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Skin-Melanocytic Tumors

Sentinel node biopsy for melanoma

 

Last major update: November 2008 - next update November 2009

Revised: 11 July 2009

Author: Nat Pernick, M.D., PathologyOutlines.com, Inc.

Copyright: (c) 2002-2009, PathologyOutlines.com, Inc.

 

Definition

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● Sentinel lymph node is defined as first extracutaneous target of lymphogenous tumor cell spread and the potential source of subsequent lymph node metastases and distant metastases

● Lymphatic mapping and sentinel lymph node biopsy are widely used for staging

 

Recommendations

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● Use for thick (Semin Diagn Pathol 2008;25:86) and thin melanomas (1 mm thick or less, Arch Surg 2008;143:892)

● Tumor in sentinel node by H&E predicts recurrence (Mod Path 2007;20:427), usually leads to dissection of lymph nodes in affected nodal basin (Ann Surg Oncol 2008;15:1566), which reduces recurrence (Curr Treat Options Oncol 2008 Nov 8 [Epub ahead of print])

● Measuring antimony (originating from antimony sulfide colloid) can confirm sentinel nature of node (Mod Path 2004;17:1191)

 

Treatment and prognosis

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● Predictors of positive sentinel nodes: Breslow thickness > 1 mm (Int J Surg 2008;6:205); lymphatic invasion using D2-40, ulceration (Arch Dermatol 2008;144:462), younger age (Ann Surg Oncol 2008;15:630)

● Predictors of positive nonsentinel nodes in sentinel node positive patients (occurs in 20-35%): amount of tumor in sentinel node, Breslow thickness of primary melanoma, density of dendritic WBCs in sentinel node paracortex (Mod Path 2004;17:747); also perinodal intralymphatic tumor (Ann Surg Oncol 2008;15:1723), depth of invasion in sentinel node (Ann Surg Oncol 2008;15:1202)

● S100 and NKI-C3 are most sensitive stains for nodal metastases, but are nonspecific; MART1 is most specific (AJSP 2001;25:1039)

● S100 and MART1 together are recommended (Hum Path 2004;35:217)

● Intraoperative touch imprints may be accurate (Anticancer Res 2008;28:465)

● Patients with triple negative (H&E, S100/HMB45, RT-PCR) nodes have a markedly improved survival (Mod Path 2008;21:438)

● Micrometastasis: single metastasis < 2 mm not associated with metastases in non-sentinel nodes (J Surg Oncol 2008;98:46)

● RT-PCR: prognostic significance of melanocytic mRNA in histologically negative nodes is controversial (significant-APMIS 2008;116:199, not significant-Mod Pathol 2007;20:427)

 

● Recommended protocols for sentinel nodes:

● (a) 3 levels at 250 micrometer intervals, each level has 1 section stained with H&E, S-100 and HMB-45 (AJSP 2005;29:305), OR

● (b) 2 H&E sections, S100 and HMB45 (AJSP 2003;27:1197)

 

Clinical images

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The name of referred object is nihms32726f1.jpg                                       The name of referred object is nihms32726f2.jpg

Schematic of intraoperative lymphatic mapping and sentinel node

 

Micro images

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Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author                                      Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Metastatic tumor by RT-PCR,                          S100 staining of nevus cells

H&E, S100, HMB45                                             and melanoma cells

 

 

Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author                                                          

HMB45                                                                   Tattoo pigment (not tumor)

 

Videos

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● Wide excision and sentinel node mapping

 

Differential diagnosis

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● Benign nevus cells - usually in capsule, also parenchyma, no atypia, MART1+, S100+, HMB45-, Ki-67 neg (AJSP 2002;26:1351, AJSP 2003;27:673)

● Histiocytes - no atypia

● Tattoo pigment (Dermatol Online J 2005;11(1):14)

 

Additional references

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● eMedicine

 

End of Skin-Melanocytic Tumors > Sentinel node biopsy for melanoma

 

 

 

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