Controversies in the management of metastatic melanoma to regional lymphatic basins

Therapeutic neck dissection in head and neck melanoma patients: Comparing extent of surgery and clinical outcome in two cohorts

BACKGROUND

The extent of surgical management of regional lymph nodes in the treatment of cutaneous head and neck melanoma on and anterior to O'Brien's watershed line is controversial. By comparing patients' cohorts of two separate melanoma expert centers we investigate the effectiveness of comprehensive versus (super-) selective neck dissection approach.

METHODS

Sixty patients with macroscopic (palpable) neck node metastases (N2b) from anterior scalp and face melanoma were retrospectively studied. Forty therapeutic modified radical neck dissections (MRND; levels I-V) combined with elective parotidectomy from The Netherlands Cancer Institute (NCI) were compared with 16 (super-) selective neck dissections [(S)SND; 3-4 levels] and 4 solely MRNDs from Erasmus Medical Center (EMC). Cohorts were analyzed for site of recurrence, overall survival (OS), melanoma-specific survival (MSS), and disease-free survival (DFS).

RESULTS

Clinical characteristics of patients were equal in both groups. In the NCI cohort 62.5% (n = 25) of patients recurred versus 65% (n = 13) in the EMC cohort. None of the NCI recurrences affected the parotid gland in contrast to 3 patients in the EMC group. Survival characteristics were not different between the two groups: OS (p = 0.56), MSS (p = 0.98), DFS (p = 0.92).

CONCLUSION

This study does not support to continue the practice of routine elective parotidectomy and MRND in melanoma patients undergoing a lymph node dissection for macroscopic (palpable) nodal disease and justifies (S)SND.

Head and neck cutaneous melanoma: 5-year survival analysis in a Serbian university center

Background

Head and neck melanoma (HNM) is specific from the anatomical and etiopathogenetic aspects. In addition to morphopathological parameters, rich vascularization and lymphatic drainage of the head and neck affect the occurrence of lymphogenic and hematogenous metastases, as well as the metastases on both sides of the neck.

Methods

A retrospective cross-sectional study included cutaneous melanoma patients who underwent surgery at a clinical center over a 10-year period. The clinical follow-up was at least 60 months. The Kaplan-Meier method was used for the survival analysis. The predictor effect of certain independent variables on a given dichotomous dependent variable (survival) was measured by the Cox regression analysis.

Results

The analysis of demographic and clinical characteristics of 116 patients with HNM revealed that there was no statistically significant difference in age and gender in the total sample. Thirty-three (28.45%) patients were already in stage III or IV of the disease at the first examination, which affected the overall survival rate. The overall 5-year survival was 30.2%. No statistically significant difference in 5-year survival was found in relation to age and location. The period without melanoma progression decreased progressively in the advanced stage. Forty-nine patients (42%) underwent surgery for lymphogenic metastases in the parotid region and/or neck during the follow-up.

Conclusions

Patients with HNM included in this study frequently presented an advanced stage of the disease at the first examination, which is reflected in a low rate of 5-year survival. Early diagnosis and adequate primary treatment can ensure longer survival.

Parotidectomy in patients with head and neck cutaneous melanoma with cervical lymph node involvement

BACKGROUND

Parotidectomy in melanoma of the coronal scalp and face with clinically involved cervical lymph node metastasis is based on predicted cervical lymphatic drainage described by O'Brien.

METHODS

In total, 40 parotidectomies with en bloc therapeutic neck dissection were retrospectively analyzed.

RESULTS

Lymphatic spread of melanoma to the parotid lymph nodes was observed in 10 of 40 specimens (25%). Eight of the 10 parotid-positive patients developed a recurrence vs 17 of the 30 parotid-negative patients (P = 0.28). There were no differences in overall survival, melanoma-specific survival, and disease-free survival between the parotid-positive and parotid-negative patients.

CONCLUSION

Although in this series no survival differences were found, parotidectomy still merits a sustained role in therapeutic neck dissection procedures to improve regional control and to prevent facial nerve damage after surgery for a second relapse from occult metastases in the parotid.

Treatment of Clinically Positive Cervical Lymph Nodes by Limited Local Node Excision and Adjuvant Radiotherapy in Melanoma Patients with Major Comorbidities

INTRODUCTION

When cervical lymph nodes are clinically positive for metastatic melanoma, surgeons may be hesitant to recommend a therapeutic complete lymph node dissection if the patient is elderly or has major comorbidities. A limited local node excision of the clinically positive nodes only, followed by adjuvant radiotherapy to the entire node field, may be an effective alternative in such patients.

