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PubMed2001

Nondetection of sentinel lymph node with lymphoscintigraphy as a result of massive malignant invasion shown by positron emission tomography.

PURPOSE: The authors report the complementary roles of lymphoscintigraphy in sentinel node mapping and F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) in a massively invaded sentinel node. MATERIALS AND METHODS: A 49-year-old woman was referred to the authors' institution after the resection of a malignant melanoma (Clark IV, Breslow 5.25) of the right buttock. No evidence of regional or distant organ metastases was observed on bone scintigraphy or thoracoabdominal or cerebral computed tomographs. Preoperative lymphoscintigraphy showed drainage around a circular structure, without any node detected. F-18 FDG PET imaging detected an area of focal, markedly hypermetabolic activity at the same location. RESULTS: The focal, markedly hypermetabolic activity detected by F-18 FDG PET corresponded to a massively invaded sentinel node not shown by lymphoscintigraphy but found and removed at the time of surgery. Radical regional lymphadenectomy showed only one small additional lymph node micrometastasis detected after immunohistochemical staining for S-100 protein and HMB45 antigen. CONCLUSIONS: This case emphasizes the complementary roles of lymphoscintigraphy sentinel node mapping and F-18 FDG PET. Indeed, a massively invaded sentinel node may be detected by PET but missed by lymphoscintigraphy.

Female↗
PubMedDate not supplied

Use of sentinel node lymphoscintigraphy in malignant melanoma.

Lymphoscintigraphy is a sensitive, inexpensive, relatively noninvasive method of identifying lymphatic drainage patterns and sentinel lymph nodes in patients with malignant melanoma. Lymphoscintigraphy with filtered technetium-99m sulfur colloid allows prompt visualization of the lymphatic system, produces high-quality images, and delivers a low radiation dose to the patient. In addition, good regional lymph node retention is seen with filtered Tc-99m sulfur colloid, improving the success rate of intraoperative gamma probe localization. In combination with surgical localization, lymphoscintigraphy allows preoperative and intraoperative identification of the sentinel node in patients with intermediate thickness melanomatous lesions, obviating radical lymph node dissection in most patients and possibly prolonging their survival. Variables such as tumor location, type and preparation of radiopharmaceutical, injection technique, imaging technique, and prior surgical intervention influence the efficacy of lymphoscintigraphy. Nevertheless, lymphoscintigraphy is recommended as a cost-effective preoperative procedure in all patients planning to undergo elective lymph node dissection. Because of the unpredictability of lymphatic drainage, preoperative scintigraphic findings may lead to changes in surgical management.

Animals↗
PubMed2001

Breast cancer: variables affecting sentinel lymph node visualization at preoperative lymphoscintigraphy.

PURPOSE: To compare patients with visualized sentinel lymph nodes (SLNs) and patients with nonvisualized SLNs, with a focus on variables affecting SLN visualization at preoperative lymphoscintigraphy and on nodal drainage basins as related to tumor location. MATERIALS AND METHODS: One hundred thirty-six patients who had breast cancer underwent preoperative lymphoscintigraphy before SLN biopsy. Patients with visualized and nonvisualized SLNs were compared for age; tumor site, size, and histologic findings; injection guidance method; diagnostic biopsy type; interval between biopsy and lymphoscintigraphy; intraoperative identification method; and surgical identification rate. Visualized SLN drainage basins were noted. RESULTS: Ninety-nine patients had visualized and 37 had nonvisualized SLNs, without statistically significant differences in tumor site, size, and histologic findings; injection guidance method; diagnostic biopsy type; and interval between biopsy and lymphoscintigraphy. Ninety-nine (73%) of the 136 SLNs were visualized at lymphoscintigraphy; 30 (81%) of the 37 nonvisualized SLNS were identified at surgery. Of the seven SLNs not identified at surgery, five were mapped with radiocolloid only. Patients with nonvisualized SLNs were older than those with visualized SLNs. Eleven (46%) of 24 tumors with internal mammary drainage were in the outer part of the breast. CONCLUSION: Patients with and those without visualization differed in age, SLN identification at surgery, and surgical identification method. Nonvisualized status does not preclude axillary metastasis. In older patients with nonvisualized SLNs, blue dye may aid in SLN detection, as compared with isotope-only localization.

Adult↗
PubMed2005

Fallacies of preoperative lymphoscintigraphy in detecting sentinel node in breast cancer.

