eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Head & Neck Surgery

Sentinel Lymph Node Biopsy in Patients With Squamous Cell Carcinoma

Author: Amit Dwivedi, MD, Assistant Professor of Surgery, University of Louisville
Coauthor(s): Karl J D'Silva, MD, Fellow in Hematology/Oncology, Department of Internal Medicine, Breslin Cancer Center, Michigan State University; Nafisa K Kuwajerwala, MD, Staff Surgeon, Breast Oncology, William Beaumont Hospital; Thabet Abbarah, MD, FACS, Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers
Contributor Information and Disclosures

Updated: May 22, 2008

Introduction

Cutaneous squamous cell carcinoma (SCC) is a malignant tumor of keratinizing epidermal cells. This type of skin cancer is the second leading cause of death after melanoma, and it is the second most common type of nonmelanoma skin cancer after basal cell carcinoma.

Most SCCs occur on the sun-exposed areas of the head and the neck. The most common route of spread for metastatic SCC is lymphatic in nature. In SCC of the upper aerodigestive tract, especially the neck, both the investigation and the treatment of a patient with a clinically N0 neck remain controversial. Depending on the classification of the tumor according to the TNM staging system, approximately 30% of patients with SCC of the head and neck have subclinical metastases in the neck, and knowledge of lymph node disease alters management.

Although CT scanning and MRI are commonly used to classify tumors of the neck, their overall accuracy is limited. The only highly accurate means of identifying lymph node disease is to perform a staging lymph node dissection. For disease in its early stages, clinicians are reluctant to perform an elective lymph node dissection because of the associated morbidity and lack of beneficial effects.

The sentinel lymph node (SLN) is the first lymph node to drain a metastatic tumor cell that drains via the lymphatic route. The concept of the SLN is based on the orderly progression of tumor cells within the lymphatic system. Mapping of the lymph flow from the tumor site to the regional lymphatic drainage area can be used to identify the primary draining lymph node (ie, SLN). If the SLN can be identified and examined for the presence of tumor metastases, an elective lymph node dissection for staging does not need to be performed.

History of the Procedure

The concept of the SLN originated in 1977 when Cabanas described mapping of the first lymph node–draining penile carcinoma. In 1977, Robinson et al described the use of cutaneous lymphoscintigraphy in the nodal basin for truncal melanomas using colloidal gold scanning. The development of lymphatic mapping at the end of the 1980s was a breakthrough in making the sentinel node concept applicable to various types of malignancies.

In 1993, Alex et al introduced the use of technetium Tc 99m sulfur colloid, a radioactive tracer, which is injected intradermally around a primary melanoma site, followed by an imaging study and subsequent intraoperative use of a gamma probe to localize the sentinel node.1 Initial results of the SLN procedure in carcinoma of the head and the neck have been reported with mixed success. In a series of cases using radiocolloid alone, Koch et al remained unconvinced of its role in the management of patients with carcinoma of the head and the neck.2 Pitman et al were unable to find any lymph nodes that stained blue in patients who were injected with blue dye alone.3 Alex and Krag performed the first successful SLN biopsy of the head and the neck on a patient with a supraglottic carcinoma.4

Problem

Approximately 100,000 cases of SCC are diagnosed in the United States each year. Approximately 80% of ultraviolet light–induced SCCs develop on the arms, head, or neck.

Frequency

The frequency of cutaneous SCC, as with all nonmelanoma skin cancers, is increasing.

Etiology

Any of the following may cause SCC: exposure to sunlight; chemical carcinogens, such as arsenic and hydrocarbons; human papillomavirus; ionizing radiation; cigarette smoke; chronic irritation or ulceration; or alcohol. In addition, immunocompromised patients have a much higher risk of developing SCC. Two genes, PATCHED and TP53, have been identified that usually prevent cancers but are inactivated in patients with SCC; TP53 is mutated in more than 90% of patients with SCC.

Pathophysiology

SCC arises from basal keratinocytes of the skin. It typically manifests as a firm nodule on an erythematous base with elevated borders and insidious margins. Central ulceration or crusting may be present. Irregular nests of epidermal cells invading the dermis in varying degrees characterize SCC. Grading is based on the degree of cell differentiation. The most common route of spread for metastatic SCC is lymphatic in nature.

Presentation

SCCs of the skin typically manifest on the head, neck, or arms. They usually have elevated and rolled edges with central ulceration. Well-differentiated SCCs are likely to manifest as firm erythematous nodules of varying sizes, sometimes with an area of central hyperkeratosis. The tumor is usually firm, although tumors in more advanced cases can be soft and friable. Erosion and ulceration are more common with SCCs. Poorly differentiated SCCs are more apt to manifest as faintly erythematous nodules or plaques that are not well defined; ulceration is also common.

Indications

Elective dissection of a clinically negative (ie, N0) neck causes overtreatment for most patients, while no equivocal advantage in survival has been demonstrated when compared with a delayed dissection for patients with metastases in the neck. SLN biopsy can help determine the presence of lymph node metastases in patients with T1-T2, N0 oral and oropharyngeal SCCs.

