Sentinel lymph node biopsy followed by lymph node dissection for localised primary cutaneous melanoma

Exploring the causal relationship between interleukin-6 or C reactive protein and malignant melanoma using a two-sample Mendelian randomization approach

The goal was to explore the effect of interleukin-6 (IL6) and C reactive protein (CRP) on malignant melanoma (MM) using two-sample Mendelian randomization.

Methods

Data for this study were obtained from the IEU Open GWAS project website for genome-wide association study data (GWAS) on interleukin-6, C reactive protein levels and malignant melanoma. Inverse variance weighted (IVW) method was mainly used and supplemented with MR-Egger regression and weighted median. Finally, horizontal multivariate validity and heterogeneity tests were performed to assess the stability and reliability of the results.

Results

The results of univariate two-sample MR analyses showed no significant effect of CRP on MM: inverse variance weighting method (OR=0.999, 95% CI: 0.998-1.001, P=0.343), MR-Egger regression (OR= 1.000, 95% CI: 0.998-1.001, P= 0.180), and weighted median method (OR= 0.999, 95% CI: 0.997 to 1.000, P= 0.583), and weighted model (OR= 0.999, 95% CI: 0.998 to 1.001, P= 0.328). Also,IL-6 had no significant effect on MM: inverse variance weighting method (OR= 1.001, 95% CI: 0.999 to 1.002, P=0.461), MR-Egger regression (OR= 1.000, 95% CI: 0.997 to 1.004, P= 0.910), weighted median method (OR= 1.000, 95% CI: 0.998 to 1.002, P= 0.749), and weighted mode (OR= 1.000, 95% CI: 0.998 to 1.002, P= 0.820).

Conclusion

There was no causal relationship between C-reactive protein and IL-6 on the risk of malignant melanoma.

Population-Based Validation of the MIA and MSKCC Tools for Predicting Sentinel Lymph Node Status

Importance

Patients with melanoma are selected for sentinel lymph node biopsy (SLNB) based on their risk of a positive SLN. To improve selection, the Memorial Sloan Kettering Cancer Center (MSKCC) and Melanoma Institute Australia (MIA) developed predictive models, but the utility of these models remains to be tested.

Objective

To determine the clinical utility of the MIA and MSKCC models.

Design, Setting, and Participants

This was a population-based comparative effectiveness research study including 10 089 consecutive patients with cutaneous melanoma undergoing SLNB from the Swedish Melanoma Registry from January 2007 to December 2021. Data were analyzed from May to August 2023.

Main Outcomes and Measures,

The predicted probability of SLN positivity was calculated using the MSKCC model and a limited MIA model (using mitotic rate as absent/present instead of count/mm2 and excluding the optional variable lymphovascular invasion) for each patient. The operating characteristics of the models were assessed and compared. The clinical utility of each model was assessed using decision curve analysis and compared with a strategy of performing SLNB on all patients.

Results

Among 10 089 included patients, the median (IQR) age was 64.0 (52.0-73.0) years, and 5340 (52.9%) were male. The median Breslow thickness was 1.8 mm, and 1802 patients (17.9%) had a positive SLN. Both models were well calibrated across the full range of predicted probabilities and had similar external area under the receiver operating characteristic curves (AUC; MSKCC: 70.8%; 95% CI, 69.5-72.1 and limited MIA: 69.7%; 95% CI, 68.4-71.1). At a risk threshold of 5%, decision curve analysis indicated no added net benefit for either model compared to performing SLNB for all patients. At risk thresholds of 10% or higher, both models added net benefit compared to SLNB for all patients. The greatest benefit was observed in patients with T2 melanomas using a threshold of 10%; in that setting, the use of the nomograms led to a net reduction of 8 avoidable SLNBs per 100 patients for the MSKCC nomogram and 7 per 100 patients for the limited MIA nomogram compared to a strategy of SLNB for all.

Conclusions and Relevance

This study confirmed the statistical performance of both the MSKCC and limited MIA models in a large, nationally representative data set. However, decision curve analysis demonstrated that using the models only improved selection for SLNB compared to biopsy in all patients when a risk threshold of at least 7% was used, with the greatest benefit seen for T2 melanomas at a threshold of 10%. Care should be taken when using these nomograms to guide selection for SLNB at the lowest thresholds.

The Reporting and Methodological Quality of Systematic Reviews Underpinning Clinical Practice Guidelines Focused on the Management of Cutaneous Melanoma: Cross-Sectional Analysis

BACKGROUND

Clinical practice guidelines (CPGs) inform evidence-based decision-making in the clinical setting; however, systematic reviews (SRs) that inform these CPGs may vary in terms of reporting and methodological quality, which affects confidence in summary effect estimates.

OBJECTIVE

Our objective was to appraise the methodological and reporting quality of the SRs used in CPGs for cutaneous melanoma and evaluate differences in these outcomes between Cochrane and non-Cochrane reviews.

METHODS

We conducted a cross-sectional analysis by searching PubMed for cutaneous melanoma guidelines published between January 1, 2015, and May 21, 2021. Next, we extracted SRs composing these guidelines and appraised their reporting and methodological rigor using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) checklists. Lastly, we compared these outcomes between Cochrane and non-Cochrane SRs. All screening and data extraction occurred in a masked, duplicate fashion.

