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Clementi M, Di Furia M, Sista F, Mackay AR, Guadagni S. Successful laparoscopic trans-peritoneal repair of an incisional inguinal hernia, resulting from deep lymph node dissection for melanoma: A case report. Int J Surg Case Rep 2020; 67:82-85. [PMID: 32044563 PMCID: PMC7013140 DOI: 10.1016/j.ijscr.2020.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/10/2020] [Accepted: 01/17/2020] [Indexed: 01/19/2023] Open
Abstract
Groin incisional hernia may result like late complication of deep pelvic dissection. When this type of inguinal ventral hernia develops, the surgeon is facing some problems different to the common ventral hernia repair. Most of these difficulties may be overcome using laparoscopic approach. We present a case of successful laparoscopic repair of a giant ventral hernia developed like late complication of deep pelvic dissection for melanoma. To our knowledge, no other laparoscopic repair of this type of ventral hernia has been previously reported.
Introduction Deep pelvic lymph node dissection for cancer may result in incisional inguinal hernias. We present a case report of successful laparoscopic trans-peritoneal repair of a large ventral inguinal hernia that developed following ileo-inguinal lymph node dissection (CLND) for melanoma. Case presentation A successful 3 port laparoscopic trans-peritoneal procedure was performed on a 56-year-old female for the repair of a left inguinal hernia, developed 13 months following CLND for melanoma. The large oval 18 × 14 cm inguinal defect, with superior margins bordering the conjoint tendon and inferior margins bordering the ileo-psoas muscle, femoral vessels and nerve, was not closed in order to avoid excessive tension and was repaired by fixing a 25 × 20 cm intra-peritoneal mesh to abdominal borders at superior and lateral margins with permanent fasteners and at the inferior margin by a cyanoacrylate-glued overlap to protect femoral vessels and nerves from damage. No hernia recurrence was observed 8 months following this procedure. Discussion Incisional inguinal hernias, following CLND, are rare but present a challenge to surgeons due to the difficulty in identifying both anatomical plains and safe sites for stable repair. Conclusions We report a laparoscopic trans-peritoneal approach for the safe, reproducible and efficacious repair of incisional inguinal hernias that result from CLND. In our opinion prevention of hernia recurrence can be achieved by a intraperitoneal large mesh fixed at superior and lateral margin borders with permanent fasteners and using cyanoacrylate glue to overlap inferior margin borders in order to prevent vessels and/or nerve injury.
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Affiliation(s)
- M Clementi
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100 L'Aquila, Italy.
| | - M Di Furia
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100 L'Aquila, Italy.
| | - F Sista
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100 L'Aquila, Italy.
| | - A R Mackay
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100 L'Aquila, Italy.
| | - S Guadagni
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100 L'Aquila, Italy.
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Tsutsumida A, Takahashi A, Namikawa K, Yamazaki N, Uhara H, Teramoto Y, Takenouchi T, Fukushima S, Yokota K, Uehara J, Matsushita S, Shibayama Y, Hatta N, Masui Y, Uchi H, Fujisawa Y, Ogata D. Frequency of level II and III axillary nodes metastases in patients with positive sentinel lymph nodes in melanoma: a multi-institutional study in Japan. Int J Clin Oncol 2016; 21:796-800. [DOI: 10.1007/s10147-015-0944-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/19/2015] [Indexed: 10/22/2022]
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Teramoto Y, Nakamura Y, Sato S, Yamazaki N, Yamamoto A. Low Probability of Lymphatic Drainage to Cloquet's Node Is of Limited Value as Indicator for Pelvic Lymph Node Dissection in Patients with Lower Limb Melanoma. Lymphat Res Biol 2015; 14:109-14. [PMID: 26495774 DOI: 10.1089/lrb.2015.0007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES For patients with melanoma, the choice between an inguinal lymph node dissection (ILND) alone and both an ILND and a pelvic lymph node dissection (PLND) is controversial. Although Cloquet's node (CN) is considered the sentinel pelvic node, evaluation of this factor to predict pelvic node status has produced varied results. We investigated inguinal and pelvic lymphatic drainage patterns and focused on CN to clarify whether CN status could be an indicator of PLND. METHODS Patients with primary cutaneous lower limb melanoma who underwent lymphatic mapping and sentinel lymph node biopsy (SLNB) using dynamic lymphoscintigraphy and SPECT/CT were retrospectively reviewed. RESULTS Thirty-two patients underwent lymphatic mapping and SLNB. Each patient's CN was identified by SPECT/CT. A radioactive CN was detected in only 37.5% (12/32) of patients, and no lymphatic drainage to CN occurred in 62.5% (20/32). In 37.5% (12/32) of patients, the lymph drained directly from the inguinal to the pelvic nodes bypassing CN. CONCLUSION In melanoma patients, lymphatic drainage from the lower extremity does not always pass from the inguinal node to the pelvic nodes via CN. Tumor-negative status of CN alone is of limited value as an indicator for avoiding PLND.
