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Winder AA, Spillane AJ, Smith AL. ASO Author Reflections: Impact of an Online Risk Calculator for Sentinel Node Positivity on Management of Patients with T1 and T2 Melanomas. Ann Surg Oncol 2024:10.1245/s10434-024-15590-5. [PMID: 38874872 DOI: 10.1245/s10434-024-15590-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Alec A Winder
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - Andrew J Spillane
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Royal North Shore Hospital, Sydney, NSW, Australia
- Mater Hospital, Sydney, NSW, Australia
| | - Andrea L Smith
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
- The Daffodil Centre, University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, NSW, Australia.
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Winder AA, Boyer Z, Ch'ng S, Stretch JR, Saw RPM, Shannon KF, Pennington TE, Nieweg OE, Varey AHR, Scolyer RA, Thompson JF, Cust AE, Lo SN, Spillane AJ, Smith AL. Impact of an Online Risk Calculator for Sentinel Node Positivity on Management of Patients with T1 and T2 Melanomas. Ann Surg Oncol 2024:10.1245/s10434-024-15456-w. [PMID: 38802717 DOI: 10.1245/s10434-024-15456-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 04/28/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Predicting which patients with American Joint Committee on Cancer (AJCC) T1-T2 melanomas will have a positive sentinel lymph node (SLN) is challenging. Melanoma Institute Australia (MIA) developed an internationally validated SLN metastatic risk calculator. This study evaluated the nomogram's impact on T1-T2 melanoma patient management at MIA. METHODS SLN biopsy (SLNB) rates were compared for the pre- and post-nomogram periods of 1 July 2018-30 June 2019 and 1 August 2020-31 July 2021, respectively. RESULTS Overall, 850 patients were identified (pre-nomogram, 383; post-nomogram, 467). SLNB was performed in 29.0% of patients in the pre-nomogram group and 34.5% in the post-nomogram group (p = 0.091). The overall positivity rate was 16.2% in the pre-nomogram group and 14.9% in the post-nomogram group (p = 0.223). SLNB was performed less frequently in T1a melanoma patients in the pre-nomogram group (1.1%, n = 2/177) than in the post-nomogram group (8.6%, n = 17/198) [p ≤ 0.001]. This increase was particularly for melanomas with a risk score ≥ 5%, with an SLN positivity rate of 11.8% in the post-nomogram group (p = 0.004) compared with zero. For T1b melanomas with a risk score of > 10%, the SLNB rate was 40.0% (8/20) pre-nomogram and 75.0% (12/16) post-nomogram (p = 0.049). CONCLUSIONS In this specialized center, the SLN risk calculator appears to influence practice for melanomas previously considered low risk for metastasis, with increased use of SLNB for T1a and higher-risk T1b melanomas. Further evaluation is required across broader practice settings. Melanoma management guidelines could be updated to incorporate the availability of nomograms to better select patients for SLNB than previous criteria.
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Affiliation(s)
- Alec A Winder
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.
| | - Zoe Boyer
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Sydney Ch'ng
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Mater Hospital, Sydney, NSW, Australia
| | - Jonathan R Stretch
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Mater Hospital, Sydney, NSW, Australia
| | - Robyn P M Saw
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Mater Hospital, Sydney, NSW, Australia
| | - Kerwin F Shannon
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Mater Hospital, Sydney, NSW, Australia
| | - Thomas E Pennington
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Mater Hospital, Sydney, NSW, Australia
| | - Omgo E Nieweg
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Alexander H R Varey
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Anne E Cust
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- The Daffodil Centre, University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Serigne N Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Andrew J Spillane
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Royal North Shore Hospital, Sydney, NSW, Australia
- Mater Hospital, Sydney, NSW, Australia
| | - Andrea L Smith
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
- The Daffodil Centre, University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, NSW, Australia
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Zhang R, Zhang Y, Dong S, Pang K, Yang X, Wei X. Performance of indocyanine green in sentinel lymph node mapping and lymph node metastasis in penile cancer: systematic review, meta-analysis, and single-center experience. World J Urol 2023; 41:2319-2326. [PMID: 37419973 DOI: 10.1007/s00345-023-04485-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/07/2023] [Indexed: 07/09/2023] Open
Abstract
PURPOSE The aim of this study was to investigate the overall sensitivity and specificity of indocyanine green (ICG)-near-infrared (NIR) fluorescence imaging in the detection of sentinel lymph node metastasis (SLNM) in penile cancer. METHODS We searched PubMed, Embase, Web of Science, Scopus, and the Cochrane Library databases to identify manuscripts where ICG was intravenously administered prior to or during penile cancer surgery, with no restriction on language or publication status. The results extracted are presented as forest plots. RESULTS Seven studies were included in the analysis. The median sensitivity and specificity of ICG-NIR imaging for SLNM detection were 100 and 4%, respectively; the pooled sensitivity was 100.0% (95% confidence interval [CI] 97.0-100.0) and specificity was 2.0% (95% CI 1.0-3.0). There was no significant difference in the diagnostic results between different injection sites and doses in each experimental group. CONCLUSION To our knowledge, this meta-analysis is the first to summarize the diagnostic performance of ICG-NIR imaging for SLNM detection in penile cancer. ICG is sensitive in the imaging of SLN tissue, which can consequently improve the accuracy of lymph node detection. However, the specificity is very low.
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Affiliation(s)
- Rui Zhang
- Institute of Medical Technology, Peking University Health Science Center, Beijing, 100080, China
| | - Yaqin Zhang
- First Clinical Medical College, Nanjing Medical University, Nanjing, 210000, China
| | - Sihan Dong
- Institute of Medical Technology, Peking University Health Science Center, Beijing, 100080, China
| | - Kai Pang
- Instrument Science and Opto-Electronics Engineering, Beijing Information Science and Technology University, Beijing, 100192, China
| | - Xiaofeng Yang
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, 030001, China
| | - Xunbin Wei
- Institute of Medical Technology, Peking University Health Science Center, Beijing, 100080, China.
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, China.
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Sentinel lymph node biopsy in patients with T1a cutaneous malignant melanoma: A multicenter cohort study. J Am Acad Dermatol 2023; 88:52-59. [PMID: 36184008 DOI: 10.1016/j.jaad.2022.09.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/15/2022] [Accepted: 09/26/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy is not routinely recommended for T1a cutaneous melanoma due to the overall low risk of positivity. Prognostic factors for positive sentinel lymph node (SLN+) in this population are poorly characterized. OBJECTIVE To determine factors associated with SLN+ in patients with T1a melanoma. METHODS Patients with pathologic T1a (<0.80 mm, nonulcerated) cutaneous melanoma from 5 high-volume melanoma centers from 2001 to 2020 who underwent wide local excision with sentinel lymph node biopsy were included in the study. Patient and tumor characteristics associated with SLN+ were analyzed by univariate and multivariable logistic regression analyses. Age was dichotomized into ≤42 (25% quartile cutoff) and >42 years. RESULTS Of the 965 patients identified, the overall SLN+ was 4.4% (N = 43). Factors associated with SLN+ were age ≤42 years (7.5% vs 3.7%; odds ratio [OR], 2.14; P = .03), head/neck primary tumor location (9.2% vs 4%; OR, 2.75; P = .04), lymphovascular invasion (21.4% vs 4.2%; OR, 5.64; P = .01), and ≥2 mitoses/mm2 (8.2% vs 3.4%; OR, 2.31; P = .03). Patients <42 years with ≥2 mitoses/mm2 (N = 38) had a SLN+ rate of 18.4%. LIMITATIONS Retrospective study. CONCLUSION SLN+ is low in patients with T1a melanomas, but younger age, lymphovascular invasion, mitogenicity, and head/neck primary site appear to confer a higher risk of SLN+.
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Wade RG, Bailey S, Robinson AV, Lo MCI, Peach H, Moncrieff MDS, Martin J. MelRisk: Using neutrophil-to-lymphocyte ratio to improve risk prediction models for metastatic cutaneous melanoma in the sentinel lymph node. J Plast Reconstr Aesthet Surg 2022; 75:1653-1660. [PMID: 34953745 DOI: 10.1016/j.bjps.2021.11.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 09/19/2021] [Accepted: 11/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Identifying metastatic melanoma in the sentinel lymph node (SLN) is important because 80% of SLN biopsies are negative and 11% of patients develop complications. The neutrophil-to-lymphocyte ratio (NLR), a biomarker of micrometastatic disease, could improve prediction models for SLN status. We externally validated existing models and developed 'MelRisk' prognostic score to better predict SLN metastasis. METHODS The models were externally validated using data from a multicenter cohort study of 1,251 adults. Additionally, we developed and internally validated a new prognostic score `MelRisk', using candidate predictors derived from the extant literature. RESULTS The Karakousis model had a C-statistic of 0.58 (95% CI, 0.54-0.62). The Sondak model had a C-statistic of 0.57 (95% CI 0.53-0.61). The MIA model had a C-statistic of 0.60 (95% CI. 0.56-0.64). Our 'MelRisk' model (which used Breslow thickness, ulceration, age, anatomical site, and the NLR) showed an adjusted C-statistic of 0.63 (95% CI, 0.56-0.64). CONCLUSION Our prediction tool is freely available in the Google Play Store and Apple App Store, and we invite colleagues to externally validate its performance .