RESULTS

Of the SRs appraised, the mean completion rate was 66.5% (SD 12.29%) for the PRISMA checklist and 44.5% (SD 21.05%) for AMSTAR. The majority of SRs (19/50, 53%) were of critically low methodological quality, with no SRs being appraised as high quality. There was a statistically significant association (P<.001) between AMSTAR and PRISMA checklists. Cochrane SRs had higher PRISMA mean completion rates and higher methodological quality than non-Cochrane SRs.

CONCLUSIONS

SRs supporting CPGs focused on the management of cutaneous melanoma vary in reporting and methodological quality, with the majority of SRs being of low quality. Increasing adherence to PRISMA and AMSTAR checklists will likely increase the quality of SRs, thereby increasing the level of evidence supporting cutaneous melanoma CPGs.

Quality of Life Predictors in Patients With Melanoma: A Machine Learning Approach

Health related quality of life (HRQoL) is an important recognized health outcome for cancer treatments, but also disease course with slower recovery and increased morbidity. These issues are of implication in melanoma, which maintains a risk of disease progression for many years after diagnosis. This study aimed to explore and weigh factors in the perception of the quality of life and possible relationships with demographic–clinical characteristics in people with melanoma via a machine learning approach. In this observational study, patients with melanoma, without metastatic disease, were recruited from January 2020 to December 2021 with a follow-up of at least one year. Demographic variables and clinics were collected, and the 12-Item Short-Form Health Survey (SF-12) was adopted as the physical and mental aspects of the Health-Related Quality of Life (HRQoL) measure. All the variables were processed in a random forest model to weigh at each node of each tree of this machine learning regression model, their actual weight in SF-12 score. We included 203 melanoma patients, mean aged 59.25 ± 15.1 years: 56 (27%) affecting the upper limbs and 147 (73%) affecting the trunk. The model of 142 patients with no missing value, generating 92 trees (MSE = 0.45, R2 of 0.78), reported that the lesion site was the most influencing variable on HRQoL based on the decrease in Gini impurity in variable weighing at each node intersection in forest generation. In this scenario, we built two distinct models for lesion sites and demonstrated that the variable that most influenced the quality of life in upper limb melanoma was lymphedema, while BMI was in the trunk. Given these results, random forest regressions could play a crucial role in the clinical and rehabilitation approach. The machine-learning model for detecting the HRQoL predictor in melanoma patients indicates that the experienced lymphedema and BMI may influence the HRQoL perception. This study suggests that the prevention and treatment of lymphedema and bodyweight reduction might improve the quality of life in melanoma.

Enhanced risk of multiple sentinel lymph node basins in truncal and head and neck melanoma

Introduction: Truncal and head and neck melanomas have a greater propensity to drain to multiple lymph node basins (MLNB) compared to extremity melanomas, which drain predominantly to a single lymph node basin (SLNB). The objective of this study was to compare the lymphatic drainage patterns and characteristics of truncal and head and neck melanoma, to assess their clinical usefulness in areas of unpredictable drainage. Methods: A retrospective review of 143 patients with head and neck or truncal melanoma from 2014–2018 treated at a tertiary referral hospital in Melbourne, Australia. Patients scheduled for a wide local excision (WLE) and SeNBx, and those whose initial biopsy results stated melanoma type, cell type and BT, were included. Patients were excluded if they underwent nodal biopsy alone. Results: We identified 95 patients with truncal and 48 with head and neck melanoma. Drainage to MLNB was significantly higher in the truncal melanoma group (36.8%) compared to the head and neck group (10.4%) (P = 0.001). Patients with drainage to MLNB had a higher positive sentinel node biopsy (SeNBx) rate compared to those with SLNB (40.0% verus. 12.6%, P <0.0001). Truncal melanomas that drained to MLNB were associated with a significantly higher Breslow thickness (2.1 versus. 1.5, P = 0.02), ulceration (40.6% vs. 20.7%, P = 0.043) and mitotic rate (3.0 versus. 2.0, P = 0.045) compared to equivalent melanomas that drained to SLNB. Conclusion: Patients with melanomas occurring in the trunk exhibit higher rates of drainage to MLNB compared to melanomas arising in the head and neck. Patients with drainage to MLNB also demonstrate a higher rate of positive SeNBx than those with SLNB drainage. This may represent more aggressive disease pathology or later diagnosis of lesions within these locations, or a lymphatic system that is more facilitatory of spread.

Prognostic factors and population-based analysis of melanoma with sentinel lymph node biopsy

Cutaneous malignant melanoma is a rare but fatal disease in East Asia. Despite its increasing incidence, a general lack of awareness about the disease was noted. This study aims to provide population-based prognostic analysis of melanoma with sentinel lymph node biopsy (SLNB) in Taiwan. We conducted this retrospective cohort study using the data from Taiwan National Health Insurance Research Database during 1997–2013. The study cohort contains 3284 patients. The 5-year survival rates of patients undergoing SLNB and not undergoing SLNB were 45.5% and 33.6%. In multivariate analysis, age ≥ 80 years [adjusted hazard ratio (aHR) = 2.15] and male (aHR = 1.19) were associated with a poorer prognosis, while high social economic status (SES) (aHR = 0.69) and undergoing SLNB (aHR = 0.84) were good prognostic factors. Old age and low SES were associated with lower percentages of patients undergoing SLNB (P < 0.001). E-value analysis suggested robustness to unmeasured confounding. In conclusion, undergoing SLNB was associated with a better prognosis. The poor prognosis of old age and low SES may be due to decreased percentages of patients undergoing SLNB. Therefore, we recommend that SLNB should be performed on patients, especially in old age or low SES, who are candidates for SLNB according to current guidelines to achieve maximal survival.

