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Hussain Z, Heaton MJ, Snelling AP, Nobes JP, Gray G, Garioch JJ, Moncrieff MD. Risk Stratification of Sentinel Node Metastasis Disease Burden and Phenotype in Stage III Melanoma Patients. Ann Surg Oncol 2023; 30:1808-1819. [PMID: 36445500 PMCID: PMC9908720 DOI: 10.1245/s10434-022-12804-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Currently, all patients with American Joint Committee on Cancer (AJCC) pT2b-pT4b melanomas and a positive sentinel node biopsy are now considered for adjuvant systemic therapy without consideration of the burden of disease in the metastatic nodes. METHODS This was a retrospective cohort analysis of 1377 pT1-pT4b melanoma patients treated at an academic cancer center. Standard variables regarding patient, primary tumor, and sentinel node characteristics, in addition to sentinel node metastasis maximum tumor deposit size (MTDS) in millimeters and extracapsular spread (ECS) status, were analyzed for predicting disease-specific survival (DSS). RESULTS The incidence of SN+ was 17.3% (238/1377) and ECS was 10.5% (25/238). Increasing AJCC N stage was associated with worse DSS. There was no difference in DSS between the IIIB and IIIC groups. Subgroup analyses showed that the optimal MTDS cut-point was 0.7 mm for the pT1b-pT4a SN+ subgroups, but there was no cut-point for the pT4b SN+ subgroup. Patients with MTDS <0.7 mm and no ECS had similar survival outcomes as the N0 patients with the same T stage. Nodal risk categories were developed using the 0.7 mm MTDS cut-point and ECS status. The incidence of low-risk disease, according to the new nodal risk model, was 22.3% (53/238) in the stage III cohort, with 49% (26/53) in the pT2b-pT3a and pT3b-pT4a subgroups and none in the pT4b subgroup. Similar outcomes were observed for overall and distant metastasis-free survival. CONCLUSION We propose a more granular classification system, based on tumor burden and ECS status in the sentinel node, that identifies low-risk patients in the AJCC IIIB and IIIC subgroups who may otherwise be observed.
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Affiliation(s)
- Zahra Hussain
- Department of Plastic Surgery and Reconstructive Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Martin J Heaton
- Department of Plastic Surgery and Reconstructive Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Andrew P Snelling
- Department of Plastic Surgery and Reconstructive Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Jenny P Nobes
- Department of Oncology, Norfolk and Norwich University Hospital, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Gill Gray
- Department of Oncology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Jennifer J Garioch
- Norwich Medical School, University of East Anglia, Norwich, UK
- Department of Dermatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Marc D Moncrieff
- Department of Plastic Surgery and Reconstructive Surgery, Norfolk and Norwich University Hospital, Norwich, UK.
- Norwich Medical School, University of East Anglia, Norwich, UK.
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2
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Kretschmer L, Mitteldorf C, Hellriegel S, Leha A, Fichtner A, Ströbel P, Schön MP, Bremmer F. The sentinel node invasion level (SNIL) as a prognostic parameter in melanoma. Mod Pathol 2021; 34:1839-1849. [PMID: 34131294 PMCID: PMC8443441 DOI: 10.1038/s41379-021-00835-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 12/18/2022]
Abstract
Sentinel lymph node (SN) tumor burden is becoming increasingly important and is likely to be included in future N classifications in melanoma. Our aim was to investigate the prognostic significance of melanoma infiltration of various anatomically defined lymph node substructures. This retrospective cohort study included 1250 consecutive patients with SN biopsy. The pathology protocol required description of metastatic infiltration of each of the following lymph node substructures: intracapsular lymph vessels, subcapsular and transverse sinuses, cortex, paracortex, medulla, and capsule. Within the SN with the highest tumor burden, the SN invasion level (SNIL) was defined as follows: SNIL 1 = melanoma cells confined to intracapsular lymph vessels, subcapsular or transverse sinuses; SNIL 2 = melanoma infiltrating the cortex or paracortex; SNIL 3 = melanoma infiltrating the medulla or capsule. We classified 338 SN-positive patients according to the non-metric SNIL. Using Kaplan-Meier estimates and Cox models, recurrence-free survival (RFS), melanoma-specific survival (MSS) and nodal basin recurrence rates were analyzed. The median follow-up time was 75 months. The SNIL divided the SN-positive population into three groups with significantly different RFS, MSS, and nodal basin recurrence probabilities. The MSS of patients with SNIL 1 was virtually identical to that of SN-negative patients, whereas outgrowth of the metastasis from the parenchyma into the fibrous capsule or the medulla of the lymph node indicated a very poor prognosis. Thus, the SNIL may help to better assess the benefit-risk ratio of adjuvant therapies in patients with different SN metastasis patterns.
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Affiliation(s)
- Lutz Kretschmer
- Department of Dermatology, Venereology and Allergology, University Medical Center, Göttingen, Germany.
| | - Christina Mitteldorf
- grid.411984.10000 0001 0482 5331Department of Dermatology, Venereology and Allergology, University Medical Center, Göttingen, Germany
| | - Simin Hellriegel
- grid.411984.10000 0001 0482 5331Department of Dermatology, Venereology and Allergology, University Medical Center, Göttingen, Germany
| | - Andreas Leha
- grid.411984.10000 0001 0482 5331Department of Medical Statistics, University Medical Center, Göttingen, Germany
| | - Alexander Fichtner
- grid.411984.10000 0001 0482 5331Institute of Pathology, University Medical Center, Göttingen, Germany
| | - Philipp Ströbel
- grid.411984.10000 0001 0482 5331Institute of Pathology, University Medical Center, Göttingen, Germany
| | - Michael P. Schön
- grid.411984.10000 0001 0482 5331Department of Dermatology, Venereology and Allergology, University Medical Center, Göttingen, Germany
| | - Felix Bremmer
- grid.411984.10000 0001 0482 5331Institute of Pathology, University Medical Center, Göttingen, Germany
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Dammeijer F, van Gulijk M, Mulder EE, Lukkes M, Klaase L, van den Bosch T, van Nimwegen M, Lau SP, Latupeirissa K, Schetters S, van Kooyk Y, Boon L, Moyaart A, Mueller YM, Katsikis PD, Eggermont AM, Vroman H, Stadhouders R, Hendriks RW, Thüsen JVD, Grünhagen DJ, Verhoef C, van Hall T, Aerts JG. The PD-1/PD-L1-Checkpoint Restrains T cell Immunity in Tumor-Draining Lymph Nodes. Cancer Cell 2020; 38:685-700.e8. [PMID: 33007259 DOI: 10.1016/j.ccell.2020.09.001] [Citation(s) in RCA: 309] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/28/2020] [Accepted: 08/31/2020] [Indexed: 12/31/2022]
Abstract
PD-1/PD-L1-checkpoint blockade therapy is generally thought to relieve tumor cell-mediated suppression in the tumor microenvironment but PD-L1 is also expressed on non-tumor macrophages and conventional dendritic cells (cDCs). Here we show in mouse tumor models that tumor-draining lymph nodes (TDLNs) are enriched for tumor-specific PD-1+ T cells which closely associate with PD-L1+ cDCs. TDLN-targeted PD-L1-blockade induces enhanced anti-tumor T cell immunity by seeding the tumor site with progenitor-exhausted T cells, resulting in improved tumor control. Moreover, we show that abundant PD-1/PD-L1-interactions in TDLNs of nonmetastatic melanoma patients, but not those in corresponding tumors, associate with early distant disease recurrence. These findings point at a critical role for PD-L1 expression in TDLNs in governing systemic anti-tumor immunity, identifying high-risk patient groups amendable to adjuvant PD-1/PD-L1-blockade therapy.