Relevant Anatomy

SCCs of the skin typically manifest on sun-exposed areas of the head, neck, or arms.

Contraindications

Contraindications to a SLN biopsy are a palpable lymph node, tumors larger than 4-5 cm, disruption of lymphatic drainage, prior extensive surgery (eg, dissection of the neck), previous radiation to the head and the neck, and allergy to dye.

More on Sentinel Lymph Node Biopsy in Patients With Squamous Cell Carcinoma

Overview: Sentinel Lymph Node Biopsy in Patients With Squamous Cell Carcinoma
Workup: Sentinel Lymph Node Biopsy in Patients With Squamous Cell Carcinoma
Treatment: Sentinel Lymph Node Biopsy in Patients With Squamous Cell Carcinoma
Follow-up: Sentinel Lymph Node Biopsy in Patients With Squamous Cell Carcinoma
References
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References

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  2. Koch WM, Choti MA, Civelek AC, et al. Gamma probe-directed biopsy of the sentinel node in oral squamous cell carcinoma. Arch Otolaryngol Head Neck Surg. Apr 1998;124(4):455-9. [Medline].

  3. Pitman KT, Johnson JT, Edington H, et al. Lymphatic mapping with isosulfan blue dye in squamous cell carcinoma of the head and neck. Arch Otolaryngol Head Neck Surg. Jul 1998;124(7):790-3. [Medline].

  4. Alex JC, Krag DN. The gamma-probe-guided resection of radiolabeled primary lymph nodes. Surg Oncol Clin N Am. Jan 1996;5(1):33-41. [Medline].

  5. Alex JC, Sasaki CT, Krag DN, et al. Sentinel lymph node radiolocalization in head and neck squamous cell carcinoma. Laryngoscope. Feb 2000;110(2 Pt 1):198-203. [Medline].

  6. Asthana S, Deo SV, Shukla NK. Intraoperative neck staging using sentinel node biopsy and imprint cytology in oral cancer. Head Neck. May 2003;25(5):368-72. [Medline].

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  12. Martinez JC, Cook JL. High-risk cutaneous squamous cell carcinoma without palpable lymphadenopathy: is there a therapeutic role for elective neck dissection?. Dermatol Surg. Apr 2007;33(4):410-20. [Medline].

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  14. Pillsbury HC 3rd, Clark M. A rationale for therapy of the N0 neck. Laryngoscope. Oct 1997;107(10):1294-315. [Medline].

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  19. Shoaib T, Soutar DS, MacDonald DG, et al. The accuracy of head and neck carcinoma sentinel lymph node biopsy in the clinically N0 neck. Cancer. Jun 1 2001;91(11):2077-83. [Medline].

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  21. Woolgar JA, Vaughan ED, Scott J, Brown JS. Pathological findings in clinically false-negative and false-positive neck dissections for oral carcinoma. Ann R Coll Surg Engl. Jul 1994;76(4):237-44. [Medline].

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Further Reading

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Keywords

sentinel lymph node biopsy in patients with squamous cell carcinoma, sentinel node, SN, SLN, SLN biopsy, SLN mapping, sentinel lymph node mapping, skin malignancy, skin cancer, skin squamous cell cancer, squamous cell skin cancer, skin cancer diagnosis, skin SCC, squamous cell carcinoma, SCC, squamous skin cancer, SC cancer, cutaneous SCC, cutaneous squamous cell carcinoma, sun exposure, lymph node disease, lymph node cancer, head and neck SCC, head and neck cancer, head and neck carcinoma, head and neck malignancy, head and neck squamous cell carcinoma, lymph node dissection

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Contributor Information and Disclosures

Author

Amit Dwivedi, MD, Assistant Professor of Surgery, University of Louisville
Amit Dwivedi, MD is a member of the following medical societies: American College of Surgeons and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Karl J D'Silva, MD, Fellow in Hematology/Oncology, Department of Internal Medicine, Breslin Cancer Center, Michigan State University
Karl J D'Silva, MD is a member of the following medical societies: Massachusetts Medical Society
Disclosure: Nothing to disclose.

Nafisa K Kuwajerwala, MD, Staff Surgeon, Breast Oncology, William Beaumont Hospital
Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Thabet Abbarah, MD, FACS, Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers
Thabet Abbarah, MD, FACS is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Medical Editor

M Abraham Kuriakose, MD, DDS, FRCS, Chairman, Head and Neck Institute, Amrita Institute of Medical Sciences
M Abraham Kuriakose, MD, DDS, FRCS is a member of the following medical societies: American Association for Cancer Research, American Head and Neck Society, British Association of Oral and Maxillofacial Surgeons, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Nader Sadeghi, MD, FRCS(C), Associate Professor of Surgery, Director of Head and Neck Surgery, Division of Otolaryngology, George Washington University
Nader Sadeghi, MD, FRCS(C) is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, Federation of Medical Specialists in Quebec, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Advanced Headache Intervention Consulting fee Consulting; Covidien Corp Consulting fee Consulting

 
 
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