Melanoma: Staging and Follow-Up

Cancer staging is the process determining to which extent a cancer has spread and where it is located in the body. A thorough staging is of utmost importance, not only because it provides the most accurate prognostic estimation, but also because several crucial decisions, such as the treatment choice and the follow-up strategy, vary according to the tumor's stage. The current staging system for melanoma is based on the 8^th edition of TNM classification issued by the American Joint Committee on Cancer (AJCC) in 2017. It includes a clinical and a pathological staging, both consisting of 5 stages (0-IV). The stage of a melanoma is determined by several factors, among which the Breslow thickness, the pathological presence or absence of ulceration in the primary tumor, the presence and the number of tumor-involved regional lymph nodes, the presence or absence of in-transit, satellite and/or microsatellite metastases, and the presence of distant metastases. Following melanoma diagnosis, an accurate medical workup, in line with the stage and the physical examination, should be performed. A continuous patient monitoring is fundamental to detect a potential relapse or a second primary melanoma and should be lifelong. However, there is still no universally adopted follow-up strategy program and different follow-up schemes have been suggested. Future prospective studies are needed to evaluate different follow-up protocols according to the adopted therapy, as novel recent therapies (targeted and immunotherapies) are being increasingly used. Key MessagesProper staging is of utmost importance because it provides accurate prognostic estimation. Several crucial decisions, such as the treatment choice and the follow up strategy, are based on the tumor stage.Physical examination during staging procedure and follow-up visits are important to avoid unnecessary imaging and laboratory tests that could increase the patients' anxiety. A personalized approach taking into consideration the patient's risk factors, is strongly recommended.Melanoma patients should be kept under surveillance lifelong due to an increased risk of developing a second primary melanoma and the risk of recurrence. Higher intensity follow-up strategies during the first 5 years are recommended due to higher rates of regional or distant relapse.

Regional lymph node infiltration and thick lesions are associated with poor prognosis in high-risk resected melanomas: A retrospective cohort study

Background

Acral lentiginous and mucosal melanoma that represent lesions without cumulative sun-induced damages account for 65% of melanomas among Asians but constitute only 5% in Caucasians. The distinct clinical manifestations might influence the clinical course, response to treatment, and outcomes. Factors associated with the prognosis of high-risk resected melanoma in Asians are still rarely reported.

Methods

Clinical, histological determinants of non-distant metastatic melanoma patients who underwent complete resection in 2014–9 were analyzed.

Results

Mucosal melanoma, nodular melanoma, and acral lentiginous melanoma accounted for 45.1%, 40.2%, and 14.2% of total melanoma cases (N = 82), respectively. Among cutaneous melanomas, all patients were diagnosed with Breslow's depth more than 4 mm (T4), 51% with ulceration, 95.6% with diameter more than 6 mm, 59% with lympho-vascular invasion, and 74% with regional lymph node infiltration. In mucosal melanomas, 78.3% were diagnosed in advanced stages, 14.5% with regional spread to lymph nodes and 77% with regional infiltration beyond mucosa. Lesions with ulceration were associated with higher risk of distant metastasis (OR 3.003, 95%CI:1.01–9.09). Infiltration into regional lymph node was associated with shorter overall survival (median survivals were 17 vs 23.4 months, Mantel-Cox test P = 0.049). Patients diagnosed at Breslow T4 were also associated with poorer overall survival than T1-3 (median survivals were 23 vs 32 months, Mantel-Cox test P = 0.047).

Conclusion

The majority of melanoma patients in our population were diagnosed in advanced stages with a higher risk for recurrence and progression into distant metastasis. Regional lymph node involvement and thicker tumor (T4) were associated with poor prognosis.

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Most of melanoma patients in Indonesia are diagnosed with high-risk of progression and worse survival.

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Revealing factors-associated with high-risk of disease progression is important to set up surveillance program.

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Refinement of public education and care delivery are required to advance management of melanoma in Indonesia.

Prognostic Role of Non-Identification of Sentinel Lymph Node in Cutaneous Melanoma Patients: An Observational Retrospective Study

Simple Summary

Sentinel lymph node status is the most important prognostic factor for patients with cutaneous melanoma, but occasionally it is not possible to identify the sentinel lymph node. Little is known in cutaneous melanoma literature about the phenomenon of non-identification of sentinel lymph node and its prognostic implications. In this study we observed that not identifying the sentinel lymph node involves a worse nodal disease-free survival, but not a worse melanoma-specific survival than a negative sentinel lymph node. Potentially, patients with non-identified SLN should receive a follow-up schedule like that of patients with positive SLN.

Abstract

Background: Sentinel lymph node (SLN) status is recognized as the most important prognostic factor for patients with cutaneous melanoma. However, sometimes it is not possible to identify SLN. The phenomenon of non-identification of SLN and its prognostic role have not been thoroughly evaluated in melanoma literature. The objective of this study was to identify which patient or tumor variables may be associated to non-identification of SLN and to evaluate the prognostic role of non-identification of SLN. Methods: Observational retrospective study of 834 cutaneous melanoma patients who underwent SLN biopsy at Instituto Valenciano de Oncología. Results: Forty-two patients (5%) presented non-identification of SLN. Patients with age at diagnosis of ≥ 64 years, obesity (BMI ≥ 30), and head and neck localization were at higher risk of non-identification of SLN. Non-identified SLN patients had worse nodal disease-free survival with respect to negative SLN patients, but not worse melanoma-specific survival. Conclusions: Our findings suggest a need to follow-up patients with non-identified SLN in the same way as patients with positive SLN.