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Affiliation(s)
- Floris Dammeijer
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, the Netherlands; Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Mandy van Gulijk
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, the Netherlands; Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Evalyn E Mulder
- Department of Surgical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Melanie Lukkes
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Larissa Klaase
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Menno van Nimwegen
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sai Ping Lau
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Surgical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Kitty Latupeirissa
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sjoerd Schetters
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Yvette van Kooyk
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Louis Boon
- Polpharma Biologics, Utrecht, the Netherlands
| | - Antien Moyaart
- Department of Pathology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yvonne M Mueller
- Department of Immunology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Peter D Katsikis
- Department of Immunology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Heleen Vroman
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, the Netherlands; Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ralph Stadhouders
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cell Biology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Rudi W Hendriks
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jan von der Thüsen
- Department of Pathology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Dirk J Grünhagen
- Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Surgical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Cornelis Verhoef
- Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Surgical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Thorbald van Hall
- Department of Medical Oncology, Oncode Institute, Leiden University Medical Center, Leiden, the Netherlands.
| | - Joachim G Aerts
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, the Netherlands; Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, the Netherlands.
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4
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Mulder EEAP, Dwarkasing JT, Tempel D, van der Spek A, Bosman L, Verver D, Mooyaart AL, van der Veldt AAM, Verhoef C, Nijsten TEC, Grunhagen DJ, Hollestein LM. Validation of a clinicopathological and gene expression profile model for sentinel lymph node metastasis in primary cutaneous melanoma. Br J Dermatol 2020; 184:944-951. [PMID: 32844403 PMCID: PMC8247350 DOI: 10.1111/bjd.19499] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The Clinicopathological and Gene Expression Profile (CP-GEP) model was developed to accurately identify patients with T1-T3 primary cutaneous melanoma at low risk for nodal metastasis. OBJECTIVES To validate the CP-GEP model in an independent Dutch cohort of patients with melanoma. METHODS Patients (aged ≥ 18 years) with primary cutaneous melanoma who underwent sentinel lymph node biopsy (SLNB) between 2007 and 2017 at the Erasmus Medical Centre Cancer Institute were eligible. The CP-GEP model combines clinicopathological features (age and Breslow thickness) with the expression of eight target genes involved in melanoma metastasis (ITGB3, PLAT, SERPINE2, GDF15, TGFBR1, LOXL4, CXCL8 and MLANA). Using the pathology result of SLNB as the gold standard, performance measures of the CP-GEP model were calculated, resulting in CP-GEP high risk or low risk for nodal metastasis. RESULTS In total, 210 patients were included in the study. Most patients presented with T2 (n = 94, 45%) or T3 (n = 70, 33%) melanoma. Of all patients, 27% (n = 56) had a positive SLNB, with nodal metastasis in 0%, 30%, 54% and 16% of patients with T1, T2, T3 and T4 melanoma, respectively. Overall, the CP-GEP model had a negative predictive value (NPV) of 90·5% [95% confidence interval (CI) 77·9-96.2], with an NPV of 100% (95% CI 72·2-100) in T1, 89·3% (95% CI 72·8-96·3) in T2 and 75·0% (95% CI 30·1-95·4) in T3 melanomas. The CP-GEP indicated high risk in all T4 melanomas. CONCLUSIONS The CP-GEP model is a noninvasive and validated tool that accurately identified patients with primary cutaneous melanoma at low risk for nodal metastasis. In this validation cohort, the CP-GEP model has shown the potential to reduce SLNB procedures in patients with melanoma.
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Affiliation(s)
- E E A P Mulder
- Departments of, Department of, Surgical Oncology, Erasmus Medical Centre (MC) Cancer Institute, Rotterdam, the Netherlands.,Department of, Medical Oncology, Erasmus Medical Centre (MC) Cancer Institute, Rotterdam, the Netherlands
| | - J T Dwarkasing
- Department of Scientific & Clinical Development, SkylineDx, Rotterdam, the Netherlands
| | - D Tempel
- Department of Scientific & Clinical Development, SkylineDx, Rotterdam, the Netherlands
| | - A van der Spek
- Department of Scientific & Clinical Development, SkylineDx, Rotterdam, the Netherlands
| | - L Bosman
- Department of Scientific & Clinical Development, SkylineDx, Rotterdam, the Netherlands
| | - D Verver
- Departments of, Department of, Surgical Oncology, Erasmus Medical Centre (MC) Cancer Institute, Rotterdam, the Netherlands
| | - A L Mooyaart
- Department of, Pathology, Erasmus Medical Centre (MC) Cancer Institute, Rotterdam, the Netherlands
| | - A A M van der Veldt
- Department of, Medical Oncology, Erasmus Medical Centre (MC) Cancer Institute, Rotterdam, the Netherlands.,Department of, Radiology & Nuclear Medicine, Erasmus Medical Centre (MC) Cancer Institute, Rotterdam, the Netherlands
| | - C Verhoef
- Departments of, Department of, Surgical Oncology, Erasmus Medical Centre (MC) Cancer Institute, Rotterdam, the Netherlands
| | - T E C Nijsten
- Department of, Dermatology, Erasmus Medical Centre (MC) Cancer Institute, Rotterdam, the Netherlands
| | - D J Grunhagen
- Departments of, Department of, Surgical Oncology, Erasmus Medical Centre (MC) Cancer Institute, Rotterdam, the Netherlands
| | - L M Hollestein
- Department of, Dermatology, Erasmus Medical Centre (MC) Cancer Institute, Rotterdam, the Netherlands.,Department of Research, Comprehensive Cancer Centre The Netherlands (IKNL), Utrecht, the Netherlands
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5
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Farrow NE, Raman V, Williams TP, Nguyen KY, Tyler DS, Beasley GM. Adjuvant Therapy is Effective for Melanoma Patients with a Positive Sentinel Lymph Node Biopsy Who Forego Completion Lymphadenectomy. Ann Surg Oncol 2020; 27:5121-5125. [PMID: 32314157 DOI: 10.1245/s10434-020-08478-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Multiple adjuvant therapies for melanoma have been approved since 2015 based on randomized trials demonstrating improvements in recurrence-free survival (RFS) with adjuvant therapy after surgical resection of high-risk disease. Inclusion criteria for these trials required performance of a completion lymph node dissection (CLND) for positive sentinel lymph node (pSLN) disease. OBJECTIVE We aimed to describe current practice for adjuvant therapies in patients with pSLN without CLND (active surveillance [AS]), and to evaluate recurrence in these patients. METHODS Melanoma patients with pSLN between 2016 and 2019 were identified at two institutions. Demographic information, disease and treatment characteristics, and recurrence details were reviewed retrospectively. Patients were stratified by recurrence and patient-, treatment- and tumor-related characteristics were compared using Fisher's exact test and t test for categorical and continuous variables, respectively. RESULTS Overall, 245 SLN biopsies were performed, of which 36 (14.7%) were pSLN. Of 36 pSLN, 4 underwent CLND and 32 underwent AS, of whom 22 (68.8%) received adjuvant therapy with the anti-programmed death-1 (PD1) inhibitor nivolumab (16/22), anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitor ipilimumab (3/22), or BRAF/MEK inhibitors (3/22). At a median follow up of 13.3 months, 7/32 (21.9%) patients on AS recurred, including 4/22 (18.2%) who received adjuvant therapy and 3/10 (30.0%) who did not. Tumor ulceration was significantly associated with recurrence. While not significant, acral lentiginous subtype appeared more common among those with recurrence. CONCLUSION The majority (68.8%) of patients with pSLN managed without CLND were treated with adjuvant therapy. The 1-year RFS for patients managed with adjuvant therapy without CLND was 82%, which is similar to modern adjuvant therapy trials requiring CLND.
