EANM practice guidelines for lymphoscintigraphy and sentinel lymph node biopsy in melanoma. Eur J Nucl Med Mol Imaging. 2015;42:1750-1766. [PMID: 26205952 DOI: 10.1007/s00259-015-3135-1]

A bibliometric analysis of sentinel lymph node biopsy in melanoma of the top 90 cited publications

BACKGROUND

This bibliometric analysis aims to describe research trends and assess the methodological quality of the highest-impact SLNB research in melanoma.

METHODS

We identified the 90 most cited publications on SLNB in melanoma using Web of Science, covering all available journal years (from 2005 to date). The Oxford Center for Evidence-Based Medicine (OCEBM) Levels of Evidence (LOE) were used to assess the methodological quality of each study.

RESULTS

The 90 most cited publications on SLNB in melanoma collectively garnered 10,314 citations. Citation counts per publication ranged from 44 to 1,405 (mean 114.6 ± 185.2), with the highest-cited study authored by Professor Donald Morton et al. The majority of publications was classified as LOE 3 (n = 36). The United States of America (USA) led in publication output with 43 articles. Professors Merrick Ross (USA) and John Thompson (Australia) were the leading authors by publication count. The University of Sydney (Australia), University of Texas System, and Anderson Cancer Center (USA) were the top contributing institutions. Annals of Surgical Oncology published most articles.

CONCLUSIONS

This bibliometric analysis provides a comprehensive overview and valuable reference for future researchers in the field of SLNB in melanoma.

Heterogeneous Distribution and Absorbed Dose of Radiolabeled Nanoparticles and Colloids in Sentinel Lymph Nodes

Background: For breast cancer staging, radiolabeled colloids and superparamagnetic iron oxide nanoparticles (SPIONs) are used for sentinel lymph node (SLN) imaging. This study characterized the intranodal activity distribution and absorbed dose distribution. Material and Methods: Six patients diagnosed with primary breast cancer were intradermally injected with 99mTc-Nanocoll. The SLNs were resected, weighed, and measured for activity. Three groups of six rats were subcutaneously injected into the hind paw with either 99mTc-Nanocoll, 99mTc-SPIONs, or 68Ga-SPIONs. Macro- and small-scale dosimetry calculations were performed using autoradiography images of cryosections of SLNs from patients and animals. Results: The mean absorbed dose in patient SLNs was 0.5 ± 0.3 mGy/MBq for 99mTc-Nanocoll and 3.4 ± 1.8 mGy/MBq, assuming a 99mTc-Nanocoll-based distribution of 68Ga-SPIONs. Due to different decay characteristics, the heterogeneity in the absorbed dose differed between 99mTc-SPIONs and 68Ga-SPIONs with a maximum to mean absorbed dose ratio of 2.7 ± 0.3 and 1.6 ± 0.2, respectively. Conclusions: This study shows that 99mTc- and 68Ga-SPIONs and 99mTc-nanocolloids have similar activity distribution in human and animal lymph nodes. Small-scale dosimetry models combined with clinical patient biokinetics may serve as a bridge between organ and tissue dosimetry and the interpretation of intrinsic geometric variation and its uncertainties in absorbed dose.

A Comparative Analysis of Sentinel Lymph Node Sampling Utilizing Sentinel Lymphoscintigraphy Alone Versus the Combined Application of Sentinel Lymphoscintigraphy and Fluorescence Lymphangiography

BACKGROUND

Sentinel lymph node biopsy (SLNB) plays a crucial role in the clinical staging of cutaneous melanoma, influencing both treatment decisions and survival prognosis. This study aims to evaluate the benefits of combining indocyanine green (ICG) angiography with sentinel lymphoscintigraphy compared to the use of isolated sentinel lymphoscintigraphy.

MATERIALS AND METHODS

A retrospective analysis was conducted comparing patients who underwent SLNB with isolated sentinel lymphoscintigraphy (isolated group) to those who received SLNB with a combined approach involving both sentinel lymphoscintigraphy and ICG lymphangiography (combined group). The success rates of SLNB, the incidence of false negatives, and the feasibility of using ICG alone were assessed.

RESULTS

The success rate for detecting at least 1 lymph node was 92.6% in the isolated group and 100% in the combined group. Among the 16 patients in the isolated group with negative SLNB results, 3 (18.7%) experienced lymph node recurrence. In contrast, none of the 16 patients in the combined group exhibited recurrence (P > 0.05). The combined method resulted in a 26.7% increase in the average number of excised lymph nodes compared to the isolated method.

CONCLUSIONS

The integration of ICG lymphangiography with sentinel lymphoscintigraphy enhances lymph node sampling and detection sensitivity, thereby reducing the false-negative rate. However, there is insufficient evidence to support the adequacy of using ICG alone for SLNB.

Is there still a place for lymph node dissection for stage III melanoma since the approval of adjuvant therapy

PURPOSE OF REVIEW

This review aims to explore the evolving management strategies for stage III melanoma, focusing on the comparative effectiveness of traditional surgical approaches like complete lymph node dissection (CLND) versus modern adjuvant therapies. It also examines the latest evidence on the efficacy, risks, and complications of these strategies, emphasizing the role of shared decision-making between patients and clinicians.

RECENT FINDINGS

Recent clinical trials and meta-analyses, including the MSLT-II and DeCOG-SLT studies, have demonstrated that CLND may not significantly improve survival outcomes in melanoma patients with sentinel lymph node biopsy (SLNB)-positive status. Instead, a shift towards observation combined with adjuvant therapies such as immune checkpoint inhibitors and targeted therapies (for BRAF-mutant melanoma) has been observed. These approaches have been associated with similar or improved recurrence-free survival rates and reduced treatment-related complications. However, challenges remain in establishing standardized protocols for adjuvant therapy use.

SUMMARY

The management of stage III melanoma is rapidly transitioning from routine CLND towards a more individualized approach that incorporates active surveillance and adjuvant therapies based on tumor biology and patient-specific factors. Multidisciplinary discussions are essential to guide treatment decisions, and further research is required to develop clear, evidence-based protocols.

Next day sentinel node biopsy for melanoma after lymphoscintigraphy using 99mTc-labelled nanocolloid does not adversely affect long-term outcomes

OBJECTIVE

Sentinel Lymph Node Biopsy (SLNB) is an important management tool for early-stage melanoma. Different radiopharmaceuticals are used internationally to localise the sentinel node using lymphoscintigraphy (LSG) before surgery. Recent reports have suggested that a delayed interval between LSG and SLNB using 99mTc-labelled nanocolloid tracer has an adverse survival impact, but not with 99mTc-labelled antimony sulphide colloid. This study aims to analyse survival outcome in a prospective cohort of melanoma patients undergoing same day or next day SLNB after LSG using 99mTc-labelled nanocolloid.

METHODS

Outcome data were reviewed for patients undergoing SLNB, stratified by time interval between LSG and SLNB at a single UK academic centre. Kaplan-Meier survival analysis was used to assess overall survival (OS), melanoma-specific survival (MSS) and progression-free survival (PFS). Cox multivariable regression analysis identified independent risk factors.

RESULTS

925 patients had LSG using the 99mTc-nanocolloid tracer between 2009 and 2019, with a median follow-up of 6.36 years. No difference was seen on univariate analysis in OS, MSS, PFS, or nodal recurrence between patients undergoing same day or next day SLNB (Log-rank P = 0.437, 0.293, 0.587, 0.342 respectively). In addition, nodal recurrence as first site or anytime site of recurrence in SLNB negative patients was similar between the groups (Log-rank P = 0.093 and 0.457 respectively). Stratified analysis of time did not demonstrate an outcome difference (MSS Log-rank P = 0.938). Cox multivariable regression did not show time interval to independently influence OS, MSS or PFS.

CONCLUSIONS

We do not find a significant effect on long-term outcomes when SLNB is performed the day after LSG with 99mTc-labelled nanocolloid tracer. We infer that tracer migration is not clinically significant within 24 h of injection based on long term clinical outcome data.

