Melanoma patients with iliac nodal metastases can be cured

Superficial and deep lymph node dissection for stage III cutaneous melanoma: clinical outcome and prognostic factors

Background

The aims of this retrospective analysis were to evaluate the effect of combined superficial and deep groin dissection on disease-free and melanoma-specific survival, and to identify the most important factors for predicting the involvement of deep nodes according to clinically or microscopically detected nodal metastases.

Methods

Between January 1996 and December 2005, 133 consecutive patients with groin lymph node metastases underwent superficial and deep dissection at the National Cancer Institute, Naples. Lymph node involvement was clinically evident in 84 patients and detected by sentinel node biopsy in 49 cases.

Results

The 5-year disease-free survival was significantly better for patients with superficial lymph node metastases than for patients with involvement of both superficial and deep lymph nodes (34.9% vs. 19.0%; P = 0.001). The 5-year melanoma-specific survival was also significantly better for patients with superficial node metastases only (55.6% vs. 33.3%; P = 0.001).

Conclusions

Metastasis in the deep nodes is the strongest predictor of both disease-free and melanoma-specific survival. Deep groin dissection should be considered for all patients with groin clinical nodal involvement, but might be spared in patients with a positive sentinel node. Prospective studies will clarify the issue further.

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.

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.

Controversies in the management of metastatic melanoma to regional lymphatic basins

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.

Differential expression of vascular endothelial growth factor-A isoforms at different stages of melanoma progression

Vascular endothelial growth factor-A (VEGF-A) is an important mediator of angiogenesis in normal and neoplastic tissues. Total VEGF-A levels have been associated with melanoma progression, but the relative contributions of each isoform is unknown. To determine whether differences in the production of any or all of the major VEGF-A isoforms are related to stage of progression, we compared message levels for the three major isoforms of VEGF in melanoma specimens from different stages of progression.Primary melanomas (N = 18), primary recurrences (N = 5), regional dermal metastases (N = 11), nodal metastases (N = 12), normal lymph nodes (N = 18), and distant metastases (N = 9) were prospectively collected. Samples from the horizontal and vertical growth phases of primary tumors were also collected from five additional patients. Message levels for the three major VEGF-A isoforms were measured using real-time quantitative reverse-transcriptase polymerase chain reaction and normalized to beta-actin mRNA levels. There was a marked increase in the expression of all three VEGF-A isoforms from the vertical growth phase tissue as compared with the horizontal growth phase tissue. Primary tumors, local recurrences, regional dermal metastases, nodal metastases, and distant metastases all produced more VEGF(121) and VEGF(165) than negative nodes. Nodal metastases produced the highest level of these two isoforms, higher even than distant metastases. There was no significant difference in VEGF(189) message among the groups. Melanomas in the vertical growth phase produce more VEGF-A (all isoforms) than in the horizontal growth phase. Nodal metastases produce the highest levels of VEGF(121) and VEGF(165), but not VEGF(189) as compared with other stages of progression. These data suggest that the soluble forms of VEGF-A might be an important factor in melanoma metastasis to regional lymph nodes.

Patterns of recurrence in patients with melanoma and histologically negative but RT-PCR-positive sentinel lymph nodes

BACKGROUND

We studied the patterns of recurrence of patients with only reverse transcriptase-polymerase chain reaction (RT-PCR) evidence of regional nodal spread to see whether or not proposed treatment interventions are likely to be effective.

STUDY DESIGN

One hundred seventy-five patients who underwent selective lymphadenectomy for clinical stage I and II melanomas were included in this analysis. We preserved a portion of each sentinel lymph node (SLN) in liquid nitrogen in the operating room and performed RT-PCR on the specimens to detect the melanoma/melanocyte-specific marker tyrosinase. We then compared the pattern of recurrence (regional dermal metastases, regional nodal recurrence, or distant metastatic spread) of the patients with histologically positive SLNs to that of patients who had histologically negative SLNs.

RESULTS

The mean followup time of the 175 patients was 33.83 months (SD = 15.94, median = 34.17, maximum = 62.95, minimum = 6.21). Thirty-four patients had at least one histologically positive SLN, and 17 of these patients had a recurrence (50%). Of the 141 patients that had histologically negative SLNs, 73 had SLNs that were also negative for tyrosinase by RT-PCR, and none of these patients had a recurrence. Of the 68 patients that had histologically negative but RT-PCR-positive SLNs, 14 had a recurrence (20.6%).

CONCLUSIONS

Because the pattern of recurrence of patients with only RT-PCR evidence of melanoma in SLNs was identical to that in patients who had histologically evident melanoma in the SLN and underwent subsequent completion lymphadenectomy, we conclude that completion lymphadenectomy might be ineffective in decreasing the recurrence rate of patients with only RT-PCR evidence of melanoma in SLNs.

Early stage (I, II, III) melanoma

Metastatic melanoma beyond the regional nodes (American Joint Committee on Cancer stage IV) is a highly lethal disease. Few affected individuals survive beyond 5 years despite aggressive treatment. Clearly, effective adjuvant therapies to prevent the development of stage IV disease in at-risk patients are worthwhile and acceptable to patients, even if they are associated with significant toxicities. Improvements in our understanding of the prognosis and staging of melanoma have allowed us to better categorize patients based on their risk of developing metastatic disease, permitting the development of logical strategies using adjuvant therapies with toxicity profiles that are appropriate based on the level of risk for recurrence. Adherence to the standards of care for the surgical management of melanoma patients with high-risk primary disease or regional disease will help optimize the benefit that can be derived from adjuvant therapy. Clinical trials remain critically important as we seek to improve the outcome for melanoma patients, but for high-risk melanoma patients outside the context of clinical trials, adjuvant therapy with high-dose interferon-alfa2b should be considered a standard treatment option.

The value of Cloquet's node in predicting melanoma nodal metastases in the pelvic lymph node basin

BACKGROUND

A selection of melanoma patients with groin metastases can benefit from a pelvic (iliac/obturator) lymph node dissection in addition to the infrainguinal dissection. However, there are no reliable criteria to determine which patients may benefit from such an inguinal-pelvic lymphadenectomy.

METHODS

In 142 patients (group A) out of a review of 214 groin dissections performed between 1980 and 1994, the tumor status of Cloquet's node was traced retrospectively. In 52 additional patients (group B), the status of Cloquet's node was registered prospectively. The number of positive lymph nodes and the total numbers of retrieved nodes were recorded as well. All patients underwent a combined therapeutic inguinal-pelvic lymph node dissection between January 1995 and June 1999 in a tertiary referral center.

RESULTS

Cloquet's node was free of disease in 18 of 39 patients with involved pelvic nodes in the retrospective study (sensitivity, 54%; negative predictive value, 83%). In the prospective study, 9 of the 20 patients with involved pelvic nodes had a tumor-free Cloquet's node (sensitivity, 55%; negative predictive value, 78%). Additional immunohistochemical staining of Cloquet's node resulted in a sensitivity of 65%. In the combined group A&B, the number of positive nodes in the inguinal region (cutoff point more than three nodes) had a sensitivity of 41% and a negative predictive value of 78% to determine the pelvic nodal status. When we combined the number of positive inguinal nodes and Cloquet's node in group A&B, the best sensitivity was 56% and the best negative predictive value was 82%.

CONCLUSIONS

Cloquet's node has a low sensitivity to predict the pelvic nodal tumor status. This was barely improved when we accounted for the number of positive inguinal nodes. Groin lymph node dissections should encompass the iliac and obturator compartments in patients with palpable inguinal node metastases.