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Affiliation(s)
- Ryckie G Wade
- Faculty of Medicine and Health, Worsley Building, University of Leeds, Leeds, UK; Department of Plastic and Reconstructive Surgery, Leeds General Infirmary, Leeds, UK.
| | - Samuel Bailey
- Department of Plastic and Reconstructive Surgery, Leeds General Infirmary, Leeds, UK
| | - Alyss V Robinson
- Faculty of Medicine and Health, Worsley Building, University of Leeds, Leeds, UK
| | - Michelle C I Lo
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Howard Peach
- Department of Plastic and Reconstructive Surgery, Leeds General Infirmary, Leeds, UK
| | - Marc D S Moncrieff
- Department of Plastic & Reconstructive Surgery, Norfolk & Norwich University Hospital NHS Trust, Norwich, UK; Norwich Medical School, University of East Anglia, Norwich, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Huang H, Fu Z, Ji J, Huang J, Long X. Predictive Values of Pathological and Clinical Risk Factors for Positivity of Sentinel Lymph Node Biopsy in Thin Melanoma: A Systematic Review and Meta-Analysis. Front Oncol 2022; 12:817510. [PMID: 35155254 PMCID: PMC8829564 DOI: 10.3389/fonc.2022.817510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/10/2022] [Indexed: 11/25/2022] Open
Abstract
Background The indications for sentinel lymph node biopsy (SLNB) for thin melanoma are still unclear. This meta-analysis aims to determine the positive rate of SLNB in thin melanoma and to summarize the predictive value of different high-risk features for positive results of SLNB. Methods Four databases were searched for literature on SLNB performed in patients with thin melanoma published between January 2000 and December 2020. The overall positive rate and positive rate of each high-risk feature were calculated and obtained with 95% confidence intervals (CIs). Both unadjusted odds ratios (ORs) and adjusted ORs (AORs) of high-risk features were analyzed. Pooled effects were estimated using random-effects model meta-analyses. Results Sixty-six studies reporting 38,844 patients with thin melanoma who underwent SLNB met the inclusion criteria. The pooled positive rate of SLNB was 5.1% [95% confidence interval (CI) 4.9%-5.3%]. Features significantly predicted a positive result of SLNB were thickness≥0.8 mm [AOR 1.94 (95%CI 1.28-2.95); positive rate 7.0% (95%CI 6.0-8.0%)]; ulceration [AOR 3.09 (95%CI 1.75-5.44); positive rate 4.2% (95%CI 1.8-7.2%)]; mitosis rate >0/mm2 [AOR 1.63 (95%CI 1.13-2.36); positive rate 7.7% (95%CI 6.3-9.1%)]; microsatellites [OR 3.8 (95%CI 1.38-10.47); positive rate 16.6% (95%CI 2.4-36.6%)]; and vertical growth phase [OR 2.76 (95%CI 1.72-4.43); positive rate 8.1% (95%CI 6.3-10.1%)]. Conclusions The overall positive rate of SLNB in thin melanoma was 5.1%. The strongest predictor for SLN positivity identified was microsatellites on unadjusted analysis and ulceration on adjusted analysis. Breslow thickness ≥0.8 mm and mitosis rate >0/mm2 both predict SLN positivity in adjusted analysis and increase the positive rate to 7.0% and 7.7%. We suggest patients with thin melanoma with the above high-risk features should be considered for giving an SLNB.
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Affiliation(s)
- Hanzi Huang
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ziyao Fu
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiang Ji
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiuzuo Huang
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao Long
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Dreyfuss I, Kamath P, Frech F, Hernandez L, Nouri K. Squamous cell carcinoma: 2021 updated review of treatment. Dermatol Ther 2022; 35:e15308. [PMID: 34997811 DOI: 10.1111/dth.15308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 12/31/2021] [Indexed: 11/28/2022]
Abstract
Squamous cell carcinoma is the second most common cutaneous malignancy, requiring early diagnosis to prevent metastasis. Updated guidelines in the definition of clinical features, diagnostic modalities, grading, staging, surgical, and nonsurgical treatment methods are necessary. Diagnostic methods from biopsy, dermoscopy, and reflectance confocal microscopy have improved to include high-frequency ultrasonography, optical coherence tomography, and computed tomography. Non-surgical treatment methods include topical therapy, cryosurgery, photodynamic therapy, and radiation. Surgical treatment methods include surgical excision with margins and Mohs surgery. Clinical trials encourage further research to address the knowledge base of genetic variations and lymph node metastasis.
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Affiliation(s)
- Isabella Dreyfuss
- Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, Florida, USA
| | - Preetha Kamath
- Mercer University/Orange Park Medical Center/HCA Healthcare, Orange Park, Florida, USA
| | - Fabio Frech
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Loren Hernandez
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Keyvan Nouri
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida, USA
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Morrison S, Han D. Re-evaluation of Sentinel Lymph Node Biopsy for Melanoma. Curr Treat Options Oncol 2021; 22:22. [PMID: 33560505 DOI: 10.1007/s11864-021-00819-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 12/13/2022]
Abstract
OPINION STATEMENT The vast majority of patients newly diagnosed with melanoma present with clinically localized disease, and sentinel lymph node biopsy (SLNB) is a standard of care in the management of these patients, particularly in intermediate thickness cases, in order to provide important prognostic data. However, SLNB also has an important role in the management of patients with other subtypes of melanoma such as thick melanomas, certain thin melanomas, and specific histologic variants of melanoma such as desmoplastic melanoma. Furthermore, there have been technical advances in the SLNB technique, such as the development of newer radiotracers and use of SPECT/CT, and there is some data to suggest performing a SLNB may be therapeutic. Finally, the management of patients with a positive sentinel lymph node (SLN) has undergone dramatic changes over the past several years based on the results of recent important clinical trials. Treatment options for patients with SLN metastases now include surveillance, completion lymph node dissection, and adjuvant therapy with checkpoint inhibitors and targeted therapy. SLNB continues to play a crucial role in the management of patients with melanoma, allowing for risk stratification, potential regional disease control, and further treatment options for patients with a positive SLN.
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Affiliation(s)
- Steven Morrison
- Division of Surgical Oncology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Dale Han
- Division of Surgical Oncology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
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Špirić Z, Vještica M, Erić M. Survival prediction in patients with cutaneous melanoma by tumour lymphangiogenesis. Acta Clin Belg 2020; 75:379-387. [PMID: 31210586 DOI: 10.1080/17843286.2019.1629076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objectives: Melanoma induces lymphangiogenesis by secreting lymphangiogenic growth factors. The aim of this study was to examine the role of tumour lymphangiogenesis in survival of patients with cutaneous melanoma. Methods: Immunostaining of one hundred melanoma specimens was done with lymphatic-specific antibody D2-40. The quantification of tumour lymphangiogenesis - lymphatic vessel density (LVD) and lymphatic vessel area (LVA) - was calculated by computer-assisted morphometric analysis. Results: High intratumoural LVD, high peritumoural LVD, male gender, greater tumour thickness and Clark level IV/V were significantly associated with shorter disease-free survival (p= 0.001, p= 0.004, p= 0.004, p= 0.000 and p= 0.008, respectively) and melanoma-specific survival (p= 0.002, p= 0.002, p= 0.001, p= 0.000 and p= 0.017, respectively), while the trunk melanoma site was significantly associated only with shorter disease-free survival (p= 0.033). No significant association of LVA with survival was found. At multivariate analysis, peritumoural LVD [hazard ratio (HR) = 2.143, 95% confidence interval (CI) 1.097-4.189, p= 0.026)] and melanoma thickness (HR = 1.276, 95%CI 1.106-1.473, p= 0.001) were independent predictors of disease-free survival, while intratumoural LVD (HR = 3.446, 95%CI 1.465-8.109, p= 0.005), peritumoural LVD (HR = 2.742, 95%CI 1.313-5.725, p= 0.007) and gender (HR = 2.880, 95%CI 1.304-6.362, p= 0.009) were independent predictors of melanoma-specific survival. Conclusion: Тhis study shows that LVD enables better prediction of survival than melanoma thickness and other clinical-pathological parameters. Intratumoural LVD is the most significant predictor of melanoma-specific survival, while only peritumoural LVD has a significant impact on both, a disease-free survival and a melanoma-specific survival.
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Affiliation(s)
- Zorica Špirić
- Department of Nuclear Medicine and Thyroid Gland Diseases, University Clinical Centre of the Republic of Srpska, Banja Luka, Republic of Srpska, Bosnia and Herzegovina
| | - Milka Vještica
- Department of Oncology, University Clinical Centre of the Republic of Srpska, Banja Luka, Republic of Srpska, Bosnia and Herzegovina
| | - Mirela Erić
- Department of Anatomy, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
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Lee AY, Friedman EB, Sun J, Potdar A, Daou H, Farrow NE, Farley CR, Vetto JT, Han D, Tariq M, Shapiro R, Beasley G, Contreras CM, Osman I, Lowe M, Zager JS, Berman RS. The Devil's in the Details: Discrepancy Between Biopsy Thickness and Final Pathology in Acral Melanoma. Ann Surg Oncol 2020; 27:5259-5266. [PMID: 32529271 DOI: 10.1245/s10434-020-08708-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE We hypothesized that initial biopsy may understage acral lentiginous melanoma (ALM) and lead to undertreatment or incomplete staging. Understanding this possibility can potentially aid surgical planning and improve primary tumor staging. METHODS A retrospective review of primary ALMs treated from 2000 to 2017 in the US Melanoma Consortium database was performed. We reviewed pathology characteristics of initial biopsy, final excision specimens, surgical margins, and sentinel lymph node biopsy (SLNB). RESULTS We identified 418 primary ALMs (321 plantar, 34 palmar, 63 subungual) with initial biopsy and final pathology results. Median final thickness was 1.8 mm (range 0.0-19.0). There was a discrepancy between initial biopsy and final pathology thickness in 180 (43%) patients with a median difference of 1.6 mm (range 0.1-16.4). Final T category was increased in 132 patients (32%), including 47% of initially in situ, 32% of T1, 39% of T2, and 28% of T3 lesions. T category was more likely to be increased in subungual (46%) and palmar (38%) melanomas than plantar (28%, p = 0.01). Among patients upstaged to T2 or higher, 71% had ≤ 1-cm margins taken. Among the 27 patients upstaged to T1b or higher, 8 (30%) did not have a SLNB performed, resulting in incomplete initial staging. CONCLUSIONS In this large series of ALMs, final T category was frequently increased on final pathology. A high index of suspicion is necessary for lesions initially in situ or T1 and consideration should be given to performing additional punch biopsies, wider margin excisions, and/or SLNB.
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Affiliation(s)
- Ann Y Lee
- Department of Surgery, NYU Langone Health, 462 First Ave, NBV 15S6, New York, NY, 10016, USA.
| | - Erica B Friedman
- Department of Surgery, NYU Langone Health, 462 First Ave, NBV 15S6, New York, NY, 10016, USA
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Aishwarya Potdar
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Hala Daou
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Clara R Farley
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - John T Vetto
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Dale Han
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Marvi Tariq
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Richard Shapiro
- Department of Surgery, NYU Langone Health, 462 First Ave, NBV 15S6, New York, NY, 10016, USA
| | | | - Carlo M Contreras
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Iman Osman
- Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, NY, USA
| | - Michael Lowe
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Russell S Berman
- Department of Surgery, NYU Langone Health, 462 First Ave, NBV 15S6, New York, NY, 10016, USA
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Biomarkers Predictive of Survival and Response to Immune Checkpoint Inhibitors in Melanoma. Am J Clin Dermatol 2020; 21:1-11. [PMID: 31602560 DOI: 10.1007/s40257-019-00475-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Immunotherapy has revolutionized the treatment of melanoma. Targeting of the immune checkpoints cytotoxic T-lymphocyte-associated protein 4 and programmed cell death protein 1 has led to improved survival in a subset of patients. Unfortunately, the use of immune checkpoint inhibitors is associated with significant side effects and many patients do not respond to treatment. Thus, there is an urgent need both for prognostic biomarkers to estimate risk and for predictive biomarkers to determine which patients are likely to respond to therapy. In this review, prognostic and predictive biomarkers that are an active area of research are outlined. Of note, certain transcriptomic signatures are already used in the clinic, albeit not routinely, to prognosticate patients. In the predictive setting, programmed cell death protein ligand 1 expression has been shown to correlate with benefit but is not precise enough to be used as an exclusionary biomarker. Future investigation will need to focus on biomarkers that are easily reproducible, cost effective, and accurate. The use of readily available clinical material, such as serum or hematoxylin and eosin-stained images, may offer one such path forward.
