Discordant lymphatic drainage patterns revealed by serial lymphoscintigraphy in cutaneous head and neck malignancies

Wide Local Excision Before Sentinel Lymph Node Biopsy in Melanoma

BACKGROUND

Current guidelines suggest that wide local excision of thick melanomas be delayed until sentinel lymph node biopsies can be performed.

OBJECTIVE

To examine the literature and determine if there is a scientific basis for delaying wide local excision of thick melanomas.

MATERIALS AND METHODS

A narrative review of the literature was undertaken to examine all available studies on the subject.

RESULTS

There is no evidence that prior excision compromises sentinel lymph node identification. There are multiple unsubstantiated suggestions that large rotation flaps may lead to false negatives.

CONCLUSION

There is no basis for delaying wide local excision of thick melanomas until a sentinel lymph node biopsy can be performed.

Virtual reality-based training and pre-operative planning for head and neck sentinel lymph node biopsy

OBJECTIVE

Sentinel lymph node biopsy (SLNB) is crucial for managing head and neck skin cancer. However, variable lymphatic drainage can complicate SLN detection when using Single-Photon Emission Computed Tomography (SPECT) or lymphoscintigraphy. Virtual Reality (VR) can contribute to pre-operative planning by simulating a realistic 3D model, which improves orientation. VR can also facilitate real-patient training outside the operating room. This study explored using a VR platform for pre-operative planning in head and neck skin cancer patients undergoing SLNBs and assessed its value for residential training.

MATERIALS AND METHODS

In this prospective technology pilot study, attending surgeons and residents who performed 21 SLNB operations on patients with head and neck skin cancers (81% males, mean age 69.2 ± 11.3) used a VR simulation model based on each patient's pre-operative SPECT scan to examine patient-specific anatomy. After surgery, they completed a questionnaire on the efficiency of the VR simulation as a pre-operative planning tool and training device for residents.

RESULTS

The attending surgeons rated the VR model's accuracy at 8.3 ± 1.6 out of 10. Three-quarters (76%) of residents reported increased confidence after using VR. The physicians rated the platform's contribution to residents' training at 7.4 ± 2.1 to 8.9 ± 1.3 out of 10.

CONCLUSION

A VR SLNB simulation can accurately portray marked sentinel lymph nodes. It was rated high as a surgical planning and teaching tool among attending surgeons and residents alike and may play a role in pre-operative planning and resident training. Further studies are needed to explore its applications in practice.

Head and neck melanoma: outcome and predictors in a population-based cohort study

Background

To evaluate predictive clinico-pathological characteristics on outcome in head and neck melanoma (HNM) in a population-based study with particular emphasis on the prognostic effect of sentinel lymph node biopsy (SLNB), Charlson comorbidity index (CCI) and distinct tumor localisations.

Methods

Here we primarily describe a retrospective multicenter population-based cohort study with 402 patients having undergone resection with curative intent of HNM between 2010 and 2017. SLNB was used in the diagnosis of 79 HNM patients. Outcome was analyzed, focusing on SLNB, CCI as well as tumor localisation. Overall survival (OAS) und recurrence free survival (RFS) was examined by uni- and multivariate analysis.

Results

Histopathologically verified lymph node metastasis according to SLNB was associated with impaired RFS in HNM patients (p = 0.004). Especially in higher tumor stages, the sole implementation of SLNB improved survival significantly in the present cohort (p = 0.042). With most of the HNM being located in the face, melanoma of the scalp and neck could be linked to deteriorated patient’s outcome in uni- as well as multivariate analysis (p = 0.021, p = 0.004).

Conclusions

SLNB is a useful tool in predicting development of distant metastasis after HNM resection with curative intent. Especially in higher tumor stages, performing a SLNB ameliorated survival of HNM patients. Additionally, CCI as well as a distinct tumor localisations in HNM were identified as important risk factors in our population-based cohort study.

Cranial nerve outcomes in regionally recurrent head & neck melanoma after sentinel lymph node biopsy

OBJECTIVE

Characterize long-term cranial nerve (CN) outcomes following sentinel lymph node biopsy (SLNB) based management for head and neck cutaneous melanoma (HNCM).

METHODS

Longitudinal review of HNCM patients undergoing SLNB from 1997-2007.

RESULTS

Three hundred fifty-six patients were identified, with mean age 53.5 ± 19.0 years, mean Breslow depth 2.52 ± 1.87 mm, and 4.9 years median follow-up. One hundred five (29.4%) patients had SLNB mapping to the parotid basin. Eighteen patients had positive parotid SLNs and underwent immediate parotidectomy / immediate completion lymph node dissection (iCLND), with six possessing positive parotid non-sentinel lymph nodes (NSLNs). Fifty-two of 356 (14.6%) patients developed delayed regional recurrences, including 20 total intraparotid recurrences: five following false negative (FN) parotid SLNB, three following prior immediate superficial parotidectomy, two following iCLND without parotidectomy, and the remaining 12 parotid recurrences had negative extraparotid SLNBs. Parotid recurrences were multiple (4.9 mean recurrent nodes) and advanced (n = 4 extracapsular extension), and all required salvage dissection including parotidectomy. Immediate parotidectomy/iCLND led to no permanent CN injuries. Delayed regional HNCM macrometastasis precipitated 16 total permanent CN injuries in 13 patients: 10 CN VII, five CN XI, and one CN XII deficits. Fifty percent (n = 10) of parotid recurrences caused ≥1 permanent CN deficits.