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Affiliation(s)
- Norma E Farrow
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Vignesh Raman
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Taylor P Williams
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Kayla Y Nguyen
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Douglas S Tyler
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Georgia M Beasley
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Management Recommendations for Merkel Cell Carcinoma-A Danish Perspective. Cancers (Basel) 2020; 12:cancers12030554. [PMID: 32121063 PMCID: PMC7139291 DOI: 10.3390/cancers12030554] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 02/23/2020] [Accepted: 02/25/2020] [Indexed: 02/06/2023] Open
Abstract
Merkel cell carcinoma (MCC) is a rare malignant neuroendocrine carcinoma of the skin with a poor prognosis and an apparent increase in incidence. Due to its rarity, evidence-based guidelines are limited, and there is a lack of awareness among clinicians. This review constitutes the consensus management recommendations developed by the Danish MCC expert group and is based on a systematic literature search. Patients with localized disease are recommended surgical excision and adjuvant radiotherapy to the primary site; however, this may be omitted in patients with MCC with low risk features. Patients with regional lymph node involvement are recommended complete lymph node removal and adjuvant radiotherapy in case of extracapsular disease. Metastatic disease was traditionally treated with chemotherapy, however, recent clinical trials with immune therapy have been promising. Immune checkpoint inhibitors targeting the programmed cell death protein 1(PD-1)/programmed death-ligand 1(PD-L1) axis should therefore be strongly considered as first-line treatment for fit patients. A 5-year follow-up period is recommended involving clinical exam every 3 months for 2 years and every 6 months for the following 3 years and PET-CT one to two times a year or if clinically indicated. These national recommendations are intended to offer uniform patient treatment and hopefully improve prognosis.
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Hanks JE, Kovatch KJ, Ali SA, Roberts E, Durham AB, Smith JD, Bradford CR, Malloy KM, Boonstra PS, Lao CD, McLean SA. Sentinel Lymph Node Biopsy in Head and Neck Melanoma: Long-term Outcomes, Prognostic Value, Accuracy, and Safety. Otolaryngol Head Neck Surg 2020; 162:520-529. [PMID: 32041486 DOI: 10.1177/0194599819899934] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the long-term outcomes of sentinel lymph node biopsy (SLNB) for head and neck cutaneous melanoma (HNCM). STUDY DESIGN Retrospective cohort study. SETTING Tertiary academic medical center. SUBJECTS AND METHODS Longitudinal review of a 356-patient cohort with HNCM undergoing SLNB from 1997 to 2007. RESULTS Descriptive characteristics included the following: age, 53.5 ± 19 years (mean ± SD); sex, 26.8% female; median follow-up, 4.9 years; and Breslow depth, 2.52 ± 1.87 mm. Overall, 75 (21.1%) patients had a positive SLNB. Among patients undergoing completion lymph node dissection following positive SLNB, 20 (27.4%) had at least 1 additional positive nonsentinel lymph node. Eighteen patients with local control and negative SLNB developed regional disease, indicating a false omission rate of 6.4%, including 10 recurrences in previously unsampled basins. Ten-year overall survival (OS) and melanoma-specific survival (MSS) were significantly greater in the negative sentinel lymph node (SLN) cohort (OS, 61% [95% CI, 0.549-0.677]; MSS, 81.9% [95% CI, 0.769-0.873]) than the positive SLN cohort (OS, 31% [95% CI, 0.162-0.677]; MSS, 60.3% [95% CI, 0.464-0.785]) and positive SLN/positive nonsentinel lymph node cohort (OS, 8.4% [95% CI, 0.015-0.474]; MSS, 9.6% [95% CI, 0.017-0.536]). OS was significantly associated with SLN positivity (hazard ratio [HR], 2.39; P < .01), immunosuppression (HR, 2.37; P < .01), angiolymphatic invasion (HR, 1.91; P < .01), and ulceration (HR, 1.86; P < .01). SLN positivity (HR, 3.13; P < .01), angiolymphatic invasion (HR, 3.19; P < .01), and number of mitoses (P = .0002) were significantly associated with MSS. Immunosuppression (HR, 3.01; P < .01) and SLN status (HR, 2.84; P < .01) were associated with recurrence-free survival, and immunosuppression was the only factor significantly associated with regional recurrence (HR, 6.59; P < .01). CONCLUSIONS Long-term follow up indicates that SLNB showcases durable accuracy, safety, and prognostic importance for cutaneous HNCM.
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Affiliation(s)
- John E Hanks
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Kevin J Kovatch
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - S Ahmed Ali
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Emily Roberts
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Alison B Durham
- Department of Dermatology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Joshua D Smith
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Carol R Bradford
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, USA.,University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Philip S Boonstra
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher D Lao
- Department of Medical Oncology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Scott A McLean
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
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Peach H, Board R, Cook M, Corrie P, Ellis S, Geh J, King P, Laitung G, Larkin J, Marsden J, Middleton M, Moncrieff M, Nathan P, Powell B, Pritchard-Jones R, Rodwell S, Steven N, Lorigan P. Current role of sentinel lymph node biopsy in the management of cutaneous melanoma: A UK consensus statement. J Plast Reconstr Aesthet Surg 2020; 73:36-42. [DOI: 10.1016/j.bjps.2019.06.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 06/09/2019] [Indexed: 10/26/2022]
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9
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Namikawa K, Aung PP, Milton DR, Tetzlaff MT, Torres-Cabala CA, Curry JL, Nagarajan P, Ivan D, Ross M, Gershenwald JE, Prieto VG. Correlation of Tumor Burden in Sentinel Lymph Nodes with Tumor Burden in Nonsentinel Lymph Nodes and Survival in Cutaneous Melanoma. Clin Cancer Res 2019; 25:7585-7593. [PMID: 31570567 DOI: 10.1158/1078-0432.ccr-19-1194] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/02/2019] [Accepted: 09/25/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE In patients with cutaneous melanoma, metastasis in a nonsentinel lymph node (non-SLN) is a strong independent adverse prognostic factor. However, patients with a tumor-involved SLN no longer routinely undergo completion lymph node dissection (CLND). We hypothesized that SLN tumor burden may predict non-SLN tumor burden. EXPERIMENTAL DESIGN We compared tumor burden parameters between SLN and non-SLN in patients with cutaneous melanoma who underwent SLN biopsy with a positive SLN during 2003 to 2008 at The University of Texas MD Anderson Cancer Center. RESULTS We identified 336 eligible patients with a positive SLN. Of these, 308 (92%) underwent CLND, and 35 (10%) had non-SLN metastasis. The median follow-up time was 6.0 years. For patients with maximum diameter of tumor in the SLN ≤2.0 mm, >2.0-5.0 mm, and >5.0 mm, non-SLN metastasis was detected in 5 of 200 patients (3%), 10 of 63 patients (16%), and 20 of 57 patients (35%), and the mean maximum diameters of the non-SLN tumor deposits were 0.09, 1.56, and 2.71 mm, respectively (P < 0.0001). The percentage of patients with both subcapsular and intraparenchymal non-SLN tumor was higher for patients with SLN tumor in both locations than for patients with SLN tumor in only one location (P < 0.0001). Extranodal extension in a non-SLN was more common in patients with extranodal extension in an SLN (P = 0.003). CONCLUSIONS In patients with cutaneous melanoma who undergo CLND, SLN tumor burden predicts non-SLN tumor burden. SLN tumor burden parameters provide accurate prognostic stratification independent of non-SLN status and should be considered for incorporation into future staging systems and integrated risk models.
