Stratifying SLN incidence in intermediate thickness melanoma patients

Invasive Cutaneous Melanoma: Evaluating the Prognostic Significance of Some Parameters Associated with Lymph Node Metastases

Background and Objectives: This study aimed to assess the clinical-pathological profile of patients with invasive cutaneous melanomas and to identify the parameters with a prognostic role in the lymph nodal spread of this malignant tumor. Materials and Methods: We performed a retrospective study on patients with invasive cutaneous melanomas who underwent surgery in the "Pius Brînzeu" County Clinical Emergency Hospital from Timișoara, Romania, and were evaluated for the status of loco-regional lymph nodes. We selected and analyzed some parameters searching for their relationship with lymph node metastases. Results: We identified 79 patients with invasive cutaneous melanomas (29 men and 50 women, mean age 59.36 years). A percentage of 58.3% of melanomas had Breslow tumor thickness >2 mm; 69.6% of melanomas showed a Clark level IV-V. Tumor ulceration was present in 59.5% of melanomas. A mitotic rate of ≥5 mitoses/mm² was observed in 48.1% of melanomas. Tumor-infiltrating lymphocytes (TILs), non-brisk, were present in 59.5% of cases and 22.8% of patients had satellite/in-transit metastasis (SINTM). Tumor regression was identified in 44.3% of cases. Lymph nodes metastases were found in 43.1% of patients. Statistical analysis showed that lymph node metastases were more frequent in melanomas with Breslow thickness >2 mm (p = 0.0002), high Clark level (p = 0.0026), mitotic rate >5 mitoses/mm² (p = 0.0044), ulceration (p = 0.0107), lymphovascular invasion (p = 0.0182), SINTM (p = 0.0302), and non-brisk TILs (p = 0.0302). Conclusions: The Breslow thickness >2 mm, high Clark level, high mitotic rate and ulceration are the most important prognostic factors for lymph nodal spread in cutaneous melanomas. However, some melanomas without these clinical-pathological features can have an unexpected, aggressive evolution, which entails the necessity of close and prolonged clinical follow-up of patients, including those with lesions considered without risk.

The Evolution of the Sentinel Node Biopsy in Melanoma

The growing repertoire of approved immune-checkpoint inhibitors and targeted therapy has revolutionized the adjuvant treatment of melanoma. While the treatment of primary cutaneous melanoma remains wide local excision (WLE), the management of regional lymph nodes continues to evolve in light of practice-changing clinical trials and dramatically improved adjuvant therapy. With large multicenter studies reporting no benefit in overall survival for completion lymph node dissection (CLND) after a positive sentinel node biopsy (SLNB), controversy remains regarding patient selection and clinical decision-making. This review explores the evolution of the SLNB in cutaneous melanoma in the context of a rapidly changing adjuvant treatment landscape, summarizing the key clinical trials which shaped current practice guidelines.

Redesigning Sentinel Lymph Node Biopsy Guidelines in Melanoma Cases

Background

Accurately staging and prognosticating melanoma classically depends on a sentinel lymph node biopsy (SLNB). The mainstay predictors of SLNB positivity according to the American Joint Committee on Cancer (AJCC) are Breslow depth and ulceration. Nevertheless, even with these predictors, negative SLNBs, even in deep melanomas, are a common occurrence and may result in unnecessary invasive procedures for patients. This suggests that the parameters for determining SLNB candidates are a potential area for improvement in surgical dermatology (surgical oncology and plastic surgery).

Methods

The authors conducted a systemic review to assess current AJCC guidelines on when a SLNB in melanoma is indicated. We also investigated how age, mitotic rate, lymphovascular invasion, satellitosis, melanoma subtype, anatomical location, and an immunocompromised state affected positivity rates in sentinel lymph node biopsies in melanoma.

Results

These variables significantly impacted SLNB positivity rates and serve as evidence to support the proposal of redesigning SLNB guidelines in melanoma.