CONCLUSIONS

Regional HNCM macrometastases and salvage dissection confer marked CN injury risk, whereas early surgical intervention via SLNB ± iCLND ± immediate parotidectomy yielded no CN injuries. Further, superficial parotidectomy performed in parotid-mapping HNCM does not obviate delayed intraparotid recurrences, which increase risk of CN VII injury. Despite lack of a published disease-specific survival advantage in melanoma, early disease control in cervical and parotid basins is paramount to minimize CN complications.

LEVEL OF EVIDENCE

4 (retrospective case series) Laryngoscope, 130:1707-1714, 2020.

The Lymphoscintigraphic Study of Unpredictable Head and Neck Cutaneous Melanoma Lymphatic Drainage

Head and neck cutaneous melanoma (HNCM) does not always follow standard lymphatic drainage; typical expected lymphatic pathways are associated with unexpected ones. The aim of this study was to investigate the relation between the primary HNCM sites and all possible lymphatic drainage pathways by lymphoscintigraphy with a special focus on the unexpected sentinel lymph node (SLNs) detection. We retrospectively analyzed 67 patients (46 M, 21 F; mean age 63 years) who underwent lymphoscintigraphy from January 2004 to November 2018. 99mTc-serum albumin was injected intra-dermally at the dose of 18–37 MBq in 0.2–0.4 mL. All patients underwent dynamic and static image acquisition. For all patients, the relation between the expected and unexpected SLNs was performed using the “Sidney Melanoma Unit Database” as our reference. The relation was performed also according to the primary HNCM localization. Cohens’ kappa was calculated. In 61/67 (91%) of patients, SLNs were detected only in predictable sites, while in six/67 (9%), unexpected SLNs were revealed. In all patients, the agreement proportion was 91% (95% confidence interval CI 0.8–0.96) and Cohen’s K was 0.11 (95% CI 0–0.43). Regarding the primary melanoma sites, the nasolabial field HNCM showed the highest rate of concordance (K = 0.60; 95%, CI 0.32–0.89) while the preauricular region HNCM revealed the highest rate of discordance with the clinically predictable drainage. The HNCM lymphatic drainage is extremely variable in regard to both the sites and the number of involved SLNs. The lymphoscintigraphic study is highly recommended to identify all possible SLNs in order to perform an accurate staging for all patients and to avoid missing unexpected SLNs.

Sentinel Lymph Node Biopsy in Head and Neck Melanoma: Long-term Outcomes, Prognostic Value, Accuracy, and Safety

OBJECTIVE

To evaluate the long-term outcomes of sentinel lymph node biopsy (SLNB) for head and neck cutaneous melanoma (HNCM).

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary academic medical center.

SUBJECTS AND METHODS

Longitudinal review of a 356-patient cohort with HNCM undergoing SLNB from 1997 to 2007.

RESULTS

Descriptive characteristics included the following: age, 53.5 ± 19 years (mean ± SD); sex, 26.8% female; median follow-up, 4.9 years; and Breslow depth, 2.52 ± 1.87 mm. Overall, 75 (21.1%) patients had a positive SLNB. Among patients undergoing completion lymph node dissection following positive SLNB, 20 (27.4%) had at least 1 additional positive nonsentinel lymph node. Eighteen patients with local control and negative SLNB developed regional disease, indicating a false omission rate of 6.4%, including 10 recurrences in previously unsampled basins. Ten-year overall survival (OS) and melanoma-specific survival (MSS) were significantly greater in the negative sentinel lymph node (SLN) cohort (OS, 61% [95% CI, 0.549-0.677]; MSS, 81.9% [95% CI, 0.769-0.873]) than the positive SLN cohort (OS, 31% [95% CI, 0.162-0.677]; MSS, 60.3% [95% CI, 0.464-0.785]) and positive SLN/positive nonsentinel lymph node cohort (OS, 8.4% [95% CI, 0.015-0.474]; MSS, 9.6% [95% CI, 0.017-0.536]). OS was significantly associated with SLN positivity (hazard ratio [HR], 2.39; P < .01), immunosuppression (HR, 2.37; P < .01), angiolymphatic invasion (HR, 1.91; P < .01), and ulceration (HR, 1.86; P < .01). SLN positivity (HR, 3.13; P < .01), angiolymphatic invasion (HR, 3.19; P < .01), and number of mitoses (P = .0002) were significantly associated with MSS. Immunosuppression (HR, 3.01; P < .01) and SLN status (HR, 2.84; P < .01) were associated with recurrence-free survival, and immunosuppression was the only factor significantly associated with regional recurrence (HR, 6.59; P < .01).