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Affiliation(s)
- Kenjiro Namikawa
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
- Department of Dermatologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Phyu P Aung
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Denái R Milton
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael T Tetzlaff
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carlos A Torres-Cabala
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jonathan L Curry
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Doina Ivan
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Merrick Ross
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey E Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Victor G Prieto
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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10
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Fayne RA, Macedo FI, Rodgers SE, Möller MG. Evolving management of positive regional lymph nodes in melanoma: Past, present and future directions. Oncol Rev 2019; 13:433. [PMID: 31857858 PMCID: PMC6902307 DOI: 10.4081/oncol.2019.433] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 11/20/2019] [Indexed: 12/29/2022] Open
Abstract
Sentinel lymph node (SLN) biopsy has become the standard of care for lymph node staging in melanoma and the most important predictor of survival in clinically node-negative disease. Previous guidelines recommend completion lymph node dissection (CLND) in cases of positive SLN; however, the lymph nodes recovered during CLND are only positive in a minority of these cases. Recent evidence suggests that conservative management (i.e. observation) has similar outcomes compared to CLND. We sought to review the most current literature regarding the management of SLN in metastatic melanoma and to discuss potential future directions.
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Affiliation(s)
- Rachel A Fayne
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
| | - Francisco I Macedo
- Department of Surgery, North Florida Regional Medical Center, University of Central Florida College of Medicine, Miami, FL, USA
| | - Steven E Rodgers
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
| | - Mecker G Möller
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine
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11
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van Akkooi ACJ, Hayes A. Recent developments in lymph node surgery for melanoma. Br J Dermatol 2019; 180:5-7. [PMID: 30604533 DOI: 10.1111/bjd.17143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- A C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121 - Room U2·38, 1066 CX, Amsterdam, the Netherlands
| | - A Hayes
- Melanoma Unit, Department of Academic Surgery, Royal Marsden NHS Trust, London, U.K
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12
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Passmore-Webb B, Gurney B, Yuen H, Sloane J, Lee J, Proctor M, Sundram F, Newlands C, Sharma S. Sentinel lymph node biopsy for melanoma of the head and neck: a multicentre study to examine safety, efficacy, and prognostic value. Br J Oral Maxillofac Surg 2019; 57:891-897. [DOI: 10.1016/j.bjoms.2019.07.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/26/2019] [Indexed: 11/25/2022]
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Abstract
Melanoma is an aggressive malignancy arising from melanocytes in the skin and rarely in extracutaneous sites. The understanding of pathology of melanoma has evolved over the years, with the initial classifications based on the clinical and microscopic features to the current use of immunohistochemistry and genetic sequencing. The depth of invasion and lymph node metastasis are still the most important prognostic features of melanoma. Other important prognostic features include ulceration, lymphovascular invasion, mitosis, and tumor-infiltrating lymphocytes. This article reviews the pathology of melanoma and its precursor lesions, along with the recent advances in pathologic diagnosis of melanoma.
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Affiliation(s)
- Asmita Chopra
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh, Room A-422, Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA.
| | - Rohit Sharma
- Department of Surgery, Marshfield Medical Center, 1000 North Oak Avenue, Marshfield, WI 54449, USA
| | - Uma N M Rao
- Department of Pathology, University of Pittsburgh School of Medicine, Section of Bone/Soft Tissue, Melanoma Pathology, UPMC Presbyterian Shadyside, Room WG2.9, 5230 Centre Avenue, Pittsburgh, PA 15232, USA
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Belgrano V, Katsarelias D, Mattsson J, Olofsson Bagge R. Sentinel node for malignant melanoma: An observational study of a consecutive single centre experience. Eur J Surg Oncol 2019; 45:225-230. [DOI: 10.1016/j.ejso.2018.08.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 08/24/2018] [Accepted: 08/30/2018] [Indexed: 01/25/2023] Open
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15
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Kwak M, Farrow NE, Salama AKS, Mosca PJ, Hanks BA, Slingluff CL, Beasley GM. Updates in adjuvant systemic therapy for melanoma. J Surg Oncol 2019; 119:222-231. [PMID: 30481375 PMCID: PMC6330126 DOI: 10.1002/jso.25298] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 10/25/2018] [Indexed: 12/20/2022]
Abstract
There has been a rapid increase in adjuvant therapies approved for treatment following surgical resection of stages III/IV melanoma. We review current indications for adjuvant therapy, which currently includes a heterogenous group of stages III and IV patients with melanoma. We describe several pivotal clinical trials of systemic immune therapies, targeted immune therapies, and adjuvant vaccine strategies. Finally, we discuss the evidence for selecting the most appropriate treatment regimen(s) for the individual patient.
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Affiliation(s)
- Minyoung Kwak
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Norma E Farrow
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Paul J Mosca
- Department of Surgery, Duke University, Durham, North Carolina
| | - Brent A Hanks
- Department of Medicine, Duke University, Durham, North Carolina
- Department of Pharmacology and Cancer Biology
| | - Craig L Slingluff
- Department of Surgery, University of Virginia, Charlottesville, Virginia
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Patients with sentinel lymph node positive melanoma: Who needs completion lymph node dissection? Am J Surg 2018; 215:868-872. [PMID: 29397888 DOI: 10.1016/j.amjsurg.2018.01.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/21/2018] [Accepted: 01/22/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Completion lymph node dissection (CLND) for melanoma after positive sentinel lymph node biopsy (SLNB) was recently shown to improve regional but not overall survival, likely due to the majority of patients harboring no further nodal disease. We sought to determine predictors of non-sentinel node (NSN) positivity. METHODS Retrospective review of prospectively collected data on melanoma patients undergoing SLNB. RESULTS 116 patients underwent 119 CLNDs. The incidence of NSN positivity was 17.6%; the average number of positive NSNs in those cases was 1.5. Cervical and inguinofemoral location were most likely to yield positive NSN(s) (40% each). Conversely, the axilla was least likely at 18% (p < 0.001). The average number of nodes harvested was 13 for NSN negative cases and 20 for NSN positive cases (p = 0.005). Tumor thickness increased the probability of positive NSN(s) (OR 1.2, p = 0.02). CONCLUSIONS Tumor thickness and nodal basin were predictors of NSN metastasis, factors that could help determine which patients may benefit from CLND. Further, CLNDs with fewer nodes may inadequately clear residual nodal disease.
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Schmalbach CE, Bradford CR. Completion lymphadenectomy for sentinel node positive cutaneous head & neck melanoma. Laryngoscope Investig Otolaryngol 2018; 3:43-48. [PMID: 29492467 PMCID: PMC5824115 DOI: 10.1002/lio2.136] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/22/2017] [Accepted: 12/24/2017] [Indexed: 12/13/2022] Open
Abstract
The application and utility of melanoma sentinel lymph node biopsy (SLNB) has evolved significantly since its inception over two decades ago. The current focus has shifted from a staging modality to potentially a therapeutic intervention. Recent research to include large multi-institutional randomized trials have attempted to answer the question: is a completion lymph node dissection (CLND) required following a positive SLNB? This review provides an evidence-based, contemporary review of the utility of CLND for SLNB positive head and neck cutaneous melanoma patients. Level of Evidence NA.