Conclusions

Integrating the current AJCC guidelines with the newly examined variables will create patient-specific recommendations centered on the aim of reducing the number of invasive procedures while increasing SLNB positivity rates and prognostication.

Evaluation of the Indications for Sentinel Node Biopsy in Early-Stage Melanoma with the Advent of Adjuvant Systemic Therapy: An International, Multicenter Study

BACKGROUND

Patients presenting with early-stage melanoma (AJCC pT1b-pT2a) reportedly have a relatively low risk of a positive SNB (~5-10%). Those patients are usually found to have low-volume metastatic disease after SNB, typically reclassified to AJCC stage IIIA, with an excellent prognosis of ~90% 5-year survival. Currently, adjuvant systemic therapy is not routinely recommended for most patients with AJCC stage IIIA melanoma. The purpose was to assess the SN-positivity rate in early-stage melanoma and to identify primary tumor characteristics associated with high-risk nodal disease eligible for adjuvant systemic therapy METHODS: An international, multicenter retrospective cohort study from 7 large-volume cancer centers identified 3,610 patients with early primary cutaneous melanomas 0.8-2.0 mm in Breslow thickness (pT1b-pT2a; AJCC 8th edition). Patient demographics, primary tumor characteristics, and SNB status/details were analyzed.

RESULTS

The overall SNB-positivity rate was 11.4% (412/3610). Virtually all SNB-positive patients (409/412; 99.3%) were reclassified to AJCC stage IIIA. Multivariate analysis identified age, T-stage, mitotic rate, primary site and subtype, and lymphovascular invasion as independent predictors of sentinel node status. A mitotic rate of >1/mm2 was associated with a significantly increased SN-positivity rate and was the only significant independent predictor of high-risk SNB metastases (>1 mm maximum diameter).

CONCLUSIONS

The new treatment paradigm brings into question the role of SNB for patients with early-stage melanoma. The results of this large international cohort study suggest that a reevaluation of the indications for SNB for some patients with early-stage melanoma is required.

Predictors of Nodal Metastasis in Cutaneous Head and Neck Cancers

PURPOSE OF REVIEW

The complex and varied drainage patterns in the head and neck present a challenge in the regional control of cutaneous neoplasms. Lymph node involvement significantly diminishes survival, often warranting more aggressive treatment. Here, we review the risk factors associated with lymphatic metastasis, in the context of the evolving role of sentinel lymph node biopsy.

RECENT FINDINGS

In cutaneous head and neck melanomas, tumor thickness, age, size, mitosis, ulceration, and specific histology have been associated with lymph node metastasis (LNM). In head and neck cutaneous squamous cell carcinomas, tumor thickness, size, perineural invasion, and immunosuppression are all risk factors for nodal metastasis. The risk factors for lymph node involvement in Merkel cell carcinoma are not yet fully defined, but emerging evidence indicates that tumor thickness and size may be  associated with regional metastasis. The specific factors that predict a greater risk of LNM for cutaneous head and neck cancers generally include depth of invasion, tumor size, mitotic rate, ulceration, immunosuppression, and other histopathological factors.

Surgery for Cutaneous Squamous Cell Carcinoma and its Limits in Advanced Disease

Surgery remains the first-line therapeutic option for most patients with cutaneous squamous cell carcinoma (cSCC). However, in the current therapeutic landscape, surgery must attempt to the complete tumor resection (R0 resection) with the lowest risk of surgical complications. This double aim is usually accomplished through standard excision with clinical margins in patients with low-risk tumors or by some of the micrographically controlled surgery procedures for patients with tumors at high-risk of local recurrence and metastasis. Surgery is also a first-line treatment for nodal metastases of cSCC as well as an option to consider in patients who develop recurrences while receiving immunotherapy, or as a palliation procedure in patients with advanced tumors. Neoadjuvant immunotherapy, that is the use of a medical treatment before surgery, is under investigation in patients with cSCC. The decision-making process and guidelines recommendations regarding cSCC surgery are reviewed in this manuscript.