CONCLUSIONS

Long-term follow up indicates that SLNB showcases durable accuracy, safety, and prognostic importance for cutaneous HNCM.

Nonmelanoma Skin Cancer

This article reviews the most common nonmelanoma skin cancers affecting the head and neck region. Although the most common of these malignancies rarely result in mortality, local morbidity caused by the tumors and their extirpation cannot be underestimated. Complete tumor extirpation with pathologically confirmed negative margins is the gold standard. Regional and distant metastases are rare, but must be treated appropriately should they occur. Although reconstructive surgery can be life changing for the patients and rewarding for the clinicians, it behooves the treating surgeons to remain true to oncologic principles above all else.

Sentinel lymph node biopsy in periocular merkel cell carcinoma: a case report

BACKGROUND

The National Comprehensive Cancer Network guidelines for Merkel cell carcinoma recommend performance of the sentinel lymph node biopsy in all patients with clinically negative nodal disease for staging and treatment. Nevertheless, sentinel lymph node biopsy in the periocular region is debated as tumors are typically smaller and lymphatic variability can make performance procedurally problematic.

CASE PRESENTATION

We present a case of a Caucasian patient in their seventies who presented with a 1.0 cm periocular Merkel cell carcinoma, who underwent Mohs surgery with a Tenzel flap repair, that was found to have a positive sentinel lymph node biopsy, but who, despite parotidectomy, selective neck dissection, and radiation, succumbed to the disease.

CONCLUSIONS

Evidence in both the site-specific and non-specific literature demonstrates: (1) Worsening prognosis with extent of lymph node burden, (2) improvements in our abilities to perform lymphoscintigraphy, (3) locoregional and distant metastatic disease in patients with tumor sizes ≤1 cm, and (4) significant rates of sentinel lymph node positivity in patients with tumor sizes ≤1 cm. Our case supports that sentinel lymph node biopsy should be considered in all clinically nodal negative periocular Merkel cell carcinoma, regardless of size, and despite limited site-specific studies on the subject.

Drainage Patterns to Nontraditional Nodal Regions and Level IIB in Cutaneous Head and Neck Malignancy

OBJECTIVES

(1) Determine the frequency of nontraditional sentinel lymph node (SLN) locations in cutaneous head and neck malignancy and (2) determine the frequency of level IIB SLNs in cutaneous head and neck malignancy.

DESIGN

Case series with chart review.

SETTING

Tertiary academic hospital.

SUBJECTS AND METHODS

In total, 145 consecutive sentinel lymph node biopsy (SLNB) specimens for cutaneous head and neck malignancies were reviewed from 2007 to 2015. Nodal regions were categorized into levels I to V, parotid, external jugular (EJ), perifacial, suboccipital, and postauricular regions. Primary locations were divided into scalp, forehead, cheek, ear, neck, nose, periocular, and lip. Frequencies of sentinel lymph node (SLN) locations for each primary location were determined.

RESULTS

Parotid, EJ, perifacial, suboccipital, postauricular, and level IIB lymph SLNs were identified as nontraditional lymph node regions at risk in head and neck cutaneous malignancy. EJ SLNs were present in over 15% of all cases and over 25% of periocular and cheek lesions. Perifacial SLNs were frequently present in nose and lip lesions. Suboccipital and postauricular nodes were only present in scalp lesions. Level II was the most common location for a SLN. In total, 15.9% of all cases involved level IIB. Scalp and ear primary lesions were most likely to drain to level IIB.

CONCLUSIONS

Nontraditional SLN locations, such as EJ, perifacial, suboccipital, postauricular, and parotid, as well as level IIB, are important sites of drainage for head and neck cutaneous malignancy. Prediction of at-risk lymph node regions is important to help guide SLNBs, elective and completion neck lymphadenectomy and radiation, and long-term observation.

Focus on Merkel cell carcinoma: diagnosis and staging

Merkel cell carcinoma is a rare lymphophilic skin tumor of neuroendocrine origin with the potential for rapid progression. Small, localized lesions are diagnosed and treated clinically, but advanced tumors often undergo imaging evaluation. Due to its rarity, radiologists are unaware of evocative imaging features and usually do not consider Merkel cell carcinoma in the differential diagnosis of soft tissue tumors. Appropriate staging is important to determine appropriate treatment and has an impact on patient prognosis. Multimodality imaging is usually needed, and there is no consensus on the optimal imaging strategy. The purpose of this article is to review various aspects of Merkel cell carcinoma imaging and look in detail at how optimal multimodality staging should be carried out.

A systematic review of patients with Merkel cell carcinoma of the head and neck and a negative sentinel lymph node biopsy

Background

A negative sentinel lymph node biopsy (SLNB) from patients with head and neck Merkel cell carcinoma (HNMCC) may allow the patient to avoid further adjunctive therapies. However, there is considerable regional variability of lymphatic drainage from primary sites involving the head and neck, and Merkel cell carcinoma (MCC) has aggressive biologic behavior.

Objective

The primary aim of this systematic review was to document the incidence of regional recurrence and mortality from HNMCC patients after a negative SLNB.

