Eur J Nucl Med Mol Imaging (2010) 37:736–741 DOI 10.1007/s00259-009-1358-8
ORIGINAL ARTICLE
Sentinel node detection by lymphoscintigraphy and sentinel lymph node biopsy in vulvar melanoma Giuseppe Trifirò & Laura L. Travaini & Francesca Sanvito & Monica Pacifici & Andrew Mallia & Mahila E. Ferrari & Andrea Vertua & Angelo Maggioni & Giovanni Paganelli & Mario G. Sideri
Received: 15 October 2009 / Accepted: 7 December 2009 / Published online: 27 January 2010 # Springer-Verlag 2010
Abstract Purpose Vulvar melanoma is a rare malignant tumour. Its surgical excision is the mainstay of treatment whilst the surgical management of regional lymph nodes remains controversial; on the contrary elective inguinofemoral lymphadenectomy causes considerable morbidity. Lymphoscintigraphy (LS) and sentinel lymph node biopsy (SLNB) are accurate staging procedures of lymph node status in breast cancer and cutaneous melanoma patients. In this retrospective paper we report our experience of LS and SLNB in vulvar melanoma patients. Methods Twenty-two consecutive patients with a diagnosis of vulvar melanoma were treated at our institute: patients with clinically positive groin nodes or with previous surgery on the primary tumour were excluded. Twelve were selected for our analysis. All patients underwent G. Trifirò (*) : L. L. Travaini : M. Pacifici : A. Vertua : G. Paganelli Nuclear Medicine Division, European Institute of Oncology, Via G. Ripamonti 435, 20141 Milan, Italy e-mail:
[email protected] F. Sanvito : M. G. Sideri Preventive Gynaecology Unit, European Institute of Oncology, Milan, Italy A. Mallia Nuclear Medicine Division, Ospedale San Paolo, Milan, Italy M. E. Ferrari Medical Physics, European Institute of Oncology, Milan, Italy A. Maggioni Gynaecology Department, Institute of Oncology, Milan, Italy
sentinel lymph node localization with LS the day before surgery and the surgical procedure of SLNB associated with radical surgery. Results Six patients had metastatic SLNB and in five of six (83.3%) it was the only positive node. In the other six patients SLNB was negative for metastatic disease. No skip metastases were observed. In SLNB negative patients the mean Breslow thickness was 2.06 mm (range: 0.60–7.10) and only one patient showed a high Breslow thickness (patient 8). In SLNB positive patients the mean Breslow thickness was 4.33 mm (1.8–6.0). Conclusion Our data indicate that, even in vulvar melanoma, the sentinel lymph node pathological status predicts the pathological status of the remaining groin nodes and suggests that elective groin dissection can be spared in cases of a negative SLNB. Breslow thickness (1.0 mm in thickness for locoregional control and prevention of distant metastases [15]. Our data indicate that negative nodes can be found in patients with a tumour thickness of more than 1 mm: in the present series three of six patients. Identification of these patients with the technique of SLNB has the potential to avoid the unnecessary morbidity associated with the procedure of a complete inguinofemoral lymph node dissection. LS and SLNB are widely used in patients with breast cancer, cutaneous melanoma and other malignancies [21–24]. Several studies have examined the role of the SLN in vulvar cancers patients [10]. Recently the results of a large prospective study on SLNB in 259 patients with early-stage squamous cell vulvar cancer [14] showed that this technique can safely replace inguinofemoral lymphadenectomy. However, there are few reported cases on SLNB in vulvar melanoma patients [15–20]: a literature review revealed a total number of 32 vulvar melanomas investigated.
Eur J Nucl Med Mol Imaging (2010) 37:736–741
Our results on 12 patients indicate that even in vulvar melanoma the sentinel node pathological status predicts the pathological status of the remaining groin nodes. All of the patients with negative SLN were negative on complete inguinofemoral lymphadenectomy, and two negative SLN patients, who did not undergo lymphadenectomy, were free from disease at 75 (patient 2) and 87 (patient 11) months, respectively. As other authors we achieved a 100% rate of SLN visualization, confirming that LS has a high rate of successful localization. This methodology has proved to be useful in identifying positive nodes, but has to be further validated for the in vivo localization; indeed, only in two patients the localization had been performed during surgery, while for the other ten patients the identification of the active SLNs had been performed once the lymphadenectomy had been accomplished (“ex vivo” localization), because in these patients the lymphadenectomy was considered the primary endpoint. The result of the present series confirms the importance of SLNB in patients with vulvar melanoma. In addition, the present and literature data on vulvar melanoma, combined with the cutaneous melanoma and squamous cell vulvar cancer data, suggest that in selected patients, with a negative SLNB, the disabling surgery of a complete inguinofemoral lymphadenectomy can be safely omitted. In this group of patients the technique is particularly attractive as there is no consensus on the use of elective vs deferred lymphadenectomy and the prognosis of the disease is mostly related to the biological properties of this rare entity rather than by an aggressive surgical approach, especially at the groin level. Finally, due to the rarity of the disease, the possibility to test the value of this technique in a prospective randomized study is not plausible.
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