Ultrasound, CT, MRI, or PET-CT for staging and re-staging of adults with cutaneous melanoma

BACKGROUND

Melanoma is one of the most aggressive forms of skin cancer, with the potential to metastasise to other parts of the body via the lymphatic system and the bloodstream. Melanoma accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Various imaging tests can be used with the aim of detecting metastatic spread of disease following a primary diagnosis of melanoma (primary staging) or on clinical suspicion of disease recurrence (re-staging). Accurate staging is crucial to ensuring that patients are directed to the most appropriate and effective treatment at different points on the clinical pathway. Establishing the comparative accuracy of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT imaging for detection of nodal or distant metastases, or both, is critical to understanding if, how, and where on the pathway these tests might be used.

OBJECTIVES

Primary objectivesWe estimated accuracy separately according to the point in the clinical pathway at which imaging tests were used. Our objectives were:• to determine the diagnostic accuracy of ultrasound or PET-CT for detection of nodal metastases before sentinel lymph node biopsy in adults with confirmed cutaneous invasive melanoma; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging in adults with cutaneous invasive melanoma:○ for detection of any metastasis in adults with a primary diagnosis of melanoma (i.e. primary staging at presentation); and○ for detection of any metastasis in adults undergoing staging of recurrence of melanoma (i.e. re-staging prompted by findings on routine follow-up).We undertook separate analyses according to whether accuracy data were reported per patient or per lesion.Secondary objectivesWe sought to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging (detection of any metastasis) in mixed or not clearly described populations of adults with cutaneous invasive melanoma.For study participants undergoing primary staging or re-staging (for possible recurrence), and for mixed or unclear populations, our objectives were:• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of nodal metastases;• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases according to metastatic site.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included studies of any design that evaluated ultrasound (with or without the use of fine needle aspiration cytology (FNAC)), CT, MRI, or PET-CT for staging of cutaneous melanoma in adults, compared with a reference standard of histological confirmation or imaging with clinical follow-up of at least three months' duration. We excluded studies reporting multiple applications of the same test in more than 10% of study participants.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2)). We estimated accuracy using the bivariate hierarchical method to produce summary sensitivities and specificities with 95% confidence and prediction regions. We undertook analysis of studies allowing direct and indirect comparison between tests. We examined heterogeneity between studies by visually inspecting the forest plots of sensitivity and specificity and summary receiver operating characteristic (ROC) plots. Numbers of identified studies were insufficient to allow formal investigation of potential sources of heterogeneity.

MAIN RESULTS

We included a total of 39 publications reporting on 5204 study participants; 34 studies reporting data per patient included 4980 study participants with 1265 cases of metastatic disease, and seven studies reporting data per lesion included 417 study participants with 1846 potentially metastatic lesions, 1061 of which were confirmed metastases. The risk of bias was low or unclear for all domains apart from participant flow. Concerns regarding applicability of the evidence were high or unclear for almost all domains. Participant selection from mixed or not clearly defined populations and poorly described application and interpretation of index tests were particularly problematic.The accuracy of imaging for detection of regional nodal metastases before sentinel lymph node biopsy (SLNB) was evaluated in 18 studies. In 11 studies (2614 participants; 542 cases), the summary sensitivity of ultrasound alone was 35.4% (95% confidence interval (CI) 17.0% to 59.4%) and specificity was 93.9% (95% CI 86.1% to 97.5%). Combining pre-SLNB ultrasound with FNAC revealed summary sensitivity of 18.0% (95% CI 3.58% to 56.5%) and specificity of 99.8% (95% CI 99.1% to 99.9%) (1164 participants; 259 cases). Four studies demonstrated lower sensitivity (10.2%, 95% CI 4.31% to 22.3%) and specificity (96.5%,95% CI 87.1% to 99.1%) for PET-CT before SLNB (170 participants, 49 cases). When these data are translated to a hypothetical cohort of 1000 people eligible for SLNB, 237 of whom have nodal metastases (median prevalence), the combination of ultrasound with FNAC potentially allows 43 people with nodal metastases to be triaged directly to adjuvant therapy rather than having SLNB first, at a cost of two people with false positive results (who are incorrectly managed). Those with a false negative ultrasound will be identified on subsequent SLNB.Limited test accuracy data were available for whole body imaging via PET-CT for primary staging or re-staging for disease recurrence, and none evaluated MRI. Twenty-four studies evaluated whole body imaging. Six of these studies explored primary staging following a confirmed diagnosis of melanoma (492 participants), three evaluated re-staging of disease following some clinical indication of recurrence (589 participants), and 15 included mixed or not clearly described population groups comprising participants at a number of different points on the clinical pathway and at varying stages of disease (1265 participants). Results for whole body imaging could not be translated to a hypothetical cohort of people due to paucity of data.Most of the studies (6/9) of primary disease or re-staging of disease considered PET-CT, two in comparison to CT alone, and three studies examined the use of ultrasound. No eligible evaluations of MRI in these groups were identified. All studies used histological reference standards combined with follow-up, and two included FNAC for some participants. Observed accuracy for detection of any metastases for PET-CT was higher for re-staging of disease (summary sensitivity from two studies: 92.6%, 95% CI 85.3% to 96.4%; specificity: 89.7%, 95% CI 78.8% to 95.3%; 153 participants; 95 cases) compared to primary staging (sensitivities from individual studies ranged from 30% to 47% and specificities from 73% to 88%), and was more sensitive than CT alone in both population groups, but participant numbers were very small.No conclusions can be drawn regarding routine imaging of the brain via MRI or CT.