METHODS

All patients who had presented with a primary head and neck melanoma or an unknown primary site and had subsequently undergone limited local node excision and adjuvant radiotherapy for macroscopically involved cervical nodes between 1993 and 2010 at a tertiary referral center were selected for study.

RESULTS

Twenty-eight patients were identified, with a median age of 78 years and a median of 2 major comorbidities. The 5-year regional control, disease-free survival, and overall survival rates were 69%, 44%, and 50%, respectively. At the time of data analysis, seven patients were alive without evidence of disease. Twenty-one patients had died: 11 of melanoma (4 with neck recurrence) and 10 of other causes (2 with neck recurrence).

CONCLUSIONS

Excision of clinically positive metastatic cervical lymph nodes followed by radiotherapy provides satisfactory regional disease control without risking serious morbidity or mortality in melanoma patients whose general condition is considered a contraindication for therapeutic complete lymph node dissection.

[Malignant head and neck melanoma: Part 2: Therapy]

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.

Risk Factors for Positive Deep Pelvic Nodal Involvement in Patients with Palpable Groin Melanoma Metastases: Can the Extent of Surgery be Safely Minimized? : A Retrospective, Multicenter Cohort Study

Background

Patients with palpable melanoma groin metastases have a poor prognosis. There is debate whether a combined superficial and deep groin dissection (CGD) is necessary or if superficial groin dissection (SGD) alone is sufficient.

Aim

The aim of this study was to analyze risk factors for deep pelvic nodal involvement in a retrospective, multicenter cohort of palpable groin melanoma metastases. This could aid in the development of an algorithm for selective surgery in the future.

Methods

This study related to 209 therapeutic CGDs from four tertiary centers in The Netherlands (1992–2013), selected based on complete preoperative imaging and pathology reports. Analyzed risk factors included baseline and primary tumor characteristics, total and positive number of inguinal nodes, inguinal lymph node ratio (LNR) and positive deep pelvic nodes on imaging (computed tomography [CT] ± positron emission tomography [PET], or PET − low-dose CT).

Results

Median age was 57 years, 54 % of patients were female, and median follow-up was 21 months (interquartile range [IQR] 11–46 months). Median Breslow thickness was 2.10 mm (IQR 1.40–3.40 mm), and 26 % of all primary melanomas were ulcerated. Positive deep pelvic nodes occurred in 35 % of CGDs. Significantly fewer inguinal nodes were positive in case of negative deep pelvic nodes (median 1 [IQR 1–2] vs. 3 [IQR 1–4] for positive deep pelvic nodes; p < 0.001), and LNR was significantly lower for negative versus positive deep pelvic nodes [median 0.15 (IQR 0.10–0.25) vs. 0.33 (IQR 0.14–0.54); p < 0.001]. A combination of negative imaging, low LNR, low number of positive inguinal nodes, and no extracapsular extension (ECE) could accurately predict the absence of pelvic nodal involvement in 84 % of patients.

Conclusions

Patients with negative imaging, few positive inguinal nodes, no ECE, and low LNR have a low risk of positive deep pelvic nodes and may safely undergo SGD alone.

Surgical management of metastatic melanoma in the era of targeted systemic therapies

Treatment strategies for metastatic melanoma have changed markedly in recent times due to the advent of targeted systemic therapies. In addition to these developments, surgery remains a useful adjunct that can confer survival benefits in selected patients. In this review, we examine the current literature to highlight the role of surgical intervention in metastatic melanoma in the era of targeted systemic therapies.

Managing regional metastasis in patients with cutaneous head and neck melanoma - is selective neck dissection appropriate?

BACKGROUND

Neck dissection is recommended for patients with head and neck cutaneous melanoma and nodal metastasis. However, there appears to be no clear evidence to guide the extent of nodal resection.

METHODS

Loco-regional recurrence (LR), overall survival (OS) and progression free survival (PFS) was retrospectively compared between patients who had Comprehensive neck dissection (CND) and Selective neck dissection (SND).