CD103+ T Lymphocyte Count Linked to the Thickness of Invasion on Acral Melanoma without E-Cadherin Involvement

Background

Acral melanoma (AM) is a malignancy that originates from melanocytes, located in an anatomical area without sun exposure, aggressive, resistant to chemotherapy, and quickly metastasize. The invasion capability of tumor cells is the main factor for metastasis in malignancy. E-cadherin is a marker of tumor progressivity that has an important role in the process of invasion. The responsibility of E-cadherin in the invasion process of AM is not well known. CD103 is an immune component found in the tumor microenvironment that contributes to melanoma progression control, whereas E-cadherin is the ligand for CD103.

Purpose

The objective of this research was to see if there was an association between E-cadherin and CD103 immunoexpression and the thickness of invasion in AM.

Materials and Methods

This is observational cross-sectional research. Formalin-fixed paraffin-embedded (FFPE) acral melanoma tissue samples were collected during 2014–2020 at the Department of Anatomic Pathology, Dr. Hasan Sadikin Hospital, Bandung. A total of 40 samples were collected, including 20 cases of invasive melanoma less than 4 mm thickness and 20 cases of invasive melanoma greater than 4 mm thickness. All samples were immunostained with E-cadherin and CD103. Chi-Square test was used to examine the association concerning E-cadherin and CD103 with the thickness of invasion, respectively. The p-value of 0.05 was chosen as the significance level.

Results

This study showed an insignificant association between E-cadherin immunoexpression and the thickness of invasion on AM (p = 0.4272). CD103 immunoexpression had a significant association with the thickness of invasion on AM (p = 0.0001).

Conclusion

The findings revealed that CD103 in AM is associated with the thickness of invasion, and it may play important functions throughout the invasion process despite the uninvolvement of E-cadherin.

Age and Melanocytic Lesions

Age plays a dynamic role in incidence, presentation, and extent of disease for cutaneous melanoma. Even within the spectrum of juvenile melanoma, there exists a range of spitzoid and nonspitzoid melanocytic and melanoma lesions. Spitzoid melanomas, a more favorable disease in juvenile patients, are malignant lesions and require treatment as such. Lymph node metastases in melanoma occur at lower rates in older patients compared with younger counterparts, yet the rate of metastases is still high. Age appears to play an important role in the development and progression of melanoma, and understanding the differences across age populations is important when counseling patients.

Deep learning approach to predict sentinel lymph node status directly from routine histology of primary melanoma tumours

AIM

Sentinel lymph node status is a central prognostic factor for melanomas. However, the surgical excision involves some risks for affected patients. In this study, we therefore aimed to develop a digital biomarker that can predict lymph node metastasis non-invasively from digitised H&E slides of primary melanoma tumours.

METHODS

A total of 415 H&E slides from primary melanoma tumours with known sentinel node (SN) status from three German university hospitals and one private pathological practice were digitised (150 SN positive/265 SN negative). Two hundred ninety-one slides were used to train artificial neural networks (ANNs). The remaining 124 slides were used to test the ability of the ANNs to predict sentinel status. ANNs were trained and/or tested on data sets that were matched or not matched between SN-positive and SN-negative cases for patient age, ulceration, and tumour thickness, factors that are known to correlate with lymph node status.

RESULTS

The best accuracy was achieved by an ANN that was trained and tested on unmatched cases (61.8% ± 0.2%) area under the receiver operating characteristic (AUROC). In contrast, ANNs that were trained and/or tested on matched cases achieved (55.0% ± 3.5%) AUROC or less.

CONCLUSION

Our results indicate that the image classifier can predict lymph node status to some, albeit so far not clinically relevant, extent. It may do so by mostly detecting equivalents of factors on histological slides that are already known to correlate with lymph node status. Our results provide a basis for future research with larger data cohorts.

