Head & Neck Melanoma and Sentinel Lymph Node Biopsy in …



Title: The Utility of Sentinel Lymph Node Biopsy in Head and Neck Melanoma in the Pediatric Population

Authors: Salvatore J. Pacella, MD and Riley Rees, MD. Departments of Surgery (Division of Plastic Surgery ) University of Michigan Health System, Ann Arbor, Michigan

The technique of intraoperative lymphatic mapping (IOLM) and sentinel lymph node biopsy (SLNB) has proven beneficial in staging adult patients with melanoma of the head and neck, where there is great variability in lymphatic drainage. [1] This technique has also been applied to pediatric patients with truncal cutaneous melanomas in an effort to determine nodal status without the morbidity associated with complete lymph node dissection. [2] However, the utility of SLNB in head and neck melanoma in the pediatric population has not been established. In addition, patients with borderline or atypical melanocytic proliferations of unknown biologic potential with melanoma in the differential diagnosis can be challenging to treat given the uncertainty of their diagnosis and the potential for metastasis. [3] The objective of this study was to examine the experience at our center with IOLM and SLNB for cutaneous melanoma of the head and neck in the pediatric population, as well as to examine the utility of this technique in pediatric patients with boderline atypical melanocytic proliferations of the head and neck.

METHODS: We reviewed the records of seven pediatric patients with head and neck melanoma or borderline melanocytic proliferations of unknown biologic potential who underwent IOLM and SLNB between 1998 and 2001. All sentinel lymph node specimens were examined by a melanoma dermatopathologist for the presence of metastatic melanoma.

RESULTS: The mean operative time for each case was 3hrs 8 min (range 2:15-3:50). All seven pediatric patients who underwent extirpation of a primary head and neck melanoma and preoperative lymphoscintigraphy had unique and identifiable basins of drainage to regional nodal groups (Table 1). Four (57%) of seven patients had at least 1 positive sentinel lymph node. Overall, five (26%) of 19 sentinel nodes resected had evidence of metastatic melanoma. Of the patients with positive sentinel lymph nodes, two of the primary lesions were diagnosed as melanoma while two were initially considered atypical melanocytic proliferations of uncertain biologic potential with melanoma in the differential diagnosis. One (25%) of four patients had evidence of an additional positive lymph node from the complete lymphadenectomy (Table 2).

CONCLUSIONS: Sentinel lymph nodes in pediatric patients with melanoma of the head and neck can be successfully mapped and biopsied similar to adult patients. In addition, this procedure can provide critical diagnostic information for those pediatric patients with diagnostically challenging, controversial or borderline melanocytic lesions.

References:

1. Wells KE, Cruse CW, Daniels S, et al. The use of lymphscintigraphy in melanoma of the head and neck. Plast Reconstr Surg 1994; 93:757-759.

2. Davidoff AM, Cirrincione C, Seigler HF. Malignant melanoma in children. Ann Surg Onc 1994; 1(4):278-82.

3. Johnson TM, Sondak VK, Su LD, et al.: Is it a benign spitz nevus or a malignant melanoma? Primary Care and Cancer 2000, 20:41-44.

Table I: Summary of surgical information.(The Utility of Sentinel Lymph Node Biopsy in Head and Neck Melanoma in the Pediatric Population)

|Patient |Margin of |Presence of dye |Basin of drainage |Total # sentinel|# nodes removed |Closure of |Surgical margin|Sentinel lymph node status |

| |Resection |(Identifiable to | |nodes removed |/location (size largest node)|defect/complications |positive? | |

| | |surgeon?) | | | | | | |

|1 |2 cm |+(Y) |Left posterior |1 |1 posterior auricular |STSG to scalp |yes |positive (1/1) |

| | | |auricular | |(1.5x1.5x1 cm) | | | |

|2 |1 cm |+(N) |Left jugulodigastric &|3 |2 jugulodigastric |local skin flaps |no |negative (3/3) |

| | | |left parotid | |(2x 2x1.5 cm) | | | |

| | | | | |1 parotid | | | |

|3* |0.5 cm |+(Y) |Left jugulodigastric |3 |2 jugulodigastric |local skin flaps |no |negative (0/3) |

| | | |and left tail of | |(1.3x1.1x0.6 cm) | | | |

| | | |parotid | |1 parotid | | | |

|4 |3-4 cm |+(Y) |Right anterior |1 |1 anterior cervical (1.5 x1x1|local fasciocutaneous flaps|no |negative (0/1) |

| | | |cervical | |cm) |and STSG | | |

|5* |1 cm |+(Y) |Bilateral axillae |5 |4 right axilla (0.7 x0.6 x1 |primary closure |no |positive (2/4 right axilla,|

| | | | | |cm) | | |0/1 left axilla) |

| | | | | |1 left axilla | | | |

|6* |1 cm |+(Y) |Right parotid, right |2 |1 parotid (1x0.7x0.5 cm) |FTSG to ear |no |positive (1/2 |

| | | |jugulodigastric | |1 jugulodigastric (2.4x1x0.8 | | |jugulodigastric) |

| | | | | |cm) | | | |

|7 |1 cm |+(Y) |Right jugular chain |4 |1 preauricular |Local skin flaps, z-plasty |no |positive (1/4 preauricular)|

| | | | | |2 external jugular | | | |

| | | | | |1 midjugular (1.1x0.8x0.4 cm)| | | |

* Indicates patients with original biopsy specimens interpreted by dermatopathologist as atypical melanocytic proliferation of uncertain biologic potential vs. malignant melanoma; Y=yes; N=no; STSG=split thickness skin graft; FTSG=full thickness skin graft.

Table II: Surgical outcome after wide local excision of pediatric head and neck lesions followed by IOLM and sentinel node biopsy. (The Utility of Sentinel Lymph Node Biopsy in Head and Neck Melanoma in the Pediatric Population)

|Patient |Need for second |Second Procedure |Time from 1st |Surgical Outcome Second |Adjuvant therapy |Follow-up time |Recurrence? |

| |procedure? | |procedure |Procedure | | | |

|1 |Yes |1) Reexcision of surgical site |2 wks |1) No Residual Melanoma |Interferon alfa-2b |40 mos. |No |

| | |with 3 cm margins | |2) No metastatic extension | | | |

| | |2) Left superficial parotidectomy | |3) 1/60 nodes | | | |

| | |3) Left modified radical neck | |positive for metastatic | | | |

| | |dissection | |melanoma | | | |

|2 |No |n/a |n/a |n/a |Interferon alfa-2b |26 mos |No |

|3* |No |n/a |n/a |n/a |Interferon alfa-2b |9 mos |No |

|4 |No |n/a |n/a |n/a |Interferon alfa-2b |9 mos |No |

|5* |Yes |Right axillary lymph node |4 wks |32 nodes negative for |Interferon alfa-2b |6 mos |No |

| | |dissection | |metastatic melanoma | | | |

|6* |Yes |Right modified radical neck |3 wks |44 nodes (level I-V) negative|Interferon alfa-2b |5 mos |No |

| | |dissection | |for metastatic melanoma | | | |

|7 |Yes |1) Right superficial parotidectomy|3 wks |1) No metastatic extension |Interferon alfa-2b |4 mos |No |

| | |2) Right modified radical neck | |2) 47 nodes (level I-V) | | | |

| | |dissection | |negative for metastatic | | | |

| | | | |melanoma | | | |

* Indicates patients with original biopsy specimens interpreted by dermatopathologist as atypical melanocytic proliferation of uncertain biologic potential vs. malignant melanoma, n/a=non-applicable.

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