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EANM Practice Guidelines for Lymphoscintigraphy and Sentinel Lymph Node Biopsy in Melanoma

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EANM Practice Guidelines for Lymphoscintigraphy and Sentinel Lymph Node Biopsy in Melanoma Eur J Nucl Med Mol Imaging (2015) 42:1750–1766 DOI 10.1007/s00259-015-3135-1 GUIDELINES EANM practice guidelines for lymphoscintigraphy and sentinel lymph node biopsy in melanoma 1 1 2 3 Christina Bluemel & Ken Herrmann & Francesco Giammarile & Omgo E. Nieweg & 2 4 5 6 Julien Dubreuil & Alessandro Testori & Riccardo A. Audisio & Odysseas Zoras & 1 3 7,8 9 Michael Lassmann & Annette H. Chakera & Roger Uren & Sotirios Chondrogiannis & 10 9 Patrick M. Colletti & Domenico Rubello Received: 2 July 2015 /Accepted: 7 July 2015 /Published online: 25 July 2015 # Springer-Verlag Berlin Heidelberg 2015 Abstract (EANM) to promote high-quality lymphoscintigraphy. The Purpose Sentinel lymph node biopsy is an essential staging final result has been discussed by distinguished experts from tool in patients with clinically localized melanoma. The har- the EANM Oncology Committee, national nuclear medicine vesting of a sentinel lymph node entails a sequence of proce- societies, the European Society of Surgical Oncology (ESSO) dures with participation of specialists in nuclear medicine, and the European Association for Research and Treatment of radiology, surgery and pathology. The aim of this document Cancer (EORTC) melanoma group. The document has been is to provide guidelines for nuclear medicine physicians endorsed by the Society of Nuclear Medicine and Molecular performing lymphoscintigraphy for sentinel lymph node de- Imaging (SNMMI). tection in patients with melanoma. Conclusion The present practice guidelines will help nuclear Methods These practice guidelines were written and have been medicine practitioners play their essential role in providing approved by the European Association of Nuclear Medicine high-quality lymphatic mapping for the care of melanoma patients. * Domenico Rubello Keywords Sentinel lymph node . Melanoma . [email protected] Lymphoscintigraphy . Radioguided surgery 1 Department of Nuclear Medicine, Universitätsklinikum Würzburg, Würzburg, Germany Preamble 2 Médecine Nucléaire, Hospices Civils de Lyon and EA 3738, Université Claude Bernard Lyon 1, Lyon, France These practice guidelines for sentinel lymph node biopsy 3 Melanoma Institute Australia, The Poche Centre, North (SLNB) in melanoma approved by the European Association Sydney, Australia of Nuclear Medicine (EANM) and the Society of Nuclear 4 European Institute of Oncology, Milan, Italy Medicine and Molecular Imaging (SNMMI) aim to promote 5 St Helens Teaching Hospital, University of Liverpool, St Helens, UK the use of nuclear medicine procedures of high quality. These 6 Department of Surgical Oncology, University Hospital of Heraklion, guidelines are intended to assist practitioners in providing ap- Heraklion, Greece propriate nuclear medicine care for patients. These guide- 7 Sydney Medical School, The University of Sydney, Sydney, NSW, lines are not inflexible rulesorrequirementsofprac- Australia tice and are not intended, nor should they be used, to 8 Alfred Nuclear Medicine and Ultrasound, RPAH Medical Centre, establish a legal standard of care. For these reasons Newtown, NSW, Australia and those set forth below, the SNMMI and EANM 9 Department of Nuclear Medicine, PET/CT Centre, Radiology, caution against the use of these guidelines in litigation NeuroRadiology, Medical Physics, ‘Santa Maria della Misericordia’ in which the clinical decisions of a practitioner are Hospital, Rovigo, Italy called into question. 10 Department of Radiology, University of Southern California, The ultimate judgment regarding the propriety of any spe- Los Angeles, CA, USA cific procedure or course of action must be made by medical Eur J Nucl Med Mol Imaging (2015) 42:1750–1766 1751 professionals taking into account the unique circumstances of Goals each case. Thus, an approach that differs from the guidelines does not necessarily imply that the approach is below the The aim of these practice guidelines is to provide general standard of care. To the contrary, a conscientious practitioner information about the SLN procedure in patients with mela- may responsibly adopt a course of action different from the noma. The guidelines describe protocols currently used rou- one set forth in the guidelines when, in the reasonable judg- tinely, but do not include all existing procedures. They should ment of the practitioner, such course of action is indicated by therefore not be taken as excluding other nuclear medicine the condition of the patient, limitations of available resources modalities that can be used to obtain comparable results. or advances in knowledge or technology subsequent to publi- The present guidelines for nuclear medicine practitioners