ࡱ> _a^7  bjbjUU oh7|7|lttttttt4h $,DD"fffAAAm,o,o,o,o,o,o,$- /,tAAAAA,ttff,A"tftfm,Am,!r&Ttta'f8 #c!'a' ,0,/'20A0a'ttttTitle: The Utility of Sentinel Lymph Node Biopsy in Head and Neck Melanoma in the Pediatric Population Authors: Salvatore J. Pacella, MD and Riley Rees, MD. Departments of Surgery (Division of Plastic Surgery ) University of Michigan Health System, Ann Arbor, Michigan The technique of intraoperative lymphatic mapping (IOLM) and sentinel lymph node biopsy (SLNB) has proven beneficial in staging adult patients with melanoma of the head and neck, where there is great variability in lymphatic drainage. [1] This technique has also been applied to pediatric patients with truncal cutaneous melanomas in an effort to determine nodal status without the morbidity associated with complete lymph node dissection. [2] However, the utility of SLNB in head and neck melanoma in the pediatric population has not been established. In addition, patients with borderline or atypical melanocytic proliferations of unknown biologic potential with melanoma in the differential diagnosis can be challenging to treat given the uncertainty of their diagnosis and the potential for metastasis. [3] The objective of this study was to examine the experience at our center with IOLM and SLNB for cutaneous melanoma of the head and neck in the pediatric population, as well as to examine the utility of this technique in pediatric patients with boderline atypical melanocytic proliferations of the head and neck. METHODS: We reviewed the records of seven pediatric patients with head and neck melanoma or borderline melanocytic proliferations of unknown biologic potential who underwent IOLM and SLNB between 1998 and 2001. All sentinel lymph node specimens were examined by a melanoma dermatopathologist for the presence of metastatic melanoma. RESULTS: The mean operative time for each case was 3hrs 8 min (range 2:15-3:50). All seven pediatric patients who underwent extirpation of a primary head and neck melanoma and preoperative lymphoscintigraphy had unique and identifiable basins of drainage to regional nodal groups (Table 1). Four (57%) of seven patients had at least 1 positive sentinel lymph node. Overall, five (26%) of 19 sentinel nodes resected had evidence of metastatic melanoma. Of the patients with positive sentinel lymph nodes, two of the primary lesions were diagnosed as melanoma while two were initially considered atypical melanocytic proliferations of uncertain biologic potential with melanoma in the differential diagnosis. One (25%) of four patients had evidence of an additional positive lymph node from the complete lymphadenectomy (Table 2). CONCLUSIONS: Sentinel lymph nodes in pediatric patients with melanoma of the head and neck can be successfully mapped and biopsied similar to adult patients. In addition, this procedure can provide critical diagnostic information for those pediatric patients with diagnostically challenging, controversial or borderline melanocytic lesions. References: Wells KE, Cruse CW, Daniels S, et al. The use of lymphscintigraphy in melanoma of the head and neck. Plast Reconstr Surg 1994; 93:757-759. Davidoff AM, Cirrincione C, Seigler HF. Malignant melanoma in children. Ann Surg Onc 1994; 1(4):278-82. Johnson TM, Sondak VK, Su LD, et al.: Is it a benign spitz nevus or a malignant melanoma? Primary Care and Cancer 2000, 20:41-44. Table I: Summary of surgical information.