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Affiliation(s)
- Cecelia E Schmalbach
- Department of Otolaryngology-Head & Neck Surgery Indiana University School of Medicine, Roudebush VA Medical Center Indianapolis Indiana U.S.A
| | - Carol R Bradford
- School of Medicine University of Michigan Ann Arbor Michigan U.S.A
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Minutilli E, Feliciani C. Adjuvant Therapy for Resected Stage III Melanoma Patients: High-Dose Interferon-Alpha versus Ipilimumab Combined with Kinases Inhibitors. TUMORI JOURNAL 2018; 98:185-90. [DOI: 10.1177/030089161209800202] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
High-dose interferon-alpha remains the first-line treatment in the adjuvant therapy of metastatic melanoma. More recently, high-dose pegylated interferon-alpha-2b has been approved by the US Food and Drug Administration. Actually, an adjuvant therapy alternative to high-dose interferon-alpha is represented by ipilimumab. Moreover, combination therapy of IFN-alpha or ipilimumab with tyrosine kinase inhibitors has been proved in patients with specific mutations. It is mandatory to understand what the best adjuvant treatment is for resected metastatic melanoma patients, particularly at stage III-N1, in terms of overall survival rather than recurrence-free survival. The ECOG 1609 clinical trial compared high-dose interferon-alpha and ipilimumab alone or combined with tyrosine kinase inhibitors for the treatment of early metastatic melanoma. In the past, ECOG 1684, 1690 and 1694 trials showed improvement in recurrence-free survival more than overall survival for high-risk melanoma patients (stage IIB-III) treated with high-dose interferon-alpha, whereas more recently the EORTC 18991 trial reported successful therapeutic results in terms of recurrence-free survival rather than overall survival for stage III-N1 melanoma patients treated with high-dose pegylated interferon-alpha-2b. Toxicity was more acceptable within one year of treatment. Randomized trials have demonstrated that ipilimumab as second-line therapy is able to increase dose-dependent overall survival rates in advanced melanoma patients despite severe but reversible immune-related adverse events. Old tyrosine kinase inhibitors have been used in combination with interferon for the treatment of advanced melanoma patients with moderate benefits and increased toxicity, but new selective drugs seem to be more efficacious. Early metastatic melanoma patients (stage III-N1) should be the principal subset to be treated with the most suitable adjuvant therapy to achieve the best overall survival. New schedules have to be tested with high-dose interferon-alpha and ipilimumab alone or combined with tyrosine kinase inhibitors while waiting for results from ECOG 1609.
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Eggermont AMM, Dummer R. The 2017 complete overhaul of adjuvant therapies for high-risk melanoma and its consequences for staging and management of melanoma patients. Eur J Cancer 2017; 86:101-105. [PMID: 28968566 DOI: 10.1016/j.ejca.2017.09.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 09/18/2017] [Indexed: 12/19/2022]
Abstract
The spectacular outcomes of the phase III trials regarding nivolumab versus ipilimumab in fully resected stage IIIB/C-IV and of the combination of dabrafenib (D) plus trametinib (T) in BRAF-mutant stage III patients demonstrate that effective treatments in advanced melanoma are also highly effective in the adjuvant setting. In 2016, an overall survival benefit with adjuvant high-dose ipilimumab was demonstrated, and the European Organisation for Research and Treatment of Cancer trial 1325 comparing pembrolizumab versus placebo will complete the picture in the early 2018. Toxicity profiles are in line with the experience in advanced melanoma, i.e. favourable for the anti-PD1 agents and for D + T and problematic for ipilimumab. The 2017 outcomes are practice changing and put an end to the use of interferon (IFN) and ipilimumab. In countries with only access to IFN, its use can be restricted to patients with ulcerated melanoma, based on the individual patient data meta-analysis recently published. Because of the results of the Melanoma Sentinel Lymph node Trial-2 (MSLT-2) trial, completion lymph node dissection (CLND) will decrease sharply, leading to a lack of optimal prognostic information. Prognosis in sentinel node-positive stage IIIA/B patients is extremely heterogeneous with 5-year survival rates varying from 90% to 40% and depends mostly on the number of positive nodes identified by CLND. This information is crucial for clinical decision-making. How to guarantee optimal staging information needs to be discussed urgently. Further improvements of adjuvant therapies will have to address all these questions as well as the exploration of neoadjuvant use of active drugs and combination approaches. Important paradigm shifts in the management of high-risk melanoma patients are upon us.
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Affiliation(s)
- Alexander M M Eggermont
- Gustave Roussy Cancer Campus Grand Paris, Villejuif, France; Universite Paris-Sud, Kremlin-Bicêtre, France.
| | - Reinhard Dummer
- University Hospital Zürich, Department of Dermatology, Zürich, Switzerland
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20
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Oude Ophuis CM, Koppert L(LB, Monyé CD, Deurzen CHV, Koljenović S, Akkooi ACV, Verhoef C(K, Grünhagen DJ. Gamma probe and ultrasound guided fine needle aspiration cytology of the sentinel node (GULF) trial - overview of the literature, pilot and study protocol. BMC Cancer 2017; 17:258. [PMID: 28403815 PMCID: PMC5389093 DOI: 10.1186/s12885-017-3236-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 03/25/2017] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Sentinel node (SN) biopsy (SNB) detects clinically occult metastases of breast cancer and melanoma in 20-30%. Wound infections, seroma and lymph edema occur in up to 10%. Targeted ultrasound (US) of the SN, (with fine needle aspiration cytology (FNAC) if appropriate) has been investigated as a minimally invasive alternative, but reported sensitivity rates are too low to replace SNB. Our hypothesis is that the use of a handheld gamma probe concomitant with US may improve sensitivity. Our aim is to provide an overview of the current literature on preoperative nodal staging of clinical N0 melanoma patients, report on a pilot, and present a study protocol for a minimally invasive alternative to the SNB: Gamma probe and Ultrasound guided Fine needle aspiration cytology of the sentinel node (GULF trial). METHODS The GULF trial is a multicenter open single arm observational trial. Newly diagnosed cT1b-4N0M0 cutaneous melanoma or cT1-3N0M0 breast cancer patients, aged >18 years, presenting for SNB are eligible. 120 patients will be included for preoperative targeted gamma probe guided US and FNAC of the SN. Afterwards all patients proceed to surgical SNB. Primary endpoint is the sensitivity of FNAC. Secondary endpoints include SN identification rate and the histopathological compatibility of Core Needle Biopsy and FNAC vs. SNB. Secondary endpoints were investigated in a pilot with 10 FNACs and marker placements, and 10 FNACs combined with Core Needle Biopsy. RESULTS A pilot in 20 patients showed that SN identification rate was 90%, supporting the feasibility of this technique. DISCUSSION There is broad experience with US (in combination with FNAC) prior to SNB, but sensitivity and specificity are too low to completely abandon SNB. Promising alternative techniques potentially will replace SNB in the future but more evidence is needed in the form of prospective studies. Accurate identification of the SN for US-FNAC has been proven feasible in our pilot. When adequate sensitivity can be reached, US-FNAC provides a minimally invasive alternative for the surgical SNB procedure. TRIAL REGISTRATION The GULF trial is registered in the Netherlands Trial Registry (NTR), ID: NRT5193 . May 1st 2015.
