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Letter to the Editor in Response to “Eliminating Preoperative Lymphoscintigraphy in Extremity Melanomas”

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From the Christie NHS Foundation Trust and School of Medical
Sciences, Faculty of Biology, Medicine and Health, University of
Manchester, Manchester, United Kingdom.
Copyright © 2020 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
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Plast Reconstr Surg Glob Open 2020;8:e2846; doi: 10.1097/
GOX.0000000000002846; Published online 29 May 2020.
Letter to the Editor in Response to “Eliminating Preoperative
Lymphoscintigraphy in Extremity Melanomas”
Sharanniyan Ragavan; Won Young Yoon; Deemesh Oudit, MBBS
We read with great interest the paper by the authors
from the Plastic and Reconstructive Surgery Section
of the Yale University School of Medicine on the possibility
of eliminating preoperative lymphoscintigraphy (POLSG)
in extremity melanomas.1 It was indeed pleasing to hear
that the negative effects/costs associated with an additional
procedure like a POLSG could possibly be eliminated for
The authors based the elimination of POLSG on the
minimal atypical drainage rates for extremity tumors in
their cohort. Based on the current literature and the lit-
erature that was used by the authors themselves, how-
ever, we disagree and believe that these tumors do have
relatively unpredictable drainage patterns, and POLSG
remains necessary in all patients undergoing a sentinel
lymph node biopsy.
Vucetić et al2 concluded that, from their experience,
POLSG is essential in the management of patients with
malignant melanoma due to its sensitivity and inexpen-
siveness. This most likely stems from the high rate of
anomalous drainage of 15.0% in a 201-patient cohort
coupled with completely unpredictable drainage in 3%
of patients. In Statius Muller et al’s3 348-patient cohort,
particularly in the upper extremity, there was only 83%
predictability of drainage to the ipsilateral axilla. The
unknown nature of interval nodes in patients also need
to be highlighted, with Menes et al4 reporting that sig-
nicantly 9% of their 106 patients with a primary at the
knee or distal to the knee had popliteal node drain-
age together with conventional groin drainage. These
patients had varying patterns of drainage to the 2 nodal
basins, with the groin nodes presenting either as rst- or
second-order sentinel nodes. Interestingly, the authors
from the Sydney Melanoma Unit5 also report direct
drainage from the forearm to interpectoral or supracla-
vicular/neck nodes with or without direct drainage to
the axilla as well.
We do acknowledge that compared with the extrem-
ities, axial primaries do make up a large proportion of
aberrant drainages, with Vucetić et al2 reporting that
axial primaries had drainage discordance with classi-
cal anatomical guidelines at a rate of 39% for head/
neck and 23% for truncal lesions, with extremity
tumors draining exclusively to 1 basin. Statius Muller
et al3 concluded that extremity primaries did have pre-
dictable drainage when compared to the much higher
unpredictability rates of axial tumors, but both groups
concluded that POLSG should remain a staple of the
staging process.
It would be almost impossible to determine in which
cases aberrant sentinel node drainage will present with-
out POLSG. It is also likely that without POLSG, sen-
tinel nodes may be missed, thereby directly affecting
the staging investigation. Nodes draining to adjacent
nodal basins identified by lymphoscintigraphy should
also be harvested in the sentinel lymph node biopsy
for accuracy of staging. We, therefore, strongly believe
that there is a clear role for POLSG in cutaneous mela-
nomas for accurate staging independent of anatomical
Sharanniyan Ragavan
School of Medical Sciences, Faculty of Biology, Medicine and
Health University of Manchester
M13 9PL
United Kingdom
The authors have no nancial interest to declare in relation to the
content of this article.
1. McGregor A, Pavri SN, Kim S, et al. Eliminating preoperative
lymphoscintigraphy in extremity melanomas. Plast Reconstr Surg
Glob Open. 2018;6:e1681.
2. Vucetić B, Andreja Rogan S, Balenović A, et al. The role of
preoperative lymphoscintigraphy in surgery planning for sen-
tinel lymph node biopsy in malignant melanoma. Wien Klin
Wochenschr. 2006;118:286–293.
3. Statius Muller MG, Hennipman FA, van Leeuwen PA, et al.
Unpredictability of lymphatic drainage patterns in melanoma
patients. Eur J Nucl Med Mol Imaging. 2002;29:255–261.
4. Menes TS, Schachter J, Steinmetz AP, et al. Lymphatic drainage
to the popliteal basin in distal lower extremity malignant mela-
noma. Arch Surg. 2004;139:1002–1006.
