Primary Excision Margins and Sentinel Lymph Node Biopsy in Clinically Node-negative Melanoma of the Trunk or Extremities

Melanoma nodal management in Ontario the year after the 2012 American Society of Clinical Oncology and Society of Surgical Oncology guideline

Background

In 2012 in the United States, the American Society of Clinical Oncology and the Society of Surgical Oncology (asco/sso) published a joint guideline about indications for sentinel lymph node biopsy (slnb) in cutaneous melanoma. The guideline supported completion lymph node dissection (clnd) for all patients with positive sentinel nodes. We examined the rates and predictors of slnb and clnd for melanoma patients in Ontario (population 13.6 million) after publication of that guideline.

Methods

We used the Ontario Cancer Registry to identify patients diagnosed with cutaneous melanoma in 2013. Patient records were linked to prospectively maintained health administrative databases to obtain details for each patient, including surgical procedures.

Results

Of the 3298 patients with melanoma identified in Ontario in 2013, 1973 (59.8%) could be analyzed. Most of that group (n = 1227, 62.2%) underwent local excision alone; 746 (37.8%) had a slnb. The slnb was performed in 13.9%, 67.8%, 62.6%, and 47.2% of patients with T1, T2, T3, and T4 primary melanomas respectively. In multivariate analysis, receipt of slnb was positively associated with younger age (<80 years), higher T stage, and a non-head-and-neck primary. Of the patients who had a slnb, 136 (18.2%) were found to be node-positive. A clnd was performed in 82 of those patients (60.3%).

Conclusions

In Ontario, only two thirds of patients with intermediate-thickness melanomas (T2, T3) underwent slnb as recommended by the asco/sso guideline. Use of slnb was less frequent for patients with a head-and-neck primary and higher for younger patients (<80 years). The rate of clnd after a positive slnb was also low relative to the guideline recommendation.

Metastatic Melanoma in Sentinel Node-Negative Patients: The Ottawa Experience

BACKGROUND

Lymph node involvement is a major independent prognostic factor for survival in patients with malignant melanoma. Sentinel lymph node biopsy (SLNB) detection of microscopic nodal melanoma has been shown to improve both 5-year survival and 5-year disease-free survival.

OBJECTIVE

To determine the rate of metastatic melanoma in SLNB-negative patients at long-term follow-up.

METHODS

Study subjects include all 152 patients who had a negative SLNB and were followed at the Ottawa Regional Cancer Centre (ORCC) between 1999 and 2004. Patients with a follow-up period less than 6 months, more than 1 primary melanoma, and metastatic melanoma at diagnosis were excluded. Age at diagnosis, sex, Breslow thickness, ulceration, mitoses, regression, Clark level, anatomical location, development of metastatic melanoma, time to detection of metastatic disease, and time to death from melanoma were studied.

RESULTS

In this retrospective study at the ORCC, 40 of 140 (28.6%) patients with a single primary melanoma developed metastatic melanoma following negative SLNB at a mean follow-up of 63 months.

CONCLUSION

The rate of metastatic melanoma following negative SLNB at long-term follow-up at the ORCC is higher than the upper limit of rates reported in the literature (6%-24%). The reason for this is multifactorial, and the long follow-up period of 5 years allowed for detection of metastatic disease at a mean of 3.9 years. Long-term prognosis may be guarded in node-negative patients with a primary cutaneous melanoma, and surveillance by a multidisciplinary team is crucial.

Skin diseases of the nose

OBJECTIVES

The goal of this study was to review the main lesion types of the nasal skin and appropriate treatment strategies rather than to present a comprehensive list of all diseases that affect the skin that can involve the nose.

METHODS

We reviewed the main nasal skin lesion types and available treatment strategies. Nasal skin lesions were classified as benign, premalignant, or malignant.

RESULTS

Benign lesions of the nose include nonmalignant tumoral lesions (i.e., freckles, comedo, adenoma sebaceum [Pringle disease], hydrocystoma, fibrous papules, sebaceous hyperplasia, and rhinophyma), autoimmune and inflammatory conditions (i.e., pemphigus, sarcoidosis, systemic lupus erythematosus, facial eosinophilic granuloma, rosacea, herpes zoster infection, leishmaniasis, and leprosy), and vascular lesions (i.e., telangiectasis, hemangioma, and spider nevus). Premalignant lesions are actinic keratosis and keratoacanthoma; and malignant tumors are melanoma, basal cell carcinoma, and squamous cell carcinoma. Regardless of whether or not they are malignant, all facial lesions can yield significant cosmetic discomfort that should be evaluated carefully before commencing any curative or corrective intervention. In general, benign lesions are treated with dermabrasive modalities, such as trichloroacetic acid, phenol, salicylate, and laser ablation. Electrocautery, cryosurgery, and surgical excision are also used, although these methods may result in scar formation, which can sometimes be more problematic than the original lesion itself.

CONCLUSION

Any disease that affects the skin, especially those diseases that are triggered by ultraviolet exposure, can involve the face and nose. Cosmetic defects due both to the lesion itself and the intervention must be discussed with the patient, preferably in the presence of a first-degree relative, before commencement of treatment. As a result of heterogeneity of skin lesions of the nose, appropriate education of general practitioners as well as otorhinolaryngologists is mandatory.