Malignant Melanoma: European Practice
*
Vivian Bongers,Inne H.M. Borel Rinkes,
Peter C. Barneveld, Marijke R. Canninga-van Dijk,
Peter P. van Rijk, Willem A. van Vloten
rate lymph channels lead to nodes in separate
lymph node basins. In such cases, omitting dyna-
mic scintigraphy may result in incomplete nodal
extraction, which could produce false-negative
results [6, 7].
In the light of these results most centres have
adopted a sentinel node methodology in which
blue dye and lymphoscintigraphy are used in com-
bination. However, since the accuracy of the blue
dye technique is limited [3,4,8], we postulated that
it might be sufficient to rely on lymphoscinti-
graphy alone if an optimal protocol is available.
Therefore,the aim of this prospective study was to
assess the accuracy of lymphoscintigraphy alone
(without blue dye) for the identification of the
sentinel node, using technetium-99m nanocolloid
as the radiopharmaceutical, and two-phase dyna-
mic/static lymphoscintigraphy. Concurrently, the
incidence of alternative lymphatic drainage path-
ways as well as their impact on reliable nodal
staging was assessed.
Since the sentinel node procedure is steadily
gaining popularity for several tumour types
[9–13], a uniform implementation of a standard-
ised procedure would be advisable. In an attempt
to evaluate the current practice, we sent a postal
questionnaire to 136 nuclear physicians in 16 dif-
ferent countries in Europe. Based on the outcome
of this first independent (non-commercial) survey,
we report on the sentinel node procedure as
practised on melanoma patients by 40 European
nuclear medicine physicians from ten different
countries and against this background present
recommendations for routine implementation of
the sentinel node procedure. The ultimate goal
of the formulation of such guidelines is to attain
uniformity and international exchangeability of
results for optimal interpretation and quality
assurance.
Introduction
For many years, the subject of elective lymph node
dissection has been one of the most important
controversies in the management of patients with
malignant melanoma. The status of the regional
lymph nodes is a critical component in staging
patients with newly diagnosed melanoma, since
lymph node involvement in these patients is
known to be an unfavourable prognostic factor [1].
The majority (90%) of patients with primary
cutaneous malignant melanoma present without
clinically enlarged lymph nodes. However, it has
been estimated that approximately 15% of these
patients harbour occult lymph node micrometas-
tases [2], and accurate diagnostic identification of
such lymph node metastases in melanoma pa-
tients appears important. In an attempt to solve
this problem, location of the first-echelon lymph
node by means of the sentinel node procedure has
gained increasing acceptance over the past decade.
The sentinel node concept was introduced by
Morton et al. [3], who initially used vital blue dyes
to identify the sentinel node. However,this techni-
que fails to localise the sentinel node in approxi-
mately 20 % of cases, even in experienced hands.
Subsequent reports have shown that the per-
centage of failures to identify the sentinel node is
greatly reduced by using radiolabeled colloids in
conjunction with a small hand-held gamma probe
[4]. The presence or absence of metastases in the
sentinel node has been demonstrated to accurately
reflect the histology of the remainder of the nodal
basin [5].Additional dynamic lymphoscintigraphy
is considered to be a more convenient alternative
for lymph node mapping, particularly when sepa-
chapter
12
First published in
Eur J Nucl Med
26, 1999.
