histological analysis of the sentinel node in 2 cases, failure to identify an interval node in 1 case, initial in-transit metastasis prior to nodal recurrence in 1 case and systemic recurrence with nodal disease in 3 cases. The importance of the method of wound closure or reconstruction following wide local excision was identified as a likely cause in 4 cases, in which a rotation flap, a flap which would have involved fairly extensive incisions and significant tissue undermining, was used. In summary, the evidence suggests that for patients with primary melanoma on the trunk or extremities who have already undergone wide local excision, lymphoscintigraphy and sentinel node biopsy remain reliable, provided that a rotational flap has not been used in reconstruction. For patients with head and neck melanoma there is inadequate data to support this view and, given the high concentration of lymphatic drainage pathways in this region, there may be a higher likelihood of altered lymphatic drainage as a result of wide local excision. Table 1.3.1. Summary of studies examining the validity of lymphoscintigraphy and sentinel node biopsy for patients who have undergone previous wide local excision. Publication Number of Tumour Number of Number of Likely cause patients locations patients false for false with negative SN negative SN positive SNs biopsies biopsies Karakousis All sites 9 1 Rotation and flap Grigoropoulos, 1999 196 Kelemen et al., 47 All sites 11 3 Histology 1999 195 error in 2 cases + metastasis in other case McCready et 100 Head + neck 31 3 Rotation al., 199 excluded flap in 2 cases Leong et al., 24 Limbs only 2 1 Interval 2003 201 node missed Leong, 65 Head + neck 21 1 Rotation Ghazarian and excluded flap McCready, 2003 200
histological analysis of the sentinel node in 2 cases, failure to identify an interval node in 1 case, initial in-transit metastasis prior to nodal recurrence in 1 case and systemic recurrence with nodal disease in 3 cases. The importance of the method of wound closure or reconstruction following wide local excision was identified as a likely cause in 4 cases, in which a rotation flap, a flap which would have involved fairly extensive incisions and significant tissue undermining, was used. In summary, the evidence suggests that for patients with primary melanoma on the trunk or extremities who have already undergone wide local excision, lymphoscintigraphy and sentinel node biopsy remain reliable, provided that a rotational flap has not been used in reconstruction. For patients with head and neck melanoma there is inadequate data to support this view and, given the high concentration of lymphatic drainage pathways in this region, there may be a higher likelihood of altered lymphatic drainage as a result of wide local excision. Table 1.3.1. Summary of studies examining the validity of lymphoscintigraphy and sentinel node biopsy for patients who have undergone previous wide local excision. Publication Number of patients Tumour locations Number of patients with positive SNs Number of false negative SN biopsies Likely cause for false negative SN biopsies Karakousis and Grigoropoulos, 1999 196 All sites 9 1 Rotation flap Kelemen et al., 1999 195 47 All sites 11 3 Histology error in 2 cases + metastasis in other case McCready et al., 199 100 Head + neck excluded 31 3 Rotation flap in 2 cases Leong et al., 2003 201 24 Limbs only 2 1 Interval node missed Leong, Ghazarian and McCready, 2003 200 65 Head + neck excluded 21 1 Rotation flap