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Passmore-Webb B, Gurney B, Yuen H, Sloane J, Lee J, Proctor M, Sundram F, Newlands C, Sharma S. Sentinel lymph node biopsy for melanoma of the head and neck: a multicentre study to examine safety, efficacy, and prognostic value. Br J Oral Maxillofac Surg 2019; 57:891-897. [DOI: 10.1016/j.bjoms.2019.07.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/26/2019] [Indexed: 11/25/2022]
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Friedman C, Lyon M, Torphy RJ, Thieu D, Hosokawa P, Gonzalez R, Lewis KD, Medina TM, Rioth MJ, Robinson WA, Kounalakis N, McCarter MD, Gleisner AL. A nomogram to predict node positivity in patients with thin melanomas helps inform shared patient decision making. J Surg Oncol 2019; 120:1276-1283. [PMID: 31602665 DOI: 10.1002/jso.25720] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/19/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To develop a nomogram to estimate the probability of positive sentinel lymph node (+SLN) for patients with thin melanoma and to characterize its potential impact on sentinel lymph node biopsy (SLNB) rates. METHODS Patients diagnosed with thin (0.5-1.0 mm) melanoma were identified from the National Cancer Database 2012 to 2015. A multivariable logistic regression model was used to examine factors associated with +SLN, and a nomogram to predict +SLN was constructed. Nomogram performance was evaluated and diagnostic test statistics were calculated. RESULTS Of the 21 971 patients included 10 108 (46.0%) underwent SLNB, with a 4.0% +SLN rate. On multivariable analysis, age, Breslow thickness, lymphovascular invasion, ulceration, and Clark level were significantly associated with SLN status. The area under the receiver operating curve was 0.67 (95% confidence interval, 0.65-0.70). While 15 249 (69.4%) patients had either T1b tumors or T1a tumors with at least one adverse feature, only 2846 (13.0%) had a nomogram predicted probability of a +SLN ≥5%. Using this cut-off, the indication for a SLNB in these patients would be reduced by 81.3% as compared to the American Joint Committee on Cancer 8th edition staging criteria. CONCLUSIONS The risk predictions obtained from the nomogram allow for more accurate selection of patients who could benefit from SLNB.
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Affiliation(s)
- Chloe Friedman
- Department of Surgery, University of Colorado, Aurora, Colorado
| | - Madison Lyon
- Department of Surgery, University of Colorado, Aurora, Colorado
| | - Robert J Torphy
- Department of Surgery, University of Colorado, Aurora, Colorado
| | - Daniel Thieu
- Department of Surgery, University of Colorado, Aurora, Colorado
| | - Patrick Hosokawa
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado
| | - Rene Gonzalez
- Department of Medicine, University of Colorado, Aurora, Colorado
| | - Karl D Lewis
- Department of Medicine, University of Colorado, Aurora, Colorado
| | - Theresa M Medina
- Department of Medicine, University of Colorado, Aurora, Colorado
| | - Matthew J Rioth
- Department of Medicine, University of Colorado, Aurora, Colorado
| | | | | | | | - Ana L Gleisner
- Department of Surgery, University of Colorado, Aurora, Colorado
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Dinnes J, Ferrante di Ruffano L, Takwoingi Y, Cheung ST, Nathan P, Matin RN, Chuchu N, Chan SA, Durack A, Bayliss SE, Gulati A, Patel L, Davenport C, Godfrey K, Subesinghe M, Traill Z, Deeks JJ, Williams HC. Ultrasound, CT, MRI, or PET-CT for staging and re-staging of adults with cutaneous melanoma. Cochrane Database Syst Rev 2019; 7:CD012806. [PMID: 31260100 PMCID: PMC6601698 DOI: 10.1002/14651858.cd012806.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Jacqueline Dinnes
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | | | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Seau Tak Cheung
- Dudley Hospitals Foundation Trust, Corbett HospitalDepartment of DermatologyWicarage RoadStourbridgeUKDY8 4JB
| | - Paul Nathan
- Mount Vernon HospitalMount Vernon Cancer CentreRickmansworth RoadNorthwoodUKHA6 2RN
| | - Rubeta N Matin
- Churchill HospitalDepartment of DermatologyOld RoadHeadingtonOxfordUKOX3 7LE
| | - Naomi Chuchu
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Sue Ann Chan
- City HospitalBirmingham Skin CentreDudley RdBirminghamUKB18 7QH
| | - Alana Durack
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation TrustDermatologyHills RoadCambridgeUKCB2 0QQ
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Abha Gulati
- Barts Health NHS TrustDepartment of DermatologyWhitechapelLondonUKE11BB
| | - Lopa Patel
- Royal Stoke HospitalPlastic SurgeryStoke‐on‐TrentStaffordshireUKST4 6QG
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Kathie Godfrey
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
| | - Manil Subesinghe
- King's College LondonCancer Imaging, School of Biomedical Engineering & Imaging SciencesLondonUK
| | - Zoe Traill
- Oxford University Hospitals NHS TrustChurchill Hospital Radiology DepartmentOxfordUK
| | - Jonathan J Deeks
- University of BirminghamInstitute of Applied Health ResearchBirminghamUKB15 2TT
| | - Hywel C Williams
- University of NottinghamCentre of Evidence Based DermatologyQueen's Medical CentreDerby RoadNottinghamUKNG7 2UH
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15
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Fröhlich SM, Cazzaniga S, Kaufmann LS, Hunger RE, Seyed Jafari SM. A Retrospective Cohort Study on Patients with Lentigo Maligna Melanoma. Dermatology 2019; 235:340-345. [PMID: 31112945 DOI: 10.1159/000499689] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 03/18/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND More epidemiological data about lentigo maligna melanoma (LMM) are required to define follow-up guidelines. The study focused on recurrence, progression, and overall survival of LMM managed with primary wide local excision. METHODS In a 23-year retrospective study (1994 to 2016), a cohort of patients with LMM was evaluated by collecting data about the tumor location, the Breslow depth, the presence of ulceration, and patients' age and sex. Local recurrences, locoregional and distant metastases, and disease-free and overall survival were additionally assessed. RESULTS Overall, 150 cases (84 male, 66 female, mean age 71.3 ± 11.3 years) of single, localized, primary LMM with a mean follow-up of 6.6 ± 4.4 years were included. A total of 33 (22.2%) patients underwent sentinel lymph node biopsy (SLNB) during surgical excision. However, positive SLNB was detected in none of them. The multivariable Cox analysis indicated that age of diagnosis and male gender significantly influenced the overall survival, while a shorter disease-free survival could be correlated with a greater Breslow thickness. The metastatic potential turned out to be low, entailing 7 deaths in the context of the LMM. CONCLUSION Male gender, age over 70 at diagnosis, and a Breslow thickness greater than 0.75 mm were associated with a statistically significant decrease in overall disease-free survival in the current study. The results of the study confirm the favorable outcome of LMM. However, diagnosed patients should undertake regular follow-ups. The intensity of follow-up in these patients can be individualized based on the probability of recurrence/metastasis and overall survival. Furthermore, the study showed that SLNB might not be a necessary staging procedure in patients with LMM.
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Affiliation(s)
- Selina M Fröhlich
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simone Cazzaniga
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Centro Studi GISED, Bergamo, Italy
| | - Lilian S Kaufmann
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Uniklinik Frankfurt, Frankfurt, Germany
| | - Robert E Hunger
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland,
| | - S Morteza Seyed Jafari
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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16
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Rodriguez Otero JC, Dagatti MS, Fernandez Bussy R, Bergero A, Gorosito M, Staffieri R, Villavicencio R, Batalles SM, Pezzotto SM. Sentinel Lymph Node Biopsy in Patients With Thick Primary Cutaneous Melanoma. World J Oncol 2019; 10:112-117. [PMID: 31068991 PMCID: PMC6497010 DOI: 10.14740/wjon1181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/31/2019] [Indexed: 01/02/2023] Open
Abstract
Background The clinical value of sentinel lymph node biopsy (SLNB) in patients with thick melanoma is uncertain. The purpose of this study was to investigate the correlations between survival and lymph node status in thick melanomas. Methods Of a total of 736 melanoma patients registered between 2000 and 2016, 50 presented with thick melanomas (≥ 4.0 mm) without distant metastatic disease. All patients were examined with a whole-body magnetic resonance imaging, or computed tomography, and positron emission tomography-computed tomography depending on the incorporation of the new technology in our medical institutions. They were studied according to the following procedure: 1) preoperative determination of regional lymph node along with the estimation and localization of sentinel lymph node (SLN) (dynamic isotope lymphography); 2) intraoperative localization and SLNB (lymphatic mapping); and 3) histopathology. Patient and tumor features were collected. Results Mean follow-up was 40 months, and 37% had a follow-up ≥ 5 years. A positive SLN was identified in 28 patients (56%). No significant difference in melanoma-specific overall survival was observed in terms of the primary tumor site. Hazard ratios (HRs) were statistically significant for SLNB-positive group and mitotic rate (MR) > 3 mm2, but not for presence of ulceration. Mortality risk in the SLN-positive group was almost fourfold greater than that in the SLN-negative group at any time of follow-up. Conclusions SLN status, along with MR, can provide valuable prognostic information in patients with thick primary cutaneous melanoma.