RESULTS

There was no difference in LR, OS and PFS between CND (n=18) and SND groups (n=79). Extra capsular extension (ECE), frontal disease and increasing number of involved nodes resulted in worse OS and PFS but had no impact on LR.

CONCLUSION

Patients with disease limited to one node without ECE can be effectively treated by SND alone. In patients who have these unfavourable pathological features more extensive nodal resection does not improve outcome if they receive radiotherapy. Extent of neck dissection or adjuvant radiotherapy has no impact on overall survival.

Principles of surgical treatment of malignant melanoma

Although melanoma represents less than 5% of all skin cancers, it is responsible for the bulk of skin cancer-related deaths. Nevertheless, despite this aggressive reputation, most patients with cutaneous melanoma will be surgically cured of their disease. Early detection allows for curative resection, and 5-year survival for all stages of melanoma is 91%. This review outlines the surgical treatment of melanoma, including principles of wide local excision and management of the regional lymph nodes.

Role of neck dissection in the treatment of melanoma of the head and neck

Despite numerous studies, specific guidelines for cervical lymph node surgery in cutaneous malignant melanoma of the head and neck are still missing.In a retrospective study, the modalities of neck dissection (ND), the histologic results, and the outcome in 59 patients with cutaneous malignant melanoma of the head and neck were evaluated to verify the benefit of this therapy.Patients with proven lymph node metastasis often benefit from complete ND because about 50% of the patients showed more metastases in their ND specimen than before surgery. In addition, suspicious but not surely malignant lymph nodes often proved to be benign.This study reveals that patients with proven lymph node metastasis often benefit from complete ND because the number of infiltrated nodes is often higher than suspected; nevertheless, when planning the surgical therapy, the overall prognosis has to be kept in mind.

Individualized surgery: gamma-probe-guided lymphadenectomy in patients with clinically enlarged lymph node metastases from melanomas

Background

The value of a preoperative lymphoscintigraphy in melanoma patients with clinically evident regional lymph node metastases has not been studied. Therapeutic lymph node dissection (TLND) is regarded as the clinical standard, but the appropriate extent of TLND is controversial in all lymphatic basins.

Patients and Methods

Of the 115 consecutive patients with surgery on palpable lymph node metastases, 34 received a pre-operative lymphoscintigraphy. Lymphatic drainage to a second nodal basin outside the clinically involved basin was found in 15 cases. In 13 patients, the ectopic tumor-draining lymph nodes were excised as in a sentinel node biopsy. The lymph nodes from the TLND specimens were postoperatively separated and classified as either radioactive or non-radioactive.

Results

A total of 493 lymph nodes were examined pathologically. The largest macrometastasis maintained the ability to take up radiotracer in 77% of cases. Radioactively labeled lymph nodes carried a higher risk of being involved with metastasis. The proportions of tumor involvement for radioactive and non-radioactive lymph nodes were 44.5 and 16.9%, respectively (P=0.00002). Of the 13 ectopic nodal basins surgically explored, six harbored clinically occult metastases.

Conclusion

In patients undergoing TLND for palpable metastases, tumor-draining lymph nodes in a second, ectopic nodal basin should be excised, because they could be affected by occult metastasis. With respect to radioactive lymph nodes situated within the nodal basin of the macrometastasis but beyond the borders of a less-radical lymphadenectomy, further studies are needed.

Dominant lymph drainage in the upper extremity and upper trunk region: evaluation of lymph drainage in patients with skin melanomas

BACKGROUND

The objective of this study is to evaluate the lymph drainage from the primary focus to the regional lymph nodes in patients with melanomas of the upper extremity and upper trunk region.

METHOD

The study is a retrospective study of 20 patients with upper extremity melanomas and 14 patients with upper trunk melanomas treated with axillary lymph node dissection (ALND) or sentinel lymph node biopsy at the hospital. ALND was performed in 14 cases. In these cases, 12 were curative dissections and 2 were elective dissections. The dominant lymph drainage patterns from the primary regions were analyzed.

RESULTS

Among the upper extremity and upper trunk region melanomas, lymph drainage to Level I was determined in all cases. In these two regions there were no cases of lymph drainage to Level II not passing through Level I. Furthermore, there were no cases where sentinel lymph node or metastasis of the lymph nodes was clearly determined in Level III. Among the upper extremity melanomas, lymph drainages to the cubital (10 %) and mid-arm nodes (5 %) were established. Among the scapular region melanomas, lymph drainages to the supraclavicular nodes (25 %) were determined.