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Affiliation(s)
- Charlotte M.C. Oude Ophuis
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | - Lisa (Linetta) B. Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | - Cécile de Monyé
- Department of Radiology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | | | - Senada Koljenović
- Department of Pathology, Erasmus Medical Center, Wytemaweg 80, 3015 Rotterdam, CN The Netherlands
| | - Alexander C.J. van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 Amsterdam, CX The Netherlands
| | - Cornelis (Kees) Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | - Dirk J. Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
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Madu M, Wouters M, van Akkooi A. Sentinel node biopsy in melanoma: Current controversies addressed. Eur J Surg Oncol 2017; 43:517-533. [DOI: 10.1016/j.ejso.2016.08.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 12/17/2022] Open
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22
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Pham Dang N, Cassier S, Mulliez A, Mansard S, DʼIncan M, Barthélémy I. Eight Years' Experience of Sentinel Lymph Node Biopsy in Melanoma Using Lymphoscintigraphy and Gamma Probe Detection After Radiocolloid Mapping. Dermatol Surg 2017; 43:287-292. [PMID: 27893540 DOI: 10.1097/dss.0000000000000961] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Isosulfan blue dye peripheral injection is used in preoperative sentinel lymph node (SLN) identification alone or, to increase sensitivity, in conjunction with radiocolloid mapping. However, isosulfan blue dye has certain drawbacks and limitations. OBJECTIVE This study assesses the authors' experience of SLN biopsy using only radiocolloid tracer. MATERIALS AND METHODS Between 2000 and 2008, 218 patients underwent SLN biopsy with radiocolloid mapping, preoperative localization by lymphoscintigraphy and intraoperative confirmation by gamma probe in primary malignant cutaneous melanoma. RESULTS Mean Breslow index was 2.1 mm. The SLN biopsy success rate was above 98% at all sites and 87% in head and neck locations. The 5-year overall survival rate was 90% and that of 5-year disease-free survival was 80%. False-negative rate, with a mean follow-up time of 41 months, was 5.5%. CONCLUSION Sentinel lymph node biopsy can be successfully performed in patients with melanoma using only radiocolloid tracer without blue dye staining. In circumstances where blue dye cannot be used such as head and neck tumors, allergic reactions and pregnancy, radiocolloid tracer mapping alone is not a loss of chance for patients with melanoma.
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Affiliation(s)
- Nathalie Pham Dang
- *Department of Oral and Maxillofacial Surgery, NHE-CHU de Clermont-Ferrand, Université d'Auvergne, Clermont-Ferrand, France; †UMR Inserm/UdA, U1107, Neuro-Dol, Trigeminal Pain and Migraine, Université d'Auvergne, Clermont-Ferrand, France; ‡Department of Biostatistics, DRCI-CHU de Clermont-Ferrand, Université d'Auvergne, Clermont-Ferrand, France; §Department of Dermatology, NHE-CHU de Clermont-Ferrand, Université d'Auvergne, Clermont-Ferrand, France
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van Akkooi ACJ, Atkins MB, Agarwala SS, Lorigan P. Surgical Management and Adjuvant Therapy for High-Risk and Metastatic Melanoma. Am Soc Clin Oncol Educ Book 2017; 35:e505-14. [PMID: 27249760 DOI: 10.1200/edbk_159087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Wide local excision is considered routine therapy after initial diagnosis of primary melanoma to reduce local recurrences, but it does not impact survival. Sentinel node staging is recommended for melanomas of intermediate thickness, but it has also not demonstrated any indisputable therapeutic effect on survival. The prognostic value of sentinel node staging has been long established and is therefore considered routine, especially in light of the eligibility criteria for adjuvant therapy (trials). Whether completion lymph node dissection after a positive sentinel node biopsy improves survival is the question of current trials. The MSLT-2 study is best powered to show a potential benefit, but it has not yet reported any data. Another study, the German DECOG study, presented at the 2015 American Society of Clinical Oncology (ASCO) Annual Meeting did not show any benefit but is criticized for the underpowered design and insufficient follow-up. There is no consensus on the use of adjuvant interferon in melanoma. This topic has been the focus of many studies with different regimens (low-, intermediate-, or high-dose and/or short- or long-term treatment). Adjuvant interferon has been shown to improve relapse-free survival but failed to improve overall survival. More recently, adjuvant ipilimumab has also demonstrated an improved relapse-free survival. Overall survival data have not yet been reported due to insufficient follow-up. Currently, studies are ongoing to analyze the use of adjuvant anti-PD-1 and molecular targeted therapies (vemurafenib, dabrafenib, and trametinib). In the absence of unambiguously positive approved agents, clinical trial participation remains a priority. This could change in the near future.
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Affiliation(s)
- Alexander C J van Akkooi
- From the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; St. Luke's University Hospital, Temple University, Allentown, PA; University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Michael B Atkins
- From the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; St. Luke's University Hospital, Temple University, Allentown, PA; University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Sanjiv S Agarwala
- From the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; St. Luke's University Hospital, Temple University, Allentown, PA; University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Paul Lorigan
- From the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands; Georgetown Lombardi Comprehensive Cancer Center, Washington, DC; St. Luke's University Hospital, Temple University, Allentown, PA; University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
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Eggermont AM. Adjuvant ipilimumab in stage III melanoma: New landscape, new questions. Eur J Cancer 2016; 69:39-42. [DOI: 10.1016/j.ejca.2016.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 10/17/2016] [Indexed: 11/30/2022]
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Oude Ophuis C, Verhoef C, Rutkowski P, Powell B, van der Hage J, van Leeuwen P, Voit C, Testori A, Robert C, Hoekstra H, Grünhagen D, Eggermont A, van Akkooi A. The interval between primary melanoma excision and sentinel node biopsy is not associated with survival in sentinel node positive patients – An EORTC Melanoma Group study. Eur J Surg Oncol 2016; 42:1906-1913. [DOI: 10.1016/j.ejso.2016.05.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/15/2016] [Accepted: 05/15/2016] [Indexed: 11/17/2022] Open
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Roy JM, Whitfield RJ, Gill PG. Review of the role of sentinel node biopsy in cutaneous head and neck melanoma. ANZ J Surg 2015; 86:348-55. [DOI: 10.1111/ans.13286] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Jennifer M. Roy
- Discipline of Surgery; University of Adelaide; Adelaide South Australia Australia
- Department of Surgery; Flinders Medical Centre; Adelaide South Australia Australia
| | - Robert J. Whitfield
- Discipline of Surgery; University of Adelaide; Adelaide South Australia Australia
| | - P. Grantley Gill
- Discipline of Surgery; University of Adelaide; Adelaide South Australia Australia
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Voit CA, Gooskens SLM, Siegel P, Schaefer G, Schoengen A, Röwert J, van Akkooi ACJ, Eggermont AMM. Ultrasound-guided fine needle aspiration cytology as an addendum to sentinel lymph node biopsy can perfect the staging strategy in melanoma patients. Eur J Cancer 2014; 50:2280-8. [PMID: 24999208 DOI: 10.1016/j.ejca.2014.05.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 05/28/2014] [Accepted: 05/28/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Ultrasound guided fine needle aspiration cytology (US-guided FNAC) can identify microscopic involvement of lymph nodes as in breast cancer and avoid surgical sentinel node (SN). Its utility in melanoma patients is controversial and subject of this study. METHODS Between 2001 and 2010 over 1000 stage I/II consecutive melanoma patients prospectively underwent US-FNAC prior to SN biopsy. All patients underwent lymphoscintigraphy prior to US-FNAC. The Berlin US morphology criteria: Peripheral perfusion (PP), loss of central echoes (LCE) and balloon shaped (BS) were registered. FNAC was performed in case of presence of any of these factors. SN tumour burden was measured according to the Rotterdam criteria. All patients underwent SN or lymph node dissection (LND) in case of positive FNAC. FINDINGS Mean/median Breslow thickness was 2.58/1.57 mm. Mean/median follow-up was 56/53 months (1-132). SN positivity rate was 21%. US-FNAC Sensitivity was 71% (US only) and 51% (US-FNAC). Sensitivity of US-FNAC was highest for T4 (76%) and ulcerated melanomas (63%). PP, LCE and BS had sensitivity of 69%, 24% and 24% respectively. Sensitivity of US-FNAC increased with increasing SN tumour burden. PP was an early sign of metastasis (58% in <0.1mm metastases). Threshold size of a metastasis for FNAC was 0.3mm. Five-year survival correlated to US-FNAC status (95% in negative and 59% in positive). INTERPRETATION Ultrasound guided FNAC (US-FNAC) according to the Berlin morphology criteria could correctly identify at least half of all tumour positive sentinel nodes, prior to the surgical SN procedure. Peripheral perfusion is an early sign of metastasis, which is very sensitive, but with lower positive predictive value (PPV). It is responsible for the sensitivity of the procedure. Balloon shape is a sign of advanced metastases, with lower sensitivity, but high PPV. US-FNAC sensitivity correlated with increasing T-stage, ulceration of the primary and increasing SN tumour burden. US-FNAC status accurately predicts survival.