Methods

A systematic search of the English literature was conducted via Ovid Medline and Embase from inception until 2013 and the Cochrane Central Register of Controlled Trials from 1991 to January 2014.

Results

Twenty-three studies, with a total of 81 patients matched the inclusion criteria. The incidence of regional recurrence from the entire cohort was 12.3%, and there was a 5% mortality rate. The mean follow-up time, excluding the 30 patients who did not have individual follow-up times specified, was 32.8 months.

Limitations

This review included studies had variable follow-up durations and treatments for MCC.

Conclusions

Despite negative pathologic staging of the neck using SLNB in HNMCC patients, there is still a high incidence of regional recurrence and mortality, over a short follow-up period.

•

Merkel cell carcinoma is an aggressive neoplasm.

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Patients with a negative sentinel lymph node biopsy from head and neck Merkel cell carcinoma showed a high incidence of future regional lymph node involvement.

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In this context, a negative sentinel lymph node biopsy is not necessarily reassuring for the patient or the clinician.

Malignant melanoma in elderly patients: biological, surgical and medical issues

Malignant melanoma is an aggressive tumor with a poor prognosis for patients with advanced disease. Over the last decades, its incidence and mortality has increased in elderly population, impacting significantly on healthcare costs, considering the increase in average age of the world population. Older age is recognized as an independent poor prognostic factor for melanoma, but the scientific community now is wondering if elderly melanoma patients have worse outcome because they are not receiving the same treatment as their younger counterparts. This article summarizes current data on elderly melanoma prevention and early detection and its subsequent management, underling the differences observed between older and younger patients. It also describes age-associated alterations in immunity and how these may impact on anti-melanoma response.

Lower prevalence of lymphatic metastasis and poorer survival of the sentinel node-negative patients limit the prognostic value of sentinel node biopsy for head or neck melanomas

Head or neck location of primary cutaneous melanomas has been described as an adverse prognostic factor, but this has to be reassessed after the introduction of sentinel lymph node (SLN) excision (SLNE). Descriptive statistics, Kaplan-Meier estimates and Cox proportional hazard models were used to study retrospectively a population of 2302 consecutive melanoma patients from three German melanoma centres undergoing SLNE. Approximately 10% of the patients (N=237) had a primary melanoma located at the head or neck (HNM). In both the SLN-positive and SLN-negative subpopulation, patients with HNM were significantly older, more frequently men and had thicker primaries compared with patients with tumours in other locations. The proportion of positive SLNs was lower in HNM compared with other locations of the primary (20 vs. 26%, P=0.048). The false-negative rate was higher in HNM (17.5 vs. 8.4%, P=0.05). In patients with HNM, the SLN status was a significant factor for recurrence-free survival but not for overall survival. SLN-negative HNM patients had a significantly worse overall survival than the SLN negatives with primaries at other sites, whereas the prognosis of the SLN-positive patients was similar in both groups. The prevalence of lymph node metastases after SLNE is lower in patients with HNM compared with other melanoma locations. As a result, the prognostic information provided by the SLN for HNM seems less important. Decision making for SLNE in HNM should be carefully balanced considering the potential morbidity of the procedure.

[Lymphatic drainage of skin areas of head and neck: in vivo approach by the location of the sentinel node]

INTRODUCTION

The objective of the study was to determine the preferential territories of drainage of skin areas of the face and neck. This knowledge can guide the strategies of diagnostic (search for primary tumor skin to cervical lymphadenopathy) and treatment (determination of the extent of neck dissection to achieve in case of skin tumor).

MATERIALS AND METHODS

This is a retrospective study of the surgical procedures of sentinel node research between January 2003 and April 2011. The lymphoscintigraphic and intraoperative localization of the initial tumor site and sentinel lymph node were collected.

RESULTS AND DISCUSSION

One hundred and thirty-seven patients were included in the study. The parotid gland is a privileged territory of drainage of the head and neck skin. At cervical level, the submental region drains the lower and median part of the face (lips and chin). The posterior segments (IIb and V sector) were represented for the posterior locations of the head (ear, vertex), and cervical region.

Accuracy and prognostic value of sentinel lymph node biopsy in head and neck melanomas

BACKGROUND

Debate remains around the accuracy and prognostic implications of sentinel lymph node biopsy (SLNB) for melanoma arising in the head and neck (HN) areas because several analyses have shown discordances between clinically predicted lymphatic drainage pathways and those identified by lymphoscintigraphy. This study assesses the accuracy and prognostic value of SLNB in this critical anatomic region.

METHODS

Retrospective review of a prospectively collected melanoma database identified 331 patients with HN melanomas from January 2000 to December 2012. Primary end points included SLNB result, time to recurrence, site of recurrence, and survival. Multivariate models were constructed for analyses.

