Diagnosis and management of melanoma with regional lymph node metastases: a population-based study in France

BACKGROUND

Stage III melanoma represents a borderline situation regarding the potential curability of this potentially aggressive cancer and consequently, regional lymph node metastases (RLNM) are a major challenge for melanoma management.

OBJECTIVE

To describe the management of melanoma with RLNM as practised in France in 2008 and compare results with previous data from 2004, considering that new French recommendations were published in 2005.

METHODS

Retrospective population-based study in five regions of France totalling 8.3 million inhabitants, targeting all incident cases of RLNM diagnosed in 2008. Questionnaires were mailed to physicians to identify cases and collect data, with verification by cancer registries for cases diagnosed concomitantly with the primary tumour using sentinel lymph node biopsies (SLNB).

RESULTS

Data were collected for 101 patients in 2008, and compared to 89 cases treated in 2004. Palpation by a dermatologist was the most common circumstance of diagnosis of RLNM in 2008 (36%), followed by SLNB (29%), self-palpation by the patient (16%) and lymph node ultrasonography (6%), without significant modification from 2004. After lymphadenectomy an adjuvant therapy was proposed in 62% of cases, mainly consisting in high-dose interferon (HD-IFN) (80%). Overall, HD-IFN was proposed in 49% of cases, but effectively started in only 40% of cases after being proposed, and prematurely withdrawn in 28%, showing major changes as compared with 2004 (33%, 77% and 67%, respectively, P < 0.05). Adjuvant chemotherapy was not proposed to any patients in 2008, compared to 29% in 2004. Surveillance procedures included medical imaging less often in 2008 (76%) than in 2004 (92%) (P = 0.004), but more often included FDG-PET (23% vs. 12%, P = 0.09).

CONCLUSION

Overall, actual practice was in accordance with French recommendations. The main developments from 2004 to 2008 were the disappearance of adjuvant chemotherapies and a more accurate selection of patients for adjuvant interferon.

Adjuvant prophylactic regional radiotherapy versus observation in stage I Merkel cell carcinoma: a multicentric prospective randomized study

BACKGROUND

The treatment of stage I Merkel cell carcinoma (MCC) usually includes wide local excision (WLE) combined with irradiation of the tumor bed (ITB). No randomized study has ever been conducted in MCC. The purpose of this study was to assess the efficacy and safety of prophylactic adjuvant radiotherapy on the regional nodes.

PATIENTS AND METHODS

In this randomized open controlled study, patients for a stage I MCC treated by WLE and ITB were randomly assigned to regional adjuvant radiotherapy versus observation. Overall survival (OS) and probability of regional recurrence (PRR) were primary end points. Progression-free survival (PFS) and tolerance of irradiation were secondary end points.

RESULTS

Eighty-three patients were included before premature interruption of the trial, due to a drop in the recruitment mainly due to the introduction of the sentinel node dissection in the management of MCC. No significant improvement in OS (P = 0.989) or PFS (P = 0.4) could be demonstrated after regional irradiation, which, however, significantly reduced the PRR (P = 0.007) with 16.7% regional recurrence rate in the observation arm versus 0% in the treatment arm. The treatment was well tolerated.

CONCLUSION

The adjuvant regional irradiation significantly decreased the PRR in MCC, but benefit in survival could not be demonstrated.

[Sentinel node procedure in head and neck cutaneous melanoma]

INTRODUCTION

Sentinel lymph node (SLN) biopsy is frequently discussed in the management of cutaneous melanoma, especially in head and neck localizations where SLN biopsy is much more demanding. The benefits of SLN protocol are not proved yet. The aim of our study was to present our experience of SLN biopsy in head and neck cutaneous melanoma.

PATIENTS AND METHODS

This retrospective study included all patients managed for head and neck malignant melanoma from 2002 to 2006. We reviewed the technique, implementation and difficulties of the procedure, postoperative outcome, and complications.

RESULTS

Nineteen patients were included. An average of 2.2 lymph nodes were localized per patient using lymphoscintigraphy. Biopsy was impossible for one patient because the deep spinal node was not found. An average of 1.2 nodes was biopsied per patient. One patient presented with micrometastases. Another presented with lymphorrhea.

DISCUSSION

Sentinel node biopsy is widely performed in the management of cutaneous melanoma but remains an option for these indications in the last update of the French Society of Dermatology. SLN biopsy is difficult to implement because of the complexity of head and neck lymphatic system.