Development of an optimized MRI protocol for a rapid preoperative identification of sentinel lymph nodes using superparamagnetic iron oxide - The Gothenburg fast acquisition sentinel lymph node tracking magnetic resonance imaging protocol (GO-FAST-MRI)

INTRODUCTION

Determining sentinel lymph node (SLN) status is important for treatment decisions in patients with melanoma. Superparamagnetic iron oxide nanoparticles (SPIO) combined with MRI have emerged as an alternative to Technetium99m lymphoscintigraphy for preoperative mapping of SLN, however, the MRI protocols so far are extensive with long in-camera time. This study aimed to evaluate an optimized MRI protocol for rapid identification of SLNs using SPIO as a tracer, without compromising diagnostic quality, the GOthenburg Fast Acquisition Sentinel lymph node Tracking MRI (GO-FAST-MRI).

MATERIALS AND METHODS

In this prospective single-center pilot study, patients with confirmed melanoma on the trunk or limbs, without clinically suspected lymph node metastasis, were eligible. All patients received an injection of 0.1 mL SPIO divided into four quadrants around the scar. The GO-FAST-MRI protocol, using only T1-weighted and Dixon sequences over the axillary or inguinal basins, was conducted no earlier than 30 min post-injection. Technetium and lymphoscintigraphy were used according to routine. SLN-biopsy was performed using a handheld magnetometer and gamma probe for SLN-detection.

RESULTS

Twenty-one patients were enrolled, and SLNs were successfully identified in all with both methods. The GO-FAST-MRI protocol was performed in 4 min and detected more SLNs than lymphoscintigraphy (54 vs 42), but the number of SLNs identified during surgery with the magnetometer and gamma probe was the same (50 for both methods). Of the SLNs removed, five were found to have metastases, all of which showed uptake of SPIO and Tc99m.

CONCLUSION

The novel GO-FAST-MRI protocol, with a 4-min scan-time, was feasible in detecting SLNs in all patients. Both the preoperative SLN-mapping and intraoperative SLN-detection using the magnetic technique was comparable to the radioactive technique.

[Dermatologic surgery during pregnancy and lactation]

It may be necessary for patients to undergo (dermato-)surgical procedures during pregnancy or lactation. Often, there are no drug approvals or guidelines in this context. The following article describes the most common dermatologic surgical conditions during pregnancy and lactation, as well as the special therapeutic considerations and risks to be aware of during treatment. Dermatosurgical procedures are subject to strict indications. Most of these procedures can be performed during pregnancy, but the risks to the mother and fetus must be carefully weighed against the disadvantages of nonsurgical therapy. Although surgery can be performed safely in any trimester, the second trimester and immediate postpartum period are optimal. Surgery should not be delayed for melanoma or high-risk skin cancer. Perioperative positioning and choice of analgesics, antiseptics, anesthetics and antibiotics must be considered carefully to avoid risks to the patient, fetus and infant.

Magnetic particle imaging enables nonradioactive quantitative sentinel lymph node identification: feasibility proof in murine models

Background

Sentinel lymph node biopsy (SLNB) is an important cancer diagnostic staging procedure. Conventional SLNB procedures with 99mTc radiotracers and scintigraphy are constrained by tracer half-life and, in some cases, insufficient image resolution. Here, we explore an alternative magnetic (nonradioactive) image-guided SLNB procedure.

Purpose

To demonstrate that magnetic particle imaging (MPI) lymphography can sensitively, specifically, and quantitatively identify and map sentinel lymph modes (SLNs) in murine models in multiple regional lymphatic basins.

Materials and Methods

Iron oxide nanoparticles were administered intradermally to healthy C57BL/6 mice (male, 12-week-old, n = 5). The nanoparticles (0.675 mg Fe/kg) were injected into the tongue, forepaw, base of tail, or hind footpad, then detected by 3-dimensional MPI at multiple timepoints between 1 hour and 4 to 6 days. In this mouse model, the SLN is represented by the first lymph node draining from the injection site. SLNs were extracted to verify the MPI signal ex vivo and processed using Perl's Prussian iron staining. Paired t-test was conducted to compare MPI signal from SLNs in vivo vs. ex vivo and considered significant if P < .05.

Results

MPI lymphography identified SLNs in multiple lymphatic pathways, including the cervical SLN draining the tongue, axillary SLN draining the forepaw, inguinal SLN draining the tail, and popliteal SLN draining the footpad. MPI signal in lymph nodes was present after 1 hour and stable for the duration of the study (4-6 days). Perl's Prussian iron staining was identified in the subcapsular space of excised SLNs.

Conclusion

Our data support the use of MPI lymphography to specifically detect SLN(s) using a magnetic tracer for a minimum of 4 to 6 days, thereby providing information required to plan the SLN approach in cancer surgery. As clinical-scale MPI is developed, translation will benefit from a history of using iron-oxide nanoparticles in human imaging and recent regulatory-approvals for use in SLNB.

Surgical radioguidance with beta-emitting radionuclides; challenges and possibilities: A position paper by the EANM

Radioguidance that makes use of β-emitting radionuclides is gaining in popularity and could have potential to strengthen the range of existing radioguidance techniques. While there is a strong tendency to develop new PET radiotracers, due to favorable imaging characteristics and the success of theranostics research, there are practical challenges that need to be overcome when considering use of β-emitters for surgical radioguidance. In this position paper, the EANM identifies the possibilities and challenges that relate to the successful implementation of β-emitters in surgical guidance, covering aspects related to instrumentation, radiation protection, and modes of implementation.

Setting-up a training programme for intraoperative molecular imaging and sentinel node mapping: how to teach? How to learn?

BACKGROUND

The current expansion of image-guided surgery is closely related to the role played by radio-guided surgery in supporting the sentinel node (SN) procedure during more than three decades. The so-called triple approach (lymphoscintigraphy, gamma probe detection and blue dye) was not only essential in the seminal validation of the SN procedure but also a first collective learning effort based on skill transfer and outcome-related evaluation which laid the fundaments to delineate the field of intraoperative molecular imaging (IMI) based on a similar multimodality approach and multidisciplinary practice.

METHODS

These elements are also becoming valid in the current incorporation of SPECT/CT and PET/CT to existing and new protocols of IMI procedures and SN mapping concerning other clinical applications. On the other hand, there is a growing tendency to combine novel modern technologies in an allied role with gamma guidance in the operating room following the development of hybrid tracers and multimodal detection approaches. Against this background, learning initiatives are required for professionals working in this area.

RESULTS

This objective has led to a group of European practitioners with large experience in SN mapping and IMI applications to give shape to a programme made up out of specific learning modules aimed to be used as a conductive thread in peripherical or centralised training instances concerning the topic.

CONCLUSION

The presented work, written as a tutorial review, is placed in an available prior-art context and is primarily aimed at medical and paramedical practitioners as well as at hardware and software developers.

[Nuclear medicine procedure guideline for sentinel lymph node localization]

The authors present a procedure guideline for scintigraphic detection of sentinel lymph nodes in malignant melanoma, in breast cancer, in penile and vulva tumors, in head and neck cancer, and in prostate carcinoma. Important goals of sentinel lymph node scintigraphy comprise reduction of the extent of surgery, lower postoperative morbidity and optimization of histopathological examination focussing on relevant lymph nodes. Sentinel lymph node scintigraphy itself does not diagnose tumorous lymph node involvement and is not indicated when lymph node or distant metastases have been definitely diagnosed before sentinel lymph node scintigraphy. Procedures are compiled with the aim to reliably localise sentinel lymph nodes with a high detection rate typically in early tumour stages. New aspects in this guideline are new radiopharmaceuticals such as tilmanocept and Tc-99m-PSMA and SPECT/CT allowing an easier anatomical orientation. Initial dynamic lymphoscintigraphy in breast cancer is of little significance nowadays. Radiation exposure is low so that pregnancy is not a contraindication for sentinel lymph node scintigraphy. A one-day protocol should preferentially be used. Even with high volumes of scintigraphic sentinel lymph node procedures surgeons, theatre staff and pathologists receive a radiation exposure < 1 mSv/year so that they do not require occupational radiation surveillance. Aspects of quality control were included (scintigraphy, quality control of gamma probe, 6 h SLN course for surgeons, certified breast centers, medical surveillance center).

