Demonstration of Blue Dye and mTclabeling in Malignant Melanoma Cases

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Figure 18 shows the labeled lymphatic flow from distal to proximal in the arm, marking the direction of the drainage. Figure 19 shows early labeling of the SLN in the right axilla.

The storage of the nanocolloids can be perfectly seen as soon as 20-45 minutes after injection and is still visible next day for the intraoperative search with the gamma probe.

In Fig. 20 fast labeling of two scattered lymph nodes is shown in another case. This picture includes the possibility of skip metastasis.

Figure 21 demonstrates a lymph node that is the first to show up as labeled after injection of the nanocolloids and is obviously the sentinel node, but further secondary node labeling is already visible 45 minutes after injection.

Figure 22 documents a malignant melanoma with the primary located on the back. After peritumoral injection rapid drainage to the right-sided axillary lymph node(s) developed, but very soon drainage to the left-sided axillary nodes also started.

Fig. 16. Injection technique before tumor excision in malignant melanoma cases. The same injection technique can be used when the solution(s) is/are injected after primary excision

Fig. 17 a, b. The four-point injection sites to be used before tumor excision in the case of malignant melanomas on the trunk. Lymphatic drainage can take a one b two or in some cases more directions. In peripheral melanoma localizations (face, legs, hands, etc.) injections need only be given in a semicircle of sites

Fig. 19. Between 20 and 45 min the SLN in the right axilla can be localized in a gamma camera study; it needs to be marked on the skin surface to allow its localization next day in the operating room

Fig. 17 a, b. The four-point injection sites to be used before tumor excision in the case of malignant melanomas on the trunk. Lymphatic drainage can take a one b two or in some cases more directions. In peripheral melanoma localizations (face, legs, hands, etc.) injections need only be given in a semicircle of sites

Fig. 18. After injection of more than 30 MBq "mTc-nanocol-loids at regular intervals around the melanoma, the lymphatic drainage from the tumor site can be visualized (right arm)

Fig. 20. If the sequence of the images is fast enough (5 s/image), the dynamic of the lymphatic flow can be followed and the first lymph node, which is the sentinel, can be defined, because often a second lymph node rapidly appears in the scan. This difference is important, because in theory a skip sentinel node is possible

Fig. 21. Image recorded 45 min after peritumoral melanoma injection of "mTc-nanocolloids in the right leg, already showing more lymph nodes in the iliacal region, because the sentinel has already been passed and the second and third nodes are visualized. We therefore prefer to record dynamic images

Fig. 23. If a skip metastasis from the lesion is seen on sentinel node scintigraphy of the lower leg, the sentinel node may be in the iliacal area, either superficially or deep in the pelvic area, which needs a more complicated surgical approach. To differentiate between superficial and deep lymph nodes, image fusion between CT and sentinel node SPECT may be helpful. The images show a typical iliac superficial sentinel node

Fig. 21. Image recorded 45 min after peritumoral melanoma injection of "mTc-nanocolloids in the right leg, already showing more lymph nodes in the iliacal region, because the sentinel has already been passed and the second and third nodes are visualized. We therefore prefer to record dynamic images

Fig. 22. Peritumoral melanoma injection in the back, with rapid lymphatic drainage to the right axillary lymph nodes but also to the left axilla. Drainage starts at the bottom of the image on the left (arrow). An image of the left axilla shows lymph node uptake there as well

Figures 23 and 24 illustrate a sentinel node scintigraphy in a case of malignant melanoma on the leg, with labeling of a superficial iliacal SLN and also early labeling of a second SLN in the pelvic area, which may have developed because the superficial iliacal node has been bypassed.

In contrast to typical iliac superficial sentinel node shown in Fig. 24 a sentinel node of a leg melanoma in the pelvic area (Fig. 25) seems to be really rare.

Fig. 24. Typical late image (60 min after injection in the left leg), with several "mTc-nanocolloid-stained lymph nodes. The first lymph node to appear is the sentinel. The lower image corresponds to a higher plain in scintigraphic control, illustrating the state of flow of the labeling solution to the iliacal lymph nodes in the pelvis at a later time

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