ORIGINAL INVESTIGATION Sentinel Lymph Node Biopsy in Patients With Conjunctival and Eyelid Cancers: Experience in 17 Patients Toufic J. Maalouf, M.D.*, Gilles Dolivet, M.D.†, Karine S. Angioi, M.D., Ph.D.*, Agnes Leroux, M.D.‡, Pascal Genin, M.D.‡, and Jean-Luc George, M.D.* *Department of Oculoplastic Surgery, Ophtalmologie B, CHU Nancy-Brabois; † Department of Head and Neck Surgery, Centre Alexis Vautrin; and ‡Department of Histopathology, Centre Alexis Vautrin, Nancy, France Purpose: To assess lymph node invasion through the use of sentinel lymph node biopsy (SLNB) in conjunctival and eyelid tumor patients and ascertain the impact of this technique in therapeutic management recommended by the multidisci- plinary consensus committee. Methods: A single center prospective nonrandomized clin- ical study was conducted between January 2008 and January 2010. Seventeen patients were included: 4 (2 conjunctiva and 2 eyelid) melanomas, 4 eyelid Merkel cell tumors, 8 (2 conjunctiva, 2 eyelid, 2 eyelid and conjunctiva, 2 cornea and conjunctiva) squamous cell tumors, and 1 eyelid meibomian carcinoma. Pre- operative lymphoscintigraphy was done the day before surgery to label lymph node(s). The surgical biopsy was then performed along with an extemporaneous pathological examination followed by secondary complete lymph node dissection only in instances of positive histology. Results: In all cases, one or more sentinel lymph nodes were identified (3–13). Two biopsies (1 Merkel cell carcinoma and 1 squamous cell carcinoma) revealed neoplastic invasion and led to complete cervical node dissection. Adjunct regional treatment was indicated for 1 melanoma, for 4 Merkel cell tumors, and for 2 squamous cell carcinomas. One false negative result was noted in the group of squamous cell carcinomas after 6 months, and it was treated. No relapse or death was observed for the other 16 patients. The mean overall follow-up was 18.2 months. Conclusion: As in previous studies, we found that SLNB for eyelid and conjunctival tumors is safe and effective in identi- fying microscopically positive SLNs. This procedure may also revive interest in the study of cervicofacial lymphatic drainage. Our current investigation is to be expanded and extended to other medical teams. (Ophthal Plast Reconstr Surg 2012;28:30–34) T he sentinel lymph node biopsy (SLNB) procedure is based on the concept that a tumor preferentially drains to a first relay lymph node, which acts as a filter. Radiolabeling of this/these node(s) makes it possible to obtain a specific biopsy with less morbidity than with extensive lymphadenectomy. SLNB was introduced by Morton et al. in the early 1990s for the intraoperative lymphatic mapping of cutaneous melano- mas. 1 This method became a recommended procedure for various tumors in diverse localizations. Esmaeli et al. 3–6 sub- sequently adopted this technique for orbital tumors and pub- lished major findings regarding various tumors, including melanomas. Although unquestionably promising, the SLNB proce- dure has only been adopted by very few French ophthalmology teams. Its clinical benefits have been questioned. 7 We became interested in this treatment modality for the management of patients with eyelid and ocular surface cancers and evaluated possible changes in our management strategies. We first analyzed the feasibility of this procedure in 8 patients. 8 The present report features our results with the SLNB proce- dure in 17 patients. Our aim was to analyze the lymph node invasion accord- ing to different tumor types and locations. We intended to investigate the impact of the results obtained with SLNB relative to other factors (such as Breslow thickness, size of the tumor, or presence of ulcerations) on the therapeutic indications recommended by specific multidisciplinary consensus meet- ings. We also examined the presence and outcome of false negatives and possible changes in SLNB indications. PATIENTS AND METHODS This single prospective study was conducted between January 2008 and January 2010. Seventeen patients were included. Tumor types were as follows: 4 melanomas, 4 Merkel cell tumors, 8 squamous cell carcinomas, and 1 meibomian carcinoma. All patients were recorded as N0 using traditional imaging techniques (CT scan of the regional lymph nodes). Lymphoscintigraphy was performed under local anes- thesia the day before surgery, after the perilesional injection of a technetium Tc99m-labeled colloid. Images were acquired with a gamma camera, and the first relay node was than noted. Surgery was performed the next day with a double surgical team: an ophthalmologic surgeon for the ocular portion and an ear, nose, and throat surgeon for the lymph node biopsy. Lymph nodes were sectioned at 2-mm intervals using conventional histopathology and examined. If negative, immu- nohistochemistry was performed with hematoxylin and eosin stain, PS 100, HMB45, and Melan A for melanoma tumors, and for carcinomas, new sections at 150-nm intervals were made using histopathology and immunohistochemistry with cytokeratin AE1/AE3. A complete cervi- cal lymphadenectomy was subsequently considered for cases with positive histology (micrometastasis). The postoperative course of ac- tion was discussed at the multidisciplinary consensus meeting. Data collected for each patient (and summarized in the attached Table 1) were as follows: 1. Age, sex, and tumor histologic type. 2. Tumor location (superolateral, superomedial, internal angle, in- feromedial, inferolateral, external angle), size, thickness, and presence of ulceration. Accepted for publication July 7, 2011. The authors have no financial or conflict of interest to disclose. Author correspondence and reprint requests to Dr T. Maalouf, M.D., CHU Nancy-Brabois, Ophtalmologie B, Rue du Morvan, 54510 Vandoeu- vre les Nancy, France. E-mail: t.maalouf@chu-nancy.fr DOI: 10.1097/IOP.0b013e31822fb44b Ophthal Plast Reconstr Surg, Vol. 28, No. 1, 2012 30