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Affiliation(s)
- Yukiko Teramoto
- 1 Department of Skin Oncology/Dermatology, Saitama Medical University International Medical Center , Saitama, Japan
| | - Yasuhiro Nakamura
- 1 Department of Skin Oncology/Dermatology, Saitama Medical University International Medical Center , Saitama, Japan
| | - Sayuri Sato
- 1 Department of Skin Oncology/Dermatology, Saitama Medical University International Medical Center , Saitama, Japan
| | - Naoya Yamazaki
- 2 Department of Dermatologic Oncology, National Cancer Center Hospital , Tokyo, Japan
| | - Akifumi Yamamoto
- 1 Department of Skin Oncology/Dermatology, Saitama Medical University International Medical Center , Saitama, Japan
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Rutkowski P, Szydłowski K, Nowecki ZI, Sałamacha M, Goryń T, Mitręga-Korab B, Pieńkowski A, Dziewirski W, Zdzienicki M. The long-term results and prognostic significance of cutaneous melanoma surgery using sentinel node biopsy with triple technique. World J Surg Oncol 2015; 13:299. [PMID: 26462471 PMCID: PMC4603583 DOI: 10.1186/s12957-015-0701-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 09/03/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The sentinel lymph node biopsy (SLN) is a basic staging method in all primary cutaneous melanomas ≥pT1b. The standard technique is a triple technique consisting of preoperative lymphoscintigraphy, intraoperative blue-dye lymphography, and gamma-probe assessment. We performed the analysis of long-term results in a very large one-institution series of cutaneous melanoma patients. METHODS We have analyzed treatment results of a group of 1764 consecutive patients with cutaneous melanoma, who underwent SLN biopsy between 1997 and 2008 in one tertiary center. Additionally, we have analyzed the outcomes of a group of 473 patients with positive SLN biopsy undergoing completion lymph node dissection (CLND). Median follow-up time was 5.3 years. RESULTS Metastases to SLN (SLN+) were found in 19.9%. Eight-year overall survival (OS) rate in the entire group was 73.5%, 80% without SLN metastases (SLN-) and 50% in group with SLN+ (p < 0.001). Independent prognostic factors for OS were as follows: presence of metastases to SLN, primary tumor ulceration, and higher mitotic index (>5/mm(2)) of primary tumor. The nodal recurrences in the biopsied lymphatic basin were 5.4%. The metastases to non-sentinel lymph nodes (NSLN found in 27% of patients with SLN+) correlated (on multivariable logistic regression analysis) with primary tumor thickness >4 mm, SLN metastatic deposit size >1 mm, and extracapsular involvement of SLN. In an additionally analyzed SLN+ group, the NSLN involvement was related to poorer prognosis (8-year OS rate NSLN- vs NSLN+: 59.6 vs. 34.7%, respectively). The independent prognostic factors for OS in the SLN+ group were a higher Breslow thickness and ulceration of primary tumor, metastases to more than 1 lymph nodes. CONCLUSIONS The long-term results confirm crucial prognostic significance of SLN biopsy in cutaneous melanoma. We identified factors related to NSLN involvement, which in the future may limit indications for CLND.
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Affiliation(s)
- Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | | | - Zbigniew I Nowecki
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Maciej Sałamacha
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Tomasz Goryń
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Beata Mitręga-Korab
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Andrzej Pieńkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Wirginiusz Dziewirski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Marcin Zdzienicki
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland.