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Affiliation(s)
- Christiane A Voit
- Department of Dermatology, Charité, Humboldt University of Berlin, Berlin, Germany; European Organization for Research and Treatment of Cancer (EORTC) Melanoma Group (MG), Brussels, Belgium.
| | - Saskia L M Gooskens
- Department of Surgical Oncology, Erasmus University Medical Center - Daniel den Hoed Cancer Center, Rotterdam, The Netherlands; European Organization for Research and Treatment of Cancer (EORTC) Melanoma Group (MG), Brussels, Belgium
| | - Petra Siegel
- Department of Dermatology, Charité, Humboldt University of Berlin, Berlin, Germany
| | - Gregor Schaefer
- Department of Dermatology, Charité, Humboldt University of Berlin, Berlin, Germany
| | - Alfred Schoengen
- Department of Hematology and Oncology, Armed Forces Hospital, Ulm, Germany
| | - Joachim Röwert
- Department of Dermatology, Charité, Humboldt University of Berlin, Berlin, Germany
| | - Alexander C J van Akkooi
- Department of Surgical Oncology, Erasmus University Medical Center - Daniel den Hoed Cancer Center, Rotterdam, The Netherlands; European Organization for Research and Treatment of Cancer (EORTC) Melanoma Group (MG), Brussels, Belgium
| | - Alexander M M Eggermont
- Institut de Cancérologie Gustav Roussy, Paris-Sud/Villejuif, France; European Organization for Research and Treatment of Cancer (EORTC) Melanoma Group (MG), Brussels, Belgium
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van der Ploeg APT, Haydu LE, Spillane AJ, Quinn MJ, Saw RP, Shannon KF, Stretch JR, Uren RF, Scolyer RA, Thompson JF. Outcome following sentinel node biopsy plus wide local excision versus wide local excision only for primary cutaneous melanoma: analysis of 5840 patients treated at a single institution. Ann Surg 2014; 260:149-57. [PMID: 24633018 DOI: 10.1097/sla.0000000000000500] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Worldwide, sentinel node biopsy (SNB) is now a standard staging procedure for most patients with melanomas 1 mm or more in thickness, but its therapeutic benefit is not clear, pending randomized trial results. This study sought to assess the therapeutic benefit of SNB in a large, nonrandomized patient cohort. METHODS Patients with primary melanomas 1.00 mm or more thick or with adverse prognostic features treated with wide local excision (WLE) at a single institution between 1992 and 2008 were identified. The outcomes for those who underwent WLE plus SNB (n = 2909) were compared with the outcomes for patients in an observation (OBS) group who had WLE only (n = 2931). Median follow-up was 42 months. RESULTS Melanoma-specific survival (MSS) was not significantly different for patients in the SNB and OBS groups. However, a stratified univariate analysis of MSS for different thickness subgroups indicated a significantly better MSS for SNB patients with T2 and T3 melanomas (>1.0 to 4.0 mm thick) (P = 0.011), but this was not independently significant in multivariate analysis. Compared with OBS patients, SNB patients demonstrated improved disease-free survival (DFS) (P < 0.001) and regional recurrence-free survival (P < 0.001). There was also an improvement in distant metastasis-free survival (DMFS) for SNB patients with T2 and T3 melanomas (P = 0.041). CONCLUSIONS In this study, the outcome for the overall cohort after WLE alone did not differ significantly from the outcome after additional SNB. However, the outcome for the subgroup of patients with melanomas more than 1.0 to 4.0 mm in thickness was improved if they had a SNB, with significantly improved disease-free and DMFS.
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Affiliation(s)
- Augustinus P T van der Ploeg
- *Melanoma Institute Australia †Sydney Medical School, The University of Sydney, Sydney ‡Nuclear Medicine and Diagnostic Ultrasound, RPAH Medical Centre, Newtown, New South Wales, Australia
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Pigmentation in the sentinel node correlates with increased sentinel node tumor burden in melanoma patients. Melanoma Res 2014; 24:261-6. [DOI: 10.1097/cmr.0000000000000061] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mandalà M, Massi D. Tissue prognostic biomarkers in primary cutaneous melanoma. Virchows Arch 2014; 464:265-81. [PMID: 24487785 DOI: 10.1007/s00428-013-1526-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 12/03/2013] [Indexed: 01/04/2023]
Abstract
Cutaneous melanoma (CM) causes the greatest number of skin cancer-related deaths worldwide. Predicting CM prognosis is important to determine the need for further investigation, counseling of patients, to guide appropriate management (particularly the need for postoperative adjuvant therapy), and for assignment of risk status in groups of patients entering clinical trials. Since recurrence rate is largely independent from stages defined by morphological and morphometric criteria, there is a strong need for identification of additional robust prognostic factors to support decision-making processes. Most data on prognostic biomarkers in melanoma have been evaluated in tumor tissue samples by conventional morphology and immunohistochemistry (IHC) as well as DNA and RNA analyses. In the present review, we critically summarize main high-quality studies investigating IHC-based protein biomarkers of melanoma outcome according to Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK)-derived criteria. Pathways have been classified and conveyed in the "biologic road" previously described by Hanahan and Weinberg. Data derived from genomic and transcriptomic technologies have been critically reviewed to better understand if any of investigated proteins or gene signatures should be incorporated into clinical practice or still remain a field of melanoma research. Despite a wide body of research, no molecular prognostic biomarker has yet been translated into clinical practice. Conventional tissue biomarkers, such as Breslow thickness, ulceration, mitotic rate and lymph node positivity, remain the backbone prognostic indicators in melanoma.
