraphy in malignant melanoma . Semin Nucl Med . 1983;13:61-69.Crossref 25. Rees WV, Robinson DS, Holmes EC, Morton DL. Altered lymphatic drainage following lymphadenectomy . Cancer . 1980;45:3045-3059.Crossref 26. Morton DL. Surgical treatment for malignant melanoma . Clin Oncol . 1984;3:517-529. 27. Finck SJ, Giuliano AE, Mann BD, Morton DL. Results of ilioinguinal dissection for stage II melanoma . Ann Surg . 1982;196:180-186.Crossref 28. Storm FK, Eilber FR, Morton DL, Clark WH Jr. Malignant melanoma of the head and neck . Head Neck Surg . 1978;1:123-128.Crossref 29. Cochran AJ, Wen D-R, Morton DL. Occult tumor cells in the lymph nodes of patients with pathological stage I malignant melanoma . Am J Surg Pathol . 1988;12:612-618.Crossref 30. Cochran AJ, Wen D-R, Herschman JR. Occult melanoma in lymph nodes detected by antiserum to S-100 proteins . Int J Cancer . 1984;34:159-163.Crossref 31. Goldsmith HS, Shah JP, Kim DH. Prognostic significance of lymph node dissection in the treatment of malignant melanoma . Cancer . 1970;26:606-609.Crossref 32. Naruns PL, Nizze JA, Cochran AJ, Lee MB, Morton DL. Recurrence potential of thin primary melanomas . Cancer . 1986;57:545-548.Crossref

Journal

Archives of Surgery – American Medical Association

Published: Apr 1, 1992

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