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Sato S, Nakamura Y, Teramoto Y, Yeh YW, Maruyama H, Nakamura Y, Fujisawa Y, Fujimoto M, Yamamoto A. A novel approach for inguinal lymph node dissection without inguinal skin incision for invasive extramammary Paget disease. Dermatol Ther 2015; 28:351-4. [DOI: 10.1111/dth.12256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sayuri Sato
- Department of Skin Oncology/Dermatology; Comprehensive Cancer Center, Saitama Medical University International Medical Center; Saitama Japan
| | - Yasuhiro Nakamura
- Department of Skin Oncology/Dermatology; Comprehensive Cancer Center, Saitama Medical University International Medical Center; Saitama Japan
| | - Yukiko Teramoto
- Department of Skin Oncology/Dermatology; Comprehensive Cancer Center, Saitama Medical University International Medical Center; Saitama Japan
| | - Yu-Wen Yeh
- Department of Skin Oncology/Dermatology; Comprehensive Cancer Center, Saitama Medical University International Medical Center; Saitama Japan
| | - Hiroshi Maruyama
- Department of Dermatology; Faculty of Medicine; University of Tsukuba; Ibaraki Japan
| | - Yoshiyuki Nakamura
- Department of Dermatology; Faculty of Medicine; University of Tsukuba; Ibaraki Japan
| | - Yasuhiro Fujisawa
- Department of Dermatology; Faculty of Medicine; University of Tsukuba; Ibaraki Japan
| | - Manabu Fujimoto
- Department of Dermatology; Faculty of Medicine; University of Tsukuba; Ibaraki Japan
| | - Akifumi Yamamoto
- Department of Skin Oncology/Dermatology; Comprehensive Cancer Center, Saitama Medical University International Medical Center; Saitama Japan
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Litrowski N, Modeste ABD, Coquerel D, Courville P, Milliez PY, Joly P. Complications du curage ganglionnaire réalisé après exérèse du ganglion sentinelle dans le mélanome. Ann Dermatol Venereol 2013; 140:425-30. [DOI: 10.1016/j.annder.2013.02.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 01/04/2013] [Accepted: 02/14/2013] [Indexed: 11/29/2022]
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The analysis of the outcomes and factors related to iliac–obturator involvement in cutaneous melanoma patients after lymph node dissection due to positive sentinel lymph node biopsy or clinically detected inguinal metastases. Eur J Surg Oncol 2013; 39:304-10. [DOI: 10.1016/j.ejso.2012.12.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 09/30/2012] [Accepted: 12/12/2012] [Indexed: 11/17/2022] Open
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Postoperative Complications following Nodal Dissection and Their Association with Melanoma Recurrence. ISRN SURGERY 2013; 2013:382138. [PMID: 23533815 PMCID: PMC3600306 DOI: 10.1155/2013/382138] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 01/30/2013] [Indexed: 02/05/2023]
Abstract
Background. Although postoperative complications are common after lymph node dissection, its association with disease recurrence has not yet been fully investigated. Methods. A retrospective review of a prospectively maintained database was conducted, looking at all malignant melanoma patients with sentinel nodes positive disease requiring axillary or inguinal dissection between 2002 and 2011. Results. A total of 124 patients required nodal clearance from 317 patients with stage I/II malignant melanoma who had undergone sentinel lymph node biopsy. Of these, 104 patients met the inclusion criteria and were divided into inguinal lymph node dissections (ILND; n = 63) or axillary lymph node dissections (ALND; n = 41). Immunohistochemical deposits had higher detection rate in ALND (P = 0.01). The ILND patients had a higher recurrence rate (84.1% versus 63.4%; P = 0.02) and mortality (68.3% versus 48.8%; P = 0.05) without a significant difference in complications. In patients whom complications developed, 75% of the ILND group and 71.4% of the ALND group had disease recurrence, but without reaching a statistical value as an independent predictor of melanoma recurrence. Conclusion. Complications are common following ILND and ALND; however there is no significant difference in complications rates between the groups with some associations with recurrence without reaching a significant difference.
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Nessim C, Law C, McConnell Y, Shachar S, McKinnon G, Wright F. How Often do Level III Nodes Bear Melanoma Metastases and does it Affect Patient Outcomes? Ann Surg Oncol 2013; 20:2056-64. [DOI: 10.1245/s10434-013-2880-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Indexed: 11/18/2022]
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Key factors in reducing morbidity following inguinal node dissections. EUROPEAN JOURNAL OF PLASTIC SURGERY 2012. [DOI: 10.1007/s00238-012-0757-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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11
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Namm JP, Chang AE, Cimmino VM, Rees RS, Johnson TM, Sabel MS. Is a level III dissection necessary for a positive sentinel lymph node in melanoma? J Surg Oncol 2011; 105:225-8. [DOI: 10.1002/jso.22076] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 07/28/2011] [Indexed: 11/06/2022]
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12
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Davis PG, Serpell JW, Kelly JW, Paul E. Axillary lymph node dissection for malignant melanoma. ANZ J Surg 2010; 81:462-6. [DOI: 10.1111/j.1445-2197.2010.05491.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Radical dissection after positive groin sentinel biopsy in melanoma patients: rate of further positive nodes. Melanoma Res 2009; 19:112-8. [DOI: 10.1097/cmr.0b013e328329fe7d] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Postoperative morbidity of lymph node excision for cutaneous melanoma-sentinel lymphonodectomy versus complete regional lymph node dissection. Melanoma Res 2008; 18:16-21. [PMID: 18227703 DOI: 10.1097/cmr.0b013e3282f2017d] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
For patients with melanoma metastasis to a sentinel lymph node, subsequent complete regional lymph node dissection (CLND) is currently regarded to be the surgical standard. This approach, however, has not been confirmed by controlled studies, so that surgical morbidity is of primary importance. Using clinical examination and a questionnaire, we determined morbidity in 315 patients with axillary or inguinal lymph node excision on whom 275 sentinel lymphonodectomies (SLNEs) and 90 CLNDs were performed. The overall incidence of at least one complication following SLNE was 13.8%. The short-term complication rate was 11.3% (allergic reaction to blue dye 0%, wound breakdown 0%, haematoma 2.5%, wound infection 3.6%, seroma 6.9%). The incidence of long-term complications was 4.1% (persistent tattoo 0.4%, functional deficit 0.4%, nerve dysfunction/pain 0.7% or swelling 2.5%). All complications were mild. Significantly, the complication rate was not higher for patients aged 70 years or older. After CLND, the overall complication rate was significantly higher (65.5%, P<0.000001). The incidence of short-term complications was 50% (haematoma 0%, wound breakdown 6.7%, wound infection 24.7% or seroma 34.8%). The incidence of long-term complications was also 50% (nerve dysfunction/pain 8.9%, functional deficit 16.8%, swelling 37.1%). Overall, inguinal lymph node excision was burdened by a higher complication rate (P=0.015). Age and sex did not influence postoperative morbidity. No deaths linked to either procedure were noted. Complication rates after SLNE are low and most complications are minor and short-lasting. In contrast, CLND has been demonstrated to be a major and potentially morbid surgical procedure. This highlights the importance of testing the therapeutic value that CLND adds to the sentinel lymph node procedure.