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Affiliation(s)
| | - Maria Susana Dagatti
- School of Medicine, National University of Rosario, Santa Fe 3100, 2000 Rosario, Argentina
| | - Ramon Fernandez Bussy
- School of Medicine, National University of Rosario, Santa Fe 3100, 2000 Rosario, Argentina
| | - Adriana Bergero
- School of Medicine, National University of Rosario, Santa Fe 3100, 2000 Rosario, Argentina
| | - Mario Gorosito
- School of Medicine, National University of Rosario, Santa Fe 3100, 2000 Rosario, Argentina
| | - Roberto Staffieri
- Rosario Cardiovascular Institute, Bv. Orono 450, 2000 Rosario, Argentina
| | | | | | - Stella Maris Pezzotto
- School of Medicine, National University of Rosario, Santa Fe 3100, 2000 Rosario, Argentina
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17
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Conic RRZ, Ko J, Damiani G, Funchain P, Knackstedt T, Vij A, Vidimos A, Gastman BR. Predictors of sentinel lymph node positivity in thin melanoma using the National Cancer Database. J Am Acad Dermatol 2019; 80:441-447. [PMID: 30240775 DOI: 10.1016/j.jaad.2018.08.051] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 08/26/2018] [Accepted: 08/29/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) specimens are often obtained from patients for further staging after these patients have undergone melanoma excision. Limited data regarding predictors of SLNB positivity in thin melanoma are available. OBJECTIVE We sought to evaluate predictors of SLNB positivity in thin melanoma. METHODS Patients with cutaneous melanoma with a Breslow thickness ≤1.00 mm who received a SLNB were identified from the National Cancer Database between 2004 and 2014 (n = 9186). Predictors of SLNB positivity were analyzed using logistic regression. RESULTS In a multivariate analysis, patients <60 years of age (P < .001) and Breslow thickness >0.8 mm (P = .03) were at increased risk for positive sentinel lymph node (SLN). Moreover, on multivariate analysis, the presence of dermal mitoses increased the odds of SLN positivity by 95% (odds ratio [OR] 1.95 [95% confidence interval {CI} 1.53-2.5], P < .001), ulceration by 63% (OR 1.63 [95% CI 1.21-2.18], P < .001), and Clark level IV to V by 48% (OR 1.48 [95% CI 1.19-1.85]). Patients without ulceration but with dermal mitoses had 92% (OR 1.92 [95% CI 1.5-2.48], P < .001) increased SLN positivity. LIMITATIONS Limited survival data are available. CONCLUSIONS Younger age, a Breslow thickness >0.8 mm, the presence of dermal mitoses, ulceration, and Clark level IV to V are positive predictors of positive SLN. While the new American Joint Committee on Cancer system has removed dermal mitotic rate from staging, continued evaluation of dermal mitotic rate could be valuable for guiding surgical decision making about SLNB.
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Affiliation(s)
- Rosalynn R Z Conic
- Department of Dermatology and Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Jennifer Ko
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Giovanni Damiani
- Department of Dermatology and Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Pauline Funchain
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Thomas Knackstedt
- Department of Dermatology and Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alok Vij
- Department of Dermatology and Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Allison Vidimos
- Department of Dermatology and Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Brian R Gastman
- Department of Dermatology and Plastic Surgery, Cleveland Clinic, Cleveland, Ohio.
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18
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Bartlett EK. Current management of regional lymph nodes in patients with melanoma. J Surg Oncol 2018; 119:200-207. [PMID: 30481384 DOI: 10.1002/jso.25316] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/11/2018] [Indexed: 01/19/2023]
Abstract
The publication of recent randomized trials has prompted a significant shift in both our understanding and the management of patients with melanoma. Here, the current management of the regional lymph nodes in patients with melanoma is discussed. This review focuses on selection for sentinel lymph node biopsy, management of the positive sentinel node, management of the clinically positive node, and the controversy over the therapeutic value of early nodal intervention.
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Affiliation(s)
- Edmund K Bartlett
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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19
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Vertical Growth Phase as a Prognostic Factor for Sentinel Lymph Node Positivity in Thin Melanomas: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2018; 141:1529-1540. [PMID: 29579032 DOI: 10.1097/prs.0000000000004395] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The 2010 American Joint Committee on Cancer guidelines recommended consideration of sentinel lymph node biopsy for thin melanoma (Breslow thickness <1.0 mm) with aggressive pathologic features such as ulceration and/or high mitotic rate. The therapeutic benefit of biopsy-based treatment remains controversial. The authors conducted a meta-analysis to estimate the risk and outcomes of sentinel lymph node positivity in thin melanoma, and examined established and potential novel predictors of positivity. METHODS Three databases were searched by two independent reviewers for sentinel lymph node positivity in patients with thin melanoma. Study heterogeneity, publication bias, and quality were assessed. Data collected included age, sex, Breslow thickness, mitotic rate, ulceration, regression, Clark level, tumor-infiltrating lymphocytes, and vertical growth phase. Positivity was estimated using a random effects model. Association of positivity and clinicopathologic features was investigated using meta-regression. RESULTS Ninety-three studies were identified representing 35,276 patients with thin melanoma who underwent sentinel lymph node biopsy. Of these patients, 952 had a positive sentinel lymph node biopsy, for an event rate of 5.1 percent (95 percent CI, 4.1 to 6.3 percent). Significant associations were identified between positivity and Breslow thickness greater than 0.75 mm but less than 1.0 mm, mitotic rate, ulceration, and Clark level greater than IV. Seven studies reported on vertical growth phase, which was strongly associated with positivity (OR, 4.3; 95 percent CI, 2.5 to 7.7). CONCLUSIONS To date, this is the largest meta-analysis to examine predictors of sentinel lymph node biopsy positivity in patients with thin melanoma. Vertical growth phase had a strong association with biopsy positivity, providing support for its inclusion in standardized pathologic reporting.
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Mehralivand S, van der Poel H, Winter A, Choyke PL, Pinto PA, Turkbey B. Sentinel lymph node imaging in urologic oncology. Transl Androl Urol 2018; 7:887-902. [PMID: 30456192 PMCID: PMC6212622 DOI: 10.21037/tau.2018.08.23] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/19/2018] [Indexed: 12/15/2022] Open
Abstract
Lymph node (LN) metastases in urological malignancies correlate with poor oncological outcomes. Accurate LN staging is of great importance since patients can benefit from an optimal staging, accordingly aligned therapy and more radical treatments. Current conventional cross-sectional imaging modalities [e.g., computed tomography (CT) and magnetic resonance imaging (MRI)] are not accurate enough to reliably detect early LN metastases as they rely on size criteria. Radical lymphadenectomy, the surgical removal of regional LNs, is the gold standard of invasive LN staging. The LN dissection is guided by anatomic considerations of lymphatic drainage pathways of the primary tumor. Selection of patients for lymphadenectomy heavily relies on preoperative risk stratification and nomograms and, as a result a considerable number of patients unnecessarily undergo invasive staging with associated morbidity. On the other hand, due to individual variability in lymphatic drainage, LN metastases can occur outside of standard lymphadenectomy templates leading to potential understaging and undertreatment. In theory, metastases from the primary tumor need to pass through the chain of LNs, where the initial node is defined as the sentinel LN. In theory, identifying and removing this LN could lead to accurate assessment of metastatic status. Radiotracers and more recently fluorescent dyes and superparamagnetic iron oxide nanoparticles (SPION) are injected into the primary tumor or peritumoral and the sentinel LNs are identified intraoperatively by a gamma probe, fluorescent camera or a handheld magnetometer. Preoperative imaging [e.g., single-photon emission computed tomography (SPECT)/CT or MRI] after tracer injection can further improve preoperative planning of LN dissection. While sentinel LN biopsy is an accepted and widely used approach in melanoma and breast cancer staging, its use in urological malignancies is still limited. Most data published so far is in penile cancer staging since this cancer has a typical echelon-based lymphatic metastasizing pattern. More recent data is encouraging with low false-negative rates, but its use is limited to centers with high expertise. Current guidelines recommend sentinel LN biopsy as an accepted alternative to modified inguinal lymphadenectomy in patients with pT1G2 disease and non-palpable inguinal LNs. In prostate cancer, a high diagnostic accuracy could be demonstrated for the sentinel approach. Nevertheless, due to lack of data or high false-negative rates in other urological malignancies, sentinel LN biopsy is still considered experimental in other urological malignancies. More high-level evidence and longitudinal data is needed to determine its final value in those malignancies. In this manuscript, we will review sentinel node imaging for urologic malignancies.
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Affiliation(s)
- Sherif Mehralivand
- Department of Urology and Pediatric Urology, University Medical Center, Mainz, Germany
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Henk van der Poel
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Alexander Winter
- University Hospital for Urology, Oldenburg Hospital, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Peter L. Choyke
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Peter A. Pinto
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Baris Turkbey
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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21
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Isaksson K, Nielsen K, Mikiver R, Nieweg OE, Scolyer RA, Thompson JF, Ingvar C. Sentinel lymph node biopsy in patients with thin melanomas: Frequency and predictors of metastasis based on analysis of two large international cohorts. J Surg Oncol 2018; 118:599-605. [DOI: 10.1002/jso.25208] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/26/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Karolin Isaksson
- Department of Clinical Sciences Lund, Surgery; Lund University, Skåne University Hospital; Lund Sweden
| | - Kari Nielsen
- Department of Clinical Sciences Lund, Dermatology; Lund University, Helsingborg Hospital; Helsingborg Sweden
| | - Rasmus Mikiver
- Department of Clinical and Experimental Medicine; Regional Cancer Center South East Sweden, Linköping University; Linköping Sweden
| | - Omgo E. Nieweg
- Melanoma Institute Australia, The University of Sydney; Sydney New South Wales Australia
- Sydney Medical School, The University of Sydney; Sydney New South Wales Australia
- Departments of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital; Camperdown New South Wales Australia
| | - Richard A. Scolyer
- Melanoma Institute Australia, The University of Sydney; Sydney New South Wales Australia
- Sydney Medical School, The University of Sydney; Sydney New South Wales Australia
- Departments of Tissue Pathology and Diagnostic Oncolocy, Royal Prince Alfred Hospital; Camperdown New South Wales Australia
| | - John F. Thompson
- Melanoma Institute Australia, The University of Sydney; Sydney New South Wales Australia
- Sydney Medical School, The University of Sydney; Sydney New South Wales Australia
- Departments of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital; Camperdown New South Wales Australia
| | - Christian Ingvar
- Department of Clinical Sciences Lund, Surgery; Lund University, Skåne University Hospital; Lund Sweden
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Chiaravalloti AJ, Jinna S, Kerr PE, Whalen J, Grant-Kels JM. A deep look into thin melanomas: What's new for the clinician and the impact on the patient. Int J Womens Dermatol 2018; 4:119-121. [PMID: 30175212 PMCID: PMC6116825 DOI: 10.1016/j.ijwd.2018.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 01/31/2018] [Indexed: 11/29/2022] Open
Abstract
Melanoma incidence and mortality are on the rise and although most new cases of melanoma are thin, a significant percentage of these patients still experience disease progression. The American Joint Committee on Cancer publishes staging criteria for melanoma, which were recently updated to the 8th edition. The most significant revision from the 7th edition affects the T1b classification, which now includes melanomas with a Breslow depth of 0.8 mm to 1.0 mm. The second major revision eliminates mitoses as a criterion to upstage a thin melanoma to T1b. Although mitotic figures have been established as an independent prognostic factor, they do not have a significant correlation with sentinel lymph node (SLN) biopsy positivity. SLN status remains the most important independent prognostic factor in thin melanomas. Nonetheless, the identification of patients who are at the highest risk for having a positive SLN test result remains difficult. Importantly, a positive SLN test result has high positive predictive value, but a negative one has very low negative predictive value. Since there is no proven survival benefit in performing an SLN biopsy in T1 disease, dermatologists need to have a personalized discussion with patients with thin melanomas to review expected risks and benefits before undertaking this procedure.