Sentinel lymph node identification using NIR-II ultrabright Raman nanotags on preclinical models

Surface-enhanced Raman spectroscopy (SERS) nanotags have garnered much attention as promising bioimaging contrast agent with ultrahigh sensitivity, but their clinical translation faces challenges including biological and laser safety. As breast sentinel lymph node (SLN) imaging agents, SERS nanotags used by local injection and only accumulation in SLNs, which were removed during surgery, greatly reduce biological safety concerns. But their clinical translation lacks pilot demonstration on large animals close to humans. The laser safety requires irradiance below the maximum permissible exposure threshold, which is currently not achievable in most SERS applications. Here we report the invention of the core-shell SERS nanotags with ultrahigh brightness (1 pM limit of detection) at the second near-infrared (NIR-II) window for SLN identification on pre-clinical animal models including rabbits and non-human primate. We for the first time realize the intraoperative SERS-guided SLN navigation under a clinically safe laser (1.73 J/cm2) and identify multiple axillary SLNs on a non-human primate. No evidence of biosafety issues was observed in systematic examinations of these nanotags. Our study unveils the potential of NIR-II SERS nanotags as appropriate SLN tracers, making significant advances toward the accurate positioning of lesions using the SERS-based tracer technique.

Staff radiation doses during Sentinel Lymph Node procedure of breast cancer from injection to surgeon

The Sentinel Lymph Node (SLN) or Sentinel Lymph Node Biopsy (SLNB) technique involves various professionals from different departments in clinical settings to manage breast cancer patients properly. Tracing the nodular involvement of breast cancer patients requires radiation source Tc99m labeled with colloidal albumin to be injected at the tumor site. The patient becomes a radiation source for a sufficient time, which concerns the Nuclear Medicine (NM) and surgical staff. The study aims to provide the radiation doses of staff in the NM department during the SLN scintigraphy procedure and obtain an empirical model for calculating the radiation doses to staff in the surgical department from that particular patient. Radiation doses in SLN technique for breast cancer patients are minimal, and a sufficient number of SLN biopsy procedures can be performed by hospital staff within the category of non-radiation workers.

Caring for Pregnant Patients with Cancer: A Framework for Ethical and Patient-Centred Care

(1) Background: Caring for pregnant cancer patients is clinically and ethically complex. There is no structured ethical guidance for healthcare professionals caring for these patients. (2) Objective: This concept paper proposes a theoretically grounded framework to support ethical and patient-centred care of pregnant cancer patients. (3) Methodological approach: The framework development was based on ethical models applicable to cancer care during pregnancy-namely principle-based approaches (biomedical ethics principles developed by Beauchamp and Childress and the European principles in bioethics and biolaw) and relational, patient-focused approaches (relational ethics, ethics of care and medical maternalism)-and informed by a systematic review of clinical practice guidelines. (4) Results: Five foundational discussion themes, summarising the key ethical considerations that should be taken into account by healthcare professionals while discussing treatment and care options with these patients, were identified. This was further developed into a comprehensive ethics checklist that can be used during clinical appointments and highlights the need for a holistic view to patient treatment, care and counselling while providing ethical, patient-centric care. (5) Conclusion: The proposed framework was further operationalised into an ethics checklist for healthcare professionals that aims to help them anticipate and address ethical concerns that may arise when attending to pregnant cancer patients. Further studies exploring clinicians' attitudes towards cancer treatment in the course of pregnancy and patient experiences when diagnosed with cancer while pregnant and wider stakeholder engagement are needed to inform the development of further ethical, patient-centred guidance.

Role of methylene blue dye in sentinel node biopsy in N0 oral cavity squamous cell carcinoma

BACKGROUND

Presence of neck nodes in cases of head neck squamous cell cancers is an adverse prognostic factor. Elective neck dissection is traditionally recommended along with primary disease resection. Sentinel lymph node (SLN) is the first draining node. Sentinel lymph node biopsy (SNB) is a minimally invasive technique to identify occult nodal metastasis in early HNSCC.

METHODS

The objective of this study is to determine the identification rate of SNB using methylene blue dye (MBD) in N0 neck of Oral Squamous cell carcinoma (OSCC) and estimating specificity, sensitivity, negative predictive value and positive predictive value of SNB with frozen section (FS) analysis and in comparison to post-operative histopathological examination (HPE). It is a cross-sectional study conducted at a tertiary care centre, Lucknow, India. 21 patients of N0 OSCC from January 2019 to May 2020, were included. All patients underwent peritumoral injection with MBD. Sentinel nodes were harvested and sent for FS. Depending on FS findings, appropriate neck dissection was performed.

RESULTS

SLN was identified at level Ib and II in 19 patients (90.47%). The sensitivity, specificity, PPV and NPV in identifying SLN using MBD versus FS were 100.00%, 11.11%, 15.79% and 100.00% respectively. Whereas, SLN using MBD versus HPE specimens were 100.00%, 10.52%, 10.52% and 100.00% respectively.

CONCLUSION

Despite having 100% sensitivity, MBD alone has poor specificity. With this poor discriminatory power, it is unlikely to be employed as a diagnostic test alone. It is recommended to rely on per-operative FS for taking decision as far as extent of neck dissection in N0 neck is concerned.

Radio-Guided Occult Lesion Localization With 99m Tc for the Localization of Nonpalpable Melanoma and Soft Tissue Sarcoma Lesions: A Feasibility Study

PURPOSE OF THE REPORT

Localization techniques are needed to facilitate resection of nonpalpable lesions. In this study, the feasibility of radio-guided occult lesion localization (ROLL) with 99m Tc is investigated for the localization of nonpalpable, small, suspicious, or proven melanoma or soft tissue sarcoma lesions at various locations throughout the body.

PATIENTS AND METHODS

Patients with nonpalpable, suspicious, or proven melanoma or soft tissue sarcoma lesions were selected for this study. Within 24 hours before surgery, a median dose of 33.92 MBq 99m Tc-labeled human albumin particles ( 99m Tc-NA or 99m Tc-MAA) was injected in the lesion under ultrasound guidance. A hand-held gamma probe was used to detect the radioactive signal and guidance during surgery.

RESULTS

In this study, 20 patients with a total of 25 lesions were included and analyzed. The median size of the lesions was 1.8 cm (interquartile range [IQR], 1.8-4.0 cm), of which 44% were intramuscular located and 36% were subcutaneous, and 20% consisted of suspicious lymph nodes, mostly in the lower extremity. At median 4 hours (IQR, 3-6 hours) postinjection, 99m Tc ROLL showed a 100% intraoperative identification rate with proper signal identification with the gamma probe in all patients. With a median surgery time of 76 minutes (IQR, 45-157 minutes), all targeted lesions could be resected without 99m Tc-related complications, resulting in 88% microscopically margin-negative resection. No reoperations were needed for the same lesion.

CONCLUSIONS

The 99m Tc ROLL procedure is feasible for the localization and excision of small, nonpalpable melanoma and soft tissue sarcoma lesions at various locations in the body.

Performance of a Nonlinear Magnetic Handheld Probe for Intraoperative Sentinel Lymph Node Detection: A Phantom Study

OBJECTIVE

This study investigates the performance of the DiffMag handheld probe (nonlinear magnetometry), to be used for sentinel lymph node detection. Furthermore, the performance of DiffMag is compared with a gamma probe and a first-order magnetometer (Sentimag®, linear magnetometry).

METHODS

The performance of all three probes was evaluated based on longitudinal distance, transverse distance, and resolving power for two tracer volumes. A phantom was developed to investigate the performance of the probes for a clinically relevant situation in the floor of the mouth (FOM).

RESULTS

Considering the longitudinal distance, both DiffMag handheld and Sentimag® probe had comparable performance, while the gamma probe was able to detect at least a factor of 10 deeper. Transverse distances of 13, 11, and 51 mm were measured for the small tracer volume by the DiffMag handheld, Sentimag®, and the gamma probe, respectively. For the large tracer volume this was 21, 18, and 55 mm, respectively. The full width at half maximum, at 7 mm probe height from the phantom surface, was 14, 12, and 18 mm for the small tracer volume and 15, 18, and 25 mm for the large tracer volume with the DiffMag handheld, Sentimag®, and gamma probe, respectively.

