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Radioguided Sentinel Lymph Node Biopsy in Malignant Cutaneous Melanoma*

¹ Regional Center of Nuclear Medicine, University of Pisa Medical School, Pisa, Italy
² Institute of Clinical Physiology, National Research Council, Pisa, Italy
³ Division of Surgical Oncology, National Cancer Institute, Genoa, Italy
⁴ Division of Surgical Oncology, Department of Oncology, Biology and Genetics, University of Genoa and National Cancer Institute, Genoa, Italy
⁵ Nuclear Medicine Service, Department of Internal Medicine and Medical Specialties, University of Genoa Medical School, Genoa, Italy
⁶ Division of Nuclear Medicine, European Institute of Oncology, Milan, Italy
⁷ Department of Pathology, European Institute of Oncology, Milan, Italy
⁸ Health Physics Unit, San Martino Hospital, Genoa, Italy
⁹ Medical Oncology Unit, Santa Chiara Hospital, Pisa, Italy
¹⁰ Division of Nuclear Medicine, Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York

View larger version (54K): [in a new window]   FIGURE 1. (A) Low-magnification view of histologic section (hematoxylin–eosin staining) extending from epidermis to underlying muscle (modified from Ackerman (157)). Locations of papillary–subpapillary plexus, dermal lymphatics, subcutaneous lymphatics, communicating lymphatics along fibrous strands, and deep epifascial lymphatics are indicated. (B) Schematic representation of regions with ambiguous lymphatic drainage around midline of body as derived from classic anatomic notions (Sappey’s concept, dark gray) and from lymphoscintigraphic, functional studies (light gray). In Sappey’s notion, ambiguous lymphatic drainage (i.e., possibility of draining toward either left- or right-sided lymph nodes) corresponds to restricted area extending only approximately 5 cm on each side of midline of body. More recent lymphoscintigraphic studies show instead that ambiguous lymphatic drainage can extend to much wider area: Head, neck, and shoulders are virtually entirely included in this area, as is relevant abdominal area around waist.

View larger version (26K): [in a new window]   FIGURE 2. (A) Diagrammatic representation on logarithmic scale of approximate ranges of particle size of different 99mTc-labeled colloids for lymphoscintigraphy, as derived from various sources (manufacturers, publications). Discrepant data (indicated by additional lines in graph) are occasionally reported by different authors for some radiopharmaceuticals, depending on factors such as measurement method, stability of agent after radiolabeling, and in-house modifications of reconstitution procedure. The 2 ranges represented for filtered sulfur colloid refer to presumed ranges obtained after filtration through 100- or 220-nm filter. (B) Examples of variable estimates of particle size distribution for 99mTc-antimony sulfide and 99mTc-rhenium sulfide when assessed by different methods. HSA = human serum albumin; MF = membrane filtration; PCS = photon correlation spectroscopy; TEM = transmission electron microscopy (modified from Tsopelas (70)).

View larger version (115K): [in a new window]   FIGURE 3. Intradermal–subdermal injection of radiocolloid for lymphatic mapping in patient recently scheduled for excision of malignant cutaneous melanoma on patient’s back.

View larger version (24K): [in a new window]   FIGURE 4. Diagrammatic representation of recommended injection sites for lymphatic mapping with radiocolloid according to region of body and orientation of surgical scar.

View larger version (56K): [in a new window]   FIGURE 5. Representative scans illustrate variable patterns of lymphatic drainage in patients with primary melanomas in different regions of body. Imaging times were between 30 and 60 min after intradermal or subdermal injection of various aliquots of 99mTc-human serum albumin nanocolloid. Upper left panel shows lymphoscintigram (anterior projection) obtained from patient who recently underwent surgery for cutaneous melanoma on elbow: Lymph flows toward single sentinel node in left axilla. Upper right panel shows lymphoscintigram (anterior projection) obtained from patient with cutaneous melanoma on right thigh (just above knee): Lymph follows at least 2 main channels converging at sentinel node in right groin. Lower left panel shows lymphoscintigram (posterior projection) obtained from patient who recently underwent surgery for cutaneous melanoma on his back (just about midline): Lymph flows through several channels toward sentinel nodes in both axillae. Right lower panel shows lymphoscintigram (posterior projection) obtained from patient who recently underwent surgery for cutaneous melanoma on his back (just left of midline): Lymph follows channels to both axillae and to right groin (visualized faintly in posterior projection because of photon attenuation through body).

View larger version (24K): [in a new window]   FIGURE 6. Plot of theoretic curve for air dose rate calculated according to general formula described in text and considering 99mTc point source according to Radionuclide and Radiation Protection Data Handbook 1998 (148) (2.5–5 mGy/h/MBq at 100 cm). For normalization purposes, all dose evaluations reported in plot have been derived from published data by conversion to air dose rate calculated at injection time and at different distances from source. Theoretic curve (2.3e-5 mGy/h/MBq at 100 cm, totally independent from data points plotted in graph) well describes pattern of distribution of datasets reported by other groups, either estimated according to other formulas or measured in vivo (patients) or in vitro (phantoms). By slightly overestimating reported dose rates, general formula actually approximates values in excess—a definite plus for radiation safety purposes. – = data from Cremonesi et al. (145) (measured from patients at time of tracer injection); = data from Pijpers et al. (146) (measured from patients); = data from Pijpers et al. (146) (measured with phantom); = data from Stratmann et al. (149) (measured from patients); = data from Motta et al. (150) (estimated); • = data from Motta et al. (150) (measured from patients); x = data from Waddington et al. (151) (estimated).