Sentinel Lymph Node Biopsy for Squamous Cell Carcinoma of the Extremities: Case Report and Review of the Literature

ANTICANCER RESEARCH 31: 1443-1446 (2011) Sentinel Lymph Node Biopsy for Squamous Cell Carcinoma of the Extremities: Case Report and Review of the Literature YANG YANG LIU, WARREN M. ROZEN and RICHARD RAHDON Department of Plastic and Reconstructive Surgery, Geelong Hospital, Victoria, Australia Abstract. Background: Lymph node metastases from of SCC of the ear, for example, reaching 18.7% (3). Early squamous cell carcinoma (SCC) can reach 20% in some high detection of metastasis in high-risk SCC groups is vital to risk subgroups, and while early detection of metastasis may formulating effective management plans and potentially potentially improve overall and/or disease-specific survival, improving overall and/or disease-specific survival. techniques for early detection have not been established. One One such technique for the early detection of lymph node such technique is the use of sentinel lymph node biopsy metastasis is the use of sentinel lymph node biopsy (SLNB), (SLNB), however its role for SCC of the extremities has not which can identify the presence of nodal metastasis in the first been explored. Materials and Methods: A case that highlights tier of the draining lymphatic basin in a relatively non-invasive the utility of SLNB in this setting is described, and a systematic manner. This technique has been shown to be of value in breast review of the literature was undertaken in order to establish the carcinoma and melanoma. However, the role of SLNB in SCC current evidence for its use. Results: There have been no management has not been as widely explored. The head and prospective clinical trials performed to investigate the role of neck has been the focus of much of the literature to date on the SLNB in this setting. Thirty-two cases utilizing SLNB for use of SLNB for SCC, with no consensus as to its particular peripheral SCCs have been reported, with a 28.1% rate of role yet established, largely due to the difficulties of SLNB in positive SLN, and low false-positive and false-negative rates. this region, such as multiple draining lymphatic pathways, high No complications were reported. Conclusion: SLNB for SCC false-positive and -negative rate, difficult dissections and of the limbs has been scarcely reported, but those cases potentially greater operative morbidity. The upper and lower reported do collectively demonstrate a high positive predictive limbs offer a potentially different scenario, with the widespread value for lymph node metastasis and a low false-positive rate, utility of SLNB for melanoma in the extremities being well with poor prognostic variables identified. The efficacy of SLNB established. Despite this, the role of SLNB for SCC of the in this setting requires further investigation. extremities has not been explored. A case that highlights the utility of the technique for SCC of the extremities is described, Cutaneous squamous cell carcinoma (SCC) is the second most and a systematic review of the literature performed in order to common skin cancer, with an incidence of approximately 1% establish the current evidence for its use. in many populations (1). The overall risk of metastatic disease is low, with five-year metastatic rates reported at approximately Materials and Methods 5% (2). Certain subsets of SCC, however, have significantly higher rates of locoregional recurrence and distant metastasis, A literature review was performed, comprising an evaluation of all and factors contributing to higher metastatic potential have reported cases of SLNB for SCC of the extremities and assessment of the current evidence for the technique. This was achieved through an been identified by Rowe et al. (3). These subsets can have electronic and manual search using the search strings “sentinel lymph metastatic rates far exceeding the norm, with the metastatic rate node”, “sentinel lymph node biopsy”, “lymph node mapping”, “lymph node biopsy”, combined with “SCC”, “squamous cell carcinoma”, “limb” and/or “extremity”. The inclusion criteria comprised any publication directly studying or commenting on any cases of SLNB Correspondence to: Dr. Warren Rozen, MBBS BMedSc for SCC of the extremities. Only English language articles were PGDipSurgAnat, Ph.D., Department of Plastic and Reconstructive specifically sought. There were no exclusions, with the electronic Surgery, Geelong Hospital, Bellerine St, Victoria, Australia, 3220. search including Pubmed, Pubmed Central, Cochrane Database of Tel: +613 52267111, e-mail: [email protected] Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Ovid-MEDLINE® In-Process, and Key Words: Skin cancer, non-melanoma, lymph node, metastasis, the secondary references found via bibliographic linkage were also literature review, sentinel lymph node biopsy. retrieved. 