The effect of time to sentinel lymph node biopsy on cutaneous melanoma survival

Sentinel lymph node assessment in melanoma: current state and future directions

Assessment of sentinel lymph node status is an important step in the evaluation of patients with melanoma for both prognosis and therapeutic management. Pathologists have an important role in this evaluation. The methodologies have varied over time, from the evaluation of dimensions of metastatic burden to determination of the location of the tumour deposits within the lymph node to precise cell counting. However, no single method of sentinel lymph node tumour burden measurement can currently be used as a sole independent predictor of prognosis. The management approach to sentinel lymph node-positive patients has also evolved over time, with a more conservative approach recently recognised for selected cases. This review gives an overview of past and current status in the field with a glimpse into future directions based on prior experiences and clinical trials.

Impact of the time interval between primary melanoma excision and sentinel node biopsy: A systematic review and meta-analysis

BACKGROUND

Obtaining a sentinel lymph node biopsy (SLNB) specimen is a standard staging procedure in the management of cutaneous melanoma. However, there is no consensus on the safe time interval between the primary melanoma biopsy procedure and the SLNB procedure.

OBJECTIVE

We evaluated the association between time from biopsy to SLNB and patients' outcomes for melanoma.

METHODS

We performed this systematic review and meta-analysis based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Six retrospective studies were included. Nine thousand seven hundred five patients were identified, of which 4383 underwent a SNLB procedure at a time interval defined as early and 4574 at an interval defined as late. A combined hazard ratio of 1.25 (95% confidence interval [CI] 0.92-1.68) was determined, and there was high heterogeneity (I² = 83%; P = .002) of the SLNB time interval on melanoma-specific survival. The combined HR for disease-free survival was 1.05 (95% CI 0.95-1.15), with low heterogeneity (I² = 9%; P = .36). Regarding overall survival, a combined HR of 1.25 (95% CI 0.92-1.70) was found, with low heterogeneity (I² = 37%; P = .2).

LIMITATIONS

There is heterogeneity between some studies.

CONCLUSION

There are no significant differences in patient outcome between a short interval versus a long interval between the primary biopsy procedure and obtaining a SNLB specimen.

Does very early timing of lymph node surgery after resection of the primary tumour improve the clinical outcome of patients with melanoma?

BACKGROUND

In patients with cutaneous melanoma (CM), the time span between resection of the primary tumour and sentinel lymph node biopsy (SLNB) as well as the subsequent interval between SLNB and complete lymph node dissection (CLND) varies greatly.

AIM

To determine whether very early timing of SLNB after resection of the primary tumour, or timing of CLND after SLNB affect the clinical outcome of patients with CM, compared with longer time intervals.

METHODS

We compared the time spans between complete resection of the primary tumour and SLNB, and the interval between SLNB and CLND in a cohort of 896 patients with melanoma who had undergone SLNB. An interval between primary resection and SLNB or between SLNB and CLND of up to 7 days was classified as very early (VE-SLNB and VE-CLND, respectively). This time span was compared with intervals of > 7 days. Univariate and multivariate statistics were performed.

RESULTS

VE-SLNB was significantly associated with the presence of micrometastases. However, this was probably due to tumour thickness being significantly higher in patients with VE-SLNB compared with patients with later SLNB. Importantly, VE-SLNB was not significantly associated with disease relapse and VE-CLND was not associated with melanoma-specific death.

CONCLUSIONS

VE-SLNB and VE-CLND neither improved nor worsened the clinical outcome of patients. Thus, timing of SLNB and CLND has no influence on the overall clinical outcome of patients with melanoma. Our findings support the rational planning of lymph node surgery after resection of the primary tumour and provide help for effective patient counselling.

Timing of sentinel node biopsy independently predicts disease-free and overall survival in clinical stage I-II melanoma patients: A multicentre study of the Italian Melanoma Intergroup (IMI)

Background

Sentinel lymph node biopsy (SNB) still remains a key procedure to appropriately stage melanoma patients and to select those who are candidate to novel treatments with immunotherapy and targeted therapy in the adjuvant setting. The impact of timing of SNB on disease-free survival (DFS) and overall survival (OS) is still unclear.

Material and methods

The study was conducted at 6 Italian Melanoma Intergroup (IMI) centres and included 8953 consecutive clinical stage I-II melanoma patients who were diagnosed, treated, and followed up between November 1997 and March 2018. All patients were prospectively included in dedicated IMI database. Multivariable Cox regression analyses were performed to investigate how baseline characteristics and time interval until SNB are related to DFS and OS.

Results

Considering the whole population, at multivariable analysis, after adjusting for age, gender, Breslow thickness, site, ulceration, and the SNB status, a delay in the timing of SNB was associated with a better DFS (adjusted hazard ratio [aHR, delayed versus early SNB] 0.98, 95% confidence interval [CI] 0.97–0.99, p < 0.001) and OS (aHR 0.98, 95% CI 0.97–0.99, p = 0.001). Specifically, in patients with a negative SNB status, a beneficial impact of delayed SNB (i.e. at least 32 days after primary excision) was confirmed for DFS (aHR 0.70, 95%CI 0.63–0.79, p < 0.001) and OS (aHR 0.69, 95%CI 0.61–0.78, p < 0.001), whereas in those with a positive SNB status, DFS (aHR 0.96, 95%CI 0.84–1.09, p = 0.534) and OS (aHR 0.94 95%CI 0.81–1.08, p = 0.374) were not significantly different in patients with early or delayed SNB.