CONCLUSIONS

There was a dominant lymph drainage pattern of melanomas of the upper extremity and upper trunk region to Level I. No lymph node dissection of Level III in patients with melanomas of the upper extremity and upper trunk region is necessary unless preoperative examination determines a high possibility of metastasis-positive lymph nodes in level III.

Therapeutic surgical management of palpable melanoma groin metastases: superficial or combined superficial and deep groin lymph node dissection

Background

Management of patients with clinically detectable lymph node metastasis to the groin is by ilioinguinal or combined superficial and deep groin dissection (CGD) according to most literature, but in practice superficial groin dissection (SGD) only is still performed in some centers. The aim of this study is to evaluate the experience in CGD versus SGD patients in our center.

Methods

Between 1991 and 2009, 121 therapeutic CGD and 48 SGD were performed in 169 melanoma patients with palpable groin metastases at our institute. Median follow-up was 20 and, for survivors, 45 months.

Results

In this heterogeneous group of patients, overall (OS) and disease-free survival, local control rates, and morbidity rates were not significantly different between CGD and SGD patients. However, CGD patients had a trend towards more chronic lymphedema. Superficial lymph node ratio, the number of positive superficial lymph nodes, and the presence of deep nodes were prognostic factors for survival. CGD patients with involved deep lymph nodes (24.8%) had estimated 5-year OS of 12% compared with 40% with no involved deep lymph nodes (p = 0.001). Preoperative computed tomography (CT) scan had high negative predictive value of 91% for detection of pelvic nodal involvement.

Conclusions

This study demonstrated that survival and local control do not differ for patients with palpable groin metastases treated by CGD or SGD. Patients without pathological iliac nodes on CT might safely undergo SGD, while CGD might be reserved for patients with multiple positive nodes on SGD and/or positive deep nodes on CT scan.

Routine biopsy of Cloquet's node is of limited value in sentinel node positive melanoma patients

BACKGROUND AND OBJECTIVES

Biopsy of Cloquet's node (CN) during groin dissection has been used to indicate need for pelvic dissection. With earlier detection of microscopic regional disease in the era of sentinel node biopsy (SNB), frequency of positive CN may be so low that routine biopsy is unwarranted.

METHODS

Patients with positive groin SNB from 2000 to 2008 were identified from two centers. Cases where CN was identified at completion node dissection were selected. Lymphoscintigraphic, surgical, pathologic, and recurrence data were reviewed.

RESULTS

CN was identified in 53 cases. Median age was 44.5 years (range 7-77); median Breslow depth, 1.98 mm (range 0.5-25.0); % Clark's level IV/V, 90%; and % ulceration, 41.5%. Fifty (94.3%) underwent groin dissection alone; three others underwent concomitant pelvic dissection. Two (3.8%) patients had positive CN; both had additional indications for pelvic dissection. Delayed pelvic recurrence rate was 2/53 (3.8%); both patients had negative CN. In the three patients treated with concurrent groin and pelvic dissection, CN reflected pelvic nodal status in two cases; the third had pelvic metastases despite negative CN.

CONCLUSIONS

After positive SNB, disease involvement of CN is rare. Patients with positive biopsies of CN in the SNB era appear likely to have additional indications for pelvic dissection, minimizing utility of CN biopsy. Routine intraoperative sampling of CN may not be warranted during groin dissection for positive SNB.

Role of radiation therapy in cutaneous melanoma

Cutaneous melanoma is a disease that often has an aggressive and unpredictable course. It was historically thought to be a radioresistant neoplasm; however, substantial radiobiologic and clinical evidence has emerged to refute this notion. Improved local control has been demonstrated with the use of adjuvant radiation therapy delivered to the primary site or regional lymphatics in patients with high-risk clinical or pathologic features. Despite improved local control, high-risk cutaneous melanoma often spreads systemically, leading to poor survival. In the setting of systemic progression, radiation therapy can frequently palliate symptomatic sites of metastatic disease.

Pelvic sentinel lymph node biopsy in melanoma patients: is it worthwhile?

