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Sentinel Lymph Node Biopsy
For Other Malignancies Apart
From Breast Cancer
Suen PY
North District Hospital
Introduction
Ramon Cabanas first implemented SLNB
clinically in management of cancer-penile
cancer in 1970s
Used anatomical landmark for
identification of SLN
75 years old, practises in Brooklyn, New
York
(Cabanas RM . An
approach for the
treatment of penile
carcinoma. Cancer 1977;
39:456 – 66)
Introduction
 Principle of SLNB is to stage LN metastasis
accurately, thereby, to avoid unnecessary LN
dissection, to guide the prognosis and subsequent
management
 Nowadays, SLNB is widely used in different
cancers in term of standard management or trials
Introduction
 In general surgery, apart from breast cancer,
cutaneous malignant melanoma is another
common condition with use of SLNB
Introduction
SLNB in management of cutaneous
malignant melanoma
Is SLNB applicable to it ?
Do all cutaneous malignant melanomas
need SLNB ?
Can immediate LND for positive SLN help
these patients?
Is SLNB applicable to cutaneous
malignant melanoma ?
Cutaneous Malignant Melanoma
Most cutaneous melanoma follows the rule
of sequential metastasis in term of spread
Primary
tumour
SLN
Non-SLN
Distant
metastasis
Reintgen D et al.; The orderly progression of melanoma nodal metastasis;
Ann Surg 1994;220:759-67
Accuracy Rate Of SLNB In
Cutaneous Malignant Melanoma
The overall rate of SLN identification was 95.3%
with use of dual agents
Stebbins WG et al.; Sentinel lymph biopsy and melanoma: 2010 update Part
I;J Am Acad Dermatol May 2010 723-734
SLNB Has Good prognostic Value In
Cutaneous Malignant Melanoma
 SLN status is the most important prognostic factor for
disease-free and over all survival
 involvement of the SLN is strongly associated with a
negative disease outcome
Morton DL et al.; (2006) Sentinel-node biopsy or nodal observation in melanoma.
N Engl J Med 355:1307-1317
Balch CM et al.; Prognostic factors analysis of 17600 melanoma patients: validation
of the American Joint Committee on Cancer melanoma staging system. J Clin
Oncol 2001;19:3622-34
SLNB Has Lower Morbidity
Compared To LN Dissection
 MSLT-I: the rate of total complications for WLE
alone and WLE plus SLNB were very similar
(13.9% vs 13.8%)
 But, the total complication rate increased almost
fourfold for SLNB and SLNB plus CLND (10% vs
37%)
 The Sunbelt melanoma trial: a total complication
rate of 4.6% with SLNB and 23.2 % for CLND after
a positive SLN
SLNB is applicable to cutaneous
malignant melanoma
Do all cutaneous malignant melanomas
need SLNB?
Recommendation
SLNB is routinely recommended for
patients with clinically negative nodes and
primary lesions with 1-4mm thickness
(ASCO guideline for SLNB for melanoma)
Controversy: whether or not SLNB should
be recommended for patients with either
thin melanomas (<1mm) or thick
melanomas (>4mm)
Based on Breslow depth, a patient’s risk for
metastasis to the SLN
<1mm
4%
1-2mm
12%
2-4mm
28%
>4mm
44%
Rousseau DL et al.; Revised American Joint
Committee on Cancer staging criteria accurately
predict sentinel lymph node positivity in
clinically node-negative melanoma patients.
Ann Surg Oncol 2003;10:569-74
SLNB is recommended to be used
for malignant melanoma with
thickness 1-4mm, and in selected
cases for <1mm or >4mm
Can immediate LND for positive SLN
help patients with malignant melanoma?
No definite evidence from randomized
trials : a positive sentinel LNB followed
with complete lymph node dissection can
improve overall survival for melanoma
(MSLT-1, intergroup Melanoma Surgical
Trial, the WHO Melanoma Programme)
MSLT-I (Multi-center Selective
Lymphadenectomy Trials I)
MSLT-1
 WLE with observation increase no. of positive LN
in patients who eventually developed clinical
evidence of nodal metastasis
 As reported by Balch et al, patients with multiple
LN met. have a worse prognosis than those with
only a single LN
Balch CM et al.; A multifactorial analysis of melanoma: III.
Prognostic factors in melanoma patients with lymph node
metastasis. Ann Surg 193:377-388
Lymph node
dissection for
clinically palpable
disease has
increased operative
difficulty and postoperative morbidity
Fife K et al.; Lymph-node metastasis in patients with
melanoma: what is the optimum management? Lancet
Oncol 2001;2:614-21
Morton DL et al.; Sentinel-node biopsy or nodal
observation in melanoma. N Engl J Med 2006;355:1307-17
Immediate LND after positive SLN can
benefit patients
SLNB in Penile Cancer
 Cabanas (1970s) used anatomical landmark for
SLNB
 Nowadays, SLNB is still performed in selected
cases, usually in penile cancer with T1-2 without
clinical LN met
 Dynamic SLNB (use of dual agents)
SLNB in Oro-pharyngeal Cancer
 For management of early T1/2 oro-pharyngeal
carcinoma, most centres perform elective neck
dissection to simultaneously stage the neck LN and
remove the occult LN disease
 Only 25-30% patients harbour occult LN disease in
the neck
 The majority of neck dissection have no
therapeutic benefit but to stage the disease
 Studies : investigated the application of SLNB
SLNB in Oro-pharyngeal Cancer
SN identification rate and negative predictive
value are about 95%
observational trials
In the near future
Alkureishi LW et al, Sentinel Node Biopsy in
Head and Neck Squamous Cell Cancer: 5-Year
Follow-up of a European Multi-center Trial,
Ann Surg Oncol 2010; 17:2459-2464)
Stoeckli SJ (2007) Sentinel node biopsy for oral
and oro-pharyngeal squamous cell carcinoma of
head and neck. Laryngoscope 117: 1539-1551,
Conclusion
SLNB is applicable to malignant
melanoma
SLNB is recommended to be used for
thickness 1-4mm, and in selected cases for
<1mm or >4mm
Conclusion
immediate LND for positive SLN can help
apart from breast cancer
SLNB : malignant melanoma, penile cancer
and oro-pharyngeal cancer, etc
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