BACKGROUND: Preoperative lymphoscintigraphy is one of the three methods of evaluating sentinel nodes in patients with breast cancer; however, it has been reported to have a high false negative rate. CASE PRESENTATIONS: We report here two cases where the preoperative lymphoscintigraphy was found to be fallacious. A 44-year-old female with T2N0 breast cancer underwent preoperative lymphoscintigraphy with Tc99 sulfur colloid which failed to show any uptake in axilla or internal mammary chain. Intraoperative scintigraphy with blue dye and hand held gamma probe identified sentinel lymph node in axilla. Another patient with T2N0 lesion underwent preoperative lymphoscintigraphy which showed a sentinel lymph node in axilla and another in supraclevicular fossa. Intraoperative scintigraphy failed to show supraclevicular node however axillary node was correctly identified. CONCLUSION: These two cases further strengthen the need to carry out triple test in identification of sentinel lymph node in patients with breast cancer. It also demonstrates the fallacies of preoperative lymphoscintigraphy.

Journal Article↗
PubMed2006

Lymphoscintigraphy in detection of the regional lymph node involvement in gastric cancer.

INTRODUCTION: Involvement of regional lymph node is a critical sign in prognosis of gastric cancer. Radiological techniques are commonly used to evaluate the extension of gastric cancer. But their sensitivity and specificity are low especially in the early stage. Our aim was to assess the value of gastric lymphoscintigraphy in identifying regional lymph node involvement in patients with gastric cancer, as compared to the abdominal ultrasonography, computed tomography and postoperative histopathological evaluation. PATIENTS AND METHODS: 50 patients (12 females) with a median age of 61 years (range, 35-73 years) were included in the study. Pre-operative staging in all cases included upper gastrointestinal endoscopy and biopsy, followed by ultrasound, computed tomography and lymphoscintigraphy. 148 MBq Technetium-99m lymphoscint was injected around the tumour during endoscopy and immediately after injection, anterior, lateral and posterior images were taken in 5-min intervals using a gamma camera. Findings were compared to the findings of other tests. The sensitivity, specificity, positive predictive value, and negative predictive value of each test were calculated and compared. RESULTS: Histologically, 68% of cases (34/50) had metastasis in regional lymph nodes and all cases were accurately diagnosed by lymphoscintigraphy. Lymphoscintigraphy was significantly more sensitive for detecting lymph node involvement (P < 0.01). Both abdominal ultrasonography and CT had very low sensitivity in identifying lymph nodes. CONCLUSIONS: Lymphoscintigraphy is a promising test in the identification of regional lymph nodes pre-operatively in patients with gastric cancer. It might help the surgeon to plan the extent of dissection before surgery which may decrease postoperative complications related to unnecessary extensive lymph node dissection.

Adenocarcinoma↗
PubMed2002

[Lymphoscintigraphy in sentinel lymph node biopsy of breast cancer].

OBJECTIVE: To evaluate the feasibility of lymphoscintigraphy in sentinel lymph node biopsy of breast cancer. METHOD: Lymphoscintigraphy was performed after peritumoral or subdermal injection of radioactive colloid. Then, sentinel lymph node (SLN) biopsy guided by gamma detector probe was performed. Factors correlated with identification-detection rate were assessed. RESULTS: Lymphatic drainage was present in preoperative lymphoscintigraphy in 88(93%) out of 95 patients, with 39 (44.3%) positive for lymphatic drainage other than in the axilla. A total of 91 (95.8%) patients had their SLN identified in the intraoperative procedure. The quality of lymphoscintigraphic image was closely related to SLN identification-detection rate in the intraoperative procedure (P = 0.025). CONCLUSION: Sentinel lymph node outside the axilla can be detected by lymphoscintigraphy. The combination of lymphoscintigraphy and gamma detector probe for sentinel lymph node biopsy of breast cancer not only is acceptable but promising.

Adult↗
PubMed2004

Lymphoscintigraphy and intraoperative gamma probe-directed sentinel lymph node mapping in patients with malignant melanoma.

BACKGROUND AND PURPOSE: Lymphoscintigraphy has been considered a useful tool for sentinel lymph node (SLN) mapping for malignant melanoma. This study evaluated the usefulness of SLN detection by lymphoscintigraphy and excision with intraoperative gamma probe in Taiwanese patients with malignant melanoma. METHODS: Thirty six malignant melanoma patients in clinical stage I and II were enrolled. The Breslow thickness of the primary melanomas was </= 1.0 mm in 8 patients, 1.01 to 2.0 mm in 12 patients, 2.01 to 4.0 mm in 9 patients, >/= 4 mm in 3 patients, and unknown in 4 patients who were transferred from other hospitals and had no nodal or distant metastasis. SLN lymphoscintigraphy was performed with filtered 99mTc-sulfur colloid. An intraoperative gamma probe was used to identify the SLN for dissection. RESULTS: A total of 44 SLNs were detected in 36 patients, with a mean of 1.22 SLNs per patient. The SLN detection rate by lymphoscintigraphy was 100%. During surgery, 39 of the 44 SLNs (88.6%) in 33 of 36 patients (91.7%) were identified. SLN metastasis was found in 8 of 39 dissected SLNs (20.5%) or in 8 of 36 patients (22.2%). The SLN metastatic rate in the patients with primary melanoma with Breslow thickness </= 2.0 mm was 10.0% (2/20), and in patients with Breslow thickness > 2.0 mm was 41.7% (5/12). CONCLUSIONS: Lymphoscintigraphy and intraoperative gamma probe are useful in localizing and dissecting SLN in patients with malignant melanoma. SLN mapping changed the clinical stage in 22.2% of melanoma patients.

Adult↗
PubMed1983

[Clinical usefulness of lymphoscintigraphy by rectal submucosal injection of radioactive colloid].

Lymphoscintigraphies about 27 cases were examined by the methods of 11 cases of anal subcutaneous and 17 cases of rectal submucosal injections of 99mTc-rhenium colloid. Para-aortic nodes and common iliac nodes were visualized in more than 70% out of the 27 cases by these methods, and those images were superior to images obtained by the conventional methods with pedal subcutaneous injections. Internal iliac nodes were visualized in 78.1% by the rectal injection method while in 27.3% by the anal injection method. It was concluded that the transrectal injection method should be used to visualize internal iliac nodes. Examination efficacies of lymphoscintigraphies by these methods on detection of lymph nodes metastases which were confirmed by autopsy, operation, contrast lymphoangiography and/or X-ray CT. As for 131 regions of rectal and anal injected cases, sensitivity was calculated at 84.0% and specificity was at 89.6%. When the cases in which more than one definite defect was detected were scintigraphycally diagnosed as positive to metastasis and when calculated case by case, sensitivity was calculated at 90.9% and specificity was at 62.5% in the 27 cases. Lymphatic systems were seen specifically and systematically by using lymphoscintigraphies. Though the sensitivity was not enough for a screening test of lymph node metastases and the specificity was not enough for a test to rule out lymph node metastases, lymphoscintigraphies are clinically very useful as supplementary examinations. The lymphoscintigraphy by the method of rectal submucosal injection is much more useful as it is convenient and is the only one method to visualize the internal iliac nodes systematically.

Evaluation Studies as Topic↗
PubMed2003

[Preoperative lymphoscintigraphy to identify the sentinel lymph node in breast cancer].

INTRODUCTION: The preoperative lymphoscintigraphy to the Sentinel Node Biopsy (SNB) can reproduce the lymphatic drainage of the tumour in breast cancer. OBJECTIVES: To establish the pattern of lymphatic drainage of the mammary tumors by means of isotopic lymphoscintigraphy and determine the factors that could influence the negativity of the scintigraphy. METHODS: 121 patients with breast cancer who were going to undergo mammary surgery were studied with SNB. One day before the operation, 37 MBq 99mTc-colloidal sulphide colloid in a volume of 2 ml was injected in peritumoral tissue. Mammary lymphoscintigraphies were performed at 30 minutes and 18 hours P.I., in ANT and OA projections of the corresponding chest. After, the clinical-biological parameters and their influence on the result of the lymphoscintigraphy were analyzed. RESULTS: The scintigraphy were positive in 85 % of the patients. The axillary chain was observed in 97 % and the internal mammary chain in 11 %. The factors associated to the absence of visualization of the sentinel node were: older than 50 years (94 %), menopause (89 %), tumoral size > or = 2 cm (67 %), axillary metastases (67 %), the overexpression of C-erbB-2 oncoprotein (44 %) and proliferative activity > 10 % (67 %). CONCLUSIONS: The peritumoral injection of the radiocolloid establishes the lymphatic drainage pattern in the patients with breast cancer. Its absence of visualization can be associated to circumstances like: age > or = 50 years, menopause, tumoral size > or = 2 cm, axillary metastases, tumoral overexpression of the C-erbB-2 oncoprotein and high proliferative activity of the mammary tumor.