CONCLUSIONS

With a high resolving power but limited longitudinal distance, the DiffMag handheld probe seems suitable for detecting SLNs which are in close proximity to the primary tumor. In this study, comparable results were shown using linear magnetometry. The gamma probe reached 10 times deeper, but has a lower resolving power compared with the DiffMag handheld probe.

Virtual reality-based training and pre-operative planning for head and neck sentinel lymph node biopsy

OBJECTIVE

Sentinel lymph node biopsy (SLNB) is crucial for managing head and neck skin cancer. However, variable lymphatic drainage can complicate SLN detection when using Single-Photon Emission Computed Tomography (SPECT) or lymphoscintigraphy. Virtual Reality (VR) can contribute to pre-operative planning by simulating a realistic 3D model, which improves orientation. VR can also facilitate real-patient training outside the operating room. This study explored using a VR platform for pre-operative planning in head and neck skin cancer patients undergoing SLNBs and assessed its value for residential training.

MATERIALS AND METHODS

In this prospective technology pilot study, attending surgeons and residents who performed 21 SLNB operations on patients with head and neck skin cancers (81% males, mean age 69.2 ± 11.3) used a VR simulation model based on each patient's pre-operative SPECT scan to examine patient-specific anatomy. After surgery, they completed a questionnaire on the efficiency of the VR simulation as a pre-operative planning tool and training device for residents.

RESULTS

The attending surgeons rated the VR model's accuracy at 8.3 ± 1.6 out of 10. Three-quarters (76%) of residents reported increased confidence after using VR. The physicians rated the platform's contribution to residents' training at 7.4 ± 2.1 to 8.9 ± 1.3 out of 10.

CONCLUSION

A VR SLNB simulation can accurately portray marked sentinel lymph nodes. It was rated high as a surgical planning and teaching tool among attending surgeons and residents alike and may play a role in pre-operative planning and resident training. Further studies are needed to explore its applications in practice.

Sentinel lymph node mapping: current applications and future perspectives in thyroid carcinoma

Sentinel lymph node (SLN) mapping is a standard, minimally-invasive diagnostic method in the surgical treatment of many solid tumors, as for example melanoma and breast cancer, for detecting the presence of regional nodal metastases. A negative SLN accurately indicates the absence of metastases in the other regional lymph nodes (LN), thus avoiding unnecessary lymph nodal dissection. Papillary thyroid carcinoma (PTC) is the most common type of thyroid carcinoma (TC) with cervical LN metastases at diagnosis in 20-90%, and nodal involvement correlates with local persistence/recurrence. The SLN in PTC is an intraoperative method for staging preoperative N0 patients and for detecting metastatic LNs "in and outside" the cervical LN central compartment; it represents an alternative method to prophylactic central neck node dissection. In this review we summarize different methods and results of the use of SLN in TC. The SLN identification techniques currently used include the selective vital-dye (VD) method, 99mTc-nanocolloid planar lymphoscintigraphy with intraoperative use of a hand-held gamma probe (LS), the combination LS + VD, and the combination LS and preoperative SPECT-CT (LS + SPECT/CT). The application of the SLN procedure in TC has been described in many studies, however, the techniques are heterogeneous, and the role of SLN in TC, with indications, results, advantages and limits, is still debated.

99mTc-Tilmanocept performance for sentinel node mapping in breast cancer, melanoma, and head and neck cancer: a systematic review and meta-analysis from a European expert panel

PURPOSE

Although multiple radiopharmaceuticals are currently available for sentinel node (SN) biopsy, 99mTc-tilmanocept is of particular interest due to its low molecular weight and specific binding capability for the mannose receptors of lymphatic reticuloendothelial cells. In the current systematic review and meta-analysis, we aimed to provide an update from a European expert panel on the performance of 99mTc-tilmanocept for SN biopsy.

METHODS

A systematic literature search of the PubMed/Medline and Embase databases was performed to identify studies on the use of 99mTc-tilmanocept for SN identification in oncological patients. The articles' methodological quality was assessed before inclusion. The pooled estimates of the pre-/intraoperative detection rates (DR; proportion of patients with ≥ 1 SN identified) and/or pN + sensitivity (SN + /pN + patients ratio), with 95% confidence intervals (CIs), were calculated for breast cancer, melanoma, and head and neck cancer.

RESULTS

Twenty-four articles were included in the systematic review, and twenty-one provided data for the meta-analysis. According to data availability, the 99mTc-tilmanocept-estimated pooled preoperative and intraoperative DRs were 0.94 (95%CI, 0.88-1.01) and 0.99 (0.98-1.00) for breast cancer, 0.98 (0.96-0.99) and 1.00 (0.99-1.00) for melanoma, and 0.97 (0.93-1.02) and 0.99 (0.96-1.01) for head and neck carcinoma. Finally, the pooled sensitivity for nodal metastasis in melanoma was 0.97 (95% CI, 0.92-1.03).

CONCLUSION

99mTc-tilmanocept is a promising radiotracer for SN mapping in patients with breast cancer, melanoma, or head and neck cancer. We strongly believe that multicenter trials are still needed to assess if 99mTc-tilmanocept is superior to other radiotracers used in clinical routine.

Variability of Sentinel Lymph Node Location in Patients with Trunk Melanoma

(1) Background: Melanoma is one of the most aggressive types of neoplasia, and the management of this pathology requires a correct staging, as well as a personalized modern oncological treatment. The main objective of the study is to determine the variability of the lymphatic drainage for patients with melanomas located on the trunk and, secondarily, to determine the features of individuals who underwent sentinel lymph node biopsy (SLNB) depending on the exact location on the trunk. (2) Methods: This retrospective, observational, single-center study included 62 cases of trunk melanoma operated between July 2019 and March 2023, in which SLNB was performed and a total of 84 lymph nodes were excised. (3) Results: Patients had a median age of 54.5 (33-78) years, with 58.1% being male; the melanomas had a median Breslow index of 2.3 (0.5-12.5) mm. Approximately 64.3% of the cohort had melanoma on the upper part of the trunk (54 cases) and 35.7% had it on the lower part (30 cases). The type of anesthesia chosen was general anesthesia in 53 cases and spinal anesthesia in 9 cases (85.5% vs. 14.5%, p < 0.001). The number of sentinel lymph nodes excised was 54 for melanomas located on the upper part of the trunk (8 cervical and 46 axillary) and 30 sentinel lymph nodes for melanomas of the lower part of the trunk (16 at the axillary level and 14 at the inguinal level). Out of the 54 LNs identified in patients with melanoma on the upper part of the trunk, 13 were positive, with a total of 12 positive lymph nodes (LNs) from the axillar basin, and only one from the cervical region. Additionally, the incidence of patients with a minimum of two identified sentinel lymph nodes was 32.2%, with a total of seven having LN involvement in two basins, and only one of these cases showed positivity for malignancy. (4) Conclusions: SLNBs were more frequent in the axillary region overall, and had more positive SLNs. Moreover, melanoma on the upper part of the trunk had a higher rate of positive SLNs compared to the lower part. Tumors located on the lower part of the truck had more positive SLNs in the axillary region than in the inguinal one.

Nonvisualized sentinel node on preoperative lymphoscintigraphy in primary cutaneous melanoma: an 11-year retrospective survey

BACKGROUND

Sentinel lymph node (SLN) biopsy in cutaneous melanoma patients evaluates the regional draining basin for occult micrometastatic disease. Occasionally, nonidentification of SLN impairs the acquisition of this important prognostic factor.

OBJECTIVES

To investigate the outcomes of melanoma patients with negative lymphoscintigraphic findings and patients who underwent SLN biopsy from 2004 to 2015 ( n  = 1200) were retrospectively reviewed for tumor characteristics and clinical outcomes.

METHODS

Patients with nonvisualized lymph nodes (NV group) who underwent only preoperative lymphoscintigraphy were separated and compared with a cohort drawn from all melanoma patients who completed the surgical procedure within the same period (V group).