cation of the guidelines. offer assistance in optimizing nuclear medicine imaging The practice of medicine involves not only the science but prior to SLNB to improve the diagnostic and staging in- also the art of dealing with the prevention, diagnosis, allevia- formation from the SLN procedure. The final result has tion and treatment of disease. The variety and complexity of been discussed by distinguished experts from the EANM human conditions make it impossible at times to identify the Oncology Committee, national nuclear medicine societies, most appropriate diagnosis or to predict with certainty a par- the European Society of Surgical Oncology (ESSO) and ticular response to treatment. Therefore, it should be recog- the European Association for Research and Treatment of nized that adherence to these guidelines will not assure an Cancer (EORTC) melanoma group. The present document accurate diagnosis or a successful outcome. All that should has been endorsed by the SNMMI board. The resources be expected is that the practitioner will follow a reasonable and facilities available for patient care may vary from one course of action based on current knowledge, available re- country to another and from one medical institution to sources and the needs of the patient to deliver effective and another. safe medical care. The sole purpose of these guidelines is to assist practitioners in achieving these objectives. Background and definitions Melanoma is a global health problem and the incidence is Introduction rising worldwide [1, 2]. Important risk factors for the devel- opment of melanoma are a history of sunburn, intermittent The accurate harvesting of a sentinel lymph node (SLN) in high UV exposure, red or blond hair and a family history melanoma entails a sequence of procedures with components of melanoma [3]. The prognosis of localized melanoma is from different medical specialties, including nuclear medi- generally good and worsens in the presence of regional or cine, radiology, surgery and pathology. The topics covered distant metastases [4]. The stage of the disease provides are presented under the headings: prognostic information and guides treatment. Approximate- ly 20 % of patients with a melanoma of greater than 1. Goals 1 mm Breslow thickness have clinically occult lymph 2. Background and definitions node metastases and the risk generally increases with in- 3. Indications creasing thickness of the melanoma. Physical examination 4. Procedure success rate, and qualifications and responsi- of lymph nodes is inaccurate and small metastases elude bilities of personnel detection with imaging modalities. Therefore, histopatho- 5. Procedures in nuclear medicine logical evaluation is important [5]. 6. Procedures in the surgical suite From the late 1800s onwards, elective lymph node dissec- 7. Radiation dosimetry tion (ELND) was performed to detect and treat clinically oc- 8. Issues requiring further clarification cult lymph node metastases [6]. ELND became controversial when randomized studies did not show a survival benefit in The present practice guidelines have been prepared patients without palpable lymph nodes, but a 20 % better for nuclear medicine practitioners. The intention is to survival was noted in the subgroup of patients with involved offer assistance in optimizing the diagnostic information nodes [7]. In order to exploit this potential survival benefit, yet that can be obtained from SLN procedures. If specific without exposing patients unnecessarily to the morbidity of recommendations cannot be based on evidence from ELND, a diagnostic test was needed to detect lymph node original scientific studies, referral is made to “general metastases at this early stage. opinion” and similar expressions.Therecommendations In 1992 Morton et al. described the concept of orderly are designed to assist in the referral, performance, inter- progression of lymphatic dissemination and SLNB in 223 pretation and reporting of the SLN procedure. patients with melanoma [8]. Melanoma first drains to a 1752 Eur J Nucl Med Mol Imaging (2015) 42:1750–1766 specific regional lymph node before involving other nodes. Indications This is the SLN, which is defined as a node receiving lymphatic drainage directly from the primary tumour [9]. Indications for SLNB in patients with melanoma include, but Tumour cells are present in the SLN before subsequent are not limited to, the following. SLNB should preferably be nodes in the regional basin become involved. Therefore, performed after diagnostic excision of the primary lesion with the tumour status of the SLN indicates the overall nodal a narrow margin and histological confirmation of the diagno- status [10]. So, the aim of SLNB is to identify patients sis, and should be combined with therapeutic wide excision. with lymph node metastases at an early stage. The SLN is SLNB can be considered in patients
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