5. Thompson JF, Uren RF, Shaw HM, et al. Location of sentinel
lymph nodes in patients with cutaneous melanoma: new insights
into lymphatic anatomy. J Am Coll Surg. 1999;189:195–204.
Letter to the editor
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Full-text available
Background:. Preoperative lymphoscintigraphy (LSG) is an imaging procedure routinely used to identify the draining nodal basin in melanomas. At our institute, we have traditionally performed preoperative LSG followed by intraoperative LSG for logistical and evaluative reasons. We sought to determine if preoperative LSG could be safely eliminated in the treatment of extremity melanomas, which exhibit consistent and predictable lymphatic drainage patterns. Methods:. We reviewed the Yale Melanoma Registry 1308012545 for cutaneous extremity melanomas treated at our institution. From this registry, we calculated the incidence of atypical lymph node drainage patterns outside the axillary and inguinal regions. Based on these data, we eliminated preoperative LSG in 21 cases (8 upper extremities and 13 lower extremities). Additionally, we calculated the potential hospital charge reduction of forgoing preoperative LSG. Results:. Upper and lower extremity melanomas treated at our institution exhibited atypical lymph node drainage at a rate of 3.4% and 2.0%, respectively. The sites of atypical drainage were to the epitrochlear and popliteal regions. In all 21 cases where preoperative LSG was eliminated, we were able to correctly identify the sentinel lymph node. The potential hospital charge reduction of forgoing preoperative LSG totaled $2,393. Conclusions:. Preoperative LSG can be safely eliminated in the management of upper and lower extremity melanomas. Exceptions may be considered for primary lesions of the posterior calf, ankle, and heel as well as for patients with history of prior surgery or radiation. Forgoing preoperative LSG results in a hospital charge reduction of $2,393 and provides additional benefits to the patient. Ultimately, there is potential for significant charge reduction if applied across health care systems.
Full-text available
To evaluate four years of preoperative lymphoscintigraphy experience and the accuracy of sentinel lymph node biopsy in our institution in melanoma patients with various tumor thicknesses. An additional aim was to evaluate the recurrence rate related to pathohistological findings. During the period from February 2002 to November 2005, 201 patients underwent sentinel node biopsy. Lymphoscintigraphy for identification of sentinel nodes was performed four to six hours prior to operation of the patient. Sentinel lymph node biopsy using an intraoperative hand-held gamma probe was performed in all patients, together with wide local excision of biopsy wound or primary lesion (N=56). Immediate complete basin dissection was performed in patients with sentinel node metastases. In four patients delayed complete lymph node dissection was performed after definitive histopathologic examination of sentinel nodes. The accuracy of sentinel node biopsy was determined by comparing the intraoperative rates of sentinel node identification and the subsequent development of nodal metastases in regional nodal basins in patients with tumor-negative sentinel nodes and in those with tumorpositive sentinel nodes. Using preoperative lymphoscintigraphy, we identified sentinel nodes in all but one of the 201 patients (99.0%), and in 248 nodal basins (1.2/patient) we observed 372 sentinel nodes (1.52 sentinels/basin; 1.8 sentinels/patient). The highest number of sentinel nodes was noticed in the groin of patients with melanoma on the lower extremities (1.5/patient), followed by the axilla (1.3/patient). Anomalous lymphatic drainage patterns were observed in 15.0% of all patients. The identification rate of sentinel nodes was 99.0% overall: 100% for the groin basins, and 98.0% for the axilla and head and neck basin. Forty-two patients (20.8%) had tumor-positive sentinel nodes. Ten patients (5.0%) had local or distant recurrences during a median follow-up of 23.1 months (range 2-46). The rate of false-negative lymphatic mapping and sentinel node biopsy as measured by nodal recurrence in patients with tumor-negative sentinel nodes was 1.3%. During the follow-up period, three of 201 patients died from other diseases and three patients died as the result of melanoma metastases, with a median follow-up of 13.5 months (range 12-22). Preoperative lymphoscintigraphy is a sensitive, inexpensive and essential method for the identification of drainage basins, determination of the number and position of sentinel nodes and their location outside the usual nodal basins. Scintigraphic findings may lead to changes in surgical management due to the unpredictability of lymphatic drainage. The low incidence of regional disease recurrence in patients with tumor-negative sentinel nodes supports the use of preoperative lymphoscintigraphy and sentinel node biopsy as a safe and accurate procedure for staging the regional nodal basin in patients with malignant melanoma.