The original procedure of intraoperative lymphatic mapping by using vital blue dye initially described by Morton and colleagues in 1992 was implemented in subsequent years by the introduction of preoperative lymphoscintigraphy (LS) and intraoperative gamma detection probe to allow a better identification of sentinel nodes (SNs). However, it is common, in practice, to detect more than one radioactive node with the gamma detection probe. Whether these additional lymph nodes represent true SNs is not yet clear. The aims of this study are: to investigate the role of pelvic sentinel node biopsy in recurrent pelvic disease in those patients with negative inguinal SN, having one or more deep hot spots identified by preoperative LS (follow-up group). One hundred and four stage I/II melanoma patients with primary tumor of the lower limb and lower trunk were enrolled in a restrospective study at the European Institute of Oncology, Milan, Italy, between 2000 and 2007. All patients presented hot spots both in superficial (groin) and deep (iliac-obturator) areas during dynamic LS. The study population consisted of 35 men and 69 women with a median age of 57 years at the time of diagnosis. The median follow-up period was 49 months (SD 22.4; range, 10-98 months). Of the 104 patients, 83 had a negative SN (80%). All sentinel-lymph-node-positive patients underwent superficial and deep inguinal dissection. Two patients (2.4%; 95% confidence interval: 1.5-8.8%) with negative SNs had pelvic recurrence. Among patients who underwent ilioinguinal dissection, three (14%; 95% confidence interval: 4-35%) had positive pelvic lymph nodes. After a 60-month follow-up, 79% of patients were alive and 66% were disease free. In SN-negative patients, disease-free survival was 69% and in SN-positive patients 53%. No significant difference was found by SN status (log-rank P values 0.15). Even if the sample size of our study cannot bring to conclusive results, and further studies are needed, it might be possible that harvesting pelvic SN in those patients with pelvic hot spots at LS could modify the natural history of melanoma patients in terms of pelvic recurrence and disease free survival. We recommend to improve our knowledge in the role of pelvic sentinel node in the natural history of melanoma.

Imaging in cutaneous melanoma

Cutaneous melanoma (CM) is a common malignancy and imaging, particularly lymphoscintigraphy (LS), positron-emission tomography with 2-fluoro-2-deoxyglucose (FDG-PET), ultrasound, radiography computed tomography (CT) and magnetic resonance imaging have important roles in staging and restaging, surgical guidance, surveillance and assessment of recurrent disease. This review aims to summarize the available data regarding these and other imaging modalities in CM and provide the basis for subsequent formulation of guidelines regarding the use of imaging in CM. PubMed and Medline searches were performed and reference lists from publications were also searched. The published data were reviewed and tabulated. There is level I evidence supporting the use of LS and sentinel lymph node biopsy in nodal staging for CM. There is level III evidence demonstrating the superiority of ultrasound to palpation in the assessment of lymph nodes in CM. There is level IV evidence supporting FDG-PET in American Joint Committee on Cancer stage III/IV and recurrent CM and that FDG-PET/CT may be superior to FDG-PET. Level IV evidence also supports the use of CT in the same group of patients and the role of CT appears to be complementary to FDG-PET. Various imaging modalities, especially LS/sentinel lymph node biopsy and FDG-PET/CT, add incremental information in the management of CM and the various modalities have complementary roles depending on the clinical situation.

Extracutaneous malignant melanomas

Extracutaneous malignant melanomas are rare tumors with vexing clinical presentation and grim prognosis. Only 4%-5% of all primary melanomas do not arise from the skin. These tumors are almost uniformly fatal, even in 2006. Although a fairly good number of these lesions were reported in the literature, the lack of a side-by-side analysis of these studies has resulted in tentative conclusions that merely offer a first glimpse at the clinicopathologic diversity of these lesions. To remedy this issue, this article took an aim at presenting a literature review concerning extracutaneous malignant melanomas. It also reports several cases of extracutaneous melanomas, which I came across in my 15 years of surgical and molecular pathology practice. The study raises several notions. Extracutaneous malignant melanomas are rare but extremely aggressive lesions with a grim outcome. They include ocular, metastatic, anorectal, mucosal, nail beds, conjunctival, vaginal, urogenital, orbital, esophageal, and leptomeningial malignant melanomas. The development of these lesions lacks an association with sun damage, family history, or precursor nevi. These lesions cause considerable diagnostic consternation and their distinction from other types of tumors (such as undifferentiated carcinomas, high-grade sarcomas, and lymphomas) is critical both from a diagnostic and prognostic point of view. In the proper clinical, histological, and cytological context, immunopositivity for S100 protein, HMB45, and vimentin allows the distinction of these malignant melanomas from other histologically similar malignancies. To conclude, extracutaneous melanoma should be considered while undifferentiated neoplasms, especially those displaying prominent eosinophilic nucleoli, and the coexistence of epithelioid and spindle cells. Special staining and immunohistochemistry should be resorted to establish the diagnosis.