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Morbidity and Recurrence After Completion Lymph Node Dissection Following Sentinel Lymph Node Biopsy in Cutaneous Malignant Melanoma. Ann Surg 2008; 247:687-93. [DOI: 10.1097/sla.0b013e318161312a] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Riker AI, Kirksey L, Thompson L, Morris A, Cruse CW. Current surgical management of melanoma. Expert Rev Anticancer Ther 2007; 6:1569-83. [PMID: 17134362 DOI: 10.1586/14737140.6.11.1569] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The surgical management of melanoma has changed dramatically over the last few decades. Through the development and conduction of well-designed, prospective, randomized trials, we have been able to refine the way that we surgically manage patients with melanoma. Indeed, many important issues have been addressed through such trials: the proper surgical margins for the primary melanoma, utility of the elective lymph node dissection and the role for selective lymphadenectomy, to name a few. This review will also discuss what we have learned from past clinical trials and address several issues with regards to where we are going in the future.
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Affiliation(s)
- Adam I Riker
- Surgical Oncology Services and Associate Professor of Surgery, University of South Alabama--Mitchell Cancer Institute, Cutaneous Oncology Program, 307 North University Blvd, MSB 2015, Mobile, Alabama 36688, USA.
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van Akkooi ACJ, Bouwhuis MG, van Geel AN, Hoedemaker R, Verhoef C, Grunhagen DJ, Schmitz PIM, Eggermont AMM, de Wilt JHW. Morbidity and prognosis after therapeutic lymph node dissections for malignant melanoma. Eur J Surg Oncol 2007; 33:102-8. [PMID: 17161577 DOI: 10.1016/j.ejso.2006.10.032] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2006] [Accepted: 10/20/2006] [Indexed: 01/12/2023] Open
Abstract
Melanoma patients with clinically evident regional lymph node metastases are treated with therapeutic lymph node dissections (TLNDs). The aim of this study was to evaluate morbidity and mortality following TLND in our institution. Moreover, disease-free (DFS) and overall (OS) survival were evaluated and factors that influence prognosis after TLND were assessed. Between 1982 and 2005, 236 patients underwent a TLND. Patients, who received a palliative LND or a sentinel node procedure, were not included. The median Breslow thickness was 2.4mm. Ulceration was present in 23% of patients and unknown in 66%. 37 patients had unknown primary tumors. There were 129 ilio-inguinal, 50 axillary and 61 cervical dissections performed. 37% of the patients experienced at least one operation related complication. The most frequently seen complications were wound infections/necrosis and chronic lymph edema. Ilio-inguinal dissection patients experienced significantly more complications and a longer duration of hospitalization compared to axillary or cervical patients. The duration of hospitalization has been reduced in recent years from 12 to 5days. The mean follow-up was 29months. Kaplan-Meier estimated 5-year regional control was 79%, 5-year DFS was 19% and 5-year OS was 26%. The number of positive lymph nodes, the site of the primary tumor and extra capsular extension (ECE) were independent prognostic factors for DFS and only site and ECE for OS. In conclusion, TLND for stage III melanoma is accompanied with considerable short-term complications, and can achieve regional control and potential curation in approximately one in every four patients.