RESULTS

A negative lymphoscintigraphic scan was observed in 38 cases (3.2% of all patients). The NV group showed a significantly older age (median 66.0 vs. 48.3 years; P  < 0.0001). Head and neck melanomas were more frequent in the NV group compared to the control group (25.1 vs. 7.8%; P  = 0.009). Tumor characteristics such as ulceration and Breslow thickness do not influence the lymphoscintigraphy result. No differences were found in overall survival (OS) and disease-free survival (DFS) between the groups.

CONCLUSIONS

The nonvisualization of regional lymph nodes by lymphoscintigraphy is more frequent in older patients with head and neck melanomas. From the clinical point of view, no specific recommendation emerged for patients' management because the nonvisualization of the SLN did not show a significant influence on DFS and OS rates. However, lack of knowledge of lymph node status suggests performing a tighter follow-up eventually by ultrasound evaluation of all potential lymph node drainage basins.

The impact of sentinel lymph node mapping with hybrid single photon emission computed tomography/computed tomography in patients with melanoma. Comparison to planar radioisotopic lymphoscintigraphy

We studied the diagnostic value of 16 slices of single photon emission computed tomography (SPECT)/computed tomography (CT) in the anatomical localization, image interpretation and extra-sentinel lymph nodes (SLNs) detection compared to dynamic and static planar radioisotopic lymphoscintigraphy (PLS) in patients with melanoma. Eighty-two patients with melanoma underwent dynamic PLS, static PLS and SPECT/CT. Data were obtained using a dual head SPECT/CT 16 slices γ-camera. We evaluated the number and localization of SLNs detected with each imaging method. SPECT/CT demonstrated 48 additional SLNs in comparison with PLS in 29 patients. In five truncal and seven head-neck lesions, dynamic and static PLS failed to detect the SLNs found on SPECT/CT (false negative). In one case of truncal and one case of lower limb melanoma, the foci of increased activity interpreted on PLS as possible SLNs were confirmed to be non-nodal sites of uptake on SPECT/CT (false positive). PLS underestimated the number of SLNs detected, whereas SPECT/CT revealed higher agreement compared to the respective number from histological reports. SPECT/CT showed a better prediction of the number of SLNs and higher diagnostic parameters in comparison to planar imaging. SPECT/CT is an important complementary diagnostic modality to PLS, that improves detection, preoperative evaluation, anatomical landmarks of SLNs and surgical management of patients with melanoma.

The Characteristics of Sentinel Lymph Node Biopsy in Cutaneous Melanoma and the Particularities for Elderly Patients-Experience of a Single Clinic

BACKGROUND

Melanoma is a malignant tumor that determines approximately 80% of deaths as skin cancer-related. The sentinel lymph node (SLN) represents the first filter of tumor cells toward systemic dissemination. The primary objective was to outline the surgical specifics of the sentinel lymph node biopsy (SLNB) technique, correlate the location of the lymph node with the radiotracer load, and identify the characteristics of older patients.

METHODS

In this prospective study, 122 cases of malignant melanoma needing SLNB technique were included, between June 2019 and November 2022, resulting in 162 lymph nodes removed.

RESULTS

Patients' mean age was 54.3 ± 14.4 years old, the prevalence of 70 years and older being 20.5%. The rate of positive SLN was 24.6%, with a single drainage in 68.9% of cases. The frequency of seroma was 14.8%, while reintervention 1.6%. The inguinal nodes had the highest preoperative radiotracer load (p = 0.015). Patients 70 years old or older had significantly more advanced-stage melanoma (68.0% vs. 45.4%, p = 0.044, OR = 2.56) and a higher rate of positive SLN (40.0% vs. 20.6%, p = 0.045,OR = 2.57). Melanoma of the head and neck was more common among older individuals (32.0% vs. 9.3%, p = 0.007,OR = 4.60).

CONCLUSIONS

The SLNB has a low rate of surgical complications and the positivity of SLN is not related to radiotracer load. Elderly patients are at risk for head and neck melanoma, have more advanced stages, a higher SLN positivity, and a greater rate of surgical complications.

Preclinical feasibility of robot-assisted sentinel lymph node biopsy using multi-modality magnetic and fluorescence guidance in the head and neck

BACKGROUND

Sentinel lymph node biopsy (SLNB) is a staging procedure dependent on accurate mapping of draining lymphatics via tracers. Robot-assisted SLNB enables access to multiple neck levels with a single incision and intraoperative fluorescence guidance to the SLN.

METHODS

Lymphatic mapping in swine was done using a magnetic tracer and fluorescent dye, injected into the tongue. MRI preoperatively mapped lymphatic spread of the magnetic tracer. Dissection was performed using a da Vinci Xi robot guided by fluorescence-imaging of the dye.

RESULTS

Robot-assisted SLNB was successfully performed in all animals (n = 5). A novel MRI protocol differentiated SLNs (n = 6) from lower echelon nodes (n = 11) based on flow progression. Fluorescence imaging provided valuable intraoperative guidance and correlated with magnetic-positive nodes.

CONCLUSIONS

This study demonstrates preclinical feasibility of a robot-assisted approach to SLNB using magnetic and fluorescent tracers in the head and neck, enabling both preoperative mapping and intraoperative guidance.

Sentinel Lymph Node Biopsy in Cutaneous Melanoma, a Clinical Point of View

Sentinel lymph node biopsy (SLNB) is a surgical procedure that has been used in patients with cutaneous melanoma for nearly 30 years. It is used for both staging and regional disease control with minimum morbidity, as proven by numerous worldwide prospective studies. It has been incorporated in the recommendations of national and professional guidelines. In this article, we provide a summary of the general information on SLNB in the clinical guidelines for the management of cutaneous malignant melanoma (American Association of Dermatology, European Society of Medical Oncology, National Comprehensive Cancer Network, and Cancer Council Australia) and review the most relevant literature to provide an update on the existing recommendations for SLNB.

Sentinel Lymph Node Identification in Cutaneous Head & Neck Cancer - Lymphoscintigraphy Late Phase

OBJECTIVE

Sentinel node (SN) biopsy following lymphoscintography is recommended for high-risk cutaneous malignancies. Herein, we investigate different lymphoscintography phases, focusing on the importance of the late static phase and the resultant discovery of distal echelon solitary positive sentinel nodes that would otherwise have been overlooked.

METHODS

In this retrospective cohort study, conducted in a tertiary referral medical center, we assessed SN localization and time from tracer injection to SN identification on lymphoscintigraphy. Findings on scan were compared with SN found in the surgical field, and with the final pathological investigation.

RESULTS

Seventy-three patients, undergoing SN biopsy for head and neck skin malignancies, were investigated. Most patients were male (n = 50). The average age was 65.7 (±15.7) years and the average follow-up time was 29.1 (±22.4) months. Overall, 101 SNs were histologically investigated, demonstrating 7 positive SN. Eleven patients (15%) benefited from the late lymphoscintigraphy phase. In four studies, an SN was identified only in the late static phase, one of which was positive for the disease. In seven patients, SN was identified in the early phase with additional, different, SN on the late phase, one of which was positive for the disease. Comparing the yield (positive SNs) of early versus late phases, demonstrated the same importance (p = 0.275).

CONCLUSIONS

The late lymphoscintigraphy phase has a crucial role in high-risk HN cutaneous cancer.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:2164-2168, 2022.

99mTc-labeled colloid SPECT/CT versus planar lymphoscintigraphy for sentinel lymph node detection in patients with breast cancer: a meta-analysis

Background

The aim of this meta-analysis was to compare single-photon emission computed tomography (SPECT/CT) and planar lymphoscintigraphy (PL) in patients with primary breast cancer, undergoing lymphoscintigraphy at initial staging. Specifically, we assessed the detection rate (DR) for sentinel lymph node (SLN), the absolute number of detected SLNs by each technique, and the proportion of patients with additional SLNs detected by one technique compared to the other one. Finally, we aimed to evaluate the impact of SPECT/CT on the surgical approach.

Methods

Original articles, providing a head-to-head comparison between SPECT/CT and PL, including patients with primary breast cancer at first presentation, were searched in PubMed/MEDLINE and Scopus databases through March 31st, 2022. The DR of the imaging techniques was calculated on a per-patient analysis; studies were pooled on their odds ratios (ORs) with a random-effects model to assess the presence of a significant difference between the DRs of SPECT/CT and PL. The number of additional SLNs, calculated as relative risk (RR), and the pooled proportion of patients with additional SLNs using one imaging technique rather than the other one were investigated. The pooled ratio of surgical procedures (SLN harvesting) influenced by the use of SPECT/CT, according to the surgeons, was calculated.