AUTHORS' CONCLUSIONS

Review authors found a disappointing lack of evidence on the accuracy of imaging in people with a diagnosis of melanoma at different points on the clinical pathway. Studies were small and often reported data according to the number of lesions rather than the number of study participants. Imaging with ultrasound combined with FNAC before SLNB may identify around one-fifth of those with nodal disease, but confidence intervals are wide and further work is needed to establish cost-effectiveness. Much of the evidence for whole body imaging for primary staging or re-staging of disease is focused on PET-CT, and comparative data with CT or MRI are lacking. Future studies should go beyond diagnostic accuracy and consider the effects of different imaging tests on disease management. The increasing availability of adjuvant therapies for people with melanoma at high risk of disease spread at presentation will have a considerable impact on imaging services, yet evidence for the relative diagnostic accuracy of available tests is limited.

Association between tumor-infiltrating lymphocytes and sentinel lymph node positivity in thin melanoma

BACKGROUND

Sentinel lymph node biopsy in thin invasive primary cutaneous melanoma (up to 1mm thick) is a controversial subject. The presence of tumor-infiltrating lymphocytes could be a factor to be considered in the decision to perform this procedure.

OBJECTIVE

To evaluate the association between the presence of tumor-infiltrating lymphocytes and lymph node metastases caused by thin primary cutaneous melanoma.

METHODS

Cross-sectional study with 137 records of thin invasive primary cutaneous melanoma submitted to sentinel lymph node biopsy from 2003 to 2015. The clinical variables considered were age, sex and topography of the lesion. The histopathological variables assessed were: tumor-infiltrating lymphocytes, melanoma subtype, Breslow thickness, Clark levels, number of mitoses per mm2, ulceration, regression and satellitosis. Univariate analyzes and logistic regression tests were performed as well the odds ratio and statistical relevance was considered when p <0.05.

RESULTS

Among the 137 cases of thin primary cutaneous melanoma submitted to sentinel lymph node biopsy, 10 (7.3%) had metastatic involvement. Ulceration on histopathology was positively associated with the presence of metastatic lymph node, with odds ratio =12.8 (2.77-59.4 95% CI, p=0.001). The presence of moderate/marked tumor-infiltrating lymphocytes was shown to be a protective factor for the presence of metastatic lymph node, with OR=0.20 (0.05-0.72 95% CI, p=0.014). The other variables - clinical and histopathological - were not associated with the outcome.

STUDY LIMITATIONS

The relatively small number of positive sentinel lymph node biopsy may explain such an expressive association of ulceration with metastatization.

CONCLUSIONS

In patients with thin invasive primary cutaneous melanoma, few or absent tumor-infiltrating lymphocytes, as well as ulceration, represent independent risk factors for lymph node metastasis.

Reflectance confocal microscopy for diagnosing cutaneous melanoma in adults

BACKGROUND

Melanoma has one of the fastest rising incidence rates of any cancer. It accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Early detection and treatment is key to improving survival; however, anxiety around missing early cases needs to be balanced against appropriate levels of referral and excision of benign lesions. Used in conjunction with clinical or dermoscopic suspicion of malignancy, or both, reflectance confocal microscopy (RCM) may reduce unnecessary excisions without missing melanoma cases.

OBJECTIVES

To determine the diagnostic accuracy of reflectance confocal microscopy for the detection of cutaneous invasive melanoma and atypical intraepidermal melanocytic variants in adults with any lesion suspicious for melanoma and lesions that are difficult to diagnose, and to compare its accuracy with that of dermoscopy.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; and seven other databases. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Studies of any design that evaluated RCM alone, or RCM in comparison to dermoscopy, in adults with lesions suspicious for melanoma or atypical intraepidermal melanocytic variants, compared with a reference standard of either histological confirmation or clinical follow-up.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic threshold were missing. We estimated summary sensitivities and specificities per algorithm and threshold using the bivariate hierarchical model. To compare RCM with dermoscopy, we grouped studies by population (defined by difficulty of lesion diagnosis) and combined data using hierarchical summary receiver operating characteristic (SROC) methods. Analysis of studies allowing direct comparison between tests was undertaken. To facilitate interpretation of results, we computed values of specificity at the point on the SROC curve with 90% sensitivity as this value lies within the estimates for the majority of analyses. We investigated the impact of using a purposely developed RCM algorithm and in-person test interpretation.