Multidisciplinary management of special melanoma situations: oligometastatic disease and bulky nodal sites

Potentially resectable, advanced stage melanoma in the form of extensive palpable adenopathy or limited systemic metastases presents a significant challenge but also offers the prospect of long-term disease control. Although surgical resection is the mainstay of therapy, involvement of a multidisciplinary team is required for optimal management of these special situations. These patients need to be evaluated preoperatively by the team, discussed at a multidisciplinary conference, and treated by experienced physicians with access to the full spectrum of modern surgical and oncologic therapy. Surgical resection is generally extensive and may require en bloc resection of important anatomic structures. Adjuvant radiation or systemic therapy is required in many patients to help achieve durable regional and systemic control of disease. In addition, novel therapies, such as neoadjuvant chemotherapy, targeted therapies, or investigational intralesional therapies, may ultimately play a role in the management of these difficult clinical situations and require further evaluation, as preliminary studies show some encouraging results.

Measurement of limb volume: laser scanning versus volume displacement

BACKGROUND

Determining the prevalence and treatment success of surgical lymphedema requires accurate and reproducible measurement. A new method of measurement of limb volume is described.

METHODS

A series of inanimate objects of known and unknown volume was measured using digital laser scanning and water displacement. A similar comparison was made with 10 human volunteers. Digital scanning was evaluated by comparison to the established method of water displacement, then to itself to determine reproducibility of measurement.

RESULTS

(1) Objects of known volume: Laser scanning accurately measured the calculated volume but water displacement became less accurate as the size of the object increased. (2) Objects of unknown volume: As average volume increased, there was an increasing bias of underestimation of volume by the water displacement method. The coefficient of reproducibility of water displacement was 83.44 ml. In contrast, the reproducibility of the digital scanning method was 19.0 ml. (3) Human data: The mean difference between water displacement volume and laser scanning volume was 151.7 ml (SD +/- 189.5). The coefficient of reproducibility of water displacement was 450.8 ml whereas for laser scanning it was 174 ml.

CONCLUSION

Laser scanning is an innovative method of measuring tissue volume that combines precision and reproducibility and may have clinical utility for measuring lymphedema.

[Lymphadenectomy of the inguinal region and pelvis]

The draining lymph nodes of extra-abdominal tumors and malignant lesions of the lower extremity are located in the groin and iliac region. Malignancies with lymphatic drainage into this region include tumors of the anorectum, penis and vulva, skin (melanoma, squamous cell carcinoma), and soft tissue sarcomas. Current clinical research in biology, routes of lymphatic spread, and the possibility of marking the sentinel lymph node has directed lymphadenectomy strategy toward differential procedures, depending on the type of underlying malignancy. The spectrum of lymphadenectomy includes diagnostic lymph node removal of clinically enlarged nodes, removal of the sentinel node, and radical lymphadenectomy. Lymphadenectomy can also be indicated as a palliative procedure. The indications also depend on the type of tumor, previous treatment, and disease prognosis. This review presents the current state of indications and surgical techniques of inguinal and iliacal lymphadenectomy.

[Axillar lymphadenectomy]

Axillary dissection aims at local tumor control and staging. Among breast cancer, malignant melanoma and other solid malignancies, the nodal status is still the most important predictive and prognostic factor. Today, because of its morbidity, axillary lymphadenectomy is indicated only when the sentinel lymph node is involved by metastasis after histopathologic investigation. The surgical technique of axillary dissection is presented, complications and oncologic outcomes are summarised after dissection for breast carcinoma and malignant melanoma, respectively.

Pediatric Melanoma of the Head and Neck: A Single Institutions Experience

OBJECTIVES

The objectives of this study were to review our experience with pediatric melanoma of the head and neck and discuss proper diagnostic protocols and suggest a possible treatment algorithm.

STUDY DESIGN

The authors conducted a retrospective chart review of patients under the age of 18 who underwent treatment for melanoma of the head and neck at a tertiary care university hospital.

