SENTINEL LYMPH NODE DISSECTION

Indications

• Offered to all patients with a clinically negative nodal basin and a primary melanoma greater than 1 mm in depth

• SLND may be considered for melanoma 0.76-1.0 mm in thickness if adverse features (eg, positive deep margins, lymphovascular invasion, age < 40 years, significant vertical growth phase, increased mitotic rate, Clark level ≥IV) are present

• Melanoma that exhibits regression• Patients with deep (>4 mm) melanoma and

clinically negative nodes

Contraindications

• Systemic disease

• Fine-needle aspiration (FNA) is preferable to SLND as a first step when a patient presents with a clinically evident node

Procedure

1. Intradermal injection of a radiotracer around the melanoma lesion

2. Transport to the operative suite and induction of anesthesia

3. Intradermal injection of about 1 mL of blue dye (isosulfan blue or methylene blue [preferred]) at the site of the lesion

4. Massage of the lesion for 4-5 minutes to enhance lymphatic drainage

5. Use of a handheld gamma probe to identify “hot spots” (ie, SLNs)

Procedure

6. Placement of a small incision overlying the hot spot; incisions should be planned to allow for further dissection if this proves necessary

7. Visual search for blue nodes (guided by blue lymphatics) and use of a handheld gamma probe to identify hot nodes in the field

Procedure

8. Removal of any nodes with significant radiotracer activity, followed by ex-vivo measurement of their radioactivity counts

9. Sending of SLNs (defined as any nodes that are grossly suspicious, harbor blue dye, or have a radioactivity count greater than or equal to 10% of that of the hottest node removed) to pathology for appropriate staining

Procedure

10. Continuation of dissection until the nodal bed count is 10% of that of the hottest node removed

Once SLND is complete, wide local excision of the primary melanoma is performed