Conclusions

Our study does not support a strict time interval for SNB. These results may be useful for national guidelines, for counselling patients and reducing the number of high urgency referrals.

Does the time interval between sentinel lymph node biopsy and completion lymph node dissection affect outcome in malignant melanoma? A retrospective cohort study

Nodal clearance was recommended after positive sentinel lymph node biopsy (SLNB) despite further metastases to the regional lymph node basin being found in only 6-21% in the literature. This retrospective study was conducted to determine the role of the time interval between excision of primary melanoma and confirmed metastasis in the sentinel lymph node biopsy as well as the one between positive sentinel lymph node biopsy (SLNB-positive patients) and subsequent completion lymph node dissection (CLND) on the presence of metastases. The monocentric analysis included 121 patients with a history of completion lymph node dissection after positive SLNB from January 2005 to October 2013. Additional metastases in the regional lymph node basin (non-sentinels) were found in 14.05% (n = 17). Significant risk factors for the presence of metastases in CLND were the time between confirmed primary tumour to metastasis in sentinel lymph nodes (SLN) (p = 0.0034), N-category of TNM-classification (p = 0.0066) and independent of thickness of primary tumour (p = 0.11). If SLNB was performed up to forty-three days after confirmed primary melanoma, subsequent lymph node dissection was positive in less than 9.1%. When SLNB was performed with a delay of more than 80 days, all patients had metastases in the CLND specimens. Our data analysis suggests that delays in subsequent procedures of SLNB after diagnosis of primary melanoma may have a greater impact on positivity of non-sentinel lymph nodes than previously assumed. Our retrospective analysis may indicate the reconsideration of time schedule in the management of primary melanoma to potentially avoid local relapse in the draining lymph node region after positive SLNB.

Patterns of recurrence and retreatment outcomes among clinical stage I and II head and neck melanoma patients

BACKGROUND

The objective of this study was to determine survival outcomes in patients who underwent retreatment of recurrent cases of cutaneous melanoma of the head and neck (CMHN).

METHODS

Retrospective review of all patients who were treated for primary clinical stage I or II CMHN between January 1, 2000 and December 31, 2015.

RESULTS

Twenty percent (33/168) of the patients developed a recurrence. Sixty-six percent (4/6) of patients who developed local recurrence first and 50% (3/6) of patients who developed regional recurrence first were alive without evidence (NED) of disease at last follow-up, while 0% (0/21) of patients who developed distant or simultaneous recurrences first were NED at last follow-up. Among the 7 patients who were NED, the mean time from recurrence to last follow-up was 735 days.

CONCLUSIONS

Of patients with isolated local or regional recurrences, 58% (7/12) obtained durable curative treatment for recurrent melanoma.

Time to Procedure, Nuclear Imaging and Clinicopathological Characteristics as Predictive Factors for Sentinel Lymph Node Metastasis in Cutaneous Melanoma: A Single-Center Analysis

OBJECTIVE

Sentinel lymph node (SLN) biopsy is a widely accepted staging procedure for cutaneous melanoma patients who are at risk of clinically occult nodal metastases. Numerous predictive factors for regional lymph node metastases have been identified; however, few have been found to be reproducibly significant. Also, the role of blue dye in identification was questioned in recent trials. Time to procedure was also found to be predictive of SLN positivity, but this was not confirmed in other studies. In our study, predictive factors for metastatic involvement of SLN were analyzed, together with the role of addition blue dye in imaging on detection rate and false-negative SLN rate. An impact of time interval to procedure on the rate of SLN positivity was also explored.

METHODS

Data analysis was done in 362 cutaneous melanoma patients who underwent lymphoscintigraphy and SLN biopsy at our institution from 2010 to 2016, with a median follow-up of 29 months (1-98 months). To delineate the relation of each variable (demographical, time to procedure, and clinical and pathological variables, as well as the presence of in-transit nodes, the number of draining basins, and SLN localization on scintigraphy) with positive SLN status, we used univariate logistic regression with odds ratios representing effect size.

RESULTS

Metastatic involvement SLN was found in 67 (18.8%) of 356 patients. Detection rate was similar with or without further intraoperative SLN identification with blue dye (98.8% vs 98.17%, P > 0.05). Time to procedure was not associated with higher SLN positivity rate (P > 0.05). In univariate analysis, Breslow thickness (P < 0.001), primary ulceration lesion (P = 0.001), and lymphovascular invasion (P = 0.006) were strongly correlated with SLN positivity, as well as the site of primary tumor (P = 0.024), tumor-infiltrating lymphocytes (TILs) (P = 0.021), and sex (P = 0.026). In multivariate analysis, Breslow thickness and TILs were found to be significant independent predictors of SLN status (P < 0.05).