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Affiliation(s)
- Mario Mandalà
- Unit of Clinical and Translational Research, Medical Oncology, Department of Oncology and Hematology, Papa Giovanni XXIII Hospital, Bergamo, Italy
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31
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Ulmer A, Dietz K, Hodak I, Polzer B, Scheitler S, Yildiz M, Czyz Z, Lehnert P, Fehm T, Hafner C, Schanz S, Röcken M, Garbe C, Breuninger H, Fierlbeck G, Klein CA. Quantitative measurement of melanoma spread in sentinel lymph nodes and survival. PLoS Med 2014; 11:e1001604. [PMID: 24558354 PMCID: PMC3928050 DOI: 10.1371/journal.pmed.1001604] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 01/09/2014] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Sentinel lymph node spread is a crucial factor in melanoma outcome. We aimed to define the impact of minimal cancer spread and of increasing numbers of disseminated cancer cells on melanoma-specific survival. METHODS AND FINDINGS We analyzed 1,834 sentinel nodes from 1,027 patients with ultrasound node-negative melanoma who underwent sentinel node biopsy between February 8, 2000, and June 19, 2008, by histopathology including immunohistochemistry and quantitative immunocytology. For immunocytology we recorded the number of disseminated cancer cells (DCCs) per million lymph node cells (DCC density [DCCD]) after disaggregation and immunostaining for the melanocytic marker gp100. None of the control lymph nodes from non-melanoma patients (n = 52) harbored gp100-positive cells. We analyzed gp100-positive cells from melanoma patients by comparative genomic hybridization and found, in 45 of 46 patients tested, gp100-positive cells displaying genomic alterations. At a median follow-up of 49 mo (range 3-123 mo), 138 patients (13.4%) had died from melanoma. Increased DCCD was associated with increased risk for death due to melanoma (univariable analysis; p<0.001; hazard ratio 1.81, 95% CI 1.61-2.01, for a 10-fold increase in DCCD + 1). Even patients with a positive DCCD ≤3 had an increased risk of dying from melanoma compared to patients with DCCD = 0 (p = 0.04; hazard ratio 1.63, 95% CI 1.02-2.58). Upon multivariable testing DCCD was a stronger predictor of death than histopathology. The final model included thickness, DCCD, and ulceration (all p<0.001) as the most relevant prognostic factors, was internally validated by bootstrapping, and provided superior survival prediction compared to the current American Joint Committee on Cancer staging categories. CONCLUSIONS Cancer cell dissemination to the sentinel node is a quantitative risk factor for melanoma death. A model based on the combined quantitative effects of DCCD, tumor thickness, and ulceration predicted outcome best, particularly at longer follow-up. If these results are validated in an independent study, establishing quantitative immunocytology in histopathological laboratories may be useful clinically.
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Affiliation(s)
- Anja Ulmer
- Department of Dermatology, University of Tübingen, Tübingen, Germany
- * E-mail: (AU); (CAK)
| | - Klaus Dietz
- Department of Medical Biometry, University of Tübingen, Tübingen, Germany
| | - Isabelle Hodak
- Chair of Experimental Medicine and Therapy Research, Department of Pathology, University of Regensburg, Regensburg, Germany
| | - Bernhard Polzer
- Chair of Experimental Medicine and Therapy Research, Department of Pathology, University of Regensburg, Regensburg, Germany
- Project Group Personalized Tumor Therapy, Fraunhofer-Institut für Toxikologie und Experimentelle Medizin, Regensburg, Germany
| | - Sebastian Scheitler
- Chair of Experimental Medicine and Therapy Research, Department of Pathology, University of Regensburg, Regensburg, Germany
| | - Murat Yildiz
- Chair of Experimental Medicine and Therapy Research, Department of Pathology, University of Regensburg, Regensburg, Germany
| | - Zbigniew Czyz
- Chair of Experimental Medicine and Therapy Research, Department of Pathology, University of Regensburg, Regensburg, Germany
- Project Group Personalized Tumor Therapy, Fraunhofer-Institut für Toxikologie und Experimentelle Medizin, Regensburg, Germany
| | - Petra Lehnert
- Department of Dermatology, University of Tübingen, Tübingen, Germany
| | - Tanja Fehm
- Department of Gynecology, University of Düsseldorf, Düsseldorf, Germany
| | - Christian Hafner
- Department of Dermatology, University of Regensburg, Regensburg, Germany
| | - Stefan Schanz
- Department of Dermatology, University of Tübingen, Tübingen, Germany
| | - Martin Röcken
- Department of Dermatology, University of Tübingen, Tübingen, Germany
| | - Claus Garbe
- Department of Dermatology, University of Tübingen, Tübingen, Germany
| | - Helmut Breuninger
- Department of Dermatology, University of Tübingen, Tübingen, Germany
| | - Gerhard Fierlbeck
- Department of Dermatology, University of Tübingen, Tübingen, Germany
| | - Christoph A. Klein
- Chair of Experimental Medicine and Therapy Research, Department of Pathology, University of Regensburg, Regensburg, Germany
- Project Group Personalized Tumor Therapy, Fraunhofer-Institut für Toxikologie und Experimentelle Medizin, Regensburg, Germany
- * E-mail: (AU); (CAK)
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Patuzzo R, Maurichi A, Camerini T, Gallino G, Ruggeri R, Baffa G, Mattavelli I, Tinti MC, Crippa F, Moglia D, Tolomio E, Maccauro M, Santinami M. Accuracy and prognostic value of sentinel lymph node biopsy in head and neck melanomas. J Surg Res 2013; 187:518-24. [PMID: 24252855 DOI: 10.1016/j.jss.2013.10.037] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 10/16/2013] [Accepted: 10/18/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Debate remains around the accuracy and prognostic implications of sentinel lymph node biopsy (SLNB) for melanoma arising in the head and neck (HN) areas because several analyses have shown discordances between clinically predicted lymphatic drainage pathways and those identified by lymphoscintigraphy. This study assesses the accuracy and prognostic value of SLNB in this critical anatomic region. METHODS Retrospective review of a prospectively collected melanoma database identified 331 patients with HN melanomas from January 2000 to December 2012. Primary end points included SLNB result, time to recurrence, site of recurrence, and survival. Multivariate models were constructed for analyses. RESULTS A sentinel lymph node (SLN) was identified in all 331 patients. There were 59 patients with a positive SLN (17.8%) with a recurrence rate of 88.1% compared with 22.4% in SLN-negative patients (P < 0.0001). The 5-y overall survival was 91.2% for SLN-negative patients and 48.7% for SLN-positive patients (P < 0.0001). Patients with scalp melanoma had thicker lesions and an elevated risk of SLN positivity, recurrence, and death compared with those with other sites. Among the 272 SLN-negative patients, four patients developed regional nodal disease in the same basin and had undergone a previous SLNB procedure for a false-omission rate of 1.45%. Risks for false-negative SLN occurrences included thick and scalp melanomas. Multivariate analysis on prognostic factors affecting relapse-free survival showed positive SLNB status to be the most prognostic clinicopathologic predictor of recurrence (hazard ratio, 20.56; P < 0.0001). CONCLUSIONS SLNB for patients with HN melanomas is an accurate procedure and has prognostic value.
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Affiliation(s)
- Roberto Patuzzo
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Andrea Maurichi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Tiziana Camerini
- Scientific Directorate, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gianfranco Gallino
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Roberta Ruggeri
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giulia Baffa
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Ilaria Mattavelli
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maria Carla Tinti
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Federica Crippa
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Daniele Moglia
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elena Tolomio
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marco Maccauro
- Department of Nuclear Medicine, IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Mario Santinami
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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van der Ploeg APT, van Akkooi ACJ, Haydu LE, Scolyer RA, Murali R, Verhoef C, Thompson JF, Eggermont AMM. The prognostic significance of sentinel node tumour burden in melanoma patients: an international, multicenter study of 1539 sentinel node-positive melanoma patients. Eur J Cancer 2013; 50:111-20. [PMID: 24074765 DOI: 10.1016/j.ejca.2013.08.023] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 08/27/2013] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Sentinel node (SN) biopsy (SNB) and completion lymph node dissection (CLND) when SN-positive have become standard of care in most cancer centres for melanoