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Objectives: To systematically review the current literature on treatment of third and fourth branchial pouch sinuses with endoscopic cauterization, including chemocauterization and electrocauterization, in comparison to surgical treatment., Data Sources: PubMed, Embase, and the Cochrane Library., Review Methods: We conducted a systematic search. Studies reporting original study data were included. After assessing the directness of evidence and risk of bias, studies with a low directness of evidence or a high risk of bias were excluded from analysis. Cumulative success rates after initial and recurrent treatments were calculated for both methods. A meta-analysis was conducted comparing the success rate of electrocauterization and surgery., Results: A total of 2,263 articles were retrieved, of which seven retrospective and one prospective article were eligible for analysis. The cumulative success rate after primary treatment with cauterization ranged from 66.7% to 100%, and ranged from 77.8% to 100% after a second cauterization. The cumulative success rate after the first surgical treatment ranged from 50% to 100% and was 100% after the second surgical attempt. Meta-analysis on electrocauterization showed a nonsignificant risk ratio of 1.35 (95% confidence interval: 0.78-2.33)., Conclusions: The effectiveness of cauterization in preventing recurrence seems to be comparable to surgical treatment. However, we suggest endoscopic cauterization as the treatment of choice for third and fourth branchial pouch sinuses because of the lower morbidity rate., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: The purpose of this study was to provide anatomic guidance for the extent (technique) of suboccipital node dissection., Methods: Five human cadaver necks (9 sides) were studied. Boundaries were the superior nuchal line and external occipital protuberance (cranial), the nuchal ligament (medial), an imaginary line through C7 (caudal), and the posterior wall of the auditory channel (anterior). The overlying skin and complete thickness of the cranial part of the trapezius muscle and fascia sheath was included (deep)., Results: An average number of 4 lymph nodes per suboccipital side were found. Diameters ranged from 1 to 6 mm. Twenty nodes (63%) were located in the subcutaneous tissue, 12 (37%) were found just underneath the superficial fascia of the trapezius muscle., Conclusion: Suboccipital nodes are small and mainly located in the subcutaneous layer, with a minority just underneath the superficial fascia of the trapezius muscle. This anatomic knowledge was used to refine the suboccipital dissection., (Copyright © 2013 Wiley Periodicals, Inc.)

The lymphatic drainage of cutaneous melanomas located on the upper trunk is often complex and sometimes follows an unexpected pattern. Occasionally, even direct drainage to cervical lymph nodes is seen. In this case series, 3 patients with lymphatic drainage to the neck derived from melanomas located over the manubrium sterni are described. There appears to be a restricted area that involves the manubrium sterni from which lymphatic drainage to different cervical node basins appears more frequent. SPECT/CT was helpful in visualizing these patterns and for the localization of the sentinel nodes.

The aim of the study was to determine the incidence of lymph node recurrence in 16 melanoma patients with a minimal metastasis (Starz level I) in a sentinel node in whom a completion lymph node dissection was omitted. A secondary aim was to examine whether other melanoma-related recurrences developed. Sixteen melanoma patients with an SI-involved sentinel node, who did not undergo completion lymph node dissection, were followed for a median of 66 months. Lymph node recurrences did not occur. One of the 16 patients developed a local recurrence and another developed satellite metastases. None of the 16 patients with an SI-positive sentinel node developed a nodal recurrence, which suggests that the risk of refraining from node dissection in such patients is small. This option could be considered and discussed with the patient in terms of the risk of nonsentinel node involvement and the unsolved problem of unknown overall survival advantage.

Purpose: To determine the incidence and pattern of cervical lymphatic drainage in patients with melanomas located on the upper limb or trunk, and to evaluate our current neck dissection protocol for those patients with a N+ neck., Methods: Of 1192 melanoma patients who underwent sentinel node biopsy, 631 were selected with a primary tumor on the upper limb or trunk. All lymphoscintigrams, SPECT/CT images and operative reports were reviewed to determine the exact locations of sentinel nodes visualized preoperatively and dissected during operation., Results: Thirty-nine (6.2 %) of 631 patients with a melanoma on the upper limb or trunk showing cervical lymph node drainage were identified. In 34 (87 %) of 39 patients, sentinel nodes were excised from level IV or Vb, and in 30 of those 39 patients simultaneous from the axilla. In the remaining five patients (13 %), sentinel nodes were collected from level IIb, level III or the suboccipital region. All collected sentinel nodes were located in the intended dissection area for N+ patients. Thirteen patients (33 %) had a total of 22 tumor-positive sentinel nodes in either the axilla (n = 10), level IV (n = 2), Vb (n = 9) or suboccipital (n = 1)., Conclusions: Only a minority of the patients with upper limb or trunk melanomas demonstrated lymphatic drainage to cervical lymph node basins, with preferential drainage to levels IV and Vb. Our current dissection protocol of levels II-V, with or without extension to the suboccipital region, in those patients with involved cervical sentinel nodes seems sufficient.

Sentinel node mapping is widely applied in patients with melanoma. Although this type of skin cancer usually drains to the standard regional nodal basins, some patients have drainage to an unpredicted site. Nodes lying along a lymphatic channel, between the primary melanoma site and a common basin, are often called interval, in-transit, ectopic, intercalated, or aberrant nodes. They must be considered sentinel lymph nodes because they receive direct lymphatic drainage from a primary tumor site. Most investigators agree that interval sentinel nodes should be harvested; however, the management of melanoma patients with an involved interval sentinel node without established metastasis in the regional basin downstream is controversial. New and innovating technologies have improved nuclear medicine images, including single-photon emission computed tomography/computed tomography (SPECT/CT), a multimodal technique that fuses the radioactivity distribution detected by SPECT with the anatomic information harvested by CT. SPECT/CT does not replace the conventional planar images; it should be considered as a complementary modality for the search of sentinel lymph nodes. We report three illustrative cases that underline the decisive role of SPECT/CT with two-dimensional and three-dimensional reconstruction images to localize the uncommon periscapular sentinel nodes in patients with melanoma of the posterior trunk. The use of this image fusion technique on these patients leads to improved preoperative visualization of the sentinel nodes, may help identify additional periscapular interval sentinel nodes, and enables precise localization of the nodes with their surrounding anatomic structures. The cases are discussed together with a review of the literature.

Purpose: To investigate whether single photon emission computed tomography camera with integrated radiographic computed tomography (SPECT/CT) is of additional value compared to conventional lymphoscintigraphy in routine lymphatic mapping in patients with melanoma., Methods: Thirty-five unselected patients with a primary melanoma who were scheduled for wide local excision and sentinel node biopsy underwent conventional lymphoscintigraphy and subsequently SPECT/CT. We determined whether SPECT/CT showed additional sentinel nodes, whether it provided better information on the location of the sentinel nodes, and whether this additional anatomic information led to a change in the planned surgical approach., Results: SPECT/CT depicted the same 69 sentinel nodes as conventional lymphoscintigraphy in all 35 patients plus found eight additional sentinel nodes in seven patients (20%). In two of these patients (5.7%), an additional nodal basin had to be explored to find the extra sentinel nodes. SPECT/CT provided additional anatomic information that was helpful to the surgeon in 11 patients (31%) and led to an adjustment of the surgical approach in 10 patients (29%)., Conclusions: SPECT/CT provided relevant additional information in 16 (46%) of the 35 patients. Routine use of SPECT/CT in addition to conventional lymphoscintigraphy is recommended in melanoma patients undergoing lymphatic mapping.

Background and Objectives: The aims of the study were to determine the percentage of false-negative sentinel node procedures in melanoma patients, to investigate the time cohort of these recurrences, whether a learning phase was involved and to search for causes of the failures., Methods: Between December 1993 and December 2008, 708 melanoma patients underwent a sentinel node biopsy. The procedure was considered false-negative if a recurrence developed in the basin from which a tumor-free sentinel node had been removed. Of all false-negative cases, the pre-operative images, operative report and pathology slides were reviewed., Results: Sentinel node biopsy was positive in 164 (23%) of the patients and false-negative in 10 (1.4%), which results in a false-negative rate of 5.7%. Five of the 10 failures occurred in the first year after the sentinel node biopsy was introduced. Causes for these false-negative procedures could be attributed once to the nuclear medicine physician, once to the surgeon and twice to the pathologist., Conclusion: The sentinel node procedure failed to identify involvement in 5.7% of the patients with lymph node metastases. Half of the false-negative biopsies took place in the first year after the procedure was introduced, illustrating the existence of a learning period., (Copyright © 2011 Wiley-Liss, Inc.)

Background and Objectives: The aim of this study is to evaluate lymphatic drainage with sentinel node location data in patients with head and neck cutaneous melanoma, and to determine the implications for the extent of therapeutic neck dissections., Methods: Sixty-five patients with head and neck cutaneous melanoma without evidence of regional metastases at ultrasound guided fine needle aspiration cytology examination were included. Lymphatic drainage patterns were investigated using planar and dynamic lymphoscintigraphy, and SPECT/CT. Biopsy of sentinel nodes was guided by images and gamma probe. The incidence of discordant sentinel nodes was determined by comparing actual drainage patterns to "O'Briens map" and to the treatment guidelines of The Netherlands Cancer Institute., Results: Sentinel node identification was successful in 98% of the patients. Fifteen patients (23%) were diagnosed with a tumor-positive sentinel node. Two sentinel node-negative patients (3%) developed a regional lymph node metastasis (false-negative ratio: 12%). Twenty-three percent of the harvested sentinel nodes were discordant according to "O'Brien's map," while 14% were discordant according to the treatment guidelines of The Netherlands Cancer Institute (P < 0.001)., Conclusions: Almost a quarter of head and neck melanomas metastasize outside clinically predicted neck levels. Neck surgery guidelines of The Netherlands Cancer Institute provide for a smaller number of discordant sentinel nodes., (Copyright © 2011 Wiley-Liss, Inc.)

Background: The main aims of this study were to evaluate the occurrence of the various forms of locoregional recurrence in sentinel node-positive melanoma patients, to determine whether the different definitions that are being used to describe in-transit metastases influence this rate, and to identify factors associated with locoregional recurrence. A comparison was made with the rate of locoregional recurrence in patients who underwent lymph node dissection for palpable metastases., Methods: Between December 1993 and December 2008, a total of 141 patients underwent completion lymph node dissection because of a tumor-positive sentinel node. In the same period, 178 patients underwent a regional lymph node dissection for palpable nodal metastases., Results: In the sentinel node-positive patients, the local recurrence rate was 5%, the rate of satellite metastasis was 2%, and for in-transit metastasis, it was 15%. In patients with palpable nodal involvement, these values were 3%, 2%, and 14%, respectively. There was no statistically significant difference in locoregional recurrence-free rates between these two groups of node-positive patients (P = .172). Breslow thickness was the only predictive factor for locoregional recurrence (P = .015)., Conclusions: The rate of locoregional metastases in patients with a tumor-positive sentinel node and patients with palpable nodal involvement is similar. The present study refutes the suggestion that a positive sentinel node indicates a predisposition for developing in-transit metastases.