Preliminary study of the lymphatic drainage system of the nose and paranasal sinuses and its role in detection of sentinel metastatic nodes

Abstract

Our control group comprised 30 patients (20 females; age range 19-50 years) suffering from chronic otitis media who had an anatomically normal nose and a cNO neck on palpation. The pathological group comprised 6 patients (2 females; age range 40-85 years) suffering from sinonasal tumors: 3 SCC, 1 recurrent melanoma, 1 ameloblastoma and 1 inverted papilloma. All had a clinically staged cNO neck on palpation and CT. In the control group, lymphoscintigraphy was carried out by means of unilateral injection of radioactive gold into the head of the inferior turbinate. The tracer was identified using a gamma camera 3 and 6 h after the injection. In the pathological group the chosen tracer was technetium, which was administered 1 day prior to surgery by means of injections into the heads of the inferior and middle turbinates, into the nasal septum and into the retromaxillary gingival mucosa. The tracer was identified transcutaneously using a navigator probe in the gamma camera at 15 min, 30 min and 1 h post-injection. A mark was drawn on the skin corresponding to the hot spot of the SLN. The study was repeated 30 min before surgery. The neck incision was selected according to the location of the SLN. A hand-held gamma probe was used in the operating theatre to detect in situ the radioactivity of the surgical excisional nasal area and the cervical SLN. Once the SLN was excised its radioactivity was confirmed ex situ, taking into account that the activity counts were at least three times greater than background. Postoperatively, all SLNs were histopathologically examined and cytokeratin staining was carried out immunohistochemically using the monoclonal antibody cocktail AE1/AE3. Results. In the control group, intense activity at the injection tracer site and lower activity in the submandibular area (level I) were detected in 26.6% of cases. Nasal radioactivity persisted for 6 h post-injection and submandibular radioactivity increased, also reaching the area corresponding to neck node level II (70%). In two cases (6.6%), radioactivity was observed in the retropharyngeal nodes. In the pathological group, the SLN was found in the submandibular area (level I) in three cases, and in the ameloblastoma patient three SLNs were found at levels I-II. Three cases were false positives, and no metastases were detected using any of the histopathological procedures. The only one true positive corresponded to a female with an SCC of the maxillary infrastructure with invasion of the gingival mucosa. The histopathological code was 1 and a metastasis was detected on hematoxylin-eosin examination. In the other two cases no SLNs were detected.

Skull Base Inverted Papilloma: A Comprehensive Review

“…Dynamic MR imaging can differentiate accurately recurrent IP from postoperative changes [307]. Lymph nodes can also be assessed with MRI with similar size and peripheral characteristics as for CT. Involved nodes are heterogeneous on T2 weighting and enhance peripherally on contrast scans using fat suppression [300, 308]. Further advantages of MRI are that images can be obtained in multiple planes, there is no exposure to ionizing radiation, and there is no artefact in the presence of dental fillings.…”

“…The retropharyngeal nodes comprise the first echelon lymphatic drainage for sinus malignancies. Cervical lymph node are involved with T2 rather than T3 or T4 tumors of squamous cell histology [241, 308]. Other regional nodes that may be involved with lymphatic spread are the periparotid and level 1b nodes [257].…”

The Utility of Sentinel Node Biopsy for Sinonasal Melanoma

“…10 Fernandez et al performed a clinical evaluation of drainage patterns after injection of radiocolloid into the head of the inferior turbinate and demonstrated that the majority of the drainage was to level 1 and level 2 cervical lymph nodes and less commonly to the retropharynx. 5 In cases of sinonasal melanoma, though in general more anterior lesions will drain into the submandibular and jugulodigastric nodes and the more posterior lesions will drain into the retropharyngeal area, these neoplasms are often large and span multiple subsites, putting several drainage pathways at risk for regional metastasis. Though the rate of the regional spread at presentation is reported to be 5 to 20%, approximately 20 to 40% of patients will have a regional recurrence that complicates their disease course.…”

“…4 Some authors have questioned whether elective ipsilateral nodal dissection is warranted given the high rate of cervical metastasis at some point in the disease course; however, the lymph node basins of the sinonasal cavity are variable and posterior lesions would be expected to travel to the retropharyngeal nodes, making decisions on the extent of lymph node dissection difficult. 3,5,6 Sentinel node biopsy offers an opportunity to perform guided lymph node biopsy for at-risk lymph node basins with minimal morbidity. 7,8 We hypothesize that sentinel node biopsy would offer a minimally invasive approach to staging and treatment of the cervical nodal basin in sinonasal melanoma and report our initial experience of two patients with positive sentinel node biopsies.…”

Ameloblastoma of the Sinonasal Tract: Report of a Case with Clinicopathologic Considerations

“…As far as histogenetic considerations about sinonasal AM origin is concerned, some studies have indicated a close relation of the embryological derivation of the sinonasal tract and odontogenic apparatus [1, 4, 5, 13–16, 22]. The sinonasal tract and oral cavity communicate, in fact, until closure of the palatine shelves.…”