Adult↗
PubMed2001

Reversal of abnormal lymphoscintigraphy after placement of venous stents for correction of associated venous obstruction.

PURPOSE: The purpose of this study was to report improvement or normalization of abnormal lymphoscintigraphy in swollen lower limbs after correction of associated venous stenosis by balloon dilatation and placement of venous stent of the iliac veins. MATERIAL: Twenty-six patients with lower-limb swelling underwent balloon dilatation and placement of venous stent of the iliac veins for correction of venous stenosis. Technetium 99M-sulfur colloid lymphoscintigraphy was also abnormal (8 absent, 18 reduced) before stent placement in all 26 limbs, suggesting combined venous/lymphatic etiology for the limb swelling. Median age was 53 years. Male-to-female ratio was 1:8 and left-to-right ratio, 3:1. Fifteen patients had limb pain associated with the swelling. Severity of venous stenosis was generally underestimated by preoperative transfemoral venography as compared with intravascular ultrasound, (mean, 50% versus 77%); in five limbs (19%), transfemoral venography altogether failed to identify the venous lesion evident on intravascular ultrasound. The etiology of venous obstruction was post-thrombotic in nine limbs and nonthrombotic (web, stricture, or May-Thurner syndrome) in 17 limbs. RESULTS: Poststent lymphoscintigraphy completely normalized in 10 limbs, improved but remained abnormal in 9, and remained unchanged in 7. Clinical follow-up (mean, 1 year) showed improvement in swelling in 16 of 26 limbs (P <.022), with complete resolution of swelling in six; degree of pain also improved (P <.02), with total relief of pain in 9 of 15 patients. There was also significant improvement in all categories of a quality of life questionnaire. CONCLUSION: These findings suggest that patients with a diagnosis of lymphedema made on the basis of lymphoscintigraphy alone and consigned to conservative therapy on that basis may benefit from additional venous investigations regardless of clinical presentation suggestive of lymphedema. This report supports the practice of aggressively searching for a venous basis of edema in these patients. Correction of the venous lesion may result in normalization or improvement of the lymphoscintigraphic abnormality and in any case may yield significant symptom relief, even in some limbs where the lymphoscintigraphic abnormality failed to improve after placement of venous stent.

Catheterization↗
PubMed1998

Usefulness of Technetium-99m human serum albumin lymphoscintigraphy in chyluria.

Chyluria is a urologic manifestation of a lymphatic system disease abnormality and leads to nutritional deficiency. The case of a patient with chyluria is presented, and the results of lymphoscintigraphy with those of contrast lymphangiography are compared. Lymphoscintigraphy very clearly showed the site of the fistulae and was as precise as lymphangiography. Follow-up lymphoscintigraphy 2 months after therapy revealed no radionuclide accumulation. Lymphoscintigraphy is a useful, noninvasive, safe, and simple technique for the diagnosis and follow-up of chyluria.

Aged↗
PubMed2004

Correlation between preoperative lymphoscintigraphy and metastatic nodal disease sites in 362 patients with cutaneous melanomas of the head and neck.

OBJECTIVE: Lymphoscintigraphy for head and neck melanomas demonstrates a wide variation in lymphatic drainage pathways, and sentinel nodes (SNs) are reported in sites that are not clinically predicted (discordant). To assess the clinical relevance of these discordant node fields, the lymphoscintigrams of patients with head and neck melanomas were analyzed and correlated with the sites of metastatic nodal disease. METHODS: In 362 patients with head and neck melanomas who underwent lymphoscintigraphy, the locations of the SNs were compared with the locations of the primary tumors. The SNs were removed and examined in 136 patients and an elective or therapeutic regional lymph node dissection was performed in 40 patients. RESULTS: Lymphoscintigraphy identified a total of 918 SNs (mean 2.5 per patient). One or more SNs was located in a discordant site in 114 patients (31.5%). Lymph node metastases developed in 16 patients with nonoperated SNs, all underneath the tattoo spots on the skin used to mark the position of the SNs. In 14 patients SN biopsy revealed metastatic melanoma. After a negative SN biopsy procedure 11 patients developed regional lymph node metastases during follow-up. Elective and therapeutic neck dissections demonstrated 10 patients with nodal metastases, all located in predicted node fields. Of the 51 patients with involved lymph nodes, 7 had positive nodes in discordant sites (13.7%). CONCLUSIONS: Metastases from head and neck melanomas can occur in any SN demonstrated by lymphoscintigraphy. SNs in discordant as well as predicted node fields should be removed and examined to optimize the accuracy of staging.