Photosensitivity associated with selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are a widely prescribed group of antidepressants. We report three cases of photosensitivity induced by fluvoxamine and paroxetine. These photoallergic reactions suggest cross-reactivity between different molecules. Methylation metabolism could explain common photosensitization. Although these drugs are widely prescribed, such photosensitization is rare. Nevertheless, we consider that clinicians and patients should be aware of the risk of photosensitization and these drugs should be stopped before phototherapy or prolonged sun exposure.

[Is withdrawal of antiplatelet therapy necessary prior to skin cancer surgery?]

AIM

The aim of this study was to assess the value of discontinuing antiplatelet treatment prior to surgery for skin cancer with loss of skin of up to 10 cm in diameter. The study hypothesis postulated equivalence between discontinuation of antiplatelet therapy and continuation of these drugs during the perioperative period with regard to risk of cutaneous complications.

PATIENTS AND METHODS

This was a prospective, randomised study comparing two groups of patients on long-term antiplatelet treatment scheduled for surgery for skin carcinoma. In the first group, patients underwent surgery without change to their antiplatelet therapy while in the second, antiplatelet treatment was discontinued and substituted with either flurbiprofen or isocoagulant fractionated heparin or calcium heparin. Sixty patients took part in the study. Statistical analysis using ANOVA and Mann-Whitney non-parametric tests was performed to compare the following variables: age, sex, number of pre- and post-operative consultations, complications (haemorrhage, haematoma, separation and infection) and quality of wound healing.

RESULTS

No statistically significant difference was seen between the two groups regarding either complications or quality of wound healing.

CONCLUSION

There appear to be no rational grounds for discontinuing antiplatelet therapy in advance of skin cancer surgery involving loss of skin of up to 10 cm in diameter.

La pratique des curages ganglionnaires est-elle harmonieuse? Analyse rétrospective de 330 cas

AIM

The aim of our study was to make evident the huge variability in lymph node dissection practice.

MATERIAL AND METHODS

Therefore a retrospective study was conducted on 330 patients assessed for cervical, axillary or groin dissections. In each case the authors collected the primary diagnosis and clinical stage indicating lymph node clearance, identity of the surgeon and the pathologist, surgical technique including skin incision and landmarks of tissue removal, size of the clearance, and number of lymph nodes removed. Correlations between diagnosis, surgeon's or pathologist's identity, size of the clearance and number of nodes were analyzed using non-parametric tests.

RESULTS

Standardized procedures as axillary dissections occurred few differences between surgeons. In groin or cervical dissections statistical differences were made evident with great technical variability. There was a positive correlation between size of the piece of lymphadenectomy and number of lymph nodes removed.

CONCLUSION

Standardized procedures as axillary dissections provide few variations. Cervical and especially groin dissections should be harmonized, published and taught harmoniously in schools of surgery. So the expression "regional lymph node clearance" would mean.

[Evaluation of a method to reduce the number of sentinel nodes removed in melanoma patients: prospective study]

INTRODUCTION

Since 1992, sentinel node (SLN) biopsy was generally applied to melanoma for carcinologic staging. Literature points out an increase of nodes removed for each procedure. It means to a high cost for this procedure and it wanders from the defining concept of SLN. The aim of our study was to evaluate whether, we can minimize number of SLN removed, without influencing the reliability of carcinologic staging.

MATERIAL AND METHODS

We conducted a prospective study about 50 patients with stage one melanoma. For each patient, the SLN was identified with hand-held gamma probe technique. We removed only the hottest and all nodes greater than 70% of the hottest. We analysed the characteristics of melanoma, the success rate of this procedure, how many nodes have been removed and how many have had micro-metastases. This result was compared to two main studies with chi(2) test.

RESULTS

The success rate of this technique was 100%. We dissected 1,3 SLN for each patient, with 22% positive SLN. Statistical analyse pointed out a better selectivity of our study, rate of pathological positivity and recurrence was alike.

DISCUSSION

Our technique decreasing number of removed SLN is reliable. A minimal number of nodes doesn't distort sensitivity of carcinologic staging, and reduce cost of the procedure.

Reducing the number of sentinel nodes removed in melanoma patients: a prospective study

CONTEXT

Since 1992, sentinel lymph node (SLN) biopsy was generally applied to melanoma for tumor staging. As the literature points out, an increasing number of nodes are being removed for each procedure, driving up the cost for this procedure and wandering away from the defining concept of sentinel lymph node.

AIMS

The objective of the current study was to show that the number of sentinel lymph node s removed can be minimized without influencing the reliability of tumor staging.

