Makoto Mihara1, Hisako Hara2. 1. Department of Vascular surgery, Saiseikai Kawaguchi General Hospital, Saitama, Japan. 2. Department of Vascular surgery, Saiseikai Kawaguchi General Hospital, Saitama, Japan. ; Department of Plastic and Reconstructive Surgery, The university of Tokyo, Tokyo, Japan.
Dear Editor-in-Chief Yong-Ha Kim,We have read the paper of Nicoli et al. [1] on potential use of transferred lymph nodes as metastasis detectors. It was an interesting case report stating that vascularized lymph nodes that were transplanted after tumor resection could be detectors of tumor metastasis. It also reported the postoperative findings of positron emission tomography-computed tomography to evaluate whether there was a metastasis or not. Although we commend them for their work, we would like to point out that we have already reported the same concept as "sentinel lymph network" reconstruction [2]. In this case report, we introduced a case of epihypopharyngeal pyriform sinus cancer, for which epi- and mesopharyngeal resection and simultaneous reconstruction were performed. A left superficial circumflex iliac artery perforator (SCIP) flap was used for reconstruction, and the flap contained two lymph nodes. In the pathological examination of the transferred SCIP flap, we found that a greater number of lymphatic vessels were present in the SCIP flap than the anterolateral thigh flap that was taken from another patient (lymphatic vessel endothelial hyaluronan receptor-1 staining). In our case, like Nicoli's cases, no evidence of metastasis has been detected for 1 year postoperatively.Nicoli's paper also presented postoperative indocyanine green (ICG) lymphography findings of one case, in which distally injected ICG flowed into the transferred flap. This showed the lymphatic connection of the recipient site and transferred flap, which should have a profound meaning in terms of the concept of the "metastasis detector" of "sentinel lymph node reconstruction."As we stated in our paper, reconstruction of the sentinel lymph node system by lymph node transfer may allow establishment of a system for metastasis screening in cancer recurrence. We hope that this concept will be applied to many other patients in the future and that the technique will be beneficial to them.