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Sentinel Lymph Node Detection in Patients with Melanoma on the Shoulder and Upper Trunk-a Guidance for Surgical Planning

Aim/Introduction: Cutaneous melanoma of the trunk shows potential to drain to multiple and uncommon lymphatic basins. The aim of the study was to determine the location of common and uncommon sentinel lymph nodes (SLNs) in patients with melanoma on the shoulder and upper trunk related to anatomic subareas of primary melanoma and its impact on surgical planning. Materials and Methods: The study included 172 patients (61.6% men, mean Breslow thickness 2.941±2.82 mm) who underwent SLN biopsy from January 2015 to January 2019. For the analysis, we defined six anterior and nine posterior anatomic sub-areas of the upper trunk and two of the shoulders. We considered all other locations outside of axilla as uncommon. After peritumoral injection of 99mTc-nanocolloid, dynamic and static planar imaging was performed. SPECT/CT was performed in 9.3% of patients. Results: Melanoma distribution was mainly in the upper sub-areas of the upper trunk: in 22/26 patients with anterior and among 104/121 patients with posterior location. Anterior melanomas showed axillary drainage in 24 (92.3%) of patients ; 95.8% unilateral. Uncommon SLNs were detected in 5/26 patients: 3 supraclavicular, 1 infraclavicular and 1 subcutaneous SLN near the scar. Among patients with posterior melanoma, 93.4% had axillary drainage. Out of them, 43.4% had bilateral axillary drainage ; 28.1% from medial trunk sub-areas. In 37/121 posterior melanomas we detected 47 uncommon SLNs: 22 supraclavicular, 12 inside the triangular intermuscular space, 8 nuchals and 5 in other locations. Melanoma on the shoulders (14 right, 11 left) in all but one patient drained to ipsilateral axilla, 4/25 patients had ipsilateral supraclavicular SLNs. In total, we identified 57 uncommon SLNs in 47 (27.3%) of patients, drained mostly (81% of SLNs) from the posterior upper trunk. Eleven (23.4%) of patients showed single uncommon SLNs, without axillary involvement. The neck region was a drainage basin for 42 uncommon SLNs among 31 patients. Out of 43 excised uncommon SLNs in 34 patients, 5 were tumor-positive. Fourteen uncommon SLNs in 13 patients were not removed by the surgeon as not identified ; 4 patients out of them had tumor-positive axillary SLNs. Conclusion: Uncommon SLNs were detected in more than a quarter of our patients, mostly drained from the posterior upper trunk. The neck region was a drainage basin among two thirds of patients with uncommon S521 Eur J Nucl Med Mol Imaging (2019) 46 (Suppl 1): S1–S952 SLNs. We suggest that current multimodal approach in radioguided surgery planning should be refined in order to achieve effective surgical treatment. R

melanoma ; sentinel lymph node biopsy ; metastasis ; survival

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