MATERIALS AND METHODS

We conducted a single-arm prospective study in patients with stage I melanoma. For each patient, the sentinel lymph node was identified using the hand-held gamma probe technique. We removed only the hottest nodes as well as the nodes with radioactivity greater than 70% compared to the hottest. We analyzed the characteristics of each melanoma, the success rate of this procedure, how many nodes were removed and how many had micro metastases.

STATISTICAL ANALYSIS

The results were compared to those of the literature, previously published Porter study using the chi-square test.

RESULTS

We included 90 patients. The success rate of this technique was 100%. We dissected 1.3 sentinel lymph nodes for each patient, with 22% positive SLN. Statistical analyses point out a better selectivity of our study for a similar rate of pathological positivity and recurrence compared to the literature.

CONCLUSIONS

Our technique for decreasing the number of sentinel lymph nodes removed is reliable. The removal of minimal number of nodes doesn't compromise the sensitivity of tumor staging, while it does reduce the cost of the procedure.

The prognostic impact of the extent of lymph node dissection in patients with stage III melanoma

AIMS

To analyse disease-free and overall survival in 67 melanoma patients who underwent dissection for clinically apparent regional lymph node metastases, taking into account the total number of excised lymph nodes.

METHODS

After a median follow-up time of 16 months, 47 recurrences were observed and 43 patients died. The median disease-free and overall survival intervals were 14 and 24 months respectively.

RESULTS

Multivariate analyses revealed that the number of excised lymph nodes had a significant impact on overall survival (P=0.036) but not on disease-free survival (P=0.97). Extranodal growth was the only statistically significant prognostic factor both for disease-free (P=0.005) and overall (P=0.038) survival. Age, nodal basin, primary tumor ulceration, tumor thickness and number of positive lymph nodes were not significant prognostic factors.

CONCLUSIONS

Our results suggest that the total number of lymph nodes excised in the dissection has impact on overall survival of stage III melanoma patients and should be considered in clinical assays.

Clinical variants of the preprotuberant stage of dermatofibrosarcoma protuberans

BACKGROUND

Some cases of dermatofibrosarcoma protuberans (DFSP) do not protrude above the skin.

OBJECTIVES

To assess the prevalence of these DFSPs and further to describe their presentation and course.

METHODS

One hundred and forty-three patients were retrospectively collected. They were asked to complete a standardized questionnaire indicating the history and appearance of the DFSP from the first skin changes identified to the time of diagnosis.

RESULTS

Eighty-one DFSPs were described as protuberant ab initio, and 62 as initially nonprotuberant (npDFSP). The latter remained at this stage for a mean period of 7.6 years. Twenty-nine per cent of npDFSPs were 'morphoea-like', 19% were 'atrophoderma-like' and 42% were 'angioma-like'. Age at diagnosis was similar for both initial presentations. npDFSPs were most often misdiagnosed by physicians.

CONCLUSIONS

Nearly half the patients first identified their early DFSP-related skin changes as patches. Both this frequency and the long duration at this preprotuberant stage should prompt dermatologists to consider the diagnosis of DFSP earlier, in order to make surgical treatment easier.

La recherche du ganglion sentinelle dans le mélanome malin cutané de bas stade est-elle réellement peu invasive ?

AIM

The aim of this study was to analyze outcome in patients enrolled in sentinel node biopsy procedure in early-staged cutaneous melanoma.

MATERIAL AND METHODS

Therefore a prospective study was conducted enrolling patients presenting with early-staged cutaneous melanoma. Our study focused on age and sex, duration from diagnosis to treatment, duration of hospitalization, dressing care and work inability in current follows. Duration from scintigraphy to surgery was analyzed and compared to sensibility of the procedure. What is more we observed rate and kind of complications and economical consequences, increasing duration of dressing care and work inability. The authors aimed at evaluating costs of SLN procedure including hospitalization, lymphoscintigraphy, general anaesthesia, costs of dressings, inability and overcosts of complications.

RESULTS

Forty-five patients were enrolled in our study (sex-ratio 1/2) mean aged 60 years old. Duration from diagnosis to treatment was mean 36 days. Sensibility of the procedure was excellent in trunk and limbs cases, lower in head and neck. In current cases patients were mean hospitalized three days, underwent 20 days of dressings and work inability depended on further interferon treatment. Complications occurred in 25% as seroma or local infections requiring antibiotherapy. Duration to healing was then 45 days increasing inability. Global costs of SLN procedure were significantly higher than previous wait and watch policy.

CONCLUSION

SLN biopsy is an expensive and invasive procedure with a high rate of complications. It defers melanoma treatment, only way to gain survival.