Head and Neck Neoplasms↗
PubMed2004

Lymphatic drainage routes of the gastric cardia visualized by lymphoscintigraphy.

UNLABELLED: This study was undertaken to assess the feasibility of lymphoscintigraphy of the gastric cardia and to identify the incidence of paraesophageal lymphatic drainage, precluding total gastrectomy with esophagojejunostomy as a potentially curative therapy for gastric cardia cancer. METHODS: Ten patients scheduled for esophagectomy with high-grade dysplasia or with esophageal cancer at least 3 cm above the esophagogastric junction were enrolled in this study. Preoperatively, 111 MBq of(99m)Tc-labeled nanocolloid (n = 5) or sulfur colloid (n = 5) were injected into the submucosa of the tumor-free cardia. Subsequently, lymphoscintigraphy in combination with CT was obtained. Locoregional lymph node stations were measured for radioactivity by a gamma-probe intraoperatively and ex vivo in the resection specimen. RESULTS: In each patient, at least 1 radioactive lymph node station was detected. In total, 42 radioactive lymph node stations were detected by gamma-probe. Of those 42 areas, 38 (90%) were visible at preoperative lymphoscintigraphy. In the group of 5 patients in whom nanocolloid was used, a median of 2 (range, 1-4) node stations per patient was identified, whereas when sulfur colloid was administered a median of 6 (range, 4-8) active lymph node stations per patient could be detected (P < 0.002). Paraesophageal drainage was identified in 1 patient. CONCLUSION: Lymphoscintigraphy of the gastric cardia is feasible and can accurately determine the location of radioactive lymph nodes. Early paraesophageal lymphatic drainage is rare.

Adenocarcinoma↗
PubMed2005

[Sentinel lymphoscintigraphy in oral carcinoma: a clinical report of 10 cases].

UNLABELLED: OBJECTIVE; To determine the clinical value of preoperative in vivo location of sentinel lymph node (SLN) by lymphoscintigraphy (LS) in oral carcinoma. METHODS: 10 patients with oral carcinoma were included in this study (7 male to 3 female). 99mTc-dextron was injected peritumorally 24 h before surgery. Lymphoscintigraphy images were obtained in anterior and lateral views. SLNs were detected and removed with the aid of dye during surgery. A standard radical neck dissection was then performed, and all lymph nodes were analyzed by HE staining. RESULTS: SLNs were successfully detected in 10 regions of 8 patients via lymphoscintigraphy. Consistent with the result of LS, 15 blue-stained SLNs were identified by means of dye method in 8 of 10 regions which the LS images indicated. CONCLUSION: This study suggests that preoperative in vivo location of SLN via lymphoscintigraphy should be helpful for the application of SLNB in oral carcinoma.

Female↗
PubMed1986

Lymphoscintigraphy in lymphedema: an aid to microsurgery.

The role of lymphoscintigraphy, performed with 99mTc-labeled antimony sulfur colloid, in the diagnosis of lymphedema and as a test for selection of patients for microvascular operation was evaluated in 32 patients with primary and secondary lymphedema and four patients with other causes of leg edema. Lymphoscintigraphy clearly demonstrated if edema was of lymphatic origin. Five different image patterns were identified; abnormal image patterns could not be predicted from clinical history or physical findings. Quantitative evaluation of removal of the radioactive colloid from the injection site and appearance in lymph node sites and liver was of limited usefulness. Nine patients underwent various surgical procedures before or after lymphoscintigraphy. Lympho-venous anastomoses were possible only in patients who had patent lymph channels visible on lymphoscintigrams. Based on initial experience, lymphoscintigraphy seems to be useful to select patients for microvascular operation.

Adolescent↗
PubMed1983

Cardiovascular lymphoscintigraphy.

