Sentinel lymph node biopsy for melanoma: how many radioactive nodes should be removed?
ABSTRACT Sentinel lymph node (SLN) biopsy has become a standard method of staging patients with cutaneous melanoma. Sentinel lymph node biopsy usually is performed by intradermal injection of a vital blue dye (isosulfan blue) plus radioactive colloid (technetium sulfur colloid) around the site of the tumor. Intraoperative gamma probe detection has been shown to improve the rate of SLN identification compared to the use of blue dye alone. However, multiple sentinel nodes often are detected using the gamma probe. It is not clear whether these additional lymph nodes represent true sentinel nodes, or second-echelon lymph nodes that have received radiocolloid particles that have passed through the true sentinel node. This analysis was performed to determine the frequency with which these less radioactive lymph nodes contain metastatic disease when the most radioactive, or "hottest," node does not.
In the Sunbelt Melanoma Trial, 1184 patients with cutaneous melanoma of Breslow thickness 1.0 mm or more had sentinel lymph nodes identified. Sentinel lymph node biopsy was performed by injection of technetium sulfur colloid plus isosulfan blue dye in 99% of cases. Intraoperative determination of the degree of radioactivity of sentinel nodes (ex vivo) was measured, as well as the degree of blue dye staining.
Sentinel nodes were identified in 1373 nodal basins in 1184 patients. A total of 288 of 1184 patients (24.3%) were found to have sentinel node metastases detected by histology or immunohistochemistry. Nodal metastases were detected in 306 nodal basins in these 288 patients. There were 175 nodal basins from 170 patients in which at least one positive sentinel node was found and more than one sentinel node was harvested. Blue dye staining was found in 86.3% of the histologically positive sentinel nodes and 66.4% of the negative sentinel nodes. In 40 of 306 positive nodal basins (13.1%), the most radioactive sentinel node was negative for tumor when another, less radioactive, sentinel node was positive for tumor. In 20 of 40 cases (50%), the less radioactive positive sentinel node contained 50% or less of the radioactive count of the hottest lymph node. The cervical lymph node basin was associated with an increased likelihood of finding a positive sentinel node other than the hottest node.
If only the most radioactive sentinel node in each basin had been removed, 13.1% of the nodal basins with positive sentinel nodes would have been missed. It is recommended that all blue lymph nodes and all nodes that measure 10% or higher of the ex vivo radioactive count of the hottest sentinel node should be harvested for optimal detection of nodal metastases.
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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.Archives of Surgery 05/1992; 127(4):392-9. · 4.10 Impact Factor
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ABSTRACT: The purpose of this study was to determine whether the sentinel lymph node (SLN) localization technique, which uses blue dye and 99mTc-labeled sulfur colloid, provides advantages over blue dye alone in the management of patients with stages I and II cutaneous melanoma. The records of 626 consecutive patients with melanoma who underwent lymphatic mapping and SLN biopsy between 1991 and 1997 at the M.D. Anderson Cancer Center were reviewed. Lymphatic mapping was performed with isosulfan blue dye alone (n = 252) or in combination with 99mTc-labeled sulfur colloid accompanied by a hand-held gamma probe (n = 374). SLNs were defined as those that stained blue or demonstrated increased focal radiotracer uptake. SLN identification rates improved from 87% (dye alone) to 99% (dye and colloid) (P < .0001) with the combined technique in all anatomic sites examined. The mean number of SLNs harvested from each basin was significantly greater in the patients mapped with dye and colloid (1.74 vs 1.31; P < .0001). Occult metastatic disease was identified in 17.5% of all patients and did not significantly differ between groups. In 92% of patients who had at least one positive SLN and were mapped with both agents, lymphatic metastases were identified in the SLN that contained the greatest radiotracer uptake. SLN identification is enhanced by the addition of radiolabeled sulfur colloid and intraoperative use of the hand-held gamma probe and may identify SLNs missed by the blue dye alone. These data support the combined use of radiolabeled sulfur colloid and blue dye in lymphatic mapping procedures to improve the nodal staging of stages I and II melanoma.Surgery 08/1998; 124(2):203-10. · 3.37 Impact Factor