Validation of CP-GEP (Merlin Assay) for predicting sentinel lymph node metastasis in primary cutaneous melanoma patients: A U.S. cohort study

BACKGROUND

Approximately 85% of melanoma patients who undergo a sentinel lymph node biopsy (SLNB) are node-negative. Melanoma incidence is highest in patients ≥65 years, but their SLNB positivity rate is lower than in younger patients. CP-GEP, a model combining clinicopathologic and gene expression variables, identifies primary cutaneous melanoma (CM) patients who may safely forgo SLNB due to their low risk for nodal metastasis. Here, we validate CP-GEP in a U.S. melanoma patient cohort.

METHODS

A cohort of 208 adult patients with primary CM from the Mayo Clinic and West Virginia University was used. Patients were stratified according to their risk for nodal metastasis: CP-GEP High Risk and CP-GEP Low Risk. The main performance measures were SLNB reduction rate (RR) and negative predictive value (NPV).

RESULTS

SLNB positivity rate for the entire cohort was 21%. Most patients had a T1b (34%) or T2a (31%) melanoma. In the T1-T2 group (153 patients), CP-GEP achieved an SLNB RR of 41.8% (95% CI: 33.9-50.1) at an NPV of 93.8% (95% CI: 84.8-98.3). Subgroup analysis showed similar performance in T1-T2 patients ≥65 years of age (51 patients; SLNB positivity rate, 9.8%): SLNB RR of 43.1% (95% CI: 29.3-57.8) at an NPV of 95.5% (95% CI: 77.2-99.9).

CONCLUSION

We confirmed the potential of CP-GEP to reduce negative SLNB in all relevant age groups. Our findings are especially relevant to patients ≥65 years, where surgery is often elective. CP-GEP may guide SLNB decision-making in clinical practice.

Relationship of patient age to tumor factors and outcomes among patients undergoing sentinel node biopsy for melanoma

INTRODUCTION

Patient age has been intermittently associated with demographics and outcomes in cutaneous melanoma. We looked at the association of age and patient demographics, tumor features, and melanoma-related outcomes in patients undergoing sentinel lymph node (SLN) biopsy for melanoma.

METHODS

We reviewed demographics (age, gender), tumor features (mean Breslow thickness, ulceration, SLN positivity rates), and outcomes (all-site relapse, progression to stage IV, death from melanoma, complications) from a university-based prospective database of 1633 patients. Patients were grouped by decade of age and the impact of age was examined by univariable and multivariable analyses.

RESULTS

Increasing age was directly associated with number of patients referred for SLN biopsy, male gender, head and neck (H&N) tumor location, mean Breslow thickness, tumor ulceration, and with all -site relapse, progression to stage IV, death from melanoma and complication rates. Increasing age was indirectly associated with SLN positivity rates. Comparing ages <30 with ages >60, these trends reached statistical significance for male gender, H&N location, SLN positivity, all-site relapse, progression to stage IV (development of metastases) and death from melanoma.

CONCLUSIONS

Referrals for SLN biopsy increase with increasing patient age, yet increasing age is associated with lower SLN positivity rates. This occurs despite the fact that older patients have thicker, more ulcerated tumors, and higher melanoma-related relapse and death rates.

Model Combining Tumor Molecular and Clinicopathologic Risk Factors Predicts Sentinel Lymph Node Metastasis in Primary Cutaneous Melanoma

Purpose

More than 80% of patients who undergo sentinel lymph node (SLN) biopsy have no nodal metastasis. Here we describe a model that combines clinicopathologic and molecular variables to identify patients with thin and intermediate thickness melanomas who may forgo the SLN biopsy procedure due to their low risk of nodal metastasis.

Patients and Methods

Genes with functional roles in melanoma metastasis were discovered by analysis of next generation sequencing data and case control studies. We then used PCR to quantify gene expression in diagnostic biopsy tissue across a prospectively designed archival cohort of 754 consecutive thin and intermediate thickness primary cutaneous melanomas. Outcome of interest was SLN biopsy metastasis within 90 days of melanoma diagnosis. A penalized maximum likelihood estimation algorithm was used to train logistic regression models in a repeated cross validation scheme to predict the presence of SLN metastasis from molecular, clinical and histologic variables.