MAIN RESULTS

The search identified 18 publications reporting on 19 study cohorts with 2838 lesions (including 658 with melanoma), which provided 67 datasets for RCM and seven for dermoscopy. Studies were generally at high or unclear risk of bias across almost all domains and of high or unclear concern regarding applicability of the evidence. Selective participant recruitment, lack of blinding of the reference test to the RCM result, and differential verification were particularly problematic. Studies may not be representative of populations eligible for RCM, and test interpretation was often undertaken remotely from the patient and blinded to clinical information.Meta-analysis found RCM to be more accurate than dermoscopy in studies of participants with any lesion suspicious for melanoma and in participants with lesions that were more difficult to diagnose (equivocal lesion populations). Assuming a fixed sensitivity of 90% for both tests, specificities were 82% for RCM and 42% for dermoscopy for any lesion suspicious for melanoma (9 RCM datasets; 1452 lesions and 370 melanomas). For a hypothetical population of 1000 lesions at the median observed melanoma prevalence of 30%, this equated to a reduction in unnecessary excisions with RCM of 280 compared to dermoscopy, with 30 melanomas missed by both tests. For studies in equivocal lesions, specificities of 86% would be observed for RCM and 49% for dermoscopy (7 RCM datasets; 1177 lesions and 180 melanomas). At the median observed melanoma prevalence of 20%, this reduced unnecessary excisions by 296 with RCM compared with dermoscopy, with 20 melanomas missed by both tests. Across all populations, algorithms and thresholds assessed, the sensitivity and specificity of the Pellacani RCM score at a threshold of three or greater were estimated at 92% (95% confidence interval (CI) 87 to 95) for RCM and 72% (95% CI 62 to 81) for dermoscopy.

AUTHORS' CONCLUSIONS

RCM may have a potential role in clinical practice, particularly for the assessment of lesions that are difficult to diagnose using visual inspection and dermoscopy alone, where the evidence suggests that RCM may be both more sensitive and specific in comparison to dermoscopy. Given the paucity of data to allow comparison with dermoscopy, the results presented require further confirmation in prospective studies comparing RCM with dermoscopy in a real-world setting in a representative population.

The long-term prognostic impact of sentinel lymph node biopsy in patients with primary cutaneous melanoma: a prospective study with 10-year follow-up

Purpose

Sentinel lymph node (SLN) biopsy (SLNB) is widely accepted for staging of melanoma patients. It has been shown that clinico-pathological features such as Breslow thickness, ulceration, age, and sex are better predictors of relapse and survival than SLN status alone. The aims of this study were to evaluate the long-term (10-year) prognostic impact of SLNB and to determine predictive factors associated with SLN metastasis, relapse, and melanoma specific mortality (MSM).

Methods

This was a prospective observational study on 289 consecutive patients with primary cutaneous melanoma who underwent SLNB from January 2000 to December 2007, and followed until January 2014, at an Italian academic hospital.

Results

SLN was positive in 64 patients (22.1%). The median follow-up was 116 months (79–147 months). Ten-year disease-free survival and melanoma specific survival were poor in patients with positive SLN (58.7% and 66.4%, respectively). Only the increasing Breslow thickness resulted independently associated to an increased risk of SLN metastasis. Cox regression analysis showed that a Breslow thickness >2 mm was an independent predictor of relapse, and male sex and Breslow thickness >2 mm was a predictor of MSM. At 10 years, SLN metastasis was not significantly associated to either relapse or MSM.

Conclusion

After the fifth year of follow-up, SLN metastasis is not an independent predictive factor of relapse or mortality which are mainly influenced by the characteristics of the primary tumor and of the patient. Patients with a Breslow thickness >2 mm regardless of the SLN status should be considered at high risk for 10-year relapse and mortality.

Trends in Sentinel Lymph Node Mapping and Adjuvant Therapy in Endometrial Carcinoma

We analyzed 54,039 women with uterine cancer in the National Cancer Database from 2013 to 2014 including 38,453 (71.2%) who underwent lymphadenectomy, 1929 (3.6%) who underwent sentinel lymph node (SLN) mapping, and 13,657 (25.3%) who did not undergo nodal assessment. SLN mapping increased from 2.8% in 2013 to 4.3% in 2014 (P < 0.001). Patients treated in 2014 and those at community centers were more likely to undergo SLN biopsy, while women with advanced-stage disease, sarcomas, and grade 3 tumors were less likely to undergo SLN mapping (P < 0.05). There was no association between use of SLN biopsy and use of radiation (aRR = 0.92; 95% CI, 0.82-1.05).

Sentinel Lymph Node Biopsy and Management of Regional Lymph Nodes in Melanoma: American Society of Clinical Oncology and Society of Surgical Oncology Clinical Practice Guideline Update

PURPOSE

To update the American Society of Clinical Oncology (ASCO)-Society of Surgical Oncology (SSO) guideline for sentinel lymph node (SLN) biopsy in melanoma.

METHODS

An ASCO-SSO panel was formed, and a systematic review of the literature was conducted regarding SLN biopsy and completion lymph node dissection (CLND) after a positive sentinel node in patients with melanoma.

RESULTS

Nine new observational studies, two systematic reviews and an updated randomized controlled trial (RCT) of SLN biopsy, as well as two randomized controlled trials of CLND after positive SLN biopsy, were included.