Accurate staging of melanoma patients by sentinel node (SN) biopsy can be achieved only if all SNs draining a given melanoma site are identified and removed for detailed histologic examination. Lymphoscintigraphy with a radiolabeled colloid provides an objective and reliable method of locating SNs and demonstrates that confident prediction of their location is not possible on clinical grounds. Lymphatic drainage pathways demonstrated by preoperative lymphoscintigraphy for 1,759 patients with primary cutaneous melanomas were reviewed, and locations of SNs in these patients were documented. An SN was defined as any node receiving direct lymphatic drainage from a primary melanoma site. In many instances the cutaneous lymphatic drainage pathways were found to be at variance with longheld concepts of lymphatic anatomy. Several new pathways were identified, draining to SNs in unexpected sites. These included triangular intermuscular space SNs (from upper back and, rarely, upper limb primaries), paraaortic and retroperitoneal SNs (from upper and lower back primaries), and costal margin SNs with onward drainage to internal mammary nodes (from periumbilical primaries). Occasional drainage to node fields on the opposite side of the body was noted from head, neck, and trunk primaries, and drainage to interval nodes (by definition, SNs) outside recognized lymph node fields was also observed. Knowledge of the possibility of these unusual lymphatic drainage patterns and SN sites should help to ensure the accuracy and completeness of SN identification. Preoperative lymphoscintigraphy to definitively locate SNs is recommended for every patient undergoing an SN biopsy procedure.
We analysed the localisations of sentinel nodes (SN) found with the SN procedure to compare these sites with those that would have been predicted by conventional clinical descriptions of cutaneous lymphatic drainage. We assessed the surplus value of performing the SN procedure in melanoma patients who underwent regional nodal surgery. The SN procedure was performed in 348 patients with melanomas who were referred to our institute between 1993 and 1999. The localisations of the melanomas with the corresponding SNs were meticulously recorded on drawings of the human body and grouped according to the conventional descriptions. Predictability of lymph drainage was defined as the percentage of melanomas whose draining pattern was to the ipsilateral nearest basin, without simultaneous drainage to other basins or to an interval node. In all patients the SN procedure visualised at least one SN. We found 410 lymphatic basins in 347 patients. These basins included basins that could not have been predicted by the conventional clinical descriptions, such as multiple basins and contralateral drainage sites. For the head/neck region, SNs could be found in any of the basins described in the literature. The trunk's drainage predictability depended strongly on the melanoma localisation, ranging from 0% in the midline to 92% in one of the upper quadrants. The lower extremities had a high predictability of almost 100%, and predictability of drainage for the upper extremities ranged from 77% to 100%. In total, 34% of the patients had a cutaneous lymphatic drainage that was unpredictable, either totally or partially. We therefore conclude that an SN procedure is indispensable if the drainage site(s) are to be accurately identified.
Hypotheses Melanoma of the distal lower extremity may drain to the popliteal basin. Drainage pathways and retrieval of the popliteal sentinel nodes may affect patient outcome. Retrospective analysis of popliteal involvement in patients with stage IB or higher melanoma, operated on from August 1, 1993, to July 31, 2003. Tertiary referral, university-affiliated medical center. One hundred six melanoma patients who underwent combined lymphoscintigraphy and blue dye-guided sentinel node biopsy, radical popliteal dissection, or both. Incidence and patterns of drainage to popliteal nodes; effect on staging and outcome. Lymphoscintigraphy (n = 8) and physical examination (n = 2) identified 10 cases (9%) of draining to the popliteal basin, with concurrent drainage to the groin. Three distinct drainage patterns were identified, with different popliteal node locations. Seven of 8 popliteal sentinel nodes were retrieved, 1 of which was metastatic with no groin metastasis. Two patients had synchronous palpable popliteal and groin metastases and underwent radical groin and popliteal dissection. All 3 patients with popliteal metastases relapsed early with synchronous systemic and in-transit disease. One of 7 patients with negative sentinel nodes is alive with in-transit disease; all others are disease free. According to this series, the popliteal basin is the site of first drainage in about 9% of patients, with concurrent drainage to the groin. The 3 distinct patterns of drainage to the popliteal region and the presence of isolated popliteal metastases may affect the surgical treatment. Therefore, drainage to popliteal sentinel nodes and the pattern of this drainage should be noted in all distal lower extremity melanomas.