Imaging in melanoma local guidelines
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IMAGING IN MELANOMA – local guidelines. Dr Andrea J Howes Consultant Radiologist St Helens and Knowsley NHS Trust. Local Imaging Guidelines – how to image?. Options include CXR, ultrasound, CT, MR, and PET CT, as well as sentinel node mapping and biopsy

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IMAGING IN MELANOMA – local guidelines

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IMAGING IN MELANOMA –local guidelines

Dr Andrea J Howes

Consultant Radiologist

St Helens and Knowsley NHS Trust


Local Imaging Guidelines – how to image?

  • Options include CXR, ultrasound, CT, MR, and PET CT, as well as sentinel node mapping and biopsy

  • There are advantages and disadvantages for each


Local Imaging Guidelines – how to image?

  • Imaging should be performed after histological examination of primary and clinical assessment

  • This avoids unnecessary imaging of stage 1 patients

  • Within any clinical stage, specific symptoms or signs suggestive of metastases should be imaged accordingly


Stage 1

  • There is no evidence for any benefit of imaging in stage 1 disease


Stage 2

  • SLNB is performed locally for further staging

  • This is expensive and time consuming so CXR and US should be performed prior to this (although no evidence for imaging in stage 2A)

  • CT results in large numbers of false positives with resulting anxiety, re-scan and high radiation burden


Stage 3

  • Positive SLNB or clinical adenopathy

  • CT of chest / abdomen for nodes in neck or axilla and abdomen / pelvis for groin nodes

  • Yield low if nodes not palpable (0.5 – 3.7%)

  • Yield higher if palpable nodes (4 – 16%)

  • MR of neck nodes may be helpful

  • False positives are still a significant problem


Stage 4

  • CT of chest, abdomen and pelvis

  • Further investigations as clinically indicated

  • No evidence for imaging the brain unless symptomatic


PET CT

  • Indications for PET CT are very specific nationally

  • Locally, the only melanoma indication is where metastectomy is being considered eg: in a patient with a pulmonary nodule, to establish whether it is a metastasis and to look for evidence of other disease not seen at CT


REFERENCE

“Role of Imaging Investigations in the Staging of Primary Cutaneous Melanoma – Recommended Guidelines for MCCN with Summary of Available Evidence.”

Dr J C Herbert October 2009


SENTINEL LYMPH NODE BIOPSY IN MELANOMA – THE WHISTON EXPERIENCE

Dr Andrea J Howes

Consultant Radiologist

St Helens and Knowsley NHS Trust


CONSULTANT RADIOLOGIST EXPERIENCE

  • Whiston was one of the first centres in the country to perform SLNB

  • Dr J Herbert started SLN imaging in November 1999

  • Dr A Howesstarted SLN imaging in 2004

  • From commencing in November 1999 to end of April 2010 we had performed 564 procedures


NUCLEAR MEDICINE DEPARTMENT REQUIREMENTS

  • Large amount of legislation!

  • The Radiologist has to have a licence issued by the Health Minister (ARSAC licence) to use radioactive isotopes – there are specific training requirements

  • The licence is site specific

  • Another doctor may work under a colleagues certificate if it is only a short-term temporary absence, provided you are working under the certificate holder's written directions. 

  • The licence holder is responsible for the operating surgeons involvement with the isotope


NUCLEAR MEDICINE DEPARTMENT REQUIREMENTS

  • The department also has to be appropriately licensed (including the HSE) and needs access to a radiopharmacy (with appropriate transport licensing if required)

  • Single or dual headed gamma camera

  • SPECT CT capability may be of benefit

  • Appropriately trained radiographers / nuclear medicine technicians


WHAT DOES IT INVOLVE?

  • Time consuming!

  • Technitium 99m (Tc99m) labelled colloid

  • Injected intradermally around primary excision site

  • Dynamic images obtained allow visualisation of channels and can be useful to resolve problems such as kinks in channels (20 minutes, 60 images each – AP and lateral)


WHAT DOES IT INVOLVE?

  • Static images are obtained – usually AP and lateral (5 minutes each)

  • These images are used for marking with a Cobalt-57 tipped “pen”

  • Static oblique images (further 5 minutes) obtained to confirm position and depth

  • Position checked with gamma probe


Melanoma site

SN


Melanoma site

SN

2nd


SN

Melanoma site

SN

SN


SN

Melanoma site

SN


SPECT CT

  • A new dual headed camera with SPECT CT (Single Photon Emission Computed Tomography CT) was installed in 2005

  • SPECT CT provides SPECT images, low dose CT for anatomical localisation and fused images

  • This adds considerably to the time taken and the radiation dose, but has apparently proven invaluable in terms of surgery


OUR USE OF SPECT CT

  • Initially for localisation in head and neck melanomas to give additional information

  • Localisation where node is obscured by injection site in one plane

  • Localisation where 2 nodes are apparently close together

  • Position in large patients (eg: above or below inguinal ligament)

  • Localisation where position seems abnormal (eg: nodes found close to scapula rather than in axilla)


NUMBERS


SPECT CT NUMBERS


SPECT CT BY AREA


PROGRESS

  • Increasing numbers mean a Consultant may not always be immediately available in the department

  • Consequently 3 radionuclide radiographers (M. Caffrey, J. Winfield, J. Kerr) have trained to mark straightforward nodes

  • Consultant always involved for head and neck and other nodes needing SPECT CT as well as any others which seem technically difficult


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