RESULTS

Six patients were identified in the last 25 years at our institution. Four patients had melanomas in the auricle, one in the cheek, and one in the forehead. All occurrences identified presented in the past 7 years. All were treated with wide local excision. Three patients received sentinel lymph node biopsy, one received a neck dissection after identification of positive sentinel nodes, and two patients received postoperative interferon therapy. No surgical complications were reported. At the time of this submission, no patients were found to have recurrence of the disease.

CONCLUSIONS

Pediatric melanoma of the head and neck may be managed effectively using current techniques used in treating adult patients. The use of sentinel lymph node biopsy is recommended when the depth of invasion cannot be determined from original biopsy, the original pathologic diagnosis is ambiguous, or depth of invasion from biopsy is sufficient to warrant its use. In addition, the use of adjuvant interferon alpha-2b is recommended in patients at high risk for recurrence.

Dispelling the myths surrounding radiotherapy for treatment of cutaneous melanoma

The role of radiotherapy is well established in the management of most locally advanced and metastatic cancers; however, there has been reluctance to extend this role to melanoma. The reasons can be traced historically to in-vitro and in-vivo data suggesting that melanomas are resistant to radiation. Current findings indicate that these cancers have a wide range of sensitivity to radiation that overlaps extensively with those for common epithelial cancers: indeed, some melanomas show high sensitivity to radiation. Greater incorporation of radiotherapy into multidisciplinary management of melanoma is important because of the typical natural history of the disease (a propensity for both locoregional recurrence and distant metastases) and its poor response to systemic treatment. This review will discuss these issues and preview the strategies being developed for radiotherapy to further improve the care of patients with melanoma.

Pelvic lymph node count is an important prognostic variable for FIGO stage I and II endometrial carcinoma with high-risk histology

OBJECTIVE

To determine whether pelvic lymph node count is associated with patterns of recurrence or survival in patients with FIGO stage I and II endometrial cancer.

METHODS

Single institution retrospective study of 467 patients with FIGO stage I and II endometrial cancer treated with primary surgery including lymph node dissection. Analysis included pelvic lymph node count, histology, stage, age, race, BMI, year of surgery, depth of myometrial invasion, and adjuvant radiation. Kaplan-Meier life-tables were used to calculate survival; the Cox proportional hazards model was used to identify prognostic factors independently associated with survival.

RESULTS

Mean pelvic lymph node count was 12.6 (SD +/- 8). Distant recurrence was associated with decreased pelvic lymph node count, high-risk histology, and postoperative pelvic radiation. Pelvic lymph node count was not associated with survival by univariate analysis, however, overall (OS) and progression-free (PFS) survival were significantly better with pelvic lymph node counts >or=12 among women with high-risk histology (P < 0.001), but not among women with low-risk histology. Multivariable Cox proportional hazards regression identified increasing age, non-Caucasian race, and high-risk histology as independent negative prognostic factors for both OS and PFI. Among patients with high-risk histology, pelvic lymph node count remained an independent prognostic factor for both overall (OS) and progression-free survival (PFS) in the model, with hazard ratios of 0.28 and 0.29, respectively, when >or=12 pelvic lymph nodes were identified. Pelvic lymph node count had no association with OS or PFS in women with low-risk histology.

CONCLUSION

Pelvic lymph node count >or=12 is an important prognostic variable in patients with FIGO stage I and II endometrial cancer who have high-risk histology. Most likely, the association of survival and lymph node count in this group is the result of improved staging among patients with higher pelvic lymph node counts.

Patient Outcomes After Axillary Lymph Node Dissection for Breast Cancer: Use of Postoperative Continuous Local Anesthesia Infusion

BACKGROUND

Although considered a safe surgical procedure, axillary lymph node dissection (ALND) is associated with postoperative numbness, paresthesias, pain, and muscle weakness. Despite meticulous surgical technique and the absence of long thoracic or thoracodorsal nerve injury, the risk of these complications are reported as great as 35% to 50%, with a subset of patients developing chronic pain syndromes.

METHODS

Female patients (n = 27) undergoing Level I-II ALND for breast cancer were recruited. After ALND, patients were randomized to three groups. Group 1 received standard axillary lymph node dissection. Patients assigned to group 2 or 3 (double-blinded) received 120 h continuous 0.9% saline solution or 0.5% bupivacaine using a catheter placed into the axilla and delivered by an elastomeric pump device. After routine postoperative care, patients were discharged with oral opioid analgesics. Twice-daily assessment of pain, sedation, and nausea were conducted using validated visual-analog scale measures. Daily and total opioid analgesic requirements after surgery were recorded.

RESULTS

Patients treated with a continuous infusion of bupivacaine experienced significantly lower pain scores (P < 0.001) during the first 5 postoperative days. Postoperative opioid analgesic requirements also were significantly decreased in the bupivacaine group, and these effects persisted until postoperative day 14 (P < 0.001). Concomitant to the observed decreases in pain and oral opioid requirements, nausea and morning sedation also were significantly reduced. There were no pump-related complications, wound infections, or postoperative axillary fluid collections.

CONCLUSIONS

The use of continuous administration of bupivicaine after ALND significantly decreases pain and opioid analgesic requirements, with concomitant decreases in nausea and sedation. This study provides encouraging evidence of the therapeutic benefits of continuous infusion of local anesthesia and may represent a valuable adjunct for surgical patients who require ALND, including those with breast cancer and melanoma.

Level of Fluorodeoxyglucose Uptake Predicts Risk for Recurrence in Melanoma Patients Presenting With Lymph Node Metastases

BACKGROUND

The incidence of malignant melanoma has increased. Identification of additional prognostic factors may allow the development of individualized strategies. This multivariate analysis was undertaken to evaluate the potential role of the standard uptake value (SUV) in predicting disease-free and overall survival in melanoma patients with lymph node metastases.

METHODS

All melanoma patients with palpable lymph node metastases who where referred for a fluorodeoxyglucose positron emission tomography scan were eligible. The SUV in the lymph node metastasis was calculated. Data were analyzed (Kaplan-Meier), and differences in cumulative survival and the disease-free rate were assessed (log-rank test). Univariate and multivariate analyses (Cox proportional hazard model) were performed to determine independent prognostic factors.

RESULTS

There was no statistical difference in survival for the 38 patients with a high or low SUVmean (P = .11). However, a significant difference was found in disease-free survival (P = .03). Ulceration of the primary melanoma (P = .023) was an independent predictor of survival. For the disease-free survival, multivariate Cox regression showed adjuvant radiation (P = .001), localization of the primary melanoma (P = .017), and a high SUVmean (P = .009) as independent prognostic factors.

CONCLUSIONS

Disease-free survival of melanoma patients was prolonged in those with a low SUVmean value (P = .03) in their lymph node metastasis, as compared with those with a high SUVmean. However, this difference was not found for overall survival. In multivariate analysis, high SUVmean was an independent prognostic factor (P = .009) for disease-free survival. Prospective research should determine whether patients with a high FDG uptake in melanoma lymph node metastases could benefit from adjuvant radiation treatment or chemotherapy.

Extra nodal growth as a prognostic factor in malignant melanoma

AIM

Extra nodal growth (ENG) in lymph-node metastases may be an additional indicator for poor prognosis and increased loco-regional recurrence in patients with a cutaneous malignant melanoma (CMM). Most studies analyzing prognostic factors lack a proper definition or description of the histological criteria for extra nodal growth. The objective of this study was to evaluate this factor.

METHODS

Retrospectively 94 patients with CMM and clinically lymph-node metastases were analysed. Metastatic lymph-nodes were evaluated for ENG and if present grouped in microscopic (<2 mm) or macroscopic (>2 mm) ENG. ENG was defined as metastatic tumour which clearly extends histologically through the nodal capsule into the perinodal fatty tissue or tumour involvement in the hilar region with interruption of the smooth outline of the (presumed) capsule.

RESULTS

Ninety-four patients, median age 52 (6-92) years with CMM, median Breslow thickness 2.8 (0.2-11.0) mm. In 50 patients ENG was present (macroscopic: 32, microscopic: 18). The median follow-up was 59 (range 5-325) months. The number of loco-regional recurrence was 10; 4 in the group with and 6 in the group without ENG (n.s.). Five years survival of patients with ENG was 42% and without ENG 50% (n.s.). There was no significant difference in survival or loco-regional recurrence between microscopic or macroscopic ENG.

CONCLUSION

ENG of lymph-node metastases of CMM is of no prognostic value and has no clinical impact.