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10th
International Inter University Scientific Meeting
Academy of Studenica
PERSPECTIVES
IN MELANOMA MANAGEMENT
& NANOTECHNOLOGY IN BIOMEDICINE
Organizers:
Institute of Oncology
Sremska Kamenica; Union of Cancer Prevention
Societies of Vojvodina, Novi Sad; Clinic of Oncology, Nis; Institute
for Oncology and Radiology of Serbia, Belgrade Center for Bioengineering,
Faculty of Mechanical Engineering, University of Belgrade
President:
Vladimir Baltic Vice-presidents: Zlata
Janjic, Radan Dzodic, Borislava Nikolin; Djuro Koruga
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SENTINEL
LYMPH NODE BIOPSY IN PATIENTS WITH SKIN MELANOMA
Džodić
R, Marković I, Inić M, Žegarac M, Žuričić I.
Institute
of oncology and radiology of Serbia, Belgrade, Serbia and Montenegro
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ABSTRACT
Background
Sentinel lymph node (SLN) was defined as the first lymph node that
the tumor would drain to, within that tumor s regional lyphatic
basin. The concept of sentinel lymph node being predictive of the
status of the regional lymphatic basin is commonly atributed to
Ramon Cabanas, a South American surgeon, following his pioneering
work on the lymphatic drainage in carcinoma of the penis in 100
patients back in 1977. Gould and his collagues from the Washington
Hospital Centre published their work and first introduced sentinel
node in tumors of a parotid gland in 1951. In 1992, Morton and his
colleagues introduced the concept of SLN in to the management of
melanoma especially those affecting the trunk where the lymphatic
drainage could be ambigous, using a blue-dye (isosulphan blue) injected
around melanoma or the biopsy scar. In the early nineties, SLN concept
was applied to breast cancer using a blue dye and later using a
radioactive colloid to localize the sentinel node. Recent publishied
literature seems to support the fact that a combination of blue
dye and radioisotope gives better results than either substance
on its own..
The SLN concept was really approved in patients with skin melanoma
and clinically not involeved regional lymph nodes. It become standard
in the majority of refferent institutions around the world.
SLN mapping and detection - technique
The tehnique is consisted of preoperative injection of radio-colloid
(Tc99m) peritumoraly or arround the excision scar, followed with
lymphoscintigraphy, the day before surgery. The scan picture showes
the SLN, those with highest accumulation of radio-tracer (`hot`).
Ten minutes before the surgery, approximately 0,5 (0,2-1) ml of
vital blue dye (Metilen blau, Isosulphan blue, Patent blue V) is
injected arround the primary melanoma. After the excision the second
small incision is made in the regional lymphatic basin close to
the highest detection rate on hand-held gamma probe monitor. Fine
surgical expoloration is required in a goal to see blue lymphatic
vessels leading to the SLN. At the same time the highest radio-activity
is detected with gamma probe. If the blue node/s and `hot` ones
are different all of them has to be removed and sent on frozen-section.
If revealed metastatic immediate dissection is indicated. If not
the patient is subbmited on clinical controls according to follow-up
Protocol.
In respect to technical possibilities and feasibillity study of
the method, some institutions perform either one of the technique
or both. It is necessary to obtain identification rate, specificity
and senyitivity over 95%. It is strongly reccomended that a surgeon
has to perform at least 20 procedure in a goal this results. Also,
the skill of the pathologist in management of SLN is as much important.
Results
From 2003 and 2004. in the Institute of oncology and rdiology of
Serbia, SLN biopsy was performed in 29 patients with primary skin
melanoma. The vital dye technique was done in 27 patients, while
in two a combined (Nanocolloid +Metilen blue) technique was performed.
Overall identification rate (IR) in our series was 93%. Identification
rate using only Metilen blue was 86%, while combined with pre and
intraoperative radio-tracer detection, identification of SLN was
100%. In 30% of cases the SLN were metastatic so immediate dissections
were performed. According to our data there was a concordance between
frozen-section and standard (H&E) histology examination, so tehre
was no false negatve or false positive results.
Conclusions
SLN biopsy enables precise staginig of clinically not involved (enlarged)
regional lymph nodes at the primary operation of skin melanoma,
and timely selective dissection if lymph node metasteses were found
on frozen-section histopathology. Also, the method enables to avoid
unneccesary elective dissections in node negative patients, as well
as precede delayed dissection at the time when nodes are enlarged
and probably ocurrence of distant metastases.
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Keywords:
Sentinel lymph node, Skin melanoma |
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