Sentinel Lymph Node Biopsy for Eyelid and Conjunctival Malignancy OTA

A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Oculoplastics and Orbit Panel

Suzanne K. Freitag, MD,¹ Vinay K. Aakalu, MD, MPH,² Jeremiah P. Tao, MD,³ Edward J. Wladis, MD,⁴ Jill A. Foster, MD,⁵ Rachel K. Sobel, MD,⁶ Michael T. Yen, MD⁷

Ophthalmology, December 2020, Vol 127, 1757-1765 © 2020 by the American Academy of Ophthalmology. Click here for free access to the OTA.

Purpose: To determine the efficacy and safety of the sentinel lymph node biopsy (SLNB) in the management of eyelid and conjunctival malignancy.

Methods: A literature search was performed in August 2019 and January 2020 for articles published in English in the PubMed and Cochrane Library databases. This search yielded 151 articles that were reviewed for relevancy, of which 27 were deemed to have met the inclusion criteria for this assessment. The data from these articles were abstracted and the articles were rated for strength of evidence by the panel methodologist. 

Results: All 27 studies were rated level III, and a total of 197 SLNBs were reported. Diagnoses included conjunctival and eyelid cutaneous melanoma (85 and 42 patients, respectively), sebaceous gland carcinoma (35 patients), squamous cell carcinoma (26 patients), Merkel cell carcinoma (6 patients), pigmented epithelioid melanocytoid tumor (1 patient), mucoepidermoid carcinoma (1 patient), and signet ring carcinoma (1 patient). Tracer was found in regional lymph nodes in 100% of patients in 21 of 27 articles and in 191 of 197 patients overall. The number of lymph nodes removed ranged from 1 to 16, with most ranging from 1 to 5. Tumor-positive lymph nodes were found in 33 of 197 patients (16.8%), prompting recommendations for adjuvant treatments. Survival data were reported for 16 of these patients, with follow-up periods ranging from 3 to 36 months (average, 12.7 months). Fourteen of 16 patients received adjuvant treatments. Nine were alive and well, 1 was alive with metastases, and 6 had died of metastatic disease (including 2 patients who declined additional treatment). False-negative SLNB results were reported in 5 articles involving 9 of 197 procedure (4.6%). Complications were documented in 7 of 27 articles and included transient facial nerve weakness, persistent blue dye staining of the conjunctiva, neck hematoma, and suture abscess.

Conclusions: Sentinel lymph node biopsy is a promising procedure in patients with eyelid and conjunctival malignancy, and it is useful in identifying sentinel lymph nodes. However, at present, insufficient evidence exists showing that SLNB improves patient outcomes and survival. Recognition of microscopic metastatic disease may prove beneficial in staging and guiding adjuvant therapy. 

¹Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts

²Illinois Eye and Ear Infirmary, University of Illinois College of Medicine at Chicago, Chicago, Illinois

³Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, Irvine, California

⁴Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical Center, Albany (Slingerlands), New York

⁵Ophthalmic Surgeons and Consultants of Ohio, Ohio State University, Columbus, Ohio

⁶Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee

⁷Cullen Eye Institute, Baylor College of Medicine, Houston, Texas