RECOMMENDATIONS

Routine SLN biopsy is not recommended for patients with thin melanomas that are T1a (non-ulcerated lesions < 0.8 mm in Breslow thickness). SLN biopsy may be considered for thin melanomas that are T1b (0.8 to 1.0 mm Breslow thickness or <0.8 mm Breslow thickness with ulceration) after a thorough discussion with the patient of the potential benefits and risk of harms associated with the procedure. SLN biopsy is recommended for patients with intermediate-thickness melanomas (T2 or T3; Breslow thickness of >1.0 to 4.0 mm). SLN biopsy may be recommended for patients with thick melanomas (T4; > 4.0 mm in Breslow thickness), after a discussion of the potential benefits and risks of harm. In the case of a positive SLN biopsy, CLND or careful observation are options for patients with low-risk micrometastatic disease, with due consideration of clinicopathological factors. For higher risk patients, careful observation may be considered only after a thorough discussion with patients about the potential risks and benefits of foregoing CLND. Important qualifying statements outlining relevant clinicopathological factors, and details of the reference patient populations are included within the guideline.

Utilization of sentinel lymph node biopsy for uterine cancer

BACKGROUND

To limit the potential short and long-term morbidity of lymphadenectomy, sentinel lymph node biopsy has been proposed for endometrial cancer. The principle of sentinel lymph node biopsy relies on removal of a small number of lymph nodes that are the first drainage basins from a tumor and thus the most likely to harbor tumor cells. While the procedure may reduce morbidity, efficacy data are limited and little is known about how commonly the procedure is performed.

OBJECTIVE

We examined the patterns and predictors of use of sentinel lymph node biopsy and outcomes of the procedure in women with endometrial cancer who underwent hysterectomy.

STUDY DESIGN

We used the Perspective database to identify women with uterine cancer who underwent hysterectomy from 2011 through 2015. Billing and charge codes were used to classify women as having undergone lymphadenectomy, sentinel lymph node biopsy, or no nodal assessment. Multivariable models were used to examine clinical, demographic, and hospital characteristics with use of sentinel lymph node biopsy. Length of stay and cost were compared among the different methods of nodal assessment.

RESULTS

Among 28,362 patients, 9327 (32.9%) did not undergo nodal assessment, 17,669 (62.3%) underwent lymphadenectomy, and 1366 (4.8%) underwent sentinel lymph node biopsy. Sentinel lymph node biopsy was performed in 1.3% (95% confidence interval, 1.0-1.6%) of abdominal hysterectomies, 3.4% (95% confidence interval, 2.7-4.1%) of laparoscopic hysterectomies, and 7.5% (95% confidence interval, 7.0-8.0%) of robotic-assisted hysterectomies. In a multivariable model, more recent year of surgery was associated with performance of sentinel lymph node biopsy. Compared to abdominal hysterectomy, those undergoing laparoscopic (adjusted risk ratio, 2.45; 95% confidence interval, 1.89-3.18) and robotic-assisted (adjusted risk ratio, 2.69; 95% confidence interval, 2.19-3.30) hysterectomy were more likely to undergo sentinel lymph node biopsy. Among women who underwent minimally invasive hysterectomy, length of stay and cost were lower for sentinel lymph node biopsy compared to lymphadenectomy.

CONCLUSION

The use of sentinel lymph node biopsy for endometrial cancer increased from 2011 through 2015. The increased use was most notable in women who underwent a robotic-assisted hysterectomy.

Morbidity and oncologic outcome after saphenous vein-sparing inguinal lymphadenectomy in melanoma patients

BACKGROUND

Inguinal lymph node dissection (LND) is a surgical procedure with a high morbidity rate. Variations in surgical procedure, such as sparing of the saphenous vein, have been proposed to reduce surgical morbidity. While sparing of the saphenous vein has shown promising results in earlier studies, data for this procedure in melanoma patients are rare. In this retrospective study, we report 10-year findings on the effects of saphenous vein-sparing LND on surgical morbidity and oncologic outcomes in melanoma patients.

METHODS

A retrospective analysis of melanoma patients receiving inguinal LND in our facility between 2003 and 2013 was performed. Patients were divided into two groups: the saphenous vein resection group and the vein sparing group. Surgical morbidity, including wound infection, lymphatic fistula, severe bleeding, neurological complications, and chronic lymphedema, as well as regional recurrence-free survival were investigated.

RESULTS

A total of 106 patients were included in this study; of these, the saphenous vein was spared in 41 patients (38.7%). The rate of lymphatic fistula was 51.6 vs. 48.8%, wound infection occurred in 31.3 vs. 24.4%, and patients suffered from chronic lymphedema in 30.0 vs. 26.5% in V. saphena magna resection vs. sparing group. Differences observed, however, were not significant. No difference in regional recurrence-free survival between the two study groups was detected.

CONCLUSIONS

The results of our retrospective analysis could not confirm the promising results reported in earlier studies. Thus, sparing of the saphenous vein appears to be optional.

Epidemiology, management and survival outcomes of primary cutaneous melanoma: a ten-year overview

BACKGROUND

Malignant melanoma (MM) is the most aggressive type of skin cancer, accounting for 90% of all the skin cancer mortality. The objective of this study was providing an overview of current patient- and tumour characteristics, treatment strategies, complications and survival in patients with MM over the past ten years. Hereby, an up-to-date view of every day clinical practice is obtained.

METHODS

Files of patients treated for primary cutaneous melanoma (n = 686) in the VieCuri Medical Centre in the Netherlands between January 2002 and December 2013 were retrospectively reviewed. Relevant patient features, tumour characteristics, and (surgical) outcomes were evaluated.