(The Utility of Sentinel Lymph Node Biopsy in Head and Neck Melanoma in the Pediatric Population) PatientMargin of Resection Presence of dye (Identifiable to surgeon?)Basin of drainageTotal # sentinel nodes removed# nodes removed /location (size largest node)Closure of defect/complicationsSurgical margin positive?Sentinel lymph node status12 cm+(Y)Left posterior auricular11 posterior auricular (1.5x1.5x1 cm)STSG to scalpyespositive (1/1)21 cm+(N)Left jugulodigastric & left parotid32 jugulodigastric (2x 2x1.5 cm) 1 parotidlocal skin flapsnonegative (3/3)3*0.5 cm+(Y)Left jugulodigastric and left tail of parotid32 jugulodigastric (1.3x1.1x0.6 cm) 1 parotidlocal skin flapsnonegative (0/3)43-4 cm+(Y)Right anterior cervical11 anterior cervical (1.5 x1x1 cm)local fasciocutaneous flaps and STSGnonegative (0/1)5*1 cm+(Y)Bilateral axillae54 right axilla (0.7 x0.6 x1 cm) 1 left axillaprimary closurenopositive (2/4 right axilla, 0/1 left axilla)6*1 cm+(Y)Right parotid, right jugulodigastric21 parotid (1x0.7x0.5 cm) 1 jugulodigastric (2.4x1x0.8 cm)FTSG to earnopositive (1/2 jugulodigastric)71 cm+(Y)Right jugular chain41 preauricular 2 external jugular 1 midjugular (1.1x0.8x0.4 cm)Local skin flaps, z-plastynopositive (1/4 preauricular) * Indicates patients with original biopsy specimens interpreted by dermatopathologist as atypical melanocytic proliferation of uncertain biologic potential vs. malignant melanoma; Y=yes; N=no; STSG=split thickness skin graft; FTSG=full thickness skin graft. Table II: Surgical outcome after wide local excision of pediatric head and neck lesions followed by IOLM and sentinel node biopsy. (The Utility of Sentinel Lymph Node Biopsy in Head and Neck Melanoma in the Pediatric Population) PatientNeed for second procedure?Second ProcedureTime from 1st procedureSurgical Outcome Second ProcedureAdjuvant therapyFollow-up timeRecurrence?1Yes1) Reexcision of surgical site with 3 cm margins 2) Left superficial parotidectomy 3) Left modified radical neck dissection2 wks1) No Residual Melanoma 2) No metastatic extension 3) 1/60 nodes positive for metastatic melanomaInterferon alfa-2b40 mos.No 2Non/an/an/aInterferon alfa-2b26 mosNo 3*Non/an/an/aInterferon alfa-2b9 mosNo 4Non/an/an/aInterferon alfa-2b9 mosNo 5*YesRight axillary lymph node dissection4 wks32 nodes negative for metastatic melanomaInterferon alfa-2b6 mosNo 6*YesRight modified radical neck dissection3 wks44 nodes (level I-V) negative for metastatic melanomaInterferon alfa-2b5 mosNo 7Yes1) Right superficial parotidectomy 2) Right modified radical neck dissection3 wks1) No metastatic extension 2) 47 nodes (level I-V) negative for metastatic melanomaInterferon alfa-2b4 mosNo * Indicates patients with original biopsy specimens interpreted by dermatopathologist as atypical melanocytic proliferation of uncertain biologic potential vs. malignant melanoma, n/a=non-applicable. PAGE  PAGE 3 g pqrxyijyz  :;ce 0JmHnHu0J j0JUH*6]CJCJH*CJ5\5ghv w ^_kaqrz$Ifd & Fd@&d `@&^``@&$`d^``a$z9Sn$If no $$Ifl4 0Z~ x (#`'.