The Use of Sentinel Lymph Node Biopsy inSquamous Cell Carcinoma of the Foot:A Case Report

Derya Ozcelik, MD,1 Soner Tatlıdede, MD,2 Semra Hacıkerim, MD,3 Kemal Ugurlu, MD,4

and Murat Atay, MD5

Squamous cell carcinoma (SCC) is the second most common skin cancer in humans. Because theincidence of metastasis from SCC of the skin is rare, regional lymphadenectomy is generally notrecommended for the patients with clinically node-negative disease. However, in patients with anintermediate and high risk of metastasis, evaluation of the lymph nodes to detect the absence ofmetastatic nodal disease is a difficult task. Here, we present a patient with a large SCC on the dorsumof the foot with clinically negative inguinal and popliteal lymph nodes. Intraoperative lymphatic mappingtechnique was used to make the decision of the inguinal node dissection. Two sentinel lymph nodes thatwere biopsy negative were found; therefore, only tumor excision was performed without adding com-plete inguinal node dissection. The defect was reconstructed with the free flap. After a 4-year carcinoma-free period, we determined that the pathology of the sentinel lymph nodes reflected that of the inguinalregion.The use of selective lymphadenectomy technique in extremity SCC is very new. However, it mightbe useful in staging patients with SCC of the lower extremity by being able to detect absence or presenceof occult metastatic nodal disease and avoid unnecessary complete inguinal node dissection. (TheJournal of Foot & Ankle Surgery 43(1):60–63, 2004)

Key words: sentinel node, foot, limb, squamous cell carcinoma

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Squamous cell carcinoma (SCC) is the second mostmon skin cancer in humans. The frequency of regimetastasis of skin SCC is low, ranging from 0.5% to 5(1–3). Because the rate of metasasis is low, performinelective lymph node dissection in patients with clinicnode-negative disease is usually not recommended.the advanced lesion is found without clinically regioinvolvement, the decision of regional lymph node dissecbecomes difficult, because possibility of occult metast

From the Department of Plastic and Reconstructive Surgery, S¸ isli EtfalState Hospital, Istanbul, Turkey; and the Medmar Imaging Center,bul, Turkey. Address correspondence to: Derya O¨ zcelik, MD, Sezai Selesok., Hersek apt., 4/B, D:2, Nis¸antası, Istanbul, Tu¨rkiye 80200. E-maideryaozcelik68@yahoo.com

Dr Ozcelik’s current affiliation is Medical Faculty, DepartmentPlastic and Reconstructive Surgery, Abant I˙zzet Baysal University, Du¨zceTurkey.

1Assistant Professor, Department of Plastic and Reconstructive SuSisli Etfal State Hospital.

2Consultant, Department of Plastic and Reconstructive Surgery¸ isliEtfal State Hospital.

3Resident, Department of Plastic and Reconstructive Surgery, S¸ isli EtfalState Hospital.

4Consultant, Department of Plastic and Reconstructive Surgery¸ isliEtfal State Hospital.

5Consultant, General Surgeon, Medmar Imaging Center.Copyright © 2004 by theAmerican College of Foot and Ankle Surge1067-2516/04/4301-0011$30.00/0

doi:10.1053/j.jfas.2003.11.003

60 THE JOURNAL OF FOOT & ANKLE SURGERY

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increases in these patients. Five-year survival rates itients with metastatic disease have been reported tofrom 27% to 39% (1–3). During the past several years,technology has made it possible to map and identifylymph node(s) draining the site of a primary cutanemalignancy (4). The sentinel lymph node (SLN) is thelymph node in the lymphatic basin to receive efferent lymflow from the primary tumor site. For this reason, treflect the status of the histology of the remainder oflymph nodes in that nodal basin, assuming that metaoccurs in a sequential fashion. The success of lympmapping depends on identifying the first lymph node dring the primary tumor.

Although SLN dissection has been popularized in mnoma staging, it is believed that other cutaneous maligcies, such as poorly differentiated SCC and Merkelcarcinoma, may spread via a similar sequential and orfashion by involving an SLN within the lymphatic pathw(5). A case of a patient with a large SCC of the wrist wclinically negative axillary findings who was found to haa SLN containing metastatic tumor was reported previo(6).

The authors present a case of a patient with a largeon the dorsum of the foot with clinically negative inguiand popliteal lymph nodes and with 2 SLNs not contain

,

a metastatic tumor.

Case Report

A 55-year-old man presented with the mass on the rightfoot dorsum, which developed on burn scar tissue 2 yearsearlier. The burn scar had been present over the ankle areafor 40 years. The patient complained of the recent rapidgrowth of the mass. On examination, a 7 � 9 cm exophyticulcerated mass arising from the burn scar was noted over thedorsal surface of the right foot at the level of the ankle (Fig.1). The mass was firm and fixed to the underlying tissues.Range of the motion of the foot was not impaired by theulcerated mass. No popliteal or inguinal lymph nodes werepalpable. The results of an incisional biopsy taken from thewound determined the diagnosis of a well-differentiatedSCC. Computed tomography examination delinated nopathologic findings within the pelvic, inguinal, or poplitealarea, and there was no cortical erosion of the underlyingbones.

Because the patient had high risk factors of nodal metas-tasis, including mass size �2 cm, marked depth of invasion(3 cm), and associated burn scar (Marjolin ulcer), an intra-operative lymphatic mapping technique was planned toevaluate the inguinal lymph nodes and to decide whether theinguinal node dissection was required. Two hours preoper-atively, a peritumoral 4-point intradermal injection of 1 mCiof filtered technetium (99mTc)–labeled colloid albumin wasperformed. At the time of surgery, a hand-held gamma

FIGURE 1 Preoperative view of the dorsum of the right foot withat the level of the ankle.

detector (Fig. 2) was placed over the inguinal region and it

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recorded a signal of 2600 counts per second (c/s) by usinga number 19 probe. It was expected that this was the areacontaining the SLN. With a number 14 probe, the measur-ments were 1100 c/s on sentinel node, 4000 c/s on thesurface of the tumoral lesion, and 10 to 20 c/s in the normaltissue. The inguinal skin over the identified sentinel nodewas marked. The sentinel node found at the inferior site ofthe inguinal lymph nodes was excised through a 3-cminguinal incision and measured ex vivo by using the number14 hand-held gamma probe; the measurment was 1600 c/s.After removal, a second SLN in the same area was noted tohave a strong gamma signal of 500 c/s in situ and 1500 c/safter excision. After removal of the second SLN, the ingui-

9 cm exophytic ulcerated mass of SCC arising from the burn scar

a 7 �

FIGURE 2 The hand-held gamma detector.

43, NUMBER 1, JANUARY/FEBRUARY 2004 61

nal area had a baseline gamma signal of 30 c/s, indicatingsuccessful removal of both SLNs.

Frozen-section examination of sentinel nodes were neg-ative for metastases and inguinal node dissection was notperformed. The tumoral lesion located on the foot dorsumwas resected with a 3 cm margin of normal tissue around thelesion. A 12 � 15 cm defect was created and reconstructedwith a latissimus dorsi muscle free flap (Fig. 3). The flapsurface was covered with the skin graft. The histopathologicexamination of the specimen was well-differentiated SCC,and surgical margins, including the deep margin, were freeof the tumor. Permanent pathologic evaluation of the SLNperformed by light microscopy with hematoxylin and eosin

FIGURE 3 Early postoperative view of the right foot reconstructedwith the latissimus dorsi muscle free flap and skin graft after tumorexcision.

staining was also negative for metastatic SCC. There was no

62 THE JOURNAL OF FOOT & ANKLE SURGERY

early or late postoperative complication. At 4-year follow-up, the patient remained free of recurrence (Fig. 4).

Discussion

The use of selective lymphadenectomy with preoperativelymphoscintigraphy and intraoperative radiolymphoscintig-raphy and vital dye injections to identify SLN has provenhighly successful and reliable in patients with malignantmelanoma (4, 7). Melanoma nodal metastases are nowbelieved to occur in an orderly and sequential manner, withSLN being the first lymph node in a lymphatic basin to beinvolved (8). In the case reported by Stadelmann et al (6),the SLN was the only involved node in the basin withmetastatic disease of a cutaneous SCC of the wrist. Al-though 2 local recurrences of SCC had developed after localexcisions and complete axillary lymphadenectomy in thispatient, she remained free of recurrent local-regional andsystemic metastatic disease. As shown in that case, SCC of

FIGURE 4 Medial view of the foot 4 years after tumor excision and

reconstruction. No flap revision was performed.

the extremity also spread via a sequential and orderly fash-ion involving an SLN within the lymphatic pathway asobserved in melanoma of skin. Many more cases, however,need to be evaluated before any definitive statements aboutthe progression of the metastasis within the involved lym-phatic basin can be made for SCC of the extremity. Addi-tionally, failure to control the disease locally should beevaluated separetely from failure to assess the involvednodal basin accurately. In the case reported by Stadelmannet al (6), although the involved nodal basin was evaluatedaccurately, inadequate local excisions resulted in recur-rences.

