Technologic (R)Evolution Leads to Detection of More Sentinel Nodes in Patients with Melanoma in the Head and Neck Region

Abstract

BackgroundSentinel lymph node (SN) biopsy (SLNB) has proven to be a valuable tool for staging melanoma patients.Since its introduction in the early 1990s, this procedure has undergone several technological refinements, including the introduction of single photon emission computed tomography combined with computed tomography (SPECT/CT) as well as radio-and fluorescence-guidance. The purpose of the current study was to evaluate the effect of this technological evolution on SLNB in the head and neck region. Primary endpoint was the false-negative (FN) rate. Secondary endpoints were number of harvested SNs, overall operation time, operation time per harvested SN and postoperative complications. Patients and MethodsA retrospective database was queried for cutaneous head and neck melanoma patients who underwent SLNB at The Netherlands Cancer Institute between 1993 and 2016. The implementation of new detection techniques was divided in 4 groups: (1) 1993-2005, with preoperative lymphoscintigraphy and intraoperative use of both a gamma ray detection probe and patent blue (n=30); (2) 2006-2007, with addition of preoperative roadmaps based on SPECT/CT (n=15); (3) 2008-2009, with intraoperative use of a portable gamma camera (n=40); and (4) 2010-2016, with the addition of near-infrared fluorescence guidance (n=192). ResultsA total of 277 patients were included. At least one SN was identified in all patients. A tumor-positive SN was found in 59 patients (21.3%), 10 in group 1 (33.3%), 3 in group 2 (20.0%), 6 in group 3 (15.0%) and 40 in group 4 (20.8%). Regional recurrences of patients with tumor-negative SNs resulted in an overall FN rate of 11.9% (FN groups 1: 16.7%; 2: 0%; 3: 14.3%; 4: 11.1%). The number of harvested nodes increased with advancing technologies (p=0.003) whereas Breslow thickness and operation time per harvested SN decreased (p=0.003 and p=0.017, respectively). There was no significant difference in percentage of tumor-positive SNs, overall operation time and complication rate between the different groups. ConclusionThe use of advanced detection technologies led to a higher number of identified SNs without increase in overall operation time, which may indicate an improved surgical efficiency. Operation time per harvested SN decreased, the average FN rate remained 11.9% and unchanged over 23 years. There was no significant change in postoperative complication rate.

The impact of sentinel lymph node mapping with hybrid single photon emission computed tomography/computed tomography in patients with melanoma. Comparison to planar radioisotopic lymphoscintigraphy

“…Moreover, SPECT/CT is more expensive, requires extra time, and delivers an additional, yet low radiation dose [8,27,28]. It has been suggested that this method should only be used in patients with non-visualization of SLN on planar imaging, where drainage pattern is variable or unpredictable and when conventional imaging is difficult to interpret [8,29,30]; however, the introduction of improved SPECT/CT systems and advanced detection techniques have led to a higher number of identified SLNs and better surgical workflow, without increasing the overall operation time [31]. Nonetheless, dynamic PLS should not be abandoned, as it is the only method differentiating an additional SLN from a second-tier lymph node.…”

State of the Art: Precision Surgery Guided by Intraoperative Molecular Imaging

“…The use of fluorescence-guided SN biopsy is rising, but this field has benefited strongly from nuclear medicine; radiotracer-dye combinations for SN biopsy have existed since the 1990s with lymphoscintigraphy together with patent blue dye. Since then, refinements in technology and dyes (e.g., introduction of ICG) have increased SN biopsy efficiency, with greater numbers of SNs identified without increasing overall operation time (29).…”

A Truncated 14-Amino-Acid Myelin Protein-Zero-Targeting Peptide for Fluorescence-Guided Nerve-Preserving Surgery

“…Image-guided applications play an important role in the current progression realized in the field of head-and-neck surgery [ 1 , 2 , 3 , 4 ]. A prime example of such an approach is found in the surgical resection of sentinel nodes, a procedure that serves as a secondary means for the identification of (micro)metastatic tumor spread [ 1 , 2 , 5 , 6 ]. An upcoming application is found in the visualization of primary tumor margins [ 7 , 8 , 9 , 10 , 11 ].…”