RESULTS

A sentinel lymph node (SLN) was identified in all 331 patients. There were 59 patients with a positive SLN (17.8%) with a recurrence rate of 88.1% compared with 22.4% in SLN-negative patients (P < 0.0001). The 5-y overall survival was 91.2% for SLN-negative patients and 48.7% for SLN-positive patients (P < 0.0001). Patients with scalp melanoma had thicker lesions and an elevated risk of SLN positivity, recurrence, and death compared with those with other sites. Among the 272 SLN-negative patients, four patients developed regional nodal disease in the same basin and had undergone a previous SLNB procedure for a false-omission rate of 1.45%. Risks for false-negative SLN occurrences included thick and scalp melanomas. Multivariate analysis on prognostic factors affecting relapse-free survival showed positive SLNB status to be the most prognostic clinicopathologic predictor of recurrence (hazard ratio, 20.56; P < 0.0001).

CONCLUSIONS

SLNB for patients with HN melanomas is an accurate procedure and has prognostic value.

Value of anatomic site, histology and clinicopathological parameters for prediction of lymph node metastasis and overall survival in head and neck melanomas

INTRODUCTION

Head and neck melanoma compromises a group of aggressive tumours with varying clinical courses. This analysis was performed to find anatomic and clinicopathological parameters predictive for lymph node metastasis and overall survival.

MATERIAL AND METHODS

Data and outcome of 246 patients with a malignant melanoma in the head and neck region were retrospectively analyzed for predictive parameters.

RESULTS

Lentigo maligna melanoma (n = 115) was the most frequent histology, followed by superficial spreading (n = 63) and nodular melanoma (n = 52). More than half of the melanomas (n = 138) were in the face. Tumours of the face and anterior scalp metastasized to lymph nodes of the neck and parotid gland, whereas tumours of the posterior scalp and neck also metastasized to the nuchal region. Advanced Clark level, presence of tumour ulceration and younger age were the strongest predictors of lymph node metastasis in multivariate regression analysis (p < 0.05), but anatomic site, histological subtype and tumour thickness were also associated with lymph node metastasis. Lymph node metastases, distant metastases, ulceration, nodular subtype and non-facial site of origin were the strongest negative prognostic parameters for disease-specific overall survival (p < 0.05). In contrast, the width of resection margin (<1 cm vs. 1-2 cm vs. >2 cm) did not correlate with tumour recurrence and overall survival (p > 0.05).

CONCLUSION

Histological subtype diagnosis, anatomic site of origin as well as the established factors tumour thickness, ulceration and depth of invasion are prognostic indicators of cervical lymph node metastasis and overall survival. A resection margin of at least 1 cm seems sufficient in head and neck melanoma. The status of sentinel lymph node biopsy and neck dissection has to be proven within the next years.

Age-related disparities in use of completion lymphadenectomy for melanoma sentinel lymph node metastasis

BACKGROUND

Guidelines recommend that patients with melanoma metastatic to the sentinel lymph node (SLN) undergo a completion lymphadenectomy (CLND) of the affected lymph node basin. We have previously reported on decreased use of SLN biopsy among elderly patients. We hypothesized that elderly patients with SLN metastases would have lower rates of CLND relative to their younger counterparts.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for patients who underwent SLN biopsy for intermediate thickness cutaneous melanoma (Breslow thickness 1.01 mm-4.00 mm) from 2004 to 2008 and were found to have SLN metastasis. Patients were categorized according to age by decade. We then used multivariate logistic regression models to predict receipt of CLND. Additional covariates included sex, race/ethnicity, T stage, tumor histology, tumor location, and ulceration. The likelihood of receiving a CLND was reported as OR with 95% CI; significance was set at P ≤ 0.05.

RESULTS

Entry criteria were met by 765 patients. Of these, 548 (71.6%) patients underwent CLND. On multivariate analysis, patients in the age groups 70-79 y old (OR 0.39, CI 0.20-0.78; P = 0.007) and ≥ 80 y old (OR 0.27, CI 0.12-0.61; P = 0.001) were less likely to undergo CLND than the youngest age group (1-39 y old).

CONCLUSIONS

Elderly patients with SLN metastasis are less likely to receive CLND than their younger counterparts. A multi-center randomized clinical trial evaluating the potential survival benefit of CLND is ongoing. Further research to assess reasons why the elderly are less likely to receive CLND are needed.

Assessing rural-urban disparities in the use of sentinel lymph node biopsy for melanoma

BACKGROUND

We hypothesized that patients in urban areas with intermediate thickness cutaneous melanoma would have higher rates of sentinel lymph node biopsy (SLNB) relative to their rural-dwelling counterparts.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for patients who underwent surgery for intermediate thickness cutaneous melanoma from 2004-2008. Patients were categorized as coming from urban or rural counties based on a nine-point scale. We used multivariate logistic regression models to predict use of SLNB. Covariates examined included sex, race/ethnicity, age, T stage, tumor histology, tumor location, and ulceration. The likelihood of undergoing SLNB was reported as OR with 95% CI.

RESULTS

Of 8441 patients, 8382 (99.3%) had complete information regarding use of SLNB. On multivariate analysis, patients from rural counties had a decreased likelihood of receiving a SLNB (OR 0.87, CI 0.78-0.97; P = 0.014). Additional factors associated with a decreased likelihood of receiving a SLNB included increasing age, Asian/Hispanic/Unknown race, and head and neck or overlapping primary tumor site.

