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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

IMAGING IN MELANOMA –local guidelines

Dr Andrea J Howes

Consultant Radiologist

St Helens and Knowsley NHS Trust

local imaging guidelines how to image
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 image1
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
Stage 1
  • There is no evidence for any benefit of imaging in stage 1 disease
stage 2
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
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
Stage 4
  • CT of chest, abdomen and pelvis
  • Further investigations as clinically indicated
  • No evidence for imaging the brain unless symptomatic
pet ct
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
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

SENTINEL LYMPH NODE BIOPSY IN MELANOMA – THE WHISTON EXPERIENCE

Dr Andrea J Howes

Consultant Radiologist

St Helens and Knowsley NHS Trust

consultant radiologist experience
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
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 requirements1
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
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 involve1
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
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Melanoma site

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Melanoma site

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spect ct
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
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)
progress
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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