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Affiliation(s)
- A J Chiaravalloti
- University of Connecticut Health Center, Department of Dermatology, Farmington, Connecticut
| | - S Jinna
- University of Connecticut Health Center, Department of Dermatology, Farmington, Connecticut
| | - P E Kerr
- University of Connecticut Health Center, Department of Dermatology, Farmington, Connecticut
| | - J Whalen
- University of Connecticut Health Center, Department of Dermatology, Farmington, Connecticut
| | - J M Grant-Kels
- University of Connecticut Health Center, Department of Dermatology, Farmington, Connecticut
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Evrard D, Routier E, Mateus C, Tomasic G, Lombroso J, Kolb F, Robert C, Moya-Plana A. Sentinel lymph node biopsy in cutaneous head and neck melanoma. Eur Arch Otorhinolaryngol 2018; 275:1271-1279. [PMID: 29552728 DOI: 10.1007/s00405-018-4934-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/13/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Sentinel lymph node biopsy (SLNB) is now a standard of care for cutaneous melanoma, but it is still controversial for cutaneous head and neck melanoma (CHNM). This study aims to confirm the feasibility, accuracy and low morbidity of SLNB in CHNM and evaluate its prognostic value. METHODS A monocentric and retrospective study on patients with CHNM treated in our tertiary care center (Gustave Roussy) between January 2008 and December 2012 was performed. The feasibility, morbidity and prognostic value of this technique were analysed. RESULTS One hundred and twenty-four consecutive patients were included. SLNB was realized in 97.6% of the cases. No significant post-operative morbidity was observed. Nineteen percents of patients had a positive SN while only 14.3% of complete lymph node dissections (CLND) had additional nodal metastasis. The risk of recurrence after positive SN was significantly higher (69.2 vs 30.8%, p = 0.043). The false omission rate was low with 7.1%. Overall survival and disease-free survival were better in the negative SN group (82 vs 49%, p < 0.001 and 69.3 vs 41.8%, p = 0.0131). The risk of recurrence was significantly higher in the positive SN group (p = 0.043) and when primary tumour was ulcerated (p = 0.031). Only the mitotic rate of the primary tumour was associated with SN positivity (p = 0.049). CONCLUSION As in other sites, SLNB status is a strong prognostic factor with comparable false omission rate and no superior morbidity.
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Affiliation(s)
- D Evrard
- Head and Neck Surgery Department, Gustave Roussy Cancer Campus, Paris Sud University, Villejuif, France.
| | - E Routier
- Onco-dermatology Department, Gustave Roussy Cancer Campus, Paris Sud University, Saclay University, Villejuif, France
| | - C Mateus
- Onco-dermatology Department, Gustave Roussy Cancer Campus, Paris Sud University, Saclay University, Villejuif, France
| | - G Tomasic
- Pathology Department, Gustave Roussy Cancer Campus, Paris Sud University, Villejuif, France
| | - J Lombroso
- Nuclear Medicine Department, Gustave Roussy Cancer Campus, Paris Sud University, Villejuif, France
| | - F Kolb
- Plastic and Reconstructive Surgery Department, Gustave Roussy Cancer Campus, Paris Sud University, Villejuif, France
| | - C Robert
- Onco-dermatology Department, Gustave Roussy Cancer Campus, Paris Sud University, Saclay University, Villejuif, France
| | - A Moya-Plana
- Head and Neck Surgery Department, Gustave Roussy Cancer Campus, Paris Sud University, Villejuif, France
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Joyce KM, McInerney NM, Piggott RP, Martin F, Jones DM, Hussey AJ, Kerin MJ, Kelly JL, Regan PJ. Analysis of sentinel node positivity in primary cutaneous melanoma: an 8-year single institution experience. Ir J Med Sci 2017; 186:847-853. [PMID: 28132159 DOI: 10.1007/s11845-017-1559-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 01/11/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is a standard method for determining the pathologic status of the regional lymph nodes. AIMS The aim of our study was to determine the incidence and clinicopathologic factors predictive of SLN positivity, and to evaluate the prognostic importance of SLNB in patients with cutaneous melanoma. METHODS We performed a retrospective analysis of a prospectively maintained database of all patients who underwent SLNB for primary melanoma at our institution from 2005 to 2012. Statistical analysis was performed using χ 2 and Fischer exact test. RESULTS In total, 318 patients underwent SLNB, of which 65 were for thin melanoma (≤1 mm). There were 36 positive SLNB, 278 negative SLNB and in four cases the SLN was not located. The incidence rate for SLNB was 11.3% overall and 1.5% in thin melanomas alone. Statistical analysis identified Breslow thickness >1 mm (P = 0.006), Clark level ≥ IV (P = 0.004) and age <75 years (P = 0.035) as the strongest predictors of SLN positivity. Our overall false negativity rate was 20% (9/45) with one case of false-negative SLNB in thin melanomas. CONCLUSION Breslow thickness of the primary tumour remains the strongest predictor of SLN positivity. Our findings point to a possible limited role for SLNB in thin melanoma due to its low positivity rate, associated false-negative rate and related morbidity.
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Affiliation(s)
- K M Joyce
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland.
| | - N M McInerney
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - R P Piggott
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - F Martin
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - D M Jones
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - A J Hussey
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - M J Kerin
- Department of Surgery, Clinical Science Institute, Galway University Hospital, Galway, Ireland
| | - J L Kelly
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - P J Regan
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
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Sinnamon AJ, Neuwirth MG, Yalamanchi P, Gimotty P, Elder DE, Xu X, Kelz RR, Roses RE, Chu EY, Ming ME, Fraker DL, Karakousis GC. Association Between Patient Age and Lymph Node Positivity in Thin Melanoma. JAMA Dermatol 2017; 153:866-873. [PMID: 28724122 DOI: 10.1001/jamadermatol.2017.2497] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance More than half of all new melanoma diagnoses present as clinically localized T1 melanoma, yet sentinel lymph node biopsy (SLNB) is controversial in this population given the overall low yield. Guidelines for SLNB have focused on pathologic factors, but patient factors, such as age, are not routinely considered. Objectives To identify indicators of lymph node (LN) metastasis in thin melanoma in a large, generalizable data set and to evaluate the association between patient age and LN positivity. Design, Setting, and Participants A retrospective cohort study using the National Cancer Database, an oncology database representing patients from more than 1500 hospitals throughout the United States, was performed (2010-2013). Data analysis was conducted from October 1, 2016, to January 15, 2017. A total of 8772 patients with clinical stage I 0.50 to 1.0 mm thin melanoma undergoing wide excision and surgical evaluation of regional LNs were included for study. Main Outcome and Measures The primary outcome of interest was presence of melanoma in a biopsied regional LN. Clinicopathologic factors associated with LN positivity were characterized, using logistic regression. Age was categorized as younger than 40 years, 40 to 64 years, and 65 years or older for multivariable analysis. Classification tree analysis was performed to identify high-risk groups for LN positivity. Results Among the study cohort (n = 8772), 333 patients had nodal metastases, for an overall positivity rate of 3.8% (95% CI, 3.4%-4.2%). A total of 4087 (54.0%) patients were women. Median age was 56 years (interquartile range [IQR], 46-67) in patients with negative LNs and 52 years (IQR, 41-61) in those with positive LNs (P < .001). In multivariable analysis, younger age, female sex, thickness of 0.76 mm or larger, increasing Clark level, mitoses, ulceration, and lymphovascular invasion were independently associated with LN positivity. In decision tree analysis, patient age was identified as an important risk stratifier for LN metastases, after mitoses and thickness. Patients younger than 40 years with category T1b tumors 0.50 to 0.75 mm, who would generally not be recommended for SLNB, had an LN positivity rate of 5.6% (95% CI, 3.3%-8.6%); conversely, patients 65 years or older with T1b tumors 0.76 mm or larger, who would generally be recommended for SLNB, had an LN positivity rate of only 3.9% (95% CI, 2.7%-5.3%). Conclusions and Relevance Patient age is an important factor in estimating lymph node positivity in thin melanoma independent of traditional pathologic factors. Age therefore should be taken into consideration when selecting patients for nodal biopsy.
