Case 13 Sentinel Node Close to Primary Melanoma Site

A 42-year-old man was referred after excision biopsy of a pigmented lesion on his left midneck. Histological examination had revealed it to be a melanoma 1.8 mm in maximum thickness, invading to Clark level IV.

Preoperative lymphoscintigraphy revealed upward passage of tracer to a single sentinel node in the upper neck with subsequent demonstration of a probable second-tier node more inferiorly (Figs. 14 and 15).

At operation, the sentinel node demonstrated on the lymphoscintigram was found without difficulty, being both blue-stained and hot when examined with the gamma-ray detection probe (8978 counts per 10 seconds after removal). The site of the presumed second-tier node was explored, but only a nonblue node that was not hot with the probe was found. When the melanoma site was

Figure 14 Lymphoscintigram, lateral view (delayed image at 2.5 hours) showing injection site (IS), sentinel lymph node above and anterior to it (small arrow), and second-tier node more inferiorly (large arrow). The second sentinel node found at the time of surgery is not visible because of the bloom around the injection site.

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