Results

Sixteen studies with 2693 patients were eligible for the calculation of the DR of SPECT/CT and PL. The DR was 92.11% [95% confidence interval (95% CI) 89.32–94.50%] for SPECT/CT, and 85.12% (95% CI 80.58–89.15%) for PL, with an OR of 1.96 (95% CI 1.51–2.55) in favor of SPECT/CT. There was a relative risk of detection of larger number of SLNs (RR: 1.22, 95% CI 1.14–1.32; 12 studies; 979 patients) for SPECT/CT (n = 3983) compared to PL (n = 3321) and a significant proportion of patients with additional SLNs detected by SPECT/CT, which were missed by PL (18.88%, 95% CI: 11.72%-27.27%; 13 studies). Four articles, with a total number of 1427 patients, revealed that 23.98% of the surgical procedures benefited from the use of SPECT/CT.

Conclusions

This meta-analysis favors SPECT/CT over PL for the identification of SLN in patients with primary breast cancer at staging due to higher DR, more SLNs depicted, and a significant proportion of subjects with additional detected SLNs by SPECT/CT compared to PL. Furthermore, SPECT/CT positively influences the surgical procedure. However, PL remains a satisfactory imaging option for imaging departments not equipped with SPECT/CT due to its good patient-based DR.

Transcutaneous sentinel lymph node detection in cutaneous melanoma with indocyanine green and near-infrared fluorescence: A diagnostic sensitivity study

Sentinel lymph node (SLN) biopsy with preoperative radiocolloid-based lymphoscintigraphy and blue dye injection is considered the standard procedure for staging nodal metastases in early-stage cutaneous melanoma patients with clinically uninvolved lymph nodes. While this combination renders good accuracy in SLN detection, radiation exposure and the frequent allergic reactions to the blue dye are considered drawbacks of this technique. Indocyanine green (ICG) is a water-soluble fluorescent dye that can be identified through near-infrared fluorescence imaging (NIRFI). The aim of this prospective diagnostic sensitivity study was to assess the feasibility of ICG and NIRFI to identify SLNs in melanoma transcutaneously ("before skin incision") and to analyze the various factors influencing detection rate, in comparison to lymphoscintigraphy. This study included 93 patients undergoing SLN biopsy for cutaneous melanoma. The region and the number of the SLNs identified with lymphoscintigraphy and with ICG were recorded. Patients' characteristics, as well as tumor details were also recorded preoperatively. One hundred and ninety-four SLNs were identified through lymphoscintigraphy. The sensitivity of ICG for transcutaneous identification of the location of the SLNs was 96.1% overall, while the sensitivity rate for the number of SLNs was 79.4%. Gender and age did not seem to influence detection rate, but a body mass index >30 kg/m2 was associated with a lower identification rate of the number of SLNs (P = .045). Transcutaneous identification of SLNs through ICG and NIRFI technology is a feasible technique that could potentially replace in selected patients the standard SLN detection methodology in cutaneous melanoma.

Guidelines for Cancer Treatment during Pregnancy: Ethics-Related Content Evolution and Implications for Clinicians

(1) Background: Current scientific evidence suggests that most cancers, including breast cancer, can be treated during pregnancy without compromising maternal and fetal outcomes. This, however, raises questions regarding the ethical implications of clinical care. (2) Methods: Using a systematic literature search, 32 clinical practice guidelines for cancer treatment during pregnancy published between 2002 and 2021 were selected for analysis and 25 of them mentioned or made references to medical ethics when offering clinical management guidance for clinicians. (3) Results: Four bioethical themes were identified: respect for patient's autonomy, balanced approach to maternal and fetal beneficence, protection of the vulnerable and justice in resource allocation. Most guidelines recommended informing the pregnant patient about available evidence-based treatment options, offering counselling and support in the process of decision making. The relational aspect of a pregnant patient's autonomy was also recognized and endorsed in a significant number of available guidelines. (4) Conclusions: Recognition and support of a patient's autonomy and its relational aspects should remain an integral part of future clinical practice guidelines. Nevertheless, a more structured approach is needed when addressing existing and potential ethical issues in clinical practice guidelines for cancer treatment during pregnancy.

CT Lymphography Using Lipiodol® for Sentinel Lymph Node Biopsy in Early-Stage Oral Cancer

This study evaluated sentinel lymph node (SLN) identification with CT lymphography (CTL) following peritumoral administration of Lipiodol^® relative to conventional ^99mTc-nanocolloid lymphoscintigraphy (including SPECT/CT) in 10 early-stage oral cancer patients undergoing SLN biopsy. Patients first underwent early dynamic and static scintigraphy after peritumoral administration of ^99mTc-nanocolloid. Subsequently, Lipiodol^® was administered at the same injection sites, followed by fluoroscopy and CT acquisition. Finally, late scintigraphy and SPECT/CT were conducted, enabling the fusion of late CTL and SPECT imaging. The next day, designated SLNs were harvested, radiographically examined for Lipiodol^® uptake and histopathologically assessed. Corresponding images of CT, ^99mTc-nanocolloid lymphoscintigraphy and SPECT/late CTL fusion were evaluated. ^99mTc-nanocolloid lymphoscintigraphy identified 21 SLNs, of which 7 were identified with CTL (33%). CTL identified no additional SLNs and failed to identify any SLNs in four patients (40%). Out of six histopathologically positive SLNs, two were identified by CTL (33%). Radiographic examination confirmed Lipiodol^® uptake in seven harvested SLNs (24%), of which five were depicted by CTL. CTL using Lipiodol^® reached a sensitivity of 50% and a negative predictive value (NPV) of 75% (median follow-up: 12.3 months). These results suggest that CTL using Lipiodol^® is not a reliable technique for SLN mapping in early-stage oral cancer.

Sentinel Node Biopsy Imaging in Breast Cancer: Scatter Reduction Using 3-Dimensionally Printed Lead Shields

BACKGROUND

Point of injection scatter (SPI) confounds breast cancer sentinel lymph node detection. Round flat lead shields (FLSs) incompletely reduce SPI, requiring repositioning. We designed lead shields that reduce SPI and acquisition time.

METHODS

Two concave lead shields, a semioval lead shield (OLS) and a semispherical lead alloy shield (SLS), were created with a SICNOVA JCR 1000 3D printer to cover the point of injection (patent no. ES1219895U). Twenty breast cancer patients had anterior and anterior oblique imaging, 5 minutes and 2 hours after a single 111 MBq nanocolloid in 0.2 mL intratumoral or periareolar injection. Each acquisition was 2 minutes. Absolute and normalized background corrected scatter counts (CSCs) and scatter reduction percentage (%SR) related to the FLS were calculated. Repositionings were recorded. Differences between means of %SR (t test) and between means of CSC (analysis of variance) with Holm multiple comparison tests were determined.

RESULTS

Mean %SR was 91.8% with OLS and 92% using SLS in early images (P = 0.91) and 87.2%SR in OLS and 88.5% in late images (P = 0.66). There were significant differences between CSC using FLS and OLS (P < 0.001) and between FLS and SLS (P < 0.001), but not between OLS and SLS (P = 0.17) in early images, with the same results observed in delayed studies (P < 0.001 in relation to FLS and P = 0.1 between both curved lead shields). Repositioning was required 14/20 times with FLS, 4/20 times with OLS, and 2/20 times with SLS.

CONCLUSIONS

We designed 2 concave lead shields that significantly reduce the SPI and repositioning with sentinel lymph node lymphoscintigraphy.

