Sentinel Lymph Node Biopsy For Other Malignancies Apart From Breast Cancer

1. Suen PY North District Hospital Sentinel Lymph Node Biopsy For Other Malignancies Apart From Breast Cancer

2. Introduction • RamonCabanas 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)

3. 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

5. Introduction • In general surgery, apart from breast cancer, cutaneous malignant melanoma is another common condition with use of SLNB

6. 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?

7. Is SLNB applicable to cutaneous malignant melanoma ?

8. Cutaneous Malignant Melanoma • Most cutaneous melanoma follows the rule of sequential metastasis in term of spread Reintgen D et al.; The orderly progression of melanoma nodal metastasis; Ann Surg 1994;220:759-67

9. 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

10. 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

11. 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

12. SLNB is applicable to cutaneous malignant melanoma

13. Do all cutaneous malignant melanomas need SLNB?

14. 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)

15. Based on Breslow depth, a patient’s risk for metastasis to the SLN 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

16. SLNB is recommended to be used for malignant melanoma with thickness 1-4mm, and in selected cases for <1mm or >4mm

17. Can immediate LND for positive SLN help patients with malignant melanoma?

18. 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)

19. MSLT-I (Multi-center Selective Lymphadenectomy Trials I)

20. 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 MSLT-1 Balch CM et al.; A multifactorial analysis of melanoma: III. Prognostic factors in melanoma patients with lymph node metastasis. Ann Surg 193:377-388

21. Lymph node dissection for clinically palpable disease has increased operative difficulty and post-operative 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

22. Immediate LND after positive SLN can benefit patients

23. 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 Penile Cancer

24. 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

25. SN identification rate and negative predictive value are about 95% observational trials In the near future SLNB in Oro-pharyngeal Cancer 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,

26. 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

27. Conclusion • immediate LND for positive SLN can help • apart from breast cancer • SLNB : malignant melanoma, penile cancer and oro-pharyngeal cancer, etc

28. THANK YOU