The technique of lymphoscintigraphy when applied to the heart and blood vessels correlates well with results of anatomic investigations of arterial and cardiac lymphatic vessels reported in the literature. Five dogs and eight rabbits underwent lymphoscintigraphy of the heart and aorta, as well as the iliac, femoral, and tibial arteries. After surgical exposure, approximately 500 microCi of 99mTc-labelled antimony sulfide was injected into the myocardium or the adventitial-medial plane of an artery. The colloid particle size of 4 to 12 m mu causes resorption and transport only via the lymphatic vessels. Twenty-one preparations were imaged from 2 to 48 hours after administration. This method provides a functional demonstration that the tibial and femoral arteries of both species are invested with lymphatics. The first echelon of lymph nodes which drain muscular arteries are imaged within 2 hours. Regional lymph nodes could not be seen to drain the aorta or iliac arteries. Anterior left ventricular myocardial injection in the dog showed a single cardiac lymph node. This drainage pattern has been described previously by other investigators. In the rabbit a similarly placed injection visualized a group of regional cardiac nodes. Ligation of the collecting ducts afferent to the cardiac node in the dog prevented removal of the isotope from the heart at 3, 6, and 9 hours. At 24 hours the liver and spleen were imaged, the radiocolloid gaining entrance to the blood vascular system presumably via myocardial lymphaticovenous anastomoses. Lymphoscintigraphy reflects physiologic processes such as lymph transport, filtration, and reticuloendothelial function. It defines regional patterns of cardiac and arterial lymph drainage. It can confirm experimentally produced impairment of lymph drainage from a defined area of tissue. Lymphoscintigraphy should be useful in the investigation of the significance of lymph drainage to diseases of the heart and blood vessels.

Animals↗
PubMed1995

Mammary lymphoscintigraphy in breast cancer.

UNLABELLED: Lymphoscintigraphy has previously been used to define lymph drainage patterns and locate sentinel lymph nodes, prior to surgery, in patients with cutaneous melanoma. The aim of this study was to apply this technique to patients with breast cancer using intramammary injections placed around the primary tumor in the breast. METHODS: Lymphoscintigraphy using 99mTc-labeled antimony sulphide colloid was performed in 34 patients with a suspected primary breast cancer. Images were recorded immediately and at 2.5 hr using a LFOV digital gamma camera. Sentinel lymph node location was marked when possible. RESULTS: Lymphatic drainage patterns were successfully recorded in all but three patients. Lymph drainage was to the axillary, internal mammary, supraclavicular and, in one patient, infraclavicular node fields in various combinations but always on the same side of the body as the breast tumor. There was unexpected drainage across the center line of the breast to axillary or internal mammary nodes in 32% of patients with inner or outer quadrant lesions. Direct drainage to supraclavicular or infraclavicular nodes occurred in 20% of upper quadrant lesions. Drainage to the ipsilateral axilla occurred in 85% of patients, where a single sentinel node was seen in all cases. CONCLUSION: Intramammary lymphoscintigraphy can be used to define the lymphatic drainage patterns of individual breast cancers. The surface location of sentinel lymph nodes in the draining node fields can be marked and in the axilla their depth can be measured. It should therefore be possible to use lymphoscintigraphy, along with a blue dye injection technique or the gamma probe at surgery, to locate sentinel lymph nodes in patients with breast cancer.

Antimony↗
PubMed1993

Lymphoscintigraphy in high-risk melanoma of the trunk: predicting draining node groups, defining lymphatic channels and locating the sentinel node.

Lymphoscintigraphy was performed in 209 patients with high-risk melanoma of the trunk referred to the Sydney Melanoma Unit and considered for lymph node dissection. Lymphoscintigraphy accurately defined the draining lymph node groups and was 94% sensitive in detecting draining sites that contained metastases. When combined with the clinical finding of palpable lymph nodes, the sensitivity rose to 98%. Most patients showed lymph drainage to one or two node groups and only 22 patients showed drainage to 3 or more node groups. The major lymph channels could also be marked on the skin prior to incontinuity dissection. Most patients had multiple draining lymph channels and these often diverged significantly from each other in the path to the draining node group. The number and location of interval nodes could be determined and marked on the skin. These and the major lymph channels could thus be excised at the time of surgery. Unusual drainage patterns were sometimes seen; for example, three patients displayed a new lymph pathway with direct drainage from the back anteriorly to the para-aortic nodes. The location of the sentinel nodes in each draining lymph-node group could also be marked on the skin prior to surgery, enabling quick and accurate identification of this node, using the blue-dye technique if biopsy were to be performed. These findings lead us to recommend lymphoscintigraphy prior to wide local excision in patients with truncal melanoma who are candidates for surgery. Lymphoscintigraphy results will help plan surgery and lead to minimum surgical intervention, consistent with effective surgical management.

Female↗