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ABSTRACT: Malignant melanoma of the head and neck can metastasize to lymph nodes within the parotid gland. Selective lymphadenectomy is the modern method of staging regional lymph node basins in clinically localized melanoma. This procedure involves intraoperative lymphatic mapping and directed, selective removal of the first draining nodes or sentinel lymph nodes (SLNs). Historically, the assessment of parotid lymph nodes would involve a superficial parotidectomy with facial nerve dissection. Since 1993, 28 patients with localized melanoma of the head and neck have demonstrated lymphatic drainage to parotid lymph nodes on preoperative lymphoscintigraphy. The overall success rate of parotid selective lymphadenectomy is 86% (24 of 28 patients). Of the 28 patients, there were 6 early patients in whom blue dye alone was utilized intraoperatively, and the success rate is 50% (3 of 6 patients). When blue dye and radiocolloid mapping techniques are combined, the parotid selective lymphadenectomy is successful in 95% of patients (21 of 22 patients). Four of the 24 patients (17%) had metastases to the SLNs and underwent therapeutic superficial parotidectomy and/or modified radical neck dissection. After completion of the therapeutic superficial parotidectomy, 1 of the 4 patients was found to have an additional parotid (nonsentinel) node with melanoma metastases. None of the patients incurred injury to the facial nerve by parotid selective lymphadenectomy. To date, 2 of 28 patients (7%) have had regional recurrence to the parotid gland. Failure of the SLN technique may occur when blue dye alone is used, when human serum albumin (not sulfur colloid) is the radiocolloid, when prior wide excision and skin graft is present before lymphatic mapping, and when all SLNs are not retrieved. We conclude that parotid selective lymphadenectomy is a safe and reliable alternative to superficial parotidectomy for staging clinically localized melanoma of the head and neck.Annals of Plastic Surgery 08/1999; 43(1):1-6. · 1.38 Impact Factor
Sentinel Lymph Node Biopsy for Melanoma: How Many
Radioactive Nodes Should be Removed?
Kelly M. McMasters, MD, PhD, Douglas S. Reintgen, MD, Merrick I. Ross, MD,
Sandra L. Wong, MD, Jeffrey E. Gershenwald, MD, David N. Krag, MD, R. Dirk Noyes, MD,
Vicki Viar, RN, MSN, Patricia B. Cerrito, PhD, and Michael J. Edwards, MD
Background: Sentinel lymph node (SLN) biopsy has become a standard method of staging patients with
dye (isosulfan blue) plus radioactive colloid (technetium sulfur colloid) around the site of the tumor.
Intraoperative gamma probe detection has been shown to improve the rate of SLN identification compared to
the use of blue dye alone. However, multiple sentinel nodes often are detected using the gamma probe. It is
not clear whether these additional lymph nodes represent true sentinel nodes, or second-echelon lymph nodes
that have received radiocolloid particles that have passed through the true sentinel node. This analysis was
performed to determine the frequency with which these less radioactive lymph nodes contain metastatic
disease when the most radioactive, or “hottest,” node does not.
Materials and Methods: In the Sunbelt Melanoma Trial, 1184 patients with cutaneous mela-
noma of Breslow thickness 1.0 mm or more had sentinel lymph nodes identified. Sentinel lymph
node biopsy was performed by injection of technetium sulfur colloid plus isosulfan blue dye in 99%
of cases. Intraoperative determination of the degree of radioactivity of sentinel nodes (ex vivo) was
measured, as well as the degree of blue dye staining.
Results: Sentinel nodes were identified in 1373 nodal basins in 1184 patients. A total of 288 of 1184
Nodal metastases were detected in 306 nodal basins in these 288 patients. There were 175 nodal basins from
170 patients in which at least one positive sentinel node was found and more than one sentinel node was
negative sentinel nodes. In 40 of 306 positive nodal basins (13.1%), the most radioactive sentinel node was
negative for tumor when another, less radioactive, sentinel node was positive for tumor. In 20 of 40 cases
(50%), the less radioactive positive sentinel node contained 50% or less of the radioactive count of the hottest
lymph node. The cervical lymph node basin was associated with an increased likelihood of finding a positive
sentinel node other than the hottest node.