RESULTS

The majority of all the patients presented thin tumours (59.1% stage 1A/in situ melanoma). Men showed more ulceration (17.7% vs. 8.4%, p < .01) and a significantly higher Breslow thickness than women (1.2 mm vs. 0.9 mm, p < .01). 14.6% (40/273) underwent sentinel lymph node biopsy (SLNB); 10/40 (25%) showed nodal metastasis, 50 patients (7.3%) developed distant metastases (M: 10.6%, F: 5%, p < .01). One-, 5- and 10- year disease specific survival rates were 96%, 86% and 84%, respectively. Median survival for stage 4 MM was 3 months. Extensive surgery was uncommon (n = 3).

CONCLUSIONS

Patients generally presented with thin melanomas. Lymph node disease and distant metastases remained infrequently observed during following years, and general 1- and 5-year overall disease-specific survival rates exceeded 85%. Small numbers of rescue surgery and palliative medical treatment warrant further centralisation and investigation.

Sentinel lymph node biopsy followed by lymph node dissection for localised primary cutaneous melanoma

BACKGROUND

Melanoma is the leading cause of skin cancer-associated mortality. The vast majority of newly diagnosed melanomas are confined to the primary cutaneous site. Surgery represents the mainstay of melanoma treatment. Treatment strategies include wide excision of the primary tumour and sentinel lymph node biopsy (SLNB) to assess the status of the regional nodal basin(s). SLNB has become an important component of initial melanoma management providing accurate disease staging.

OBJECTIVES

To assess the effects and safety of SLNB followed by completion lymph node dissection (CLND) for the treatment of localised primary cutaneous melanoma.

SEARCH METHODS

We searched the following databases up to February 2015: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2015, Issue 1), MEDLINE (from 1946), EMBASE (from 1974), and LILACS ((Latin American and Caribbean Health Science Information database, from 1982). We also searched the following from inception: African Index Medicus, IndMED of India, Index Medicus for the South-East Asia Region, and six trials registers. We checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We searched ISI Web of Science Conference Proceedings from inception to February 2015, and we scanned the abstracts of major dermatology and oncology conference proceedings up to 2015.

SELECTION CRITERIA

Two review authors independently assessed all RCTs comparing SLNB followed by CLND for the treatment of primary localised cutaneous melanoma for inclusion. Primary outcome measures were overall survival and rate of treatment complications and side effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and analysed data on survival and recurrence, assessed risk of bias, and collected adverse effect information from included trials.

MAIN RESULTS

We identified and included a single eligible trial comparing SLNB with observation and published in eight different reports (from 2005 to 2014) with 2001 participants. This did not report on our first primary outcome of overall survival. The study did report on the rate of treatment complications. Our secondary outcomes of disease-specific and disease-free survival, local recurrence and distant metastases were reported. There were 1347 participants in the intermediate-thickness melanoma group and 314 in the thick melanoma group.With regard to treatment complications, short-term surgical morbidity (30 days) in 1735 participants showed no difference between SLNB and observation (risk ratio [RR] 1.11; 95% confidence interval [CI] 0.9 to 1.37) for wide excision of the tumour site but favoured observation for complications related to the regional nodal basin (RR 14.36; 95% CI 6.74 to 30.59).The study did not report the actual 10-year melanoma-specific survival rate for all included participants. Instead, melanoma-specific survival rates for each group of participants: intermediate-thickness melanoma (defined as 1.2 to 3.5 mm) and thick melanomas (defined as 3.50 mm or more) was reported.In the intermediate-thickness melanoma group there was no statistically significant difference in disease-specific survival between study groups at 10 years (81.4 ± 1.5% versus 78.3 ± 2.0%, hazard ratio [HR] 0.84; 95% CI 0.65 to 1.09). In the thick melanoma group, again there was no statistically significant difference in disease-specific survival between study groups at 10 years (58.9.3 ± 4.1% versus 64.4 ± 4.6%, HR 1.12; 95% CI 0.77 to 1.64). Combining these groups there was some heterogeneity (I² = 34%) but the total HR was not statistically significant (HR 0.92; 95% CI 0.74 to 1.14). This study failed to show any difference for its stated primary outcome.The summary estimate for disease-free survival at 10 years favoured SLNB over observation in participants with intermediate-thickness and thick melanomas (HR 0.75; 95% CI 0.63 to 0.89).With regard to the rate of local and regional recurrence as the site of first recurrence, a benefit of SLNB uniformly existed in both groups of participants with intermediate-thickness and thick melanomas (RR 0.56; 95% CI 0.45 to 0.69). This is in contrast with a uniformly unfavourable effect of SLNB with regard to the rate of distant metastases as site of first recurrence, in both groups of participants with intermediate-thickness and thick melanomas (HR 1.33; 95% CI 1.03 to 1.72).

AUTHORS' CONCLUSIONS

We contacted the trial authors querying the lack of data on overall survival which was the primary outcome of their important study. They stated "there are numerous additional analyses that have yet to be reported for the trial". We expect that overall survival data will be available in a future update of this review.Disease-free survival and rate of local and regional recurrence favoured SLNB in both groups of participants with intermediate-thickness and thick melanomas but short-term surgical morbidity was higher in the SLNB group, especially with regard to complications in the nodal basin.The evidence for the outcomes of interest in this review is of low quality due to the risk of bias and imprecision of the estimated effects. Further research may have an important impact on our estimate of the effectiveness of SLNB in managing primary localised cutaneous melanoma. Currently this evidence is not sufficient to document a benefit of SLNB when compared to observation in individuals with primary localised cutaneous melanoma.