CONCLUSIONS

Addition of blue dye did not improve SLN detection rate; time to procedure was not found to be associated with higher SLN biopsy positivity rates. Breslow thickness and TILs, as a marker of immune response to tumor, were consistently found to be significant independent predictors of SLN status.

Sentinel lymph node biopsy in malignant melanoma of the head and neck

BACKGROUND

The aim of this retrospective study was to investigate sentinel lymph node biopsy in patients with head and neck melanoma.

MATERIALS AND METHODS

Patients who underwent SLNB between 2010 and 2016 were comprised. Epidemiological, radiological, and surgical data were collected and compared to histological findings. Patients who underwent primary complete lymph node dissection were excluded.

RESULTS

74 patients underwent SLNB during this period. The most common tumor localizations were the cheek (20.4%) and ears (20.4%). Overall, 256 sentinel lymph nodes (SLN) were detected and removed, most frequently in Robbins-levels IIA and IIB as well as in the surrounding of the parotid gland. 12.3% of the SLN showed a microscopic or macroscopic metastasis. In preoperative imaging all lymph nodes with macroscopic metastasis were described as suspect but only 4 of 11 lymph nodes with microscopic metastases were described as such.

CONCLUSIONS

SLNB is an especially good procedure for the diagnosis of microscopically metastases as disease status is an important diagnostic and prognostic factor in early-stage melanoma patients. However, due to the complex lymphatic system in head and neck melanoma, a short follow-up interval is necessary in order to prevent delayed diagnosis of a nodal recurrence due to a false-negative SLN.

Impact of Time Between Diagnosis and SLNB on Outcomes in Cutaneous Melanoma

BACKGROUND

Hypothetically, delay between melanoma diagnosis and SLNB could affect outcomes, either adversely by allowing growth and dissemination of metastases, or beneficially by allowing development of an anti-melanoma immune response. Available data are conflicting about the effect of SLNB delay on patient survival. Our objective was to determine whether delay between initial diagnosis and SLNB affects outcomes in patients with cutaneous melanoma.

STUDY DESIGN

We performed query and analysis of a large prospectively maintained database of patients with primary cutaneous melanomas undergoing SLNB. An independent dataset from MSLT-1 (Multicenter Selective Lymphadenectomy Trial-1) was used for validation. Primary outcomes included disease-free survival and melanoma-specific survival.

RESULTS

Early and delayed SLNB were defined as less than 30 and 30 or more days from initial diagnosis, respectively. There were 2,483 patients that met inclusion criteria. Positive sentinel lymph nodes were identified in 17.4% (n = 432). Among all patients, 42% had SLNB 30 or more days after diagnosis and 37% of positive sentinel lymph nodes were at 30 or more days. No differences in sex, anatomic site, or histopathologic features were identified between the 2 groups. There was no difference in melanoma-specific survival or disease-free survival between those undergoing early or delayed SLNB. Examination of MSLT-1 trial data similarly demonstrated no difference in survival outcomes.

CONCLUSIONS

This, the largest study on this subject to date, found no adverse impact on long-term clinical outcomes of patients due to delay of SLNB beyond 30 days. The MSLT-1 data confirm this result. Patients can be reassured that if the operation is performed 30 or more days after diagnosis, it will not cause harm.

Timing of completion lymphadenectomy after positive sentinel node biopsy in patients with melanoma

Background

Nodal staging with sentinel node biopsy (SNB) and completion lymph node dissection (CLND) provides prognostic information to patients with melanoma and their physicians. It is not known whether the timing of CLND is associated with survival outcome and/or CLND tumour load. This study investigated whether CLND timing is associated with CLND tumour load, disease-free survival (DFS) and/or melanoma-specific survival (MSS).

Methods

A retrospective cohort of patients with SNB-positive melanoma from nine European Organisation for Research and Treatment of Cancer (EORTC) Melanoma Group centres undergoing surgery between 1993 and 2009 were examined. Patients were selected based on availability of CLND and follow-up data. The CLND interval was defined as the number of days between diagnosis and CLND. Patient and tumour characteristics were collected. Five-year DFS and MSS rates were calculated. Cox and logistic regression analysis were performed, adjusting for known prognostic/predictive indicators.

Results

A total of 784 patients were included in the study. Their median age was 51 (i.q.r. 40–62) years, and 418 patients (53·3 per cent) were men. Median Breslow thickness was 3·0 (i.q.r. 2·0–5·0) mm, and 148 patients (18·9 per cent) had a residual tumour load. Median CLND interval was 84 (i.q.r. 65–105) days. Five-year DFS and MSS rates were not significantly different for patients operated on with a median CLND interval of less than 84 days and those with an interval of at least 84 days (DFS: 54·2 versus 53·3 per cent respectively; MSS: 66·9 versus 65·1 per cent). In a multivariable Cox model, CLND interval was not a significant prognostic indicator. CLND interval was negatively correlated with identification of positive non-sentinel nodes, but following adjustment for known risk factors this effect was no longer found.

Conclusion

The time interval between diagnosis of melanoma and CLND did not influence CLND tumour load, DFS or MSS.