Conclusions: If only the most radioactive sentinel node in each basin had been removed, 13.1%
of the nodal basins with positive sentinel nodes would have been missed. It is recommended that all
blue lymph nodes and all nodes that measure 10% or higher of the ex vivo radioactive count of the
hottest sentinel node should be harvested for optimal detection of nodal metastases.
Key Words: Melanoma—Sentinel lymph node—Lymph node dissection—Lymphoscintigra-
Since the first report by Morton and colleagues in
1992,1sentinel lymph node (SLN) biopsy has become a
widely accepted method of staging regional lymph nodes
for patients with melanoma. Sentinel lymph node biopsy
is performed by intradermal injection of a vital blue dye
(isosulfan blue), a radioactive tracer (technetium sulfur
colloid), or both around the melanoma site. The sentinel
node is then identified by use of an intraoperative hand-
Received April 3, 2000; accepted September 13, 2000.
From the Division of Surgical Oncology, Department of Surgery,
James Graham Brown Cancer Center (KMM, MJE, SLW, and VV),
and Department of Mathematics (PBC), University of Louisville, Lou-
isville, Kentucky; University of South Florida, Moffitt Cancer Center,
Tampa, Florida (DSR); University of Texas M.D. Anderson Cancer
Center, Houston, Texas (MIR, JEG); Department of Surgery, Univer-
sity of Vermont, Burlington, Vermont (DNK); and LDS Hospital, Salt
Lake City, Utah (RDN).
Preliminary findings presented at the annual meeting of the Society
of Surgical Oncology, Orlando, Florida, March 4–7, 1999.
Address correspondence and reprint requests to: Dr. Kelly M.
McMasters, University of Louisville-Brown Cancer Center, 529
S. Jackson St., Louisville, KY 40202; Fax: 502-852-8031; Email:
Annals of Surgical Oncology, 8(3):192–197
Published by Lippincott Williams & Wilkins © 2001 The Society of Surgical Oncology, Inc.
held Gamma counter and by visualization of the blue dye
in an afferent lymphatic channel entering the blue-
stained sentinel node. It has been demonstrated that the
use of the blue dye in combination with the radioactive
colloid leads to optimal detection and identification of
sentinel nodes for melanoma.2–9
There is, however, some controversy about the exact
definition of a sentinel node. It has been suggested that
the blue dye staining of the afferent lymphatic channel
leading into the sentinel node is the sine qua non of a true
sentinel node, because it indicates a direct lymphatic
pathway from the site of the melanoma.10,11It is clear,
however, that radioactive colloid injection with gamma
probe detection often identifies sentinel nodes that would
not have been detected with blue dye alone, and positive
sentinel nodes that have no evidence of blue dye staining
occasionally are identified.2–9
Several different definitions of the term sentinel node
have been proposed based on the degree of radioactivity
within the node. Among these are definitions based on
the absolute number of counts in the node, or on the ratio
of the in vivo or ex vivo radioactive counts in the node
to background radioactivity or to neighboring non-senti-
nel nodes.10,11All of these definitions are somewhat
arbitrary, and none is based on empiric data related to the
likelihood of finding nodal metastases. For example, the
degree of background radioactivity is variable based on
the position of the gamma probe within the nodal basin
and the location of the primary tumor, which can account
for a significant amount of background radioactivity, or
“shine-through.” Furthermore, the absolute number of
counts in the node varies depending on the dose and type
of radioactive colloid, the injection site, time interval
from injection to operation, the type of gamma probe and
its calibration, as well as other factors.
The present study was designed to address these issues
using empiric data derived from the Sunbelt Melanoma
Trial, a large multi-institutional trial of SLN biopsy and
adjuvant therapy for melanoma. The results of this study
indicate that the most radioactive, or “hottest,” lymph
node is not always the positive sentinel node, and that it
is important to search diligently for additional sentinel
nodes, especially if significant residual radioactive back-
ground remains after the first sentinel node is removed.
Blue dye staining is usually, but not always, evident in
the positive sentinel node.
MATERIALS AND METHODS
Patients were enrolled in the Sunbelt Melanoma Trial,
a randomized prospective trial involving 60 institutions
across the United States, between June 1997 and January
2000. The study was approved at the institutional review
boards of each center. Patients with cutaneous melano-
mas of Breslow thickness 1.0 mm or more and clinically
negative regional lymph nodes were eligible. After in-
formed consent was obtained, patients underwent SLN
biopsy, during which time intraoperative determination
of blue dye staining and degree of radioactivity of each
sentinel node (ex vivo count) was determined. The pro-
tocol specified that all blue nodes, and all nodes contain-
ing 10% or more of the radioactive counts of the ex vivo
count of the hottest node should be removed and desig-
nated SLN. These guidelines have been suggested pre-
viously.11,12This analysis includes all patients in whom
at least one SLN was identified, and for whom complete
data were available regarding blue dye staining, histol-
ogy, and radioactive counts in the sentinel nodes.
Blue dye staining in each sentinel node was graded as
either none, faint blue, or obviously blue. Analysis was
performed of patients with more than one sentinel node
removed per nodal basin to determine how frequently the
less radioactive sentinel nodes were positive for meta-
static tumor. All sentinel nodes underwent histologic
analysis with hematoxylin and eosin (H&E) staining at
multiple levels followed by immunohistochemical stain-
ing for S100 protein. Sentinel nodes were divided into
blocks based on lymph node size. At least five sections
per block were evaluated by H&E staining and two
sections per block by immunohistochemical staining for
S100. Immunohistochemical staining for HMB-45 or
MART-1 was performed at some institutions as well.
Lymphatic drainage to the following nodal basins was
recorded: axilla, cervical (including supraclavicular and
parotid), inguinal, deep groin (iliac, hypogastric, and
obturator), epitrochlear, popliteal, and ectopic.
Statistical analysis was performed by ?2analysis and
Fisher’s exact test using the SAS (SAS Institute, Cary,
NC) software package. Significance was determined at
P ? .05.
Clinicopathologic characteristics of patients entered
into the study are presented in Table 1. There were 687
men and 497 women. Median age was 51 years. There
were 1373 nodal basins in 1184 patients (mean, 1.12
basins/patient). A total of 2863 sentinel nodes were iden-
tified in 1373 basins (mean, 2.08 SLN/basin). Mean and
median tumor thicknesses were 2.35 mm and 1.73 mm,
Blue dye injection in combination with radioactive
colloid was used in 99% of cases. Sentinel nodes were
identified in 99.7% of patients. A total of 288 of 1184
193SENTINEL LYMPH NODE BIOPSY FOR MELANOMA
Ann Surg Oncol, Vol. 8, No. 3, 2001
patients (24.3%) had histologic or immunohistochemical
evidence of metastatic disease in the sentinel nodes.
Nodal metastases were detected in 306 nodal basins in
these 288 patients. To determine how often a less radio-
active sentinel node is positive for tumor when the most
radioactive lymph node is not, 175 positive nodal basins
from 170 patients were identified in which more than one
sentinel node was identified. In 40 of these 175 nodal
basins, a less radioactive lymph node was positive for
tumor when the most radioactive sentinel node was neg-
ative (Table 2). Overall, in 40 of 306 nodal basins
(13.1%), the hottest node was negative when a less
radioactive node was positive. In 20 of these 40 (50%)
basins, the positive, less radioactive sentinel node mea-
sured no more than 50% of the radioactive count of the
hottest sentinel node. In two of 40 cases, the positive,
less radioactive node measured ? 10% of the hottest
sentinel node; both of these cases were in the cervical
nodal basin. In 35 of 40 basins in which the positive
sentinel node was not the hottest node, the positive node
was the first or second sentinel node identified in that
Overall, 69% of all sentinel nodes contained evidence
of blue dye staining. However, 86.3% of the positive
sentinel nodes contained blue staining, whereas only
66.4% of the histologically negative sentinel nodes con-
tained blue staining. For cases in which the positive
sentinel node was not the hottest node, blue dye staining
was apparent in 31 of 37 cases (84%) in which blue dye
Table 3 demonstrates the distribution of sentinel nodes
within nodal basins. The cervical nodal basin was asso-
ciated with an increased likelihood of finding the only
positive sentinel node that was not the hottest node, or
that was less than or equal to 50% of the ex vivo count
of the hottest node.
