Sentinel lymph node dissection

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Guard lymph node biopsy; sentinel lymphadenectomy; sentinel lymph node; Sentinel lymph node biopsy; sentinel lymphonodectomy; SLN; SLND

Definition
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Combined scintigraphic/surgical method for the detection and removal of the primary draining lymph node in the area of influence of a malignant tumor. The sentinel lymph node biopsy is currently performed for malignant melanoma from a tumor thickness of =/> 1.0 mm (for further indications see below, malignant melanoma ), for Merkel cell carcinoma and for high-risk spinocellular carcinoma of the skin (Note: The following information refers mainly to malignant melanoma, since this tumor has by far the most experience).

General information
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  • The presence of metastases in the RLNs (regional lymph nodes) indicates that the tumour was able to spread. The SLND is suitable for detecting subclinical tumour progression.
  • Metastasized tumor cells are detected histologically and immunohistologically by using appropriate antibodies.
  • The RLNs should not be regarded as passive mechanical filters for systemic seeding of the metastatic tumor.
  • As long as there is no effective adjuvant therapy for a metastatic tumour, close clinical controls and therapeutic/selective LK dissection are acceptable.
  • According to the currently available studies, the SLN status in thick melanomas (tumour thickness > 4.0 mm s. Breslow index ) can be evaluated with sufficient certainty as a prognostic factor (significantly lower 5-year survival time in pos. LK infestation than in negative status). Furthermore, the SLN status plays an important diagnostic role in Merkel cell carcinoma and high-risk squamous cell carcinoma.
  • SLND should be preferred to ELND (elective lymph node dissection) when prognostic information is required.
  • In promising adjuvant therapies, the SLND can serve as an important prognostic factor.
  • There is no sound scientific evidence that SLND followed by complete lymph node dissection improves the survival rate of melanoma patients (Breslow index 1.2-3.5 mm).

Implementation
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The primary draining lymph node detected by means of a lymph drainage scintigram and an intraoperatively inserted gamma probe is removed under local anesthesia and histologically, immunohistologically and molecularly biologically processed in cut series.

In many centers, a lymphatic dye (e.g. patent blue V) is injected into the tumor area preoperatively to additionally visualize the sentinel lymph node.

According to the results of clinical studies, SLND has proven to be an important predictive parameter.

Complications after SLND dissection can include: haematomas, lymphoedema, nerve injury, phlebothrombosis, bleeding and anaphylactic reactions caused by the (indicator dye).

The preparation of the sentinel lymph node should be evaluated according to national and international protocols (halving of the lymph node, at least 4 tissue sections per half, HE staining and additional immunohistological preparation ( Melan A, Ki 67, S100) by at least 2 experienced histopathologists.

Note(s)
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  • The prognostic relevance of tumor cell detection has not yet been clearly defined. With regard to the tumor burden, the following parameters should be included (applies to malignant melanoma):
    • Length of the largest melanoma cell conglomerate
    • Infiltration of the lymph node capsule
    • maximum penetration depth of the melanoma cells into the parenchyma starting from the lymph node capsule
    • Lymphangiosis - Accumulation of tumor cells in lymph vessels outside the lymph node.
  • The diagnostic and therapeutic significance of lymphatic drainage of certain lymph node stations that are switched into the lymph drainage or upstream of it, such as the popliteal fossa in acral localized malignant melanoma, has not been conclusively clarified.
  • The subfascially located, usually very small lymph nodes of the popliteal fossa drain the regions of the heel, the external ankle and the lateral calf. Popliteal lymph node metastases play a negligible role in clinical routine.

Literature
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  1. Aurich S et al (2016) A Case of Anaphylaxis to Patent Blue in a Patient with Sentinel Lymph Node Excision. Iran J Allergy Asthma Immunol
    15:547-550.

  2. Gutzmer R et al (2008) Sentinel lymph node status is the most important prognostic factor for thick (> or = 4 mm) melanomas. J Dtsch Dermatol Ges 6: 198-203
  3. Johnson TM et al (2006) The role of sentinel lymph node biopsy for melanoma: evidence assessment. J Am Acad Dermatol 54: 19-27
  4. Kretzschmer L, Bertsch HP (2009) Sentinel lymphonodectomy, complete regional lymphadenectomy or no lymph node surgery? Act Dermatol 35: 79-83
  5. Kretzschmer L et al. (2011) The popliteal fossa - a problem zone in sentinel lymphonodectomy. JDDG 9: 123-128
  6. Liszkay G et al (2005) Relationship between sentinel lymph node status and regression of primary malignant melanoma. Melanoma Res 15: 509-513
  7. Manson AL et al (2012) Anaphylaxis to Patent Blue V: a case series. Asia Pac Allergy 2:86-89.

  8. Paek SC et al (2006) The impact of factors beyond Breslow depth on predicting sentinel lymph node positivity in melanoma. Cancer 109: 100-108
  9. Pharis D, Zitadelli J (2003) The management of regional lymph nodes in cancer. Br J Dermatol 149: 919-925
  10. Reintgen DS et al (2001) Sentinel lymph node biopsy for melanoma: controversy despite widespread agreement. J Clin Oncol 19: 2851-2855
  11. Satzger I et al (2008) Criteria in sentinel lymph nodes of melanoma patients that predict involvement of nonsentinel lymph nodes. Ann Surg Oncol 15: 1723-1732
  12. Schwartz JL et al (2011) Features Predicting Sentinel Lymph Node Positivity in Merkel Cell Carcinoma. J Clin Oncol. 2011 [Epub ahead of print]
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Last updated on: 29.10.2020