Results

Expression of genes with roles in epithelial-to-mesenchymal transition (glia derived nexin, growth differentiation factor 15, integrin β3, interleukin 8, lysyl oxidase homolog 4, TGFβ receptor type 1 and tissue-type plasminogen activator) and melanosome function (melanoma antigen recognized by T cells 1) were associated with SLN metastasis. The predictive ability of a model that only considered clinicopathologic or gene expression variables was outperformed by a model which included molecular variables in combination with the clinicopathologic predictors Breslow thickness and patient age; AUC, 0.82; 95% CI, 0.78-0.86; SLN biopsy reduction rate of 42% at a negative predictive value of 96%.

Conclusion

A combined model including clinicopathologic and gene expression variables improved the identification of melanoma patients who may forgo the SLN biopsy procedure due to their low risk of nodal metastasis.

High level of TILs is an independent predictor of negative sentinel lymph node in women but not in men

Factors that are most associated with positive lymph node status in melanoma are Breslow thickness and ulceration. However, there are other factors that have been little explored and could help in the identification of "at risk patients" harbouring occult metastasis. The objective of this study was to determine whether intensity of tumour-infiltrating lymphocytes (TILs) in a cohort study (N = 4133) is an independent predictor of sentinel lymph node (SLN) status in patients with primary cutaneous melanoma. Of the patients with cutaneous melanoma who resulted negative for nodal metastasis, 50.7% had moderate/marked TILs versus 27.7% among those patients who resulted positive for nodal metastasis. In the multivariate analysis, controlling for sex, age, mitotic rate, ulceration and Breslow, high levels of TILs in primary invasive melanoma was associated with a lower risk of developing SLN metastasis (OR 0.46; 95% CI 0.23-0.95, p = 0.037). When the analysis was stratified by sex, the protective effect of moderate/marked TIL remained only for women (OR 0.30; 95% CI 0.10-0.93, p = 0.037) but not for men (OR 0.51; 95% CI 0.19-1.34, p = 0.172). Other independent predictors of negative lymph node were low Breslow thickness (≤ 2.0 mm) and low mitotic rate. Besides predicting a negative lymph node response, TILs were also associated with a decreased risk of 10-year mortality among females with positive lymph node. Our findings suggest that high level of TILs is an independent predictor of negative SLN status among women. Further research is warranted to confirm our findings.

Surgical Management of Lymph Nodes in Melanoma

This article provides a comprehensive evaluation of surgical management of the lymph node basin in melanoma, with historical, anatomic, and evidence-based recommendations for practice.

Indocyanine Green Fluorescence Imaging with Lymphoscintigraphy for Sentinel Node Biopsy in Melanoma: Increasing the Sentinel Lymph Node-Positive Rate

INTRODUCTION

The goal of this study was to analyze patients who underwent a sentinel lymph node biopsy (SLNB) in melanoma with the combination of radioisotope lymphoscintigraphy and indocyanine green (ICG) fluorescence imaging to compare our true positive (TP) rate, a means to perform immediate analysis of the SLNB, with that of the literature.

METHODS

Consecutive cutaneous melanoma patients who underwent SLNB with lymphoscintigraphy and ICG-based fluorescence imaging by the senior author (BG) from 2012 to 2018 were prospectively enrolled. The average expected SLN-positive rate per T stage was calculated based on three studies and compared with our SLN-positive rate.