0250-7005/2011 $2.00+.40 1443 ANTICANCER RESEARCH 31: 1443-1446 (2011) Case Report A 74-year-old female presented with a large, neglected tumor of the left leg. The lesion involved much of her posterior and lateral leg, between the ankle joint and several centimeters below the knee joint (see Figure 1). It was deeply ulcerative, with clear involvement of the deep muscular compartments. There were no palpable inguinal lymph nodes and no suggestion of distant disease on examination. Mapping punch biopsies of the tumor demonstrated a well-differentiated invasive SCC. Staging of the lesion was performed through locoregional magnetic resonance imaging (MRI) and computed tomographic (CT) staging of her chest, abdomen, pelvis and inguinal nodes. The locoregional MRI showed extensive musculoskeletal involvement, including all of the posterior compartment and peroneal musculature, from the achilles tendon to several centimeters below the popliteal fossa. CT staging showed no metastatic disease in the chest, abdomen or pelvic cavities and no suggestion of inguinal lymphadenopathy. Given the extensive local invasion and poor prognostic factors (size and depth of the tumor), it was felt that limb salvage was not possible, and that inguinal nodal disease was likely and warranted exploration. After multidisciplinary discussion and extensive discussion with the patient and family members, below-knee amputation and left inguinal SLNB were performed. Utilizing patent blue dye for sentinel lymph node mapping, a single blue sentinel node was identified, and the operation concluded uneventfully. Histopathological examination of specimens demonstrated a 160 mm SCC with extensive muscular invasion and cortical invasion of the fibula, but without lymphovascular or perineural Figure 1. Locally advanced squamous cell carcinoma (SCC) of the left infiltration. The tumor was widely completely excised. The leg, demonstrating a 160 mm tumor invading all of the posterior single sentinel node did not reveal any SCC. The patient compartment and peroneal musculature and into the fibula. recovered well with no operative complications. At six-month follow-up, the patient showed no signs of local recurrence or distant metastasis. (minimum four months’ follow-up), and of these, two showed Literature Review subsequent nodal recurrence and three showed systemic metastatic disease. Despite the incomplete data set, the false- The first report of SLNB for SCC of the extremities comprised positive rate of SLNB rate appears to be low, with positive a report by Stadelmann et al. in 1997 of SLNB for SCC of the cases demonstrating poor prognosis in most cases, and no clear upper extremity (4). Although many subsequent studies evidence of any false-positives suggested in the literature. Two attempted to assess the value of SLNB in high-risk SCC cases false-negative cases were demonstrated in the series (6.3%). of the extremities, these were all case reports or small case Although insufficient cases have been reported to reveal any series. There have been no prospective clinical trials performed valid statistics, the data suggests that a substantial proportion of to investigate the role of SLNB in this setting. patients with clinically negative nodal basins will indeed have After excluding all cases that did not describe findings of nodal disease warranting management, and similarly that in SLNB of the extremities, thirteen English-language many high-risk, poor-prognosis SCCs, nodal clearance can be publications were identified and included in the results, avoided with a negative SLNB. All the reports favored SLNB comprising cases between 1997 and 2007 (see Table I) (1, 4- as a safe procedure, and while potential risks offered included 15). Within these 13 reports, there were 32 peripheral SCC allergic reaction to patent blue dye, infection, hematoma, cases reported. From these cases, SLNB was positive in nine lymphedema and damage to nerves and other structures, no cases (28.1%), with five providing adequate follow-up data complications were reported in the included literature. 1444 Lin et al: SLNB for SCC of the Extremities Table I. Features of each of the identified cases of sentinel lymph node biopsy (SLNB) of the limbs reported in the literature. Study Tumor characteristics SLNB features Outcomes Location Risk Differentiation Depth Level of Number Number Local Follow- factors invasion of of recurrence; up SLNs positive nodal (months) identified SLNs metastasis; distant metastasis Renzi et al. (1) LL N/A Poor >4 mm Bone N/A 1 Nodal 4 Stadelmann et al. (4) UL Size=4 cm, N/A N/A Bone N/A 1 Local 14 bone involvement Ardabili et al. (5) LL N/A Well- N/A Dermis N/A 0 (false- Local 5 negative) Eastman et al. (6) UL Marjolin ulcer N/A 1 N/A UL N/A 1 N/A UL N/A 0 N/A LL N/A 1 N/A UL N/A 1 N/A LL N/A 0 N/A Hatta et al. (7) LL N/A N/A N/A N/A N/A 0 N/A N/A LL N/A N/A N/A N/A N/A 0 N/A N/A LL N/A N/A N/A N/A N/A 0 N/A N/A LL N/A N/A N/A N/A N/A 0 N/A N/A Michl et al.

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