CONCLUSIONS

Patients in rural areas are less likely to receive a SLNB for intermediate thickness cutaneous melanoma than their urban-dwelling counterparts.

A practical update of surgical management of merkel cell carcinoma of the skin

The role of surgeons in the treatment of Merkel cell carcinoma (MCC) of the skin is reviewed, with respect to diagnosis and treatment. Most of the data in the literature are case reports. Surgery is the mainstay of treatment. A wide local excision, with sentinel node (SLN) biopsy, is the recommended treatment of choice. If SLN is involved, nodal dissection should be performed; unless patient is unfit, then regional radiotherapy can be given. Surgeons should always refer patients for assessment of the need for adjuvant treatments. Adjuvant radiotherapy is well tolerated and effective to minimize recurrence. Adjuvant chemotherapy may be considered for selected node-positive patients, as per National Comprehensive Cancer Network guideline. Data are insufficient to assess whether adjuvant chemotherapy improves survival. Recurrent disease should be treated by complete surgical resection if possible, followed by radiotherapy and possibly chemotherapy. Generally results of multimodality treatment for recurrent disease are better than lesser treatments. Future research should focus on newer chemotherapy and molecular targeted agents in the adjuvant setting and for gross disease.

Radiotherapy for metastatic merkel cell carcinoma: a review of the literature

Introduction. Merkel cell carcinoma is a rare form of non-melanoma skin cancer of neuroendocrine origin. Optimal management of patients is controversial and the role of radiotherapy is unclear. Purpose. The purpose of this study was to review the efficacy of RT in the treatment of both local and distant metastatic disease from MCC. Methods. A literature search was conducted in MEDLINE (1946—January Week 1 2012) and Embase (1980–2012 Week 2). Articles of interest analyze the efficacy of radiotherapy for treatment of metastatic MCC and did not exclude case reports. Results. All articles except one focusing on the role of radiotherapy were of retrospective origin or case series. Significant limitations applied in all studies due to limited sample sizes and the retrospective nature of these studies. Radiotherapy improves locoregional control in the adjuvant setting, and many series suggest an improvement in overall survival. In cases where surgery is not possible, definitive radiotherapy may be an as-efficacious alternative. The radiosensitive nature of MCC coupled with existing reports suggests that treatment via current protocols for other primary tumors is adequate. Conclusion. Further studies should be conducted prospectively to clarify the true role of radiotherapy in metastatic MCC.

Geographic variation in utilization of sentinel lymph node biopsy for intermediate thickness cutaneous melanoma

BACKGROUND AND OBJECTIVES

Sentinel lymph node biopsy (SLNB) is the standard for evaluation of the draining lymphatic basin for intermediate thickness melanoma. Despite this, SLNB has not been uniformly adopted. We hypothesized that there are geographic areas of the United States where patients are less likely to receive SLNB.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for patients who underwent surgery for intermediate thickness cutaneous melanoma (Breslow thickness 1.00-4.00 mm) from 2004 to 2008. Patients were categorized according to geographic area based on the reporting registry. Multivariate logistic regression models predicted use of SLNB.

RESULTS

Entry criteria were met by 8957 patients. On multivariate analysis, patients from the South were less likely (OR 0.54, CI 0.48-0.62; P < 0.001) to receive a SLNB. Additional factors associated with a decreased likelihood of receiving a SLNB included head and neck primary tumor site, high or unknown serum LDH, Asian, Hispanic, Native American or unknown race, and increasing age.

CONCLUSIONS

Patients from the South were less likely to receive a SLNB for an intermediate thickness cutaneous melanoma. This report of geographic disparities on a national level should be confirmed locally to better guide interventions aimed at eliminating these disparities.

Selective radiotherapy for the treatment of head and neck Merkel cell carcinoma

BACKGROUND

The role of radiotherapy (RT) in the management of Merkel cell carcinoma (MCC) is controversial. The authors of this report evaluated the rates and patterns of failure in a selected group of patients who underwent RT for MCC of the head and neck (HN).

METHODS

The records of 145 consecutive patients with MCC of the HN who presented to the authors' institution between 1988 and 2009 were reviewed. Only patients who received RT at the institution were included. The cumulative incidence of locoregional failure (LRF), distant metastatic failure (DMF), disease progression (DP) and disease-specific death (DSD) were estimated with death as a competing risk.

RESULTS

Forty-eight patients were identified. The median follow-up was 51 months (range, 6-220 months) for living patients. LRF developed in 5 patients (10%), and those patients had a median time to recurrence of 3 months. Two of the 5 LRFs were local and developed at the edge of the treatment field; the remaining 3 LRFs were in lymph nodes and occurred outside the treatment field. DMF developed in 12 patients (25%). The estimated 5-year cumulative incidences of LRF, DP, and DSD were 10%, 30%, and 21%, respectively. Acute toxicities included 5 episodes (10%) of grade 3 dermatitis and 1 episode (2%) of grade 3 mucositis.