The impact of various definitions of a true sentinel
node on the false-negative rate is demonstrated in Table
4. Although the actual false-negative rate can be estab-
lished only by long-term follow-up to determine nodal
recurrences in basins that were found to have negative
sentinel nodes, removing all blue nodes and all nodes
that contain 10% or more of the ex vivo count of the
hottest node will minimize the false-negative rate. In the
study so far, there have been seven false-negative results.
In four of these cases, a single sentinel node was re-
moved from the nodal basin. In the other three cases, the
residual background activity after removal of the sentinel
node(s) exceeded 10% of the ex vivo count of the hottest
node. These factors suggest that further dissection and
examination of those nodal basins may have demon-
strated additional sentinel nodes that were microscopi-
cally positive at the time of SLN biopsy.
Sentinel lymph node biopsy is a highly accurate
method of staging regional lymph nodes for melanoma.
By performing focused and detailed pathologic evalua-
tion of the node or nodes most likely to contain meta-
static disease, very early metastatic nodal disease is often
detected. In the present study, 24.3% of patients with
melanomas 1.0 mm or more in thickness were found to
have histologic evidence of nodal metastasis. This is
slightly higher than the rate in many other published
series1–9and indicates that the pathologic methods used
are effective at detecting micrometastatic disease.
It is generally accepted that a blue lymphatic channel
leading to a blue node is the gold standard for identifi-
cation of the sentinel node. However, there may be two
or more lymphatic channels leading to separate sentinel
nodes. By using radioactive colloid injection with intra-
operative gamma probe detection, it usually is possible to
localize the sentinel nodes without relying completely on
Clinicopathologic features of patient population
Median age (y)
Male (n ? 687)
Female (n ? 497)
Vertical growth phase
No. nodal basins
194K. M. MCMASTERS ET AL.
Ann Surg Oncol, Vol. 8, No. 3, 2001
visualization of blue dye. As a practical matter, it may be
possible to identify the first sentinel node with blue dye
alone, but after that first node is dissected, it may be
difficult to find additional nodes. It is very common, in
fact, to localize the sentinel node with the gamma probe,
only to find blue dye staining within the node in retro-
spect only after the node has been removed. Therefore,
the gamma probe actually helps to identify blue nodes.
In most cases, the blue dye staining and radioactive
blue dye staining may not be obvious or it may not be easy
Distribution of SLN within nodal basins
BasinAxilla InguinalCervical Other
All basins: positive ? negative SLN
Basins with positive SLN
Basins with positive node that was not the hottest node
Basins with positive node ?50% of the ex vivo count of
the hottest node
* P ?.05 vs. all basins with positive SLN.
SLN, sentinel lymph node.
Patients who would have had a false negative result if only the most radioactive (“hottest”) node was removed
Ex vivo radioactive count
removedBasin Blue dye stainingPositive Node Hottest Node
Blue dye not used
Blue dye not used
Blue dye not used
195SENTINEL LYMPH NODE BIOPSY FOR MELANOMA
Ann Surg Oncol, Vol. 8, No. 3, 2001
sentinel nodes were not blue in 13.6% of cases.
The hand-held gamma counter facilitates detection of
sentinel nodes by allowing transcutaneous localization of
the site of the sentinel node, and it is possible to use the
gamma probe intraoperatively to pinpoint the direction
and location of the sentinel node or nodes. The gamma
probe also is very helpful in identifying a second or third
sentinel node, which often is difficult to detect after the
first lymph node is removed when using blue dye alone.