Interventional nuclear medicine's contribution to molecularly targeted precision surgery

The surgical approach to different pathologies, not only oncological, has evolved. As Veronesi's group has coined very graphically, we are moving from "maximum tolerable treatments to minimum effective treatments" and this journey cannot be carried out in any other way than through a multidisciplinary and multimodality approach. Multidisciplinary, because collaboration between surgeons, oncologists, radiologists, nuclear physicians, pathologists, and all those involved in patient follow-up is necessary, and multimodality, because we must move towards precision surgery tailored to each patient in which, on the part of Nuclear Medicine, hybrid imaging (SPECT/CT and PET/CT), bimodal tracers, the use of new allies such as ultrasound or our own adaptation to robotic surgery have a great deal to say. A wide range of possibilities is built on the solid foundation of preoperative scintigraphy, which makes it possible to identify the target tissues and whose knowledge prior to surgery allows the necessary surgical approach to be considered for each patient.

Radiolabeled nanomaterials for biomedical applications: radiopharmacy in the era of nanotechnology

BACKGROUND

Recent advances in nanotechnology have offered new hope for cancer detection, prevention, and treatment. Nanomedicine, a term for the application of nanotechnology in medical and health fields, uses nanoparticles for several applications such as imaging, diagnostic, targeted cancer therapy, drug and gene delivery, tissue engineering, and theranostics.

RESULTS

Here, we overview the current state-of-the-art of radiolabeled nanoparticles for molecular imaging and radionuclide therapy. Nanostructured radiopharmaceuticals of technetium-99m, copper-64, lutetium-177, and radium-223 are discussed within the scope of this review article.

CONCLUSION

Nanoradiopharmaceuticals may lead to better development of theranostics inspired by ingenious delivery and imaging systems. Cancer nano-theranostics have the potential to lead the way to more specific and individualized cancer treatment.

Appraisal of International Guidelines for Cutaneous Melanoma Management using the AGREE II assessment tool

BACKGROUND

The evidence base behind new melanoma treatments is rapidly accumulating. This is not necessarily reflected in current guidance. A recent UK-based expert consensus statement, published in JPRAS, has called for updates to the widely accepted 2015 National Institute for Health and Care Excellence (NICE) guideline for melanoma (NG14). We aimed to compare the quality of NG14 to all other melanoma guidelines published since.

METHODS

We conducted a systematic search of PubMed, Medline, and online clinical practice guideline databases to identify melanoma guidelines published between 29th July 2015 and 23rd August 2021 providing recommendations for adjuvant treatment, radiotherapy, surgical management, or follow-up care. Three authors independently assessed the quality of identified guidelines using the Appraisal of Guidelines for Research & Evaluation Instrument II (AGREE II) assessment tool, which measures six domains of guideline development. Inter-rater reliability was assessed by Kendall's coefficient of concordance (W).

RESULTS

Twenty-nine guidelines were included and appraised with excellent concordance (Kendall's W for overall guideline score 0.88, p<0.001). Overall, melanoma guidelines scored highly in the domains of 'Scope and purpose' and 'Clarity of presentation', but poorly in the 'Applicability' domain. The NICE guideline on melanoma (NG14) achieved the best overall scores.

CONCLUSION

Melanoma treatment has advanced since NG14 was published, however, the NICE melanoma guideline is of higher quality than more recent alternatives. The planned update of NG14 in 2022 is in demand.

The failure of a sentinel node biopsy due to an absence of nodal uptake of nuclear isotope in consecutive melanomas in a single patient – a physiological aberration

Nodal metastasis is an independent prognostic factor in patients with melanoma. Sentinel lymph node biopsy (SNB) is a recommended component of the management of patients with AJCC stage T1b or above. The dermal scar is injected with a Technetium-99 m (^99MTc) Nanocolloid, a radiotracer that drains into sentinel nodes to be identified on a preoperative SPECT/CT scan. Intraoperatively the sentinel nodes are located using a gamma probe and patent blue dye. A 79-year-old male was referred to the Plastics Outpatient Department for management of a biopsy proven pT4b melanoma on the right flank and a suspicious lesion on the right shoulder. He was scheduled for a SNB and wide local excision of the flank melanoma and excisional biopsy of the shoulder lesion. He received injections of ^99MTc Nanocolloid around the flank biopsy scar, however, preoperative, and intraoperative attempts to locate a node using radiological and surgical techniques were unsuccessful. The biopsy of the shoulder lesion sent for histopathology revealed a pT1b melanoma. A subsequent second SNB on the shoulder melanoma was unsuccessful, as ^99MTc Nanocolloid failed to drain into a sentinel node for a second time. The drainage function of lymphatic vessels declines with age however the complete failure of nodal uptake is exceptionally rare. Novel radiotracers such as ^99MTc Tilmanocept have shown superior lymph node tracking in recent tracers.

A Web-Based Prediction Model for Cancer-Specific Survival of Elderly Patients With Hypopharyngeal Squamous Cell Carcinomas: A Population-Based Study

Background: Hypopharyngeal squamous cell carcinomas (HPSCC) is one of the causes of death in elderly patients, an accurate prediction of survival can effectively improve the prognosis of patients. However, there is no accurate assessment of the survival prognosis of elderly patients with HPSCC. The purpose of this study is to establish a nomogram to predict the cancer-specific survival (CSS) of elderly patients with HPSCC.

Methods: The clinicopathological data of all patients from 2004 to 2018 were downloaded from the SEER database. These patients were randomly divided into a training set (70%) and a validation set (30%). The univariate and multivariate Cox regression analysis confirmed independent risk factors for the prognosis of elderly patients with HPSCC. A new nomogram was constructed to predict 1-, 3-, and 5-year CSS in elderly patients with HPSCC. Then used the consistency index (C-index), the calibration curve, and the area under the receiver operating curve (AUC) to evaluate the accuracy and discrimination of the prediction model. Decision curve analysis (DCA) was used to assess the clinical value of the model.

Results: A total of 3,172 patients were included in the study, and they were randomly divided into a training set (N = 2,219) and a validation set (N = 953). Univariate and multivariate analysis suggested that age, T stage, N stage, M stage, tumor size, surgery, radiotherapy, chemotherapy, and marriage were independent risk factors for patient prognosis. These nine variables are included in the nomogram to predict the CSS of patients. The C-index for the training set and validation was 0.713 (95% CI, 0.697–0.729) and 0.703 (95% CI, 0.678–0.729), respectively. The AUC results of the training and validation set indicate that this nomogram has good accuracy. The calibration curve indicates that the observed and predicted values are highly consistent. DCA indicated that the nomogram has a better clinical application value than the traditional TNM staging system.

Conclusion: This study identified risk factors for survival in elderly patients with HPSCC. We found that age, T stage, N stage, M stage, tumor size, surgery, radiotherapy, chemotherapy, and marriage are independent prognostic factors. A new nomogram for predicting the CSS of elderly HPSCC patients was established. This model has good clinical application value and can help patients and doctors make clinical decisions.

Analysis of the Different Lymphatic Drainage Patterns during Sentinel Lymph Node Biopsy for Skin Melanoma

In the last two decades, studies of lymphoscintigraphy imaging in lymphatic mapping reported an extreme heterogeneity of skin lymphatic drainage of some skin area, in contrast with the previous scientific literature. The aim of this study was to investigate the presence of any correlations between the topographical location of cutaneous melanoma and the topographical location of sentinel lymph nodes. Data from 165 patients undergoing sentinel lymph node biopsy between January 2013 and May 2021 were analyzed, demonstrating that melanomas in the Lumbar region presented a significant more heterogeneous drainage by site than those in the Scapular region (p < 0.01) and that melanomas in the Subscapular region were significantly more heterogeneous by laterality (unilateral vs. bilateral) than those in the Scapular region (p < 0.05). Results of this study supported the evidence of multiple lymphatic drainage as regards the sentinel node biopsy performed in skin melanoma located on the dorsal subscapular region and lumbar region. For this reason, the association of preoperative lymphoscintigraphy with another imaging evaluation is needed in these critical cutaneous areas. Recent technical developments enabling fluorescence lymphography together with indocyanine green have significantly improved the visualization of lymphatic drainage patterns at a microscopic level. In the preoperative phase, any doubt can be resolved by associating the SPET-CT scan to lymphoscintigraphy, while during the intraoperative phase, an additional evaluation with indocyanine green can be performed in doubtful cases. The aim of the duplex lymphatic mapping (pre and/or intraoperative) is an accurate search of sentinel nodes, in order to reduce the rate of false negatives.