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Affiliation(s)
- A C J van Akkooi
- Department of Surgical Oncology, Erasmus University Medical Center - Daniel den Hoed Cancer Center, 301 Groene Hilledijk, 3075 EA, Rotterdam, The Netherlands
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Galliot-Repkat C, Cailliod R, Trost O, Danino A, Collet E, Lambert D, Vabres P, Dalac S. The prognostic impact of the extent of lymph node dissection in patients with stage III melanoma. Eur J Surg Oncol 2006; 32:790-4. [PMID: 16822643 DOI: 10.1016/j.ejso.2006.04.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2006] [Accepted: 04/05/2006] [Indexed: 12/01/2022] Open
Abstract
AIMS To analyse disease-free and overall survival in 67 melanoma patients who underwent dissection for clinically apparent regional lymph node metastases, taking into account the total number of excised lymph nodes. METHODS After a median follow-up time of 16 months, 47 recurrences were observed and 43 patients died. The median disease-free and overall survival intervals were 14 and 24 months respectively. RESULTS Multivariate analyses revealed that the number of excised lymph nodes had a significant impact on overall survival (P=0.036) but not on disease-free survival (P=0.97). Extranodal growth was the only statistically significant prognostic factor both for disease-free (P=0.005) and overall (P=0.038) survival. Age, nodal basin, primary tumor ulceration, tumor thickness and number of positive lymph nodes were not significant prognostic factors. CONCLUSIONS Our results suggest that the total number of lymph nodes excised in the dissection has impact on overall survival of stage III melanoma patients and should be considered in clinical assays.
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Affiliation(s)
- C Galliot-Repkat
- Department of Dermatology, University Hospital, 2 Boulevard Marechal de Lattre de Tassigny, F-21033 Dijon, France.
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Riker AI, Glass F, Perez I, Cruse CW, Messina J, Sondak VK. Cutaneous melanoma: methods of biopsy and definitive surgical excision. Dermatol Ther 2005; 18:387-93. [PMID: 16297013 DOI: 10.1111/j.1529-8019.2005.00045.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The proper method of biopsy and definitive surgical excision of cutaneous melanoma is vital for optimal patient outcome. Clearly, the present authors' understanding of the pathophysiology of cutaneous melanoma continues to change at a rapid pace. Indeed, as the present authors' research efforts begin to expose some of the mysteries of melanoma, so do they begin to better understand the intricacies of this dreaded cancer. This article will highlight methods of biopsy for melanoma and the management of the primary tumor. The present authors review current recommendations for excision margins for the primary tumor, usefulness of lymphoscintigraphy, timing of definitive surgical excision, and issues unique for head and neck melanoma.
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Affiliation(s)
- Adam I Riker
- Cutaneous Oncology Program, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida College of Medicine, Tampa, 33612, USA.
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de Vries M, Vonkeman WG, van Ginkel RJ, Hoekstra HJ. Morbidity after axillary sentinel lymph node biopsy in patients with cutaneous melanoma. Eur J Surg Oncol 2005; 31:778-83. [PMID: 15993029 DOI: 10.1016/j.ejso.2005.05.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2004] [Accepted: 05/09/2005] [Indexed: 10/25/2022] Open
Abstract
AIM In this study, the short-term and long-term morbidity was assesed after axillary sentinel lymph node biopsy (SLNB) with or without completion axillary lymph node dissection (SLNB/ALND) in patients with cutaneous melanoma. METHODS Between 1995 and 2003, 119 axillary SLNBs were performed for cutaneous melanoma. Fifty-eight patients met the inclusion criteria and entered the study. RESULTS Forty-four patients underwent SLNB alone and 14 patients underwent axillary lymph node dissection after positive SLNB. Complications after SLNB alone: post-operative bleeding (n=2), seroma (n=1) and slight lymphedema 11%. Complications after SLNB/ALND: wound infections (n=2), seroma (n=5) and slight lymphedema 7%. There were differences between the two groups in short-term complications (p<.001) and functional limitations of the shoulder (p=.011). CONCLUSION Axillary SLNB alone had a low complication rate. However, SLNB followed by completion ALND was associated with an increased risk of short- and long-term complications.
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Affiliation(s)
- M de Vries
- Department of Surgical Oncology, University Medical Center Groningen and Groningen University, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
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Kavanagh D, Hill ADK, Djikstra B, Kennelly R, McDermott EMW, O'Higgins NJ. Adjuvant therapies in the treatment of stage II and III malignant melanoma. Surgeon 2005; 3:245-56. [PMID: 16121769 DOI: 10.1016/s1479-666x(05)80086-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The incidence of cutaneous melanoma has increased during the past three decades. The development of sentinel lymph node biopsy has facilitated better staging. Despite these improvements, 5-year survival rates for American Joint Committee on Cancer stage II and III disease range from 50%-90%. METHODS A review of the current literature concerning adjuvant therapies in patients with stage II and III malignant melanomas was undertaken. RESULTS The focus of adjuvant therapies has shifted from radiotherapy, BCG and levamisole to newer biological agents. Interferon, interleukin and vaccines have been evaluated but none of these agents have demonstrated an increase in overall survival in patients with stage II and III melanoma. Interferon can prolong disease-free interval. CONCLUSION At present, no adjuvant therapy improves overall survival in patients with stage II and III melanoma. New staging allows more accurate stratification of patients for clinical trials.