Therefore, the hand-held gamma counter may identify
additional radioactive nodes that are identified as having
blue staining only in retrospect, after they have been
removed. Thus, the combination of blue dye and radio-
active colloid may allow more accurate sentinel node
identification because a second and third true sentinel
node can be identified that might be missed with blue
dye staining alone.
On occasion, multiple radioactive lymph nodes are
detected after the most radioactive sentinel node has
been removed. In some cases, the preoperative lym-
phoscintigram identifies what appears to be an entire
chain of nodes, raising concern that the gamma probe
will identify an inordinate number of radioactive nodes.
In such cases it may be difficult to determine at what
point these less radioactive lymph nodes should be re-
moved. In the present study, 13.1% of the positive nodal
basins would have been staged incorrectly if only the
most radioactive lymph node was removed. In some
cases, these less radioactive nodes were not blue, or were
only faintly blue-stained and might have been missed if
not for gamma probe detection. The cervical nodal basin
appears most prone to have mildly radioactive nodes that
are positive for tumor, which may be a reflection of the
rich lymphatic drainage of the head and neck, and the
occasional problems in head and neck melonomas with
high background counts from the primary tumor site in
close proximity to the nodal basin (“shine-through”).
The results of this study indicate that all blue lymph
nodes, as well as any lymph nodes remaining in the basin
that contains 10% or more of the ex vivo count of the
hottest sentinel node should be removed. Following this
guideline will provide optimal detection of micrometa-
static disease. Interestingly, a recent analysis of a large
multi-institutional study found that this “10% rule” ap-
plies equally well to SLN biopsy for breast cancer.13
Even with this approach, the mean number of sentinel
nodes removed was two per patient, and it is not common
for more than three lymph nodes to fit these criteria, even
when multiple nodes are seen on the lymphoscintigram.
These data provide practical guidelines for perfor-
mance of SLN biopsy with optimal sensitivity. The Sun-
belt Melanoma Trial will further investigate the role of
adjuvant interferon alfa-2b for the treatment of patients
with very early nodal metastases and determine the va-
lidity of reverse transcriptase polymerase chain reaction
(RT-PCR) analysis as a molecular staging test for senti-
nel nodes and peripheral blood cells to determine pa-
tients at risk for recurrence or death.
Acknowledgments: This study was supported by grants
from Schering Oncology-Biotech, and the Center for Advanced
Surgical Technologies (CAST) of Norton Hospital, Louisville,
Kentucky. The authors wish to thank Carla Shelton, Kristi
Recktenwald, Sherri Matthews, and Diana Simpson for their
dedication and hard work on the Sunbelt Melanoma Trial.
1. Morton DL, Wen DR, Wong JH, et al. Technical details of intra-
operative lymphatic mapping for early stage melanoma. Arch Surg
2. Albertini JJ, Cruse CW, Rapaport D, et al. Intraoperative radio-
Impact of sentinel node definition on false-negative results
Criteria for removal of sentinel nodes
No. false negatives/
no. basins with
A. Only hottest node removed
B. Hottest node and all obviously blue nodes removedc,d
C. Hottest node and all blue nodes removedc
D. 1stor 2ndSLN identified
E. All blue nodes and all nodes ?10% of the hottest node
aThe actual false-negative rate can be determined only by long-term follow-up for recurrent nodal metastases
in basins that are found to have negative sentinel nodes.
bAll results are statistically different from category A and reduce the risk of false-negative results (P ? .02).
cThis assumes that the faintly blue or obviously blue nodes would have been identified without the Gamma
probe, or that blue dye staining could be established prior to removing the node.
dCases in which blue dye was not used have been excluded.
eCategory B is statistically different from categories C, D, and E (P ?.01).
196 K. M. MCMASTERS ET AL.
Ann Surg Oncol, Vol. 8, No. 3, 2001
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