*8b8b01$$$$4 laoqv{$If  $$Ifl4 0Z~ x (#`'.*8b8b01$$$$4 la !/9JM\$If \] @$$Ifl4 0Z~ x (#`'.*8b8b01$$$$4 la]`gl$If  $$Ifl4 0Z~ x (#`'.*8b8b01$$$$4 la7\_n$If no @$$Ifl4 0Z~ x (#`'.*8b8b01$$$$4 laorw|  !$If$If  t$$Ifl4 0Z~ x (#`'.*8b8b01$$$$4 la 13Lmy|$If  x$$Ifl4 0Z~ x (#`'.*8b8b01$$$$4 la9$If 9: $$Ifl4 0Z~ x (#`'.*8b8b01$$$$4 la:;<>#$,GXp$@&If@& ",$@&If$$Ifl4ִ*p<R&*v/F$ 0/    4 laAG_z$@&If "$@&If$$Ifl4ִ*p<R&*v/F$ 0/    4 la$@&If"$@&If$$Ifl4ִ*p<R&*v/F$ 0/    4 la %)  !$@&If$@&If)*,"$@&If$$Ifl4ִ*p<R&*v/F$ 0/    4 la,/37;NTX$@&IfXY\"$@&If$$Ifl4ִ*p<R&*v/F$ 0/    4 la\`$@&If" $@&If$$Ifl4ִ*p<R&*v/F$ 0/    4 la=PVZ$@&IfZ[]",$@&If$$Ifl4ִ*p<R&*v/F$ 0/    4 la]a!%  !$@&If$@&If %&"@&$$Ifl4ִ*p<R&*v/F$ 0/    4 la @&h]h&`#$ &P/ =!"#$^%#&P0= /!^"#$%& 0&P0= /!"^#$% i0@0 Normal_HmH sH tH 0@0 Heading 1$@&CJ<A@< Default Paragraph Font8Y@8 Document Map-D OJQJ0B@0 Body TextdCJ, @, Footer  !&)@!& Page Number(U@1( Hyperlink>*B*@P@B@ Body Text 2$da$ 5CJ\FC@RF Body Text Indentd`CJ,@b, Header  ! >  h "h Ghghvw  ^ _ k a q r z 9Snoqv{ !/9JM\]`gl7\_norw| 13Lmy|9:;<>#$,GXpAG_z %)*,/37;NTXY\`=PVZ[]a!%& 00000000000 0 0  0  0  0 0 0 `0 0 @0 00000000000@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@000 @0000|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0|0@0@0@0 0  zno\]no9:),X\Z]%  !"#$%&'()*+,-./0123 !!48@0(  B S  ?~!/@GHQoz2;EP^fw# . H S     E I J M m s  q=L!0N]+7 eo!$PSfn)3RUv i{ X \    9>JLMU7<\^_gy{|% /03478 33333333333333333333333333333333333333` a :;;" Preferred Customer6C:\My Documents\Head & Neck Surgery\ped melanoma 4.docPreferred CustomerA:\PACELLA.docPreferred Customer:C:\My Documents\Head & Neck Surgery\ped melanoma final.docPreferred Customer3C:\My Documents\Head & Neck Surgery\pedmelsynop.docPreferred CustomerOC:\WINDOWS\Application Data\Microsoft\Word\AutoRecovery save of pedmelsynop.asdPreferred CustomerOC:\WINDOWS\Application Data\Microsoft\Word\AutoRecovery save of pedmelsynop.asdPreferred CustomerOC:\WINDOWS\Application Data\Microsoft\Word\AutoRecovery save of pedmelsynop.asdPreferred Customer3C:\My Documents\Head & Neck Surgery\pedmelsynop.docPreferred Customer3C:\My Documents\Head & Neck Surgery\pedmelsynop.docPreferred Customer3C:\My Documents\Head & Neck Surgery\pedmelsynop.doch[/  J]W|e IAw>T-hh^h`o(.^`o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.hh^h`o(.808^8`0o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.h[/|e J]IAw&         q r z 9Snoqv{ 9JM\]`gl7\_norw| 13my|9:>#$,GXpAG %)*,/37;NTXY\`=PVZ[]a!%& @ d  @UnknownG:Times New Roman5Symbol3& :Arial5& :Tahoma"AhJfJfc + {G$$20d?T 2QOHead & Neck Melanoma and Sentinel Lymph Node Biopsy in the Pediatric PopulationBGI UserPreferred Customer Oh+'0$0@ \h    PHead & Neck Melanoma and Sentinel Lymph Node Biopsy in the Pediatric Populationead BGI Userck GI GI NormalrPreferred Customera2efMicrosoft Word 9.0a@0@@Nr@Nr ՜.+,0H hp  (Borders Group Inc.+ ? PHead & Neck Melanoma and Sentinel Lymph Node Biopsy in the Pediatric Population Title  !"#$%&'()*+,-./012346789:;<=>?@ABCDEFGHIJKLMOPQRSTUWXYZ[\]`Root Entry F9+b1Table50WordDocumentohSummaryInformation(NDocumentSummaryInformation8VCompObjjObjectPool9+9+  FMicrosoft Word Document MSWordDocWord.Document.89q