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Affiliation(s)
- D Kavanagh
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Mack LA, McKinnon JG. Controversies in the management of metastatic melanoma to regional lymphatic basins. J Surg Oncol 2004; 86:189-99. [PMID: 15221926 DOI: 10.1002/jso.20080] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The primary management of lymph nodes involved with metastatic melanoma is regional lymphadenectomy. Many controversies of regional lymph node dissection exist including extent and nature of the lymphadenectomy, treatment of lymphatic metastases in unusual locations and the role of adjuvant radiotherapy. Although radical neck dissection has been the gold standard for cervical disease, modified dissections do not seem to compromise regional control in appropriately selected patients. In the axilla, a Level I, II, and III dissection is most commonly performed. Combined superficial and deep groin dissection is justified for clinically palpable disease although management of patients with histologically positive yet clinically non-palpable disease is more controversial. Burden of disease, imaging, patient co-morbidity, and Cloquet nodal status must be considered. Many technical variations exist in an attempt to improve morbidity rates secondary to lymphadenectomy. Unfortunately, complication rates are difficult to compare secondary to variable study designs, definitions, and patient populations. Adjuvant radiation therapy appears warranted in patients with high risk of regional recurrence including bulky disease, extracapsular extension or cervical location.
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Affiliation(s)
- Lloyd A Mack
- Tom Baker Cancer Centre and the University of Calgary, Calgary, Alberta, Canada
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Abstract
BACKGROUND Therapeutic lymph node dissection for melanoma aims to achieve regional disease control. Radical lymphadenectomy (RLND) can be a difficult procedure associated with significant postoperative morbidity. The aims of the present study were to review regional disease control and morbidity in a series of lymphadenectomies performed within a specialist unit. METHODS The present study involved the analysis of 73 lymphadenectomies in 64 patients, from 1995 to 2001. RESULTS The overall wound complication rate after inguinal lymphadenectomy (71%) was higher than after axillary lymphadenectomy (47%; P = 0.05). After inguinal lymphadenectomy, the wound infection rate was higher (25.0%vs 5.9%; P = 0.03), delayed wound healing was more frequent (25.0%vs 5.9%; P = 0.03), and the mean time that drain tubes remained in situ was longer (12.5 vs 8.2 days; P = 0.05). There were no significant differences in seroma (46%vs 32%) rates. Lymphoedema was more common after inguinal lymphadenectomy (P < 0.02). Multivariate analysis identified inguinal RLND (P = 0.002) and increasing tumour size (P = 0.045) as predictors of wound morbidity. More patients received postoperative radiotherapy after neck RLND compared to inguinal or axilla RLND (P = 0.03). Six (8%) patients developed local recurrence after lymphadenectomy. At a median follow up of 22 months, 34 (53%) patients have died, from disseminated disease. CONCLUSIONS Radical lymphadenectomy for melanoma is associated with significant morbidity. Inguinal node dissection has a higher rate of complications than axillary dissection. Low local recurrence rates can be achieved, limiting the potential morbidity of uncontrolled regional metastatic disease.
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Affiliation(s)
- Jonathan W Serpell
- The Alfred and Frankston Hospitals, the Victorian Melanoma Service, The Alfred Hospital, the Department of Surgery, Monash University, Victoria, Australia.
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Meyer T, Merkel S, Göhl J, Hohenberger W. Lymph node dissection for clinically evident lymph node metastases of malignant melanoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2002; 28:424-30. [PMID: 12099654 DOI: 10.1053/ejso.2001.1262] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS A considerable number of melanoma patients present with clinically evident regional lymph node metastases. Factors influencing prognosis following therapeutic lymph node dissection (TLND) were evaluated. METHODS In total 140 patients (68 women, 72 men, median age 53 years) with established regional lymph node metastases, but without clinically detectable distant metastases, received cervical, axillary or ilioinguinal TLND between 1978 and 1997 and were retrospectively reviewed. Uni- and multivariate survival analysis was performed. RESULTS Median survival for all 140 patients was 25 months; the observed overall 5 year survival rate was 30%. Age greater than 50 years, primary tumour site on the trunk, more than three lymph node metastases and extracapsular spread were associated with a poor prognosis. In multivariate analysis age (< or =50 years vs >50 years, P=0.02), location of the primary tumour (non-truncal vs truncal, P=0.005), number of lymph nodes involved ( n< or =3 vsn >3, P=0.01) and extracapsular spread (none vs present, P=0.04) proved to be independent prognostic factors. CONCLUSIONS TLND is worthwhile and offers a potential chance of cure in about one-third of melanoma patients with established regional lymph node metastases. There are subgroups with a particularly poor prognosis in whom the benefit of radical surgery alone is limited.
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Affiliation(s)
- Thomas Meyer
- Department of Surgery, University of Erlangen, Erlangen, Germany.
