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.
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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
Resection
Presence of
dye
(Identifiable
to surgeon?)
Basin of
drainage
Total #
sentinel
nodes
removed
# nodes removed
/location (size largest
node)
Closure of
defect/complications
Surgical
margin
positive?
Sentinel lymph node
status
1
2 cm
+(Y)
1
yes
positive (1/1)
1 cm
+(N)
local skin flaps
no
negative (3/3)
3*
0.5 cm
+(Y)
1 posterior auricular
(1.5x1.5x1 cm)
2 jugulodigastric
(2x 2x1.5 cm)
1 parotid
2 jugulodigastric
(1.3x1.1x0.6 cm)
1 parotid
STSG to scalp
2
local skin flaps
no
negative (0/3)
4
3-4 cm
+(Y)
Left posterior
auricular
Left
jugulodigastric
& left parotid
Left
jugulodigastric
and left tail of
parotid
Right anterior
cervical
1
1 anterior cervical
(1.5 x1x1 cm)
no
negative (0/1)
5*
1 cm
+(Y)
Bilateral axillae
5
no
6*
1 cm
+(Y)
Right parotid,
right
jugulodigastric
2
4 right axilla (0.7
x0.6 x1 cm)
1 left axilla
1 parotid (1x0.7x0.5
cm)
1 jugulodigastric
(2.4x1x0.8 cm)
local
fasciocutaneous
flaps and STSG
primary closure
FTSG to ear
no
positive (2/4 right
axilla, 0/1 left
axilla)
positive (1/2
jugulodigastric)
7
1 cm
+(Y)
Right jugular
chain
4
Local skin flaps, zplasty
no
3
3
1 preauricular
2 external jugular
1 midjugular
(1.1x0.8x0.4 cm)
positive (1/4
preauricular)
* 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.
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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
1
Need for
second
procedure?
Yes
Second Procedure
Time from
1st procedure
1) Reexcision of surgical
site with 3 cm margins
2) Left superficial
parotidectomy
3) Left modified radical
neck dissection
2 wks
Surgical Outcome
Second Procedure
Adjuvant therapy
Follow-up
time
Recurrence
?
1) No Residual
Interferon alfa-2b
40 mos.
No
Melanoma
2) No metastatic
extension
3) 1/60 nodes
positive for
metastatic 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
3 wks
44 nodes (level I-V)
Interferon alfa-2b
5 mos
No
neck dissection
negative for
metastatic melanoma
7
Yes
1) Right superficial
3 wks
1) No metastatic
Interferon alfa-2b
4 mos
No
parotidectomy
extension
2) Right modified radical
2) 47 nodes (level Ineck dissection
V) 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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