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Affiliation(s)
- Andrew J Sinnamon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Madalyn G Neuwirth
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | | | - Phyllis Gimotty
- Department of Biostatics and Epidemiology, University of Pennsylvania, Philadelphia
| | - David E Elder
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia
| | - Xiaowei Xu
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Emily Y Chu
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Michael E Ming
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia
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Dinnes J, Saleh D, Newton-Bishop J, Cheung ST, Nathan P, Matin RN, Chuchu N, Bayliss SE, Takwoingi Y, Davenport C, Godfrey K, O'Sullivan C, Deeks JJ, Williams HC. Tests to assist in the staging of cutaneous melanoma: a generic protocol. Hippokratia 2017. [DOI: 10.1002/14651858.cd012806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Jacqueline Dinnes
- University of Birmingham; Institute of Applied Health Research; Birmingham UK B15 2TT
| | - Daniel Saleh
- Newcastle Hospitals NHS Trust, Royal Victoria Infirmary; Newcastle Hospitals; Newcastle UK
| | - Julia Newton-Bishop
- University of Leeds; Section of Epidemiology and Biostatistics; St James's Hospital Leeds UK LS9 7TF
| | - Seau Tak Cheung
- Dudley Hospitals Foundation Trust, Corbett Hospital; Department of Dermatology; Wicarage Road Stourbridge UK DY8 4JB
| | - Paul Nathan
- Mount Vernon Hospital; Mount Vernon Cancer Centre; Rickmansworth Road Northwood UK HA6 2RN
| | - Rubeta N Matin
- Churchill Hospital; Department of Dermatology; Old Road Headington Oxford UK OX3 7LJ
| | - Naomi Chuchu
- University of Birmingham; Institute of Applied Health Research; Birmingham UK B15 2TT
| | - Susan E Bayliss
- University of Birmingham; Institute of Applied Health Research; Birmingham UK B15 2TT
| | - Yemisi Takwoingi
- University of Birmingham; Institute of Applied Health Research; Birmingham UK B15 2TT
| | - Clare Davenport
- University of Birmingham; Institute of Applied Health Research; Birmingham UK B15 2TT
| | - Kathie Godfrey
- The University of Nottingham; c/o Cochrane Skin Group; Nottingham UK
| | | | - Jonathan J Deeks
- University of Birmingham; Institute of Applied Health Research; Birmingham UK B15 2TT
| | - Hywel C Williams
- The University of Nottingham; Centre of Evidence Based Dermatology; Queen's Medical Centre Derby Road Nottingham UK NG7 2UH
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27
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Histopathologic review of negative sentinel lymph node biopsies in thin melanomas: an argument for the routine use of immunohistochemistry. Melanoma Res 2017; 27:369-376. [DOI: 10.1097/cmr.0000000000000361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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28
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Eigentler TK, Mühlenbein C, Follmann M, Schadendorf D, Garbe C. S3-Leitlinie Diagnostik, Therapie und Nachsorge des Melanoms - Update 2015/2016, Kurzversion 2.0. J Dtsch Dermatol Ges 2017; 15:e1-e41. [DOI: 10.1111/ddg.13247] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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29
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Madu M, Wouters M, van Akkooi A. Sentinel node biopsy in melanoma: Current controversies addressed. Eur J Surg Oncol 2017; 43:517-533. [DOI: 10.1016/j.ejso.2016.08.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 12/17/2022] Open
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Lonergan PE, Nic An Riogh A, O'Kelly F, Lundon DJ, O'Sullivan D, O'Connell M, Hegarty PK. Dynamic sentinel node biopsy for penile cancer: an initial experience in an Irish Hospital. Ir J Med Sci 2017; 186:841-845. [PMID: 28102480 DOI: 10.1007/s11845-017-1558-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/11/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The presence of nodal metastases is the single most important prognostic factor in penile cancer. However, reliable assessment of nodal status in clinically node-negative (cN0) patients poses a challenge. Approximately 20% of these patients harbour occult nodal metastases. Currently available non-invasive radiological investigations are unreliable in excluding micrometastatic disease. AIM Dynamic sentinel node biopsy (DSNB) is a minimally invasive procedure for assessing lymph node involvement. We report our initial experience with DSNB in assessing the status of regional lymph nodes in cN0 penile cancer patients. METHODS DSNB was performed in penile cancer patients with at least one cN0 groin. All patients undergoing DSNB at our institution were included. Lymphoscintigraphic images were obtained from all patients, after intradermal, peritumoral injection of a Technetium-99m nanocolloid. The sentinel nodes were defined as the nodes identified on lymphoscintigraphy, which were also radioactive intraoperatively using a gamma probe. RESULTS In total, 18 groins from 11 patients underwent DSNB. Of these, 11 patients underwent bilateral DSNB and 4 had unilateral DSNB. The mean (range) age of patients at the time of presentation of their primary tumour was 63 (39-78) years. A mean of 1.2 nodes per groin was retrieved. One lymph node was positive in one patient, who subsequently underwent a bilateral inguinal lymph node dissection. Overall, the median (range) follow-up was 12.8 (2.7-31.3) months with no local or regional recurrences. CONCLUSION Further cases and longer follow-up will define the accuracy of this technique in the Irish population.
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Affiliation(s)
- P E Lonergan
- Department of Urology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
| | - A Nic An Riogh
- Department of Urology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
| | - F O'Kelly
- Department of Urology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
| | - D J Lundon
- Department of Urology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
| | - D O'Sullivan
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - M O'Connell
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - P K Hegarty
- Department of Urology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.,Mater Private Hospital, Dublin, Ireland.,Mater Private Hospital, Cork, Ireland
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31
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Madu M, Wouters MWJM, van Akkooi ACJ. Reply to "Current controversies on sentinel node biopsy in thin and thick cutaneous melanoma". Eur J Surg Oncol 2016; 43:508. [PMID: 27847285 DOI: 10.1016/j.ejso.2016.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 10/21/2016] [Indexed: 11/18/2022] Open
Affiliation(s)
- M Madu
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - M W J M Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - A C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
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Karakousis G, Gimotty PA, Bartlett EK, Sim MS, Neuwirth MG, Fraker D, Czerniecki BJ, Faries MB. Thin Melanoma with Nodal Involvement: Analysis of Demographic, Pathologic, and Treatment Factors with Regard to Prognosis. Ann Surg Oncol 2016; 24:952-959. [PMID: 27807729 DOI: 10.1245/s10434-016-5646-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although only a small proportion of thin melanomas result in lymph node metastasis, the abundance of these lesions results in a relatively large absolute number of patients with a diagnosis of nodal metastases, determined by either sentinel lymph node (SLN) biopsy or clinical nodal recurrence (CNR). METHODS Independent cohorts with thin melanoma and either SLN metastasis or CNR were identified at two melanoma referral centers. At both centers, SLN metastasis patients were included. At center 1, the CNR cohort included patients with initial negative clinical nodal evaluation followed by CNR. At center 2, the CNR cohort was restricted to those presenting in the era before the use of SLN biopsy. Uni- and multivariable analyses of melanoma-specific survival (MSS) were performed. RESULTS At center 1, 427 CNR patients were compared with 91 SLN+ patients. The 5- and 10-year survival rates in the SLN group were respectively 88 and 84 % compared with 72 and 49 % in the CNR group (p < 0.0001). The multivariate analysis showed age older than 50 years (hazard ratio [HR] 1.5; 95 % confidence interval [CI] 1.2-1.9), present ulceration (HR 1.9; 95 % CI 1.2-2.9), unknown ulceration (HR 1.6; 95 % CI 1.3-2.1), truncal site (HR 1.6; 95 % CI 1.2-2.2), and CNR (HR 3.3; 95 % CI 1.8-6.0) to be associated significantly with decreased MSS (p < 0.01 for each). The center 2 cohort demonstrated remarkably similar findings, with a 5-year MSS of 88 % in the SLN (n = 29) group and 76 % in the CNR group (n = 39, p = 0.09). CONCLUSION Patients with nodal metastases from thin melanomas have a substantial risk of melanoma death. This risk is lower among patients whose disease is discovered by SLN biopsy rather than CNR.
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Affiliation(s)
- Giorgos Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Phyllis A Gimotty
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Edmund K Bartlett
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Madalyn G Neuwirth
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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El Muntasar A, Oudit D. Lymphoscintigraphy mapping of truncal malignant melanoma: A study of 212 patients at the Christie NHS Foundation Trust. J Plast Reconstr Aesthet Surg 2016; 70:37-39. [PMID: 27693272 DOI: 10.1016/j.bjps.2016.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 08/03/2016] [Accepted: 08/31/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE Malignant melanoma (MM) on the trunk, because of its anatomical location, has multiple potential lymphatic basins to which to drain. The aim of this study is to map the location of the sentinel lymph node (SLN) on the basis of the anatomical location of the primary malignant melanoma on the trunk. METHODS Patients diagnosed with MM on the trunk who had undergone a SLN biopsy from January 2006 to March 2015 were identified in the Christie NHS Foundation Trust through a computer database search. The anterior and posterior surfaces of the trunk were divided into four sections each. RESULTS A total of 212 patients were evaluated. MM was more common on the posterior trunk, accounting for 73% of cases, and 57% of melanomas were on the right side of the trunk. The axillary basins were involved in drainage in 91.5% of all truncal melanomas. Drainage was to a single lymphatic basin in 68.3% of cases. The incidence of drainage to multiple lymphatic basins was not uniform for the anterior and posterior surfaces of the trunks. CONCLUSION One-third of MM on the posterior surface of the trunk will drain to multiple basins. Around 50% of the melanomas of the upper back drain to a contralateral basin. Independent of the location of the MM, the axillary basins were the most common location of drainage, with a total of 91% of the cohort. Therefore, the location of the SLN could be predicted, depending on the location of the MM on the trunk.
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Affiliation(s)
- Ahmed El Muntasar
- School of Medicine, University of Manchester, Oxford Rd, Manchester, M13 9PT, United Kingdom; Plastic Surgery Department, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, United Kingdom.
| | - Deems Oudit
- School of Medicine, University of Manchester, Oxford Rd, Manchester, M13 9PT, United Kingdom; Plastic Surgery Department, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, United Kingdom
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Han D, Thomas DC, Zager JS, Pockaj B, White RL, Leong SPL. Clinical utilities and biological characteristics of melanoma sentinel lymph nodes. World J Clin Oncol 2016; 7:174-188. [PMID: 27081640 PMCID: PMC4826963 DOI: 10.5306/wjco.v7.i2.174] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/05/2015] [Accepted: 02/16/2016] [Indexed: 02/06/2023] Open
Abstract
An estimated 73870 people will be diagnosed with melanoma in the United States in 2015, resulting in 9940 deaths. The majority of patients with cutaneous melanomas are cured with wide local excision. However, current evidence supports the use of sentinel lymph node biopsy (SLNB) given the 15%-20% of patients who harbor regional node metastasis. More importantly, the presence or absence of nodal micrometastases has been found to be the most important prognostic factor in early-stage melanoma, particularly in intermediate thickness melanoma. This review examines the development of SLNB for melanoma as a means to determine a patient’s nodal status, the efficacy of SLNB in patients with melanoma, and the biology of melanoma metastatic to sentinel lymph nodes. Prospective randomized trials have guided the development of practice guidelines for use of SLNB for melanoma and have shown the prognostic value of SLNB. Given the rapidly advancing molecular and surgical technologies, the technical aspects of diagnosis, identification, and management of regional lymph nodes in melanoma continues to evolve and to improve. Additionally, there is ongoing research examining both the role of SLNB for specific clinical scenarios and the ways to identify patients who may benefit from completion lymphadenectomy for a positive SLN. Until further data provides sufficient evidence to alter national consensus-based guidelines, SLNB with completion lymphadenectomy remains the standard of care for clinically node-negative patients found to have a positive SLN.
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35
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Hafström A, Romell A, Ingvar C, Wahlberg P, Greiff L. Sentinel lymph node biopsy staging for cutaneous malignant melanoma of the head and neck. Acta Otolaryngol 2016; 136:312-8. [PMID: 26767628 DOI: 10.3109/00016489.2015.1113559] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Conclusion Sentinel lymph node biopsies (SLNBs) can be performed safely and with reasonable accuracy in HNM patients. The outcome provides important prognostic information concerning DFS and further treatment. However, one must recognize that SLNB is a multidisciplinary procedure with a learning curve for all. Objectives To evaluate efficacy of performing SLNBs in a series of consecutive patients with cutaneous head and neck melanoma (HNM) ≥ T1b from introduction of the procedure and 10 years onward. Method End-points comprised of SLNB outcome, disease-free survival (DFS), and overall survival (OS). Results SNs were harvested in 128 of 160 patients (median Breslow = 2.0 mm, 29% ulcerated); success rate = 80.0%, or 92.1% if excluding patients where SLNBs were omitted due to non-localization on pre-operative imaging or because of SN-location in the parotid basin. Ten patients (7.8%) had positive SLNBs and were offered early completion neck dissections. Of the 146 patients available for follow-up (median = 27 months), 15.8% had recurrent disease. The risk of a regional nodal recurrence after a negative SLNB was 7.5%. SN-negative patients had improved DFS c.f. SN-positive patients (p < 0.001). A positive SLNB was the most important prognostic predictor of decreased DFS (hazard ratio = 5.70; p < 0.005), but had no significant impact on OS.