RESULTS

Overall, 574 consecutive patients were analyzed. Average Breslow thickness was 1.9 mm. A total of 1754 sentinel nodes were sampled; 1497 were identified by gamma probe signaling and ICG, 241 were identified by gamma probe signaling only, and 16 were identified by ICG only. There were 123 (21.4%) patients with at least one positive SLN; 113 (91.9%) had at least one positive node identified with both gamma probe signaling and ICG, 8 (6.5%) had positive node(s) identified with gamma probe signaling only, and 2 (1.6%) had positive node(s) identified with ICG only. There was an overall 21.4% SLN-positive rate, with 8% T1, 18.5% T2, 41.1% T3, and 52.4% T4, which is higher than the predicted rates for each stage.

CONCLUSIONS

With the largest cohort of patients reported who underwent a melanoma SLNB with lymphoscintigraphy and ICG, we demonstrated that this technique results in higher SLN-positive rates than predicted. Patients are being followed but, given the TP data, knowledge of our results may foster the use of this modality to improve staging and treatment options.

Characteristics Associated with Pathologic Nodal Burden in Patients Presenting with Clinical Melanoma Nodal Metastasis

BACKGROUND

Nodal observation is safe for patients with microscopic melanoma metastasis in a sentinel lymph node (LN). Complete LN dissection (CLND) remains the standard of care for patients with clinically evident LN (cLN) metastases, even though about 40% have only one pathologic LN (pLN). We sought to identify clinical features associated with having one pLN among patients with cLNs.

METHODS

Patients at three melanoma centers who underwent CLND for cLNs were identified. Clinicopathologic and imaging characteristics associated with one pLN were determined by multivariable logistic regression and classification tree analysis.

RESULTS

Of 190 patients, 90 (47.4%) had one pLN and 100 (52.6%) had more than one pLN. By multivariable logistic regression, extremity versus truncal primary (odds ratio [OR] 2.15, p = 0.012), axillary versus superficial inguinal location (OR 3.89, p = 0.009), and preoperative cross-sectional imaging demonstrating more than one versus one cLN (OR 17.1, p < 0.001) were associated with more than one pLN. The negative predictive value for additional pathologic nodal disease of preoperative imaging was 70.9%, increasing to 74.4% for positron emission tomography/computed tomography. In the subgroup of patients with one cLN, the classification tree identified two groups with < 10% risk of additional pLNs: (1) Breslow thickness > 6.55 mm (n = 17); and (2) if unknown primary or Breslow thickness ≤ 6.55 mm, then LN diameter > 1.8 cm in the inguinal location (n = 22).

CONCLUSION

The majority of patients with one cLN from melanoma by preoperative imaging will harbor no additional pathologic nodes on CLND. Safety of nodal observation after clinical nodal excision in these patients, particularly in an era of effective adjuvant therapies, deserves prospective evaluation.

Sentinel lymph node biopsy in the management of conjunctival melanoma: current insights

Purpose: To evaluate the role of sentinel lymph node biopsy (SLNB) in conjunctival melanoma (CM).

Methods: This article provides a review of the literature from PUBMED.

Results: Data on SLNB in the management of CM are scarce and only two relatively large cohorts have been reported. Although indication criteria for SLNB vary slightly, positive findings can be expected in 11%–13% of CM cases, including small tumors. False negative SLNB findings are rare (<10%). Failure to identify SLNB has been attributed to the surgical learning curve and recurrent tumors with scar tissue impeding spread of the tracer material. Reported 5-year survival rate following CM management including SLNB, is up to 79%, but there are no comparative cohort studies proving the assumed benefit. Adverse events reported were non-severe and transient.

Conclusion: Patients can potentially benefit from SLNB and the procedure can be offered to eligible patients. However, there is not enough evidence to support SLNB as a mandatory part of CM management.