Because metastases from cutaneous SCC of the ex-tremity occur primarily in the regional lymph nodes, theSLN technique may be used for the identification ofpatients who might be candidates for complete inguinalnode dissection. These procedures can result in seriouscomplications such as skin flap necrosis, severe lymphed-ema, scrotal edema, and wound infection (9 –11). If theSLN is found to be free of cancer, no further surgicalintervention is recommended and close clinical observa-tion is instituted. If an SLN is found to have metastaticdisease, a formal nodal basin resection can be performed.Such an algorithm would allow the surgeon to moreaccurately evaluate the status of the regional lymphaticbasin with a minimally invasive surgical procedure andmay spare many patients the morbidity and risks associ-ated with an unnecessary complete regional lymphade-nectomy (10). In our case, the patient had deformityrelated to the burn contracture in both his ankles. He hadlimited use of his legs but he did ambulate. This ambu-lation might be compromised if he suffered sequelaefrom extensive lymph node dissection, such as lymph-edema. Therefore, the use of the SLN biopsy in thepatient with clinically negative inguinal and popliteallymph nodes was performed and the lack of metastaticdisease obviated inguinal lymph node dissection. Addi-tionally, with a reconstructive free flap, more meaningfulambulation durable limb preservation was obtained.

The frequency of regional metastasis of skin SCC is low.Therefore, regional lymphadenectomy is generally not rec-ommended for the patients with clinically node-negativedisease. However, several factors are associated with anincreased incidence of local recurrence and metastatic dis-ease; these include tumor size and thickness, histologicdifferentiation, site of the primary tumor, immune status ofthe host, carcinomas arising from scar tissue (Marjolin’sulcer), and neurotropic SCC (12). Lesions larger than 2 cmin diameter, for example, are 3 times more likely to metas-tasize than are smaller tumors. Also, lesions invading into

reticular dermis or underlying fat have markedly greater risk

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of metastasizing than do more superficial lesions (12). Forpatients with high-risk cutaneous SCC of the lower extrem-ity with increased risk of regional metastasis SLN biopsycould theoretically provide useful insight for evaluation ofinguinal node occult metastasis. Although gamma-probelocalization and biopsy of the primary node is a safe,minimally invasive technique that is accurate and easy toperform, careful attention to sampling and interpretation ofthe SLNs is mandatory. Such techniques may also showhistologically negative lymph nodes in persons at high riskof metastasis and thereby spare the long-term morbidity ofa full-groin dissection. Additionally, it must be clearlystated that this form of treatment remains investigational.Completed randomized, prospective clinical trials are nec-essary that prove any advantage in disease-free survival,5-year survival, or local recurrence rates by using selectivelymphadenectomy in clinically node-negative patients withcutaneous SCC of the lower extremity.

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3. Lund HZ. How often does squamous cell carcinoma of the skinmetastasize? Arch Dermatol 92:635–637, 1965.

4. Morton DL, Wen D-R., Wong JH, Economou JS, Cagle LA, StormFK. Technical details of intraoperative lymphatic mapping for earlystage melanoma. Arch Surg 127:392–399, 1992.

5. Pan D. Merkel cell carcinomas: five case reports using SLN Bx. PlastReconstr Surg 110:1259–1265, 2002.

6. Stadelmann WK, Lousiville KY, Javaheri S, Cruse CW, Reintgen DS,Tampa FL. The use of selective lymphadenectomy in squamous cellcarcinoma of the wrist: a case report. J Hand Surg 22A:726–731,1997.

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8. Reintgen DS, Cruse CW, Wells K, Berman C, Fenske N, Glass F. Theorderly progression of melanoma nodal metastases. Ann Surg 220:759–767, 1994.

9. Ravi R. Morbidity following groin dissection for penile carcinoma.Br J Urol 72:941–945, 1993.

10. Ross MI. How I do it. Lymphatic mapping and sentinel node biopsyfor early stage melanoma: how we do it at the M.D. Anderson CancerCenter. J Surg Oncol 66:273–276, 1997.

11. Beitsch P, Balch C. Operative morbidity and risk factor assessment inmelanoma patients undergoing inguinal lymph node dissection. Am JSurg 164:462–465discussion 465–466, 1992.

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