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Affiliation(s)
- Anna Hafström
- a Department of ORL, Head & Neck Surgery , Skåne University Hospital , Lund , Sweden
| | - Anton Romell
- a Department of ORL, Head & Neck Surgery , Skåne University Hospital , Lund , Sweden
| | - Christian Ingvar
- b Department of Surgery , Skåne University Hospital , Lund , Sweden
| | - Peter Wahlberg
- a Department of ORL, Head & Neck Surgery , Skåne University Hospital , Lund , Sweden
| | - Lennart Greiff
- a Department of ORL, Head & Neck Surgery , Skåne University Hospital , Lund , Sweden
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Abstract
The surgical management of melanoma has undergone considerable changes over the past several decades, as new strategies and treatments have become available. Surgeons play a pivotal role in all aspects of melanoma care: diagnostic, curative, and palliative. There is a high potential for cure in patients with early-stage melanoma and the selection of an appropriate operation is very important for this reason. Staging the nodal basin has become widespread since the adoption of sentinel lymph node biopsy (SLNB) for the management of melanoma. This operation provides the best prognostic information that is currently available for patients with melanoma. The surgeon plays a central role in the palliation of symptoms resulting from nodal disease and metastases, as melanoma has a propensity to spread to almost any site in the body.
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Affiliation(s)
- Vadim P Koshenkov
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St., Suite 3001, New Brunswick, NJ, 08901, USA.
| | - Joe Broucek
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St., Suite 3001, New Brunswick, NJ, 08901, USA
| | - Howard L Kaufman
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St., Suite 3001, New Brunswick, NJ, 08901, USA
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Abstract
The current American Joint Commission for Cancer staging system for melanoma includes thickness, ulceration, and mitotic index as primary tumor factors for patients with stage I and II disease. Number and size of nodal metastases, presence of satellitosis and in-transit disease, and tumor ulceration status categorize patients with stage III disease. Presence and location of distant metastatic disease and increased lactate dehydrogenase level stratify prognosis in patients with stage IV disease. Factors predictive of sentinel lymph node positivity are also studied, particularly in patients with T1 melanomas, but are not always congruent with those predictive of survival.
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Affiliation(s)
- Edmund K Bartlett
- Department of Surgery, University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, Pennsylvania 19104, USA
| | - Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, Pennsylvania 19104, USA.
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Thin melanomas (<1 mm) and new NICE guidance for sentinel lymph node biopsy. J Plast Reconstr Aesthet Surg 2015; 69:285-6. [PMID: 26626197 DOI: 10.1016/j.bjps.2015.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 10/12/2015] [Indexed: 11/23/2022]
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39
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Zuluaga-Sepúlveda MA, Arellano-Mendoza I, Ocampo-Candiani J. [Update on surgical treatment of primary and metastatic cutaneous melanoma]. CIR CIR 2015; 84:77-84. [PMID: 26277601 DOI: 10.1016/j.circir.2015.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 12/10/2014] [Indexed: 11/27/2022]
Abstract
Melanoma is a common cutaneous tumour. It is of great importance due to its increasing incidence and aggressive behaviour, with metastasis to lymph nodes and internal organs. When suspecting melanoma, excisional biopsy should be performed to obtain complete histological information in order to determine the adverse factors such as ulceration, mitosis rate, and Breslow depth, which influence preoperative staging and provide data for sentinel lymph biopsy decision making. The indicated management for melanoma is wide local excision, observing recommended and well-established excision margins, depending on Breslow depth and anatomical location of the tumour. Therapeutic lymphadenectomy is recommended for patients with clinically or radiologically positive lymph nodes. This article reviews surgical treatment of melanoma, adverse histological factors, sentinel lymph node biopsy, and radical lymphadenectomy. Details are presented on special situations in which management of melanoma is different due to the anatomical location (plantar, subungual, lentigo maligna), or pregnancy.
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Affiliation(s)
| | - Ivonne Arellano-Mendoza
- Servicio de Dermatología, Hospital General de México Dr. Eduardo Liceaga, México D.F., México
| | - Jorge Ocampo-Candiani
- Servicio de Dermatología, Hospital Universitario Dr. José E. González, Monterrey, Nuevo LeónMéxico.
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40
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Pföhler C, Vogt T, Müller CSL. [Malignant head and neck melanoma: Part 2: Therapy]. HNO 2015. [PMID: 26219523 DOI: 10.1007/s00106-015-0034-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Resection margins of melanomas in the head and neck region often have to be adapted according anatomical circumstances. In the case of thicker primary tumors or after complete resection of locoregional lymph node metastases, adjuvant therapy with interferon-α can be performed; in some cases, adjuvant radiotherapy may also be indicated. In the case of inoperable lymph node or distant metastases, systemic treatment is required. Beside well-established mono- or polychemotherapy regimens, newer targeted therapies with BRAF inhibitors (vemurafenib, dabrafenib), mitogenic-activated protein kinase (MEK) inhibitors (trametinib, binimetinib, and cobimetinib), and kinase inhibitors (imatinib, sunitinib, nilotinib, dasatinib) are also available.
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Affiliation(s)
- C Pföhler
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Kirrbergerstrasse, 66421, Homburg/Saar, Deutschland,
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41
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Bartlett EK, Peters MG, Blair A, Etherington MS, Elder DE, Xu XG, Guerry D, Ming ME, Fraker DL, Czerniecki BJ, Gimotty PA, Karakousis GC. Identification of Patients with Intermediate Thickness Melanoma at Low Risk for Sentinel Lymph Node Positivity. Ann Surg Oncol 2015. [PMID: 26215202 DOI: 10.1245/s10434-015-4766-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Sentinel lymph node (SLN) biopsy is recommended for all patients with intermediate-thickness melanomas. We sought to identify such patients at low risk of SLN positivity. METHODS All patients with intermediate-thickness melanomas (1.01-4 mm) undergoing SLN biopsy at a single institution from 1995-2011 were included in this retrospective cohort study. Univariate and multivariate logistic regression determined factors associated with a low risk of SLN positivity. Classification and regression tree (CART) analysis was used to stratify groups based on risk of positivity. RESULTS Of the 952 study patients, 157 (16.5 %) had a positive SLN. In the multivariate analysis, thickness <1.5 mm (odds ratio [OR] 0.29), age ≥60 (OR 0.69), present tumor-infiltrating lymphocytes (OR 0.60), absent lymphovascular invasion (OR 0.46), and absent satellitosis (OR 0.44) were significantly associated with a low risk of SLN positivity. CART analysis identified thickness of 1.5 mm as the primary cut point for risk of SLN metastasis. Patients with a thickness of <1.5 mm represented 36 % of the total cohort and had a SLN positivity rate of 6.6 % (95 % confidence interval 3.8-9.4 %). In patients with melanomas <1.5 mm in thickness, the presence of additional low risk factors identified 257 patients (75 % of patients with <1.5 mm melanomas) in which the rate of SLN positivity was <5 %. CONCLUSIONS Despite a SLN positivity rate of 16.5 % overall, substantial heterogeneity of risk exists among patients with intermediate-thickness melanoma. Most patients with melanoma between 1.01 and 1.5 mm have a risk of SLN positivity similar to that in patients with thin melanomas.
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Affiliation(s)
- Edmund K Bartlett
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, USA.
| | - Madalyn G Peters
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Anne Blair
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, USA
| | - Mark S Etherington
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - David E Elder
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, USA
| | - Xiaowei G Xu
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, USA
| | - DuPont Guerry
- Hematology-Oncology Division, Department of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Michael E Ming
- Department of Dermatology, University of Pennsylvania, Philadelphia, USA
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Brian J Czerniecki
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Phyllis A Gimotty
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, USA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, USA.
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42
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A review of sentinel lymph node biopsy for thin melanoma. Ir J Med Sci 2014; 184:119-23. [PMID: 25366817 DOI: 10.1007/s11845-014-1221-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 10/27/2014] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Although there is a lack of established survival benefit of sentinel lymph node biopsy (SLNB), this technique has been increasingly applied in the staging of patients with thin (≤1.00 mm) melanoma (T1Nx), without clear supportive evidence. METHODS We review the guidelines and available literature on the indications and rationale for performing SLNB in thin melanoma. RESULTS As a consequence of the paucity of evidence of SLNB in thin melanoma, there is considerable variability in the guidelines. It is difficult to define clinicopathologic factors that reliably predict the presence of nodal metastasis. SLNB does not yet inform management in thin melanoma to improve survival outcome. CONCLUSION Based on available evidence, high risk patients with melanomas between 0.75 and 1.00 mm may be appropriate candidates to be considered for SLN biopsy after discussing the likelihood of finding evidence of nodal progression, the risks of sentinel node biopsy, and the lack of proven survival benefit from any form of surgical nodal staging.
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43
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Nothacker M, Muche-Borowski C, Kopp IB. [Measuring quality in the German Guideline Programme in Oncology (GGPO)—methodology and implementation]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2014; 108:470-80. [PMID: 25523845 DOI: 10.1016/j.zefq.2014.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/24/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022]
Abstract
The German Guideline Programme in Oncology (GGPO) is a joint initiative between the German Cancer Society, the Association of the Scientific Medical Societies in Germany and German Cancer Aid. In accordance with the aims of the German National Cancer Plan, the GGPO supports the systematic development of high-quality guidelines. To enhance implementation and evaluation, the suggestion of performance measures (PMs) derived from guideline recommendations following a standardised methodology is obligatory within the GGPO. For this purpose, PM teams are convened representing the multidisciplinary guideline development groups including clinical experts, methodologists and patient representatives as well as those organisations that take an active part in and share responsibility for documentation and quality improvement, i.e., clinical cancer registries, certified cancer centres and, if appropriate, the institution responsible for external quality assurance according to the German Social Code (SGB). The primary selection criteria for PMs include strength of the underlying recommendation (strong, grade A), existing potential for improvement of care and measurability. The premises of data economy and standardised documentation are taken into account. Between May 2008 and July 2014, 12 guidelines with suggestions for 100 PMs have been published. The majority of the suggested performance measures is captured by the specific documentation requirements of the clinical cancer registries and certified cancer centres. This creates a solid basis for an active quality management and re-evaluation of the suggested PMs. In addition, the suspension of measures should be considered if improvement has been achieved on a broad scale and for a longer period in order to concentrate on a quality-oriented, economic documentation.