CONCLUSIONS

The authors report a site-specific series of patients with HN MCC who received RT. In this group of patients with adverse features, RT was well tolerated, and LRF was low. The propensity for MCC to recur at the edge of the treatment field suggests that generous margins are appropriate when RT is administered.

Sentinel lymph node biopsy is accurate and prognostic in head and neck melanoma

BACKGROUND

Sentinel lymph node biopsy (SLNB) has emerged as a widely used staging procedure for cutaneous melanoma. However, debate remains around the accuracy and prognostic implications of SLNB for cutaneous melanoma arising in the head and neck, as previous reports have demonstrated inferior results to those in nonhead and neck regions. Through the largest single-institution series of head and neck melanoma patients, the authors set out to demonstrate that SLNB accuracy and prognostic value in the head and neck region are comparable to other sites.

METHODS

A prospectively collected database was queried for cutaneous head and neck melanoma patients who underwent SLNB at the University of Michigan between 1997 and 2007. Primary endpoints included SLNB result, time to recurrence, site of recurrence, and date and cause of death. Multivariate models were constructed for analyses.

RESULTS

Three hundred fifty-three patients were identified. A sentinel lymph node was identified in 352 of 353 patients (99.7%). Sixty-nine of the 353 (19.6%) patients had a positive SLNB. Seventeen of 68 patients (25%) undergoing completion lymphadenectomy after a positive SLNB result had at least 1 additional positive nonsentinel lymph node. Patients with local control and a negative SLNB failed regionally in 4.2% of cases. Multivariate analysis revealed positive SLNB status to be the most prognostic clinicopathologic predictor of poor outcome; hazard ratio was 4.23 for SLNB status and recurrence-free survival (P < .0001) and 3.33 for overall survival (P < .0001).

CONCLUSIONS

SLNB is accurate and its results are of prognostic importance for head and neck melanoma patients.

False-Negative Sentinel Lymph Node Biopsy in Head and Neck Melanoma

Objective. The results of sentinel lymph node biopsy (SLNB) can be useful for staging and deciding on adjuvant treatment for patients with head and neck melanoma. False-negative SLNB can result in treatment delay. This study aimed to evaluate the characteristics and outcome of patients with false-negative SLNB in cutaneous melanoma of the head and neck.

Study Design. Longitudinal cohort study using a prospective institutional tumor registry.

Setting. Academic health center.

Subjects and Methods. Data from 153 patients who underwent SLNB for melanoma of the head and neck were analyzed. False-negative biopsy was defined as recurrence of tumor in a previously identified negative nodal basin. Statistical analysis was performed on registry data.

Results. Positive sentinel lymph nodes were identified in 19 (12.4%) patients. False-negative SLNB was noted in 9 (5.9%) patients, with a false-negative SLNB rate of 32.1%. Using multivariate regression analysis, only examination of a single sentinel lymph node was a significant predictor of false-negative SLNB ( P = .01). The mean treatment delay for the false-negative SLNB group was 470 days compared with 23 days in the positive SLNB group ( P < .001). The 2-year overall survival of patients with false-negative SLNB was 75% compared with 84% and 98% in positive and negative SLNB groups, respectively ( P = .02).

Conclusions. False-negative SLNB is more likely to occur when a single sentinel lymph node is harvested. There is significant treatment delay in patients with false-negative SLNB. False-negative SLNB is associated with poor outcome in patients with melanoma of the head and neck.

[Sentinel node procedure in head and neck cutaneous melanoma]

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION

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

Tumor location predicts survival in cutaneous head and neck melanoma

BACKGROUND

Prior studies documented poorer outcomes in patients with cutaneous head and neck melanoma (CHNM) relative to those with melanoma at other sites. We evaluated survival differences attributable to tumor location in patients with CHNM.

METHODS

We queried the Surveillance, Epidemiology, and End Results (SEER) database for patients undergoing surgery for CHNM from 1988 to 2006, excluding patients without biopsy-proven diagnoses, those diagnosed at autopsy, and patients with distant metastases. Using the Kaplan-Meier method, we assessed patient, tumor, and treatment-specific factors on overall survival (OS) and melanoma specific survival (MSS). Cox proportional hazards models assessed the role of tumor location (ear, eyelid, face, lip, scalp/neck) on OS and MSS, while controlling for patient age, gender, race, tumor thickness, tumor ulceration, lymph node status, histologic subtype, type of surgery, and use of radiation. Risks of overall and melanoma-specific mortality were reported as hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

Among 27,097 patients, 10-y rates of OS and MSS were 56.1% and 84.7%, respectively. On multivariate analysis, scalp/neck primary site was associated with an increased risk of overall (HR 1.20, CI 1.14-1.26; P < 0.001) and melanoma-specific mortality (HR 1.64, CI 1.49-1.80, P < 0.001) relative to melanomas of the face. Tumors of the lip had poorer MSS (HR 1.55; CI 1.05-2.28, P = 0.03) but not OS (HR 1.03, CI 0.80-1.34; P = 0.80).