Guidance of sentinel lymph node biopsy decisions in patients with T1–T2 melanoma using gene expression profiling

Aim: Can gene expression profiling be used to identify patients with T1–T2 melanoma at low risk for sentinel lymph node (SLN) positivity? Patients & methods: Bioinformatics modeling determined a population in which a 31-gene expression profile test predicted <5% SLN positivity. Multicenter, prospectively-tested (n = 1421) and retrospective (n = 690) cohorts were used for validation and outcomes, respectively. Results: Patients 55–64 years and ≥65 years with a class 1A (low-risk) profile had SLN positivity rates of 4.9% and 1.6%. Class 2B (high-risk) patients had SLN positivity rates of 30.8% and 11.9%. Melanoma-specific survival was 99.3% for patients ≥55 years with class 1A, T1–T2 tumors and 55.0% for class 2B, SLN-positive, T1–T2 tumors. Conclusion: The 31-gene expression profile test identifies patients who could potentially avoid SLN biopsy.

Nuclear morphometric analysis in tissue as an objective tool with potential use to improve melanoma staging

Alterations in nuclear size and shape are commonly observed in cancers, and its objective evaluation may provide valuable clinical information about the outcome of the disease. Here, we applied the nuclear morphometric analysis in tissues in hematoxylin and eosin-digitized slides of nevi and melanoma, to objectively contribute to the prognostic evaluation of these tumors. To this, we analyzed the nuclear morphometry of 34 melanomas classified according to the TNM stage. Eight cases of melanocytic nevi were used as non-neoplastic tissues to set the non-neoplastic parameters of nuclear morphology. Our samples were set as G1 (control, nevi), G2 (T1T2N0M0), G3 (T3T4N0M0), G4 (T1T2N1M1), and G5 (T3T4N1M1). Image-Pro Plus 6.0 software was used to acquire measurements related to nuclear size (variable: Area) and shape (variables: Aspect, AreaBox, Roundness, and RadiusRatio, which were used to generate the Nuclear Irregularity Index). From these primary variables, a set of secondary variables were generated. All the seven primary and secondary variables related to the nuclear area were different among groups (Pillai's trace P<0.001), whereas Nuclear Irregularity Index, which is the variable related to nuclear shape, did not differ among groups. The secondary variable 'Average Area of Large Nuclei' was able to differ all pairwise comparisons, including thin nonmetastatic from thin metastatic tumors. In conclusion, the objective quantification of nuclear area in hematoxylin and eosin slides may provide objective information about the risk stratification of these tumors and has the potential to be used as an additional method in clinical decision making.

Soluble PD-L1 is a potential biomarker of cutaneous melanoma aggressiveness and metastasis in obstructive sleep apnoea patients

Obstructive sleep apnoea (OSA) upregulates the programmed cell death-1 receptor and its ligand (PD-L1) pathway, potentially compromising immunosurveillance. We compared circulating levels of soluble PD-L1 (sPD-L1) in patients with cutaneous melanoma according to the presence and severity of OSA, and evaluated relationships with tumour aggressiveness and invasiveness.In a multicentre observational study, 360 patients with cutaneous melanoma underwent sleep studies, and serum sPD-L1 levels were assayed using ELISA. Cutaneous melanoma aggressiveness indices included mitotic rate, Breslow index, tumour ulceration, Clark level and tumour stage, and sentinel lymph node (SLN) metastasis was recorded as a marker of invasiveness.sPD-L1 levels were higher in severe OSA compared to mild OSA or non-OSA patients. In OSA patients, sPD-L1 levels correlated with Breslow index and were higher in patients with tumour ulceration, advanced primary tumour stages or with locoregional disease. The incorporation of sPD-L1 to the classic risk factors to SLN metastasis led to net improvements in the classification of 27.3%.Thus, sPD-L1 levels are increased in melanoma patients with severe OSA, and, in addition, might serve as a potential biomarker of cutaneous melanoma aggressiveness and invasiveness in this group of subjects.

Current management of regional lymph nodes in patients with melanoma

The publication of recent randomized trials has prompted a significant shift in both our understanding and the management of patients with melanoma. Here, the current management of the regional lymph nodes in patients with melanoma is discussed. This review focuses on selection for sentinel lymph node biopsy, management of the positive sentinel node, management of the clinically positive node, and the controversy over the therapeutic value of early nodal intervention.