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Affiliation(s)
- Monika Nothacker
- AWMF-Institut für Medizinisches Wissensmanagement (IMWi), Marburg, Deutschland.
| | | | - Ina B Kopp
- AWMF-Institut für Medizinisches Wissensmanagement (IMWi), Marburg, Deutschland
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44
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Ma Y, Chu H, Mazumdar M. Meta-analysis of Proportions of Rare Events-A Comparison of Exact Likelihood Methods with Robust Variance Estimation. COMMUN STAT-SIMUL C 2014; 45:3036-3052. [PMID: 27605731 DOI: 10.1080/03610918.2014.911901] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The conventional random effects model for meta-analysis of proportions approximates within-study variation using a normal distribution. Due to potential approximation bias, particularly for the estimation of rare events such as some adverse drug reactions, the conventional method is considered inferior to the exact methods based on binomial distributions. In this paper, we compare two existing exact approaches-beta binomial (B-B) and normal-binomial (N-B)-through an extensive simulation study with focus on the case of rare events that are commonly encountered in medical research. In addition, we implement the empirical ("sandwich") estimator of variance into the two models to improve the robustness of the statistical inferences. To our knowledge, it is the first such application of sandwich estimator of variance to meta-analysis of proportions. The simulation study shows that the B-B approach tends to have substantially smaller bias and mean squared error than N-B for rare events with occurrences under five percent, while N-B outperforms B-B for relatively common events. Use of the sandwich estimator of variance improves the precision of estimation for both models. We illustrate the two approaches by applying them to two published meta-analysis from the fields of orthopedic surgery and prevention of adverse drug reactions.
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Affiliation(s)
- Yan Ma
- Department of Public Health, Weill Medical College of Cornell University, New York, NY 10021; Hospital for Special Surgery, New York, NY 10021
| | - Haitao Chu
- School of Public Health, University of Minnesota, Minneapolis, MN 55455
| | - Madhu Mazumdar
- Department of Public Health, Weill Medical College of Cornell University, New York, NY 10021
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45
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Munsch C, Lauwers-Cances V, Lamant L, Gentil C, Rochaix P, Garrido I, Lopez R, Chevreau C, Paul C, Meyer N. Breslow thickness, clark index and ulceration are associated with sentinel lymph node metastasis in melanoma patients: a cohort analysis of 612 patients. Dermatology 2014; 229:183-9. [PMID: 25171688 DOI: 10.1159/000362902] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 04/15/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is the most sensitive procedure for assessing nodal status in patients with primary melanoma. OBJECTIVE To evaluate the predictive ability of usual primary melanoma prognosis factors of detecting sentinel lymph node (SLN) metastasis in patients with melanoma. PATIENTS AND METHODS A cohort of 612 consecutive patients presenting with primary skin melanoma who underwent a SLNB was evaluated. Assessment of the determinants of SLN metastasis was based on general linear model analysis. The model performance was studied using the concordance statistic and the net reclassification index. The calibration was estimated using the Hosmer-Lemeshow test. RESULTS The discrimination ability did not differ significantly between Breslow thickness (0.57), Clark index (0.61), ulceration (0.57) and histological subtype (0.55). Clark index, ulceration and Breslow thickness were all significant and independent determinants of SLN metastasis. The predictive ability of the final model was 0.657. CONCLUSION Breslow thickness, Clark index and ulceration are independent predictors of a SLN metastasis.
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Affiliation(s)
- Coline Munsch
- Dermatology Department, Paul Sabatier-Toulouse III University and Larrey Hospital, Toulouse, France
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Schmalbach CE, Bradford CR. Is sentinel lymph node biopsy the standard of care for cutaneous head and neck melanoma? Laryngoscope 2014; 125:153-60. [PMID: 24986770 DOI: 10.1002/lary.24807] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 06/03/2014] [Accepted: 06/06/2014] [Indexed: 01/03/2023]
Abstract
OBJECTIVES/HYPOTHESIS Sentinel lymph node biopsy (SLNB) is considered one of the most important melanoma advancements to date. Since its inception in 1992, a plethora of data and associated controversies has emerged leading to the question: Is SLNB considered the standard of care for head and neck (HN) cutaneous melanoma? STUDY DESIGN English literature (1990-2014) review. METHODS The PubMed database search was conducted using key terms "melanoma" and "sentinel node." This review included both dedicated HN SLNB studies and larger prospective SLNB studies, in which HN patients were included among the cohort. Bibliography cross-referencing was conducted to ensure a comprehensive search. RESULTS SLNB is safe and accurate in the HN region. Review of large prospective SLNB trials identified the pathologic status of the SLN as the most important prognostic factor for recurrence and survival. Early lymphadenectomy following a positive SLNB imparts a survival benefit. CONCLUSIONS Our review of the current literature suggests that SLNB is the standard of care for selected cases of HN cutaneous melanoma. It is now incorporated into the American Joint Committee on Cancer staging system, the National Comprehensive Cancer Network practice guidelines, and numerous national and international consensus statements.
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Affiliation(s)
- Cecelia E Schmalbach
- Division of Otolaryngology-Head and Neck Surgery, The University of Alabama at Birmingham, Birmingham, Alabama
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47
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Richtig G, Richtig E, Massone C, Hofmann-Wellenhof R. Analysis of clinical, dermoscopic and histopathological features of primary melanomas of patients with metastatic disease--a retrospective study at the Department of Dermatology, Medical University of Graz, 2000-2010. J Eur Acad Dermatol Venereol 2014; 28:1776-81. [PMID: 24576192 DOI: 10.1111/jdv.12413] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Accepted: 01/25/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Incidence rates of malignant melanoma have been increasing worldwide and metastatic melanoma is still a significant problem despite widespread prevention programmes. OBJECTIVES We made a systemic review of all metastasized melanoma patients treated at the Department of Dermatology, Medical University of Graz in the years 2000-2010 and looked at the kind of melanoma type, e.g. if it has been slowly growing superficial spreading melanoma (SSM) or fast growing nodular melanoma (NM). METHODS Histological slides and clinical images of patients treated at our department between 2000 and 2010, who received chemotherapy because of proven metastatic disease were analysed with regard to growth type of their primary tumours. RESULTS A total of 88 patients met the inclusion criteria. Mean age of all patients was 57 years (median 59 years, SD ± 15 years). Of these 88 patients 51 patients (58%) (28 male patients and 23 female patients) had SSM; mean age 58 years (median 58 years, SD ± 14 years) and 37 patients (42%) (18 male patients and 19 female patients) had NM; mean age 56 years (median 61 years, SD ± 17 years). Mean Breslow thickness in the SSM group was 2.26 mm (median: 1.6 mm, SD ± 2.11 mm). In the NM group, mean Breslow thickness was 4.59 mm (median: 3.50 mm, SD ± 4.07 mm). When separated by gender, 46 melanomas were seen in the male group (28 SSM and 18 NM) and 42 melanomas in the female group (23 SSM and 19 NM). CONCLUSIONS Our results showed that more than half of the patients with metastatic disease had SSMs and not, as suspected, NMs. As SSMs are growing over a longer period to become invasive and potentially metastatic, there might be a chance to focus primary and secondary prevention programmes not only on fast growing tumours but also on slowly changes of tumours.
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Affiliation(s)
- G Richtig
- Department of Dermatology, Medical University of Graz, Graz, Austria
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48
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Pflugfelder A, Kochs C, Blum A, Capellaro M, Czeschik C, Dettenborn T, Dill D, Dippel E, Eigentler T, Feyer P, Follmann M, Frerich B, Ganten MK, Gärtner J, Gutzmer R, Hassel J, Hauschild A, Hohenberger P, Hübner J, Kaatz M, Kleeberg UR, Kölbl O, Kortmann RD, Krause-Bergmann A, Kurschat P, Leiter U, Link H, Loquai C, Löser C, Mackensen A, Meier F, Mohr P, Möhrle M, Nashan D, Reske S, Rose C, Sander C, Satzger I, Schiller M, Schlemmer HP, Strittmatter G, Sunderkötter C, Swoboda L, Trefzer U, Voltz R, Vordermark D, Weichenthal M, Werner A, Wesselmann S, Weyergraf AJ, Wick W, Garbe C, Schadendorf D. S3-guideline "diagnosis, therapy and follow-up of melanoma" -- short version. J Dtsch Dermatol Ges 2014; 11:563-602. [PMID: 23721604 DOI: 10.1111/ddg.12044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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49
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Toberer F, Werchau S, Christia E, Enk A, Schirmacher P, Helmbold P. Large lymphatic vessel density in primary malignant melanoma predicts sentinel node status. J Am Acad Dermatol 2013; 69:827-828. [PMID: 24124821 DOI: 10.1016/j.jaad.2013.04.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 04/10/2013] [Accepted: 04/16/2013] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | - Alexander Enk
- Department of Dermatology, University of Heidelberg, Germany
| | | | - Peter Helmbold
- Department of Dermatology, University of Heidelberg, Germany.
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50
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Ribero S, Osella-Abate S, Sanlorenzo M, Savoia P, Astrua C, Cavaliere G, Tomasini C, Senetta R, Macripò G, Bernengo M, Quaglino P. Favourable prognostic role of regression of primary melanoma in AJCC stage I-II patients. Br J Dermatol 2013; 169:1240-5. [DOI: 10.1111/bjd.12586] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2013] [Indexed: 01/18/2023]
Affiliation(s)
- S. Ribero
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
- Section of Dermatologic Surgery; Department of Oncology and Haematology via Cherasco 23; AOU Città della Salute e della Scienza di Torino; 10126 Turin Italy
| | - S. Osella-Abate
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
| | - M. Sanlorenzo
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
| | - P. Savoia
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
| | - C. Astrua
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
| | - G. Cavaliere
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
| | - C. Tomasini
- Division of Anatomic Pathology IV, via Cherasco; AOU Città della Salute e della Scienza di Torino; 23, 10126 Turin Italy
| | - R. Senetta
- Section of Surgical Pathology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
- Department of Laboratory Diagnostics; AOU Città della Salute e della Scienza di Torino, via Santena 7; 10126 Turin Italy
| | - G. Macripò
- Section of Dermatologic Surgery; Department of Oncology and Haematology via Cherasco 23; AOU Città della Salute e della Scienza di Torino; 10126 Turin Italy
| | - M.G. Bernengo
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
| | - P. Quaglino
- Section of Dermatology; Department of Medical Sciences; University of Turin; via Cherasco 23 10126 Turin Italy
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