Dose estimates of occupational radiation exposure during radioguided surgery of Tc-99m-PSMA-labeled lymph nodes in recurrent prostate cancer

AIM

 [^99mTc]Tc-PSMA-based radioguided surgery (TPRS) represents a curative approach for localized relapse of prostate cancer. For its simplified regulatory permission, the radiation protection authorities require a ^99mTc- activity below the exemption limit of 10 MBq at the time of surgery. Our aim was to determine the optimal amount of radioactivity (OAR) to comply with that limit and to estimate the maximum number of TPRS procedures per year and surgeon without triggering the full monitoring obligations.

METHODS

 In this retrospective study, a dose rate meter was calibrated using measurements on phantoms and from recently injected (1 min p. i.) patients to determine the activity in the patient from measured dose rates. The effective half-life of ^99mTc-PSMA-I&S in patients was determined from repeated dose rate measurements to estimate dose parameters of relevance for radiation protection. External exposures of the surgeons were measured with personal dosimeters calibrated in H_p(10). The surgeon's finger dose H_p(0.07) is estimated from radioactivity measured in resected lymph nodes. Potenzial incorporations were estimated for an activity of 10 MBq.

RESULTS

 From the first 6 subsequent patients, an effective half-life of 4.15 h was observed. Assuming an operation time 24 h p. i., the OAR was 550 MBq. Operations lasting in average 2 h in a distance of 0.25 m to the patient imply a body dose for surgeons of 4.16 µSv per procedure. Based on these estimates, the surgeon's H_p(10) is less than 1 mSv per year with up to 241 operations per year. H_p(0.07) and potential incorporation of activity do not lead to further limitations.

SUMMARY

 All radiation protection regulations are met with adherence to OAR recommended here without triggering the full monitoring obligations from radiation protection regulations.

Effectiveness of SPECT/CT Imaging for Sentinel Node Biopsy Staging of Primary Cutaneous Melanoma and Patient Outcomes

Purpose

Coregistered SPECT/CT can improve accuracy of sentinel node biopsy (SNB) for staging melanoma. This benefit has implications for pathology services and surgical practice with increased diagnostic and surgical workload. The purpose of this study was to investigate the effectiveness of SPECT/CT imaging.

Methods

SNB data were collected over a 10-year period. Preoperative SLN mapping was performed by using planar lymphoscintigraphy (LSG) for all patients (n = 1522) and after October 2015, patients underwent a second co-registered SPECT/CT scan (n = 559). The patients were stratified according to the imaging protocol. The number of nodes and nodal basins were assessed. The reasons for cancellation also were assessed.

Results

A total of 95% (1446/1522) of patients underwent a successful SNB procedure. Significantly more sentinel nodes were identified by the SPECT/CT protocol (3 vs. 2; p < 0.0001). More patients were cancelled in the SPECT/CT cohort (9.3% vs. 2.5%; p < 0.0001). Head & neck, lower limb, and AJCC IB primaries were significantly less likely to proceed to SNB. SPECT/CT identified significantly more positive SNBs (20.9% vs. 16.5%; p = 0.038). SPECT/CT imaging was associated with improved disease-free (hazard ratio [HR] = 0.74; 95% confidence interval [CI]: 0.54–1.0); p = 0.048) and disease-specific survival (HR = 0.48; 95% CI: 0.3–0.78; p = 0.003). Patients who did not proceed to SNB had a significantly increased nodal relapse rate (23.5% vs. 6.8%; HR = 3.4; 95% CI: 1.9–6.2; p < 0.0001) compared with those who underwent SNB.

Conclusions

This large cohort study confirms the increased accuracy of SPECT/CT for identifying SLN metastases, which would appear to have a significant therapeutic benefit, although an increased risk of cancellation of the SNB procedure on the day of surgery.

Head and neck melanoma: outcome and predictors in a population-based cohort study

Background

To evaluate predictive clinico-pathological characteristics on outcome in head and neck melanoma (HNM) in a population-based study with particular emphasis on the prognostic effect of sentinel lymph node biopsy (SLNB), Charlson comorbidity index (CCI) and distinct tumor localisations.

Methods

Here we primarily describe a retrospective multicenter population-based cohort study with 402 patients having undergone resection with curative intent of HNM between 2010 and 2017. SLNB was used in the diagnosis of 79 HNM patients. Outcome was analyzed, focusing on SLNB, CCI as well as tumor localisation. Overall survival (OAS) und recurrence free survival (RFS) was examined by uni- and multivariate analysis.

Results

Histopathologically verified lymph node metastasis according to SLNB was associated with impaired RFS in HNM patients (p = 0.004). Especially in higher tumor stages, the sole implementation of SLNB improved survival significantly in the present cohort (p = 0.042). With most of the HNM being located in the face, melanoma of the scalp and neck could be linked to deteriorated patient’s outcome in uni- as well as multivariate analysis (p = 0.021, p = 0.004).

Conclusions

SLNB is a useful tool in predicting development of distant metastasis after HNM resection with curative intent. Especially in higher tumor stages, performing a SLNB ameliorated survival of HNM patients. Additionally, CCI as well as a distinct tumor localisations in HNM were identified as important risk factors in our population-based cohort study.

An investigation of aspects of radiochemical purity of 99mTc-labelled human serum albumin nanocolloid

BACKGROUND

Nanocolloidal human serum albumin radiolabelled with 99mTc provides a diagnostic radiopharmaceutical for sentinel node lymphoscintigraphy. NanoHSA (Nanotop), a commercially available kit, enables the simple preparation of this radiopharmaceutical via reconstitution with pertechnetate eluted from a generator. Thin-layer chromatography is widely used for determining radiochemical purity in clinical nuclear medicine. Quality control methods recommended by the manufacturer were sometimes reported to yield variable results. Therefore, we proposed and evaluated three alternative thin-layer chromatography methods for the quality control of [99mTc]Tc-NanoHSA from a commercially available kit.

RESULTS

The radiochemical purity of [99mTc]Tc-NanoHSA determined with all methods was reproducible and met the requirements of the SPC and the European Pharmacopoeia (≥ 95%). Our quality control using iTLC-SG chromatographic paper in methyl ethyl ketone mobile phase identified only free pertechnetate as impurity, resulting in > 99% RCP. The quality control using iTLC-SG in 85% methanol or iTLC-SA in 0.9% NaCl identified an additional small fraction of a hydrophilic impurity, resulting in 95-97% RCP. Glucose was identified as a potential 99mTc-carrying hydrophilic species contributing to hydrophilic impurities.

CONCLUSION

Our quality control of [99mTc]Tc-NanoHSA with non-polar mobile phase tended to underestimate the amount of hydrophilic impurities, although without compromising the final quality of the radiopharmaceutical. Alternative TLC methods using aqueous mobile phases enabled a more accurate determination of hydrophilic impurities.

Non-Sentinel Lymph Node Detection during Sentinel Lymph Node Biopsy in Not-Complete-Lymph-Node-Dissection Era: A New Technique for Better Staging and Treating Melanoma Patients

Sentinel lymph node biopsy has been demonstrated to be an effective staging procedure since its introduction in 1992. The new American Joint Committee on Cancer (AJCC) classification did not consider the lack of information that would result from the less usage of the complete lymph node dissection as for a diagnostic purpose. Thus, this makes it difficult the correct staging and would leave about 20% of the further positive non-sentinel lymph nodes in the lymph node basin. In this paper, we aim to describe a new surgical technique that, combined with single-photon emission computed tomography-computed tomography (SPECT-CT), allows for better staging of melanoma patients. This is a prospective study that includes 104 patients with cutaneous melanoma. Sentinel lymph node biopsy was offered according to the AJCC guideline. Planar lymphoscintigraphy was performed in association with SPECT-CT, identifying and removing all non-biologically “excluded” lymph nodes, guiding the surgeon’s hand in detection and removal of lymph nodes. Even if identification and removal of non-sentinel lymph nodes is unable to increase overall survival, it definitely gives better disease control in the basin. With a “classic” setting, the risk of leaving further lymph nodes out of the sentinel lymph node procedure is around 20%, thus, basically, the surgical sentinel lymph node of first and second lymph nodes would have therapeutic value and complete lymph node dissection classically performed.