CONCLUSIONS

Patients with melanomas of the scalp/neck have poorer OS and MSS and those with lip melanomas have poorer MSS. These anatomic areas should not be overlooked when performing skin examinations.

Management of the difficult sentinel lymph node in patients with primary cutaneous melanoma

Sentinel lymph nodes (SLNs) are examined for occult melanoma metastases for accurate staging to dictate optimal therapy. The aim of this case series was to discuss clinical challenges in SLN biopsy. Ten challenging cases were identified from over 700 melanoma patients with SLN biopsy for primary cutaneous melanoma at the Yale Cancer Center Melanoma Unit. These cases were complicated by issues of (1) visualization of SLN, (2) concurrent and topographically close melanomas, (3) aberrant lymphatic drainage outside standard basins, (4) altered lymphatic drainage secondary to surgery, and (5) access to SLN. This case series identifies complex clinical scenarios encountered with SLN biopsy that should be familiar to a surgeon involved in the surgical care of melanoma patients.

Primary and metastatic malignant tumors of the scalp: an update

In recent years there have been a number of interesting advances in several topics relating to the diagnosis and treatment of cutaneous lesions with particular applicability to primary and metastatic malignancies of the scalp. In this article we provide a general update of advances in this field, and cover the more salient points relating to a variety of malignant tumors that have been reported to appear on the scalp as primary or metastatic lesions. A search and review of the literature on PubMed was made to identify and discuss relevant points relating to diagnosis and treatment of primary and metastatic tumors of the scalp. We describe the anatomy of the scalp, epidemiology of scalp tumors, theories of field cancerization and field therapy, photodynamic therapy, excisional surgical techniques and reconstruction, lymphoscintigraphy, chemoprevention, as well as details relating to atypical fibroxanthoma, Brooke-Spiegler syndrome, nevus sebaceus, cutaneous lymphoma, and metastatic disease. There is a very broad differential diagnosis for scalp nodules, which includes many different benign and malignant diseases, and treatment should be tailored accordingly. Given the potential for poor prognosis with some of the more aggressive malignancies that can be found in this anatomic area, the importance of a thorough physical examination cannot be emphasized enough, and early detection is critical to provide patients with the best chance for a favorable outcome.

The impact of (18)F-FDG PET-CT scanning for staging and management of Merkel cell carcinoma: results from Westmead Hospital, Sydney, Australia

BACKGROUND

Merkel cell carcinoma (MCC) is a rare cutaneous malignancy with high mortality. Positron emission tomography (PET) using (18)F-fluorodeoxyglucose (FDG) has been shown to be valuable in the management of many types of cancer, and the purpose of this work was to determine its utility for patients with MCC.

OBJECTIVE

We sought to evaluate the impact of (18)F-FDG PET with simultaneous computed tomography (PET-CT) on the staging and management of patients with MCC.

METHODS

We reviewed the medical records of 18 patients with MCC who underwent 21 PET-CT scans at our institution from 2006 to 2008. The impact of PET-CT on staging and management plans were evaluated.

RESULTS

There were 12 men and 6 women with median age of 79 years (range, 54 to 85 years). All proven sites of MCC greater than 5 mm were positive on PET-CT with average maximum standardized uptake values (SUV max) of 4 in primary lesions, 5.6 in nodal disease and 11.5 in distant metastases. PET-CT contributed to altered staging in 7 patients (33%) and a change in management in 9 patients (43%). Two patients were found to have a second primary malignancy, but this did not alter management.

LIMITATIONS

This was a retrospective review. Most patients had stage II or III disease, suggesting some potential referral bias.

CONCLUSIONS

(18)F-FDG PET-CT had a high impact in the management of MCC patients in our series and this investigation merits further assessment.

Modification of lymphoscintigraphic sentinel node identification before and after excisional biopsy of primary cutaneous melanoma

The aim of this study was to determine whether excision biopsy and primary closure of primary cutaneous melanoma modifies lymphatic drainage and accuracy of sentinel node biopsy. Thirty patients with 31 cutaneous melanomas were prospectively enrolled to undergo lymphoscintigraphy (LS) before and after excision biopsy. Tc-human serum albumin nanocolloid was first injected intradermally around the primary tumor and subsequently, after excision biopsy, adjacent to the scar. Sentinel nodes were identified by preoperative LS and the gamma-probe. Patent Blue V dye was injected intraoperatively before sentinel node biopsy. Intraoperative sentinel node identification was 100%. In 23 of 31 cases, both LSs were concordant in terms of nodal basins visualized. Two patients had a basin downstaged and six patients had a basin upstaged by the second LS. Only 50% of LS hot nodes stained blue (42 of 84). In 24 of 31 cases, the sentinel node was negative for metastases. Seven patients underwent complete lymph node dissection because of sentinel node positivity. Only one patient had metastases also to a non-sentinel node. After a median follow-up of 30 months lymph node metastases have not been observed in the eight discordant cases. This study shows that sentinel node identification and biopsy after lymphatic mapping is accurate after excision biopsy of primary cutaneous melanoma. Excision biopsy may, however, modify lymphatic drainage and a narrow excision margin should be performed if melanoma is suspected.