This is an update of our experience with sentinel lymph node (SLN) biopsy in eyelid tumors. Subsequent to our previously published paper, SLN biopsy has been performed in 21 patients with malignant eyelid tumors (ethical clearance ref. no. IESC/T-91/2010; Institutional Ethics Committee, All India Institute of Medical Sciences, New Delhi, India). Thus, to date we have performed SLN biopsy in 37 patients with malignant eyelid tumors (squamous cell carcinoma: 13; sebaceous cell carcinoma: 17; melanoma: 7). Hybrid single-photon emission computed tomography/computed tomography (SPECT/CT) successfully localized the SLN in 27 of 30 patients (90%). The commonest site of SLN localization was preauricular (84%), followed by submandibular (16%). Using combination (dual dye) technique, SLN could be successfully identified in 32 of 34 patients (94%). Average number of lymph nodes harvested per patient remained the same (ie, 2, range 0–4). Earlier we reported 1 patient with recurrent conjunctival melanoma in whom SPECT/CT failed to localize SLN but in whom SLN was detected a few hours later with gamma probe, probably because of delayed arrival of dye in SLN through partly damaged lymphatics. During extended study we reported 2 new patients (Patient 1: sebaceous cell carcinoma; Patient 2: conjunctival melanoma) in whom no SLN was detected on SPECT/CT and gamma probe. In Patient 1 no biopsy was performed, while in Patient 2 blue dye was injected and a preauricular incision was made. No blue node was found and a preauricular lymph node was sent for histopathology examination, which was found free of tumor. Patient 2 was operated earlier for conjunctival melanoma and the failure to detect SLN could be explained by the complete transaction of lymphatic drainage of conjunctiva during previous surgery. In Patient 1 there was no history of excision of the tumor, and the reason for failure could be lacunae in injection technique. Over a median follow-up duration of 28 months (range, 2–55 months) no local or regional recurrence has been detected. During the whole study there was a single reported false-negative SLN (1/37 patients; 2.70%) in a conjunctival melanoma patient who died of systemic metastasis at 16 months follow-up. No new false-negative result has been found and this reflects increasing technical experience with the procedure. Another death reported is of a conjunctival melanoma patient who died at 6 months follow-up with systemic metastasis. On review of histopathology slides of this patient, no micrometastasis in SLN has been detected. Thus in our study, death rate as well as the systemic metastasis rate in conjunctival melanoma is 28.57% (2/7 patients) over 2 years of follow-up. This figure is similar to what has been reported in literature. The 2 SLN-positive patients (2/37 patients; 5.40%) are alive and free of disease at their last follow-up (19.5 months, 51 months).

We conclude that SLN biopsy accurately predicts regional nodal status in eyelid malignancy and should be routinely recommended for all patients with clinically negative nodal status.