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Rao UNM, Ibrahim J, Flaherty LE, Richards J, Kirkwood JM. Implications of microscopic satellites of the primary and extracapsular lymph node spread in patients with high-risk melanoma: pathologic corollary of Eastern Cooperative Oncology Group Trial E1690. J Clin Oncol 2002; 20:2053-7. [PMID: 11956265 DOI: 10.1200/jco.2002.08.024] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To correlate the presence of extracapsular spread (ECS) of regional nodal metastases, and micrometastasis near the primary tumor, with disease outcome in the intergroup study E1690 in relation to the impact of recombinant interferon-alfa (rIFN alpha)-2b. PATIENTS AND METHODS E1690 included 642 patients with American Joint Committee on Cancer stage IIB or III cutaneous melanoma. Patients were randomized into high- and low-dose rIFN alpha-2b treatment arms and an observation arm. Pathologic slides were reviewed for selected parameters from at least half of the subjects in all three arms. Evaluation of the primary tumor included notations regarding ulceration, mitotic activity, thickness, microscopic satellites (MS), and nodal ECS on a standardized pathology form. These data were collated in relation to relapse-free survival (RFS) and overall survival (OS) at 50 months' follow-up and studied using Cox regression analysis. RESULTS Ulceration, mitotic activity, thickness, and size of tumor-bearing lymph nodes did not show a statistically significant correlation with either OS or RFS across all treatment arms. The presence of MS was correlated with RFS (P =.0008) and OS (P =.05). ECS correlated with RFS (hazard ratio = 1.44, P =.032) but not OS (P =.11). CONCLUSION The presence of MS (in 6% [18 of 308 patients]) had a significant adverse impact on both RFS (P =.0008) and OS (P =.053). Ulceration, mitotic activity, thickness, and number of positive lymph nodes had no significant effect on OS in this subset study (univariate or multivariate Cox analysis). The presence of ECS in lymph nodes had a significant adverse effect on RFS (P =.032) but not on OS.
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Affiliation(s)
- U N M Rao
- Department of Pathology, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, PA 15213-2582, USA.
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Gibbs P, Anderson C, Pearlman N, LaClaire S, Becker M, Gatlin K, O'Driscoll M, Stephens J, Gonzalez R. A phase II study of neoadjuvant biochemotherapy for stage III melanoma. Cancer 2002; 94:470-6. [PMID: 11900232 DOI: 10.1002/cncr.10186] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Phase II studies of biochemotherapy (combining interleukin-2, interferon-alpha, and multiagent chemotherapy) have reported high response rates and a significant number of durable complete responses in patients with metastatic melanoma. METHODS A pilot Phase II study was performed to explore the safety and activity of neoadjuvant biochemotherapy in patients with Stage III melanoma. Forty-eight patients were enrolled between April 1996 and May 1999. The median age of the patients was 46 years (range, 19-70 years). Two cycles of biochemotherapy were administered prior to and after complete lymph node dissection. Each cycle was comprised of cisplatin, 20 mg/m2 intravenously (i.v.), on Days 1-4; vinblastine, 1.6 mg/m2 i.v., on Days 1-4; dacarbazine, 800 mg/m2 i.v., on Day 1; interleukin-2, 9 x 10(6) IU/m2/day i.v. over 24 hours, on Days 1-4; and interferon-alpha, 5 x 10(6) IU/m2/day subcutaneously, on Days 1-5, every 3 weeks. Twelve patients did not have measurable disease. All patients were evaluable for toxicity and survival. RESULTS Clinical responses were observed in 14 of 36 patients (38.9%) with measurable disease, including 13 partial responses (36.1%) and 1 complete response (2.8%). Complete pathologic responses were noted in 4 patients (11.1%). Toxicity, although severe, was manageable and typically short-lived. There were no treatment-related deaths reported. At a median follow-up of 31 months, 38 of the 48 patients (79.2%) were alive and 31 patients (64.6%) remained free of disease progression. CONCLUSIONS Neoadjuvant biochemotherapy appears to have promising activity in patients with Stage III melanoma. A larger multicenter study currently is underway to explore this approach further.
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Affiliation(s)
- Peter Gibbs
- Oncology Department, Royal Melbourne Hospital, Parkville, Victoria, Australia
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Pidhorecky I, Lee RJ, Proulx G, Kollmorgen DR, Jia C, Driscoll DL, Kraybill WG, Gibbs JF. Risk factors for nodal recurrence after lymphadenectomy for melanoma. Ann Surg Oncol 2001; 8:109-15. [PMID: 11258774 DOI: 10.1007/s10434-001-0109-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The risk and outcome of regional failure after elective and therapeutic lymph node dissection (ELND/TLND) for microscopically and macroscopically involved lymph nodes without adjuvant radiotherapy were evaluated. METHODS Retrospective melanoma database review of 338 patients (ELND 85, TLND 253) from 1970 to 1996 with pathologically involved lymph nodes. RESULTS Regional recurrence occurred in 14% of patients treated with ELND (n = 12) and 28% of patients treated with TLND (n = 72; P = .009). Risk factors associated with nodal recurrence were advanced age, primary lesion in the head and neck region, depth of the primary lesion, number of involved lymph nodes, and extracapsular extension (ECE). For each nodal basin, the ELND group had a lower incidence of recurrence than the TLND group. The TLND group had larger lymph nodes, greater number of involved lymph nodes, and a higher incidence of ECE. The 10-year disease-specific survival was 51% vs. 30% for ELND and TLND, respectively (P = .0005). Nodal basin failure was predictive of distant metastasis, with 87% developing distant disease compared with 54% of patients without nodal recurrence (P < .0001). Of six patients who underwent a second dissection after isolated nodal recurrence, five patients have had a median disease-free interval of 79 months. CONCLUSIONS After ELND or TLND, patients who have a large tumor burden (thick primary melanoma, multiply involved lymph nodes, ECE), advanced age, and a primary lesion located in the head and neck have a significantly increased likelihood of relapse and a decreased survival. Few patients present with an isolated nodal recurrence, but the majority can be salvaged by a second dissection.
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Affiliation(s)
- I Pidhorecky
- Division of Surgical Oncology, Roswell Park Cancer Institute, State University of New York, Buffalo 14263, USA
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Stadelmann WK, McMasters K, Digenis AG, Reintgen DS. Cutaneous melanoma of the head and neck: advances in evaluation and treatment. Plast Reconstr Surg 2000; 105:2105-26. [PMID: 10839413 DOI: 10.1097/00006534-200005000-00031] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- W K Stadelmann
- Department of Surgery, and the Brown Cancer Center, University of Louisville, KY 40292, USA.
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Lee RJ, Gibbs JF, Proulx GM, Kollmorgen DR, Jia C, Kraybill WG. Nodal basin recurrence following lymph node dissection for melanoma: implications for adjuvant radiotherapy. Int J Radiat Oncol Biol Phys 2000; 46:467-74. [PMID: 10661355 DOI: 10.1016/s0360-3016(99)00431-9] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To analyze patterns of failure in malignant melanoma patients with lymph node involvement who underwent complete lymph node dissection (LND) of the nodal basin. To determine prognostic factors predictive of local recurrence in the lymph node basin in order to select patients who may benefit from adjuvant radiotherapy. METHODS AND MATERIALS A retrospective analysis of 338 patients undergoing complete LND for melanoma between 1970 and 1996 who had pathologically involved lymph nodes was performed. Mean follow-up from the time of LND was 54 months (range: 12-306 months). Lymph node basins dissected included the neck (56 patients), axilla (160 patients), and groin (122 patients). Two hundred fifty-three patients (75%) underwent therapeutic LND for clinically involved nodes, while 85 patients (25%) had elective dissections. Forty-four percent of patients received adjuvant systemic therapy. No patients received adjuvant radiotherapy to the lymph node basin. RESULTS Overall and disease-specific survival for all patients at 10 years was 30% and 36%, respectively. Overall nodal basin recurrence was 30% at 10 years. Mean time to nodal basin recurrence was 12 months (range: 2-78 months). Site of nodal involvement was prognostic with 43%, 28%, and 23% nodal basin recurrence at 10 years with cervical, axillary, and inguinal involvement, respectively (p = 0.008). Extracapsular extension (ECE) led to a 10-year nodal basin failure rate of 63% vs. 23% without ECE (p < 0.0001). Patients undergoing a therapeutic dissection for clinically involved nodes had a 36% failure rate in the nodal basin at 10 years, compared to 16% for patients found to have involved nodes after elective dissection (p = 0.002). Lymph nodes larger than 6 cm led to a failure rate of 80% compared to 42% for nodes 3-6 cm and 24% for nodes less than 3 cm (p < 0.001). The number of lymph nodes involved also predicted for nodal basin failure with 25%, 46%, and 63% failure rates at 10 years for 1-3, 4-10, and > 10 nodes involved (p = 0.0001). There was no significant difference in nodal basin control in patients with synchronous or metachronous lymph node metastases, nor in patients receiving or not receiving adjuvant systemic therapy. Nodal basin failure was predictive of distant metastasis with 87% of patients with nodal basin recurrence developing distant disease compared to 54% of patients without nodal failure (p < 0.0001). On multivariate analysis, number of positive nodes and type of dissection (elective vs. therapeutic) were significant predictors of overall and disease-specific survival. Size of the largest lymph node was also predictive of disease-specific survival. Site of nodal involvement and ECE were significant predictors of nodal basin failure. CONCLUSIONS Malignant melanoma patients with nodal involvement have a significant risk of nodal basin failure after LND if they have cervical involvement, ECE, >3 positive lymph nodes, clinically involved nodes, or any node larger than 3 cm. Patients with these risk factors should be considered for adjuvant radiotherapy to the lymph node basin to reduce the incidence of nodal basin recurrence. Patients with nodal basin failure are at higher risk of developing distant metastases.
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Affiliation(s)
- R J Lee
- Division of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, NY 14263, USA.
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