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.
● 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
● 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
● 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)
● 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)
Schematic of intraoperative lymphatic mapping and sentinel node
Metastatic tumor by RT-PCR, S100 staining of nevus cells
H&E, S100, HMB45 and melanoma cells
HMB45 Tattoo pigment (not tumor)
● Histiocytes - no atypia
● Tattoo pigment (Dermatol Online J 2005;11(1):14)
End of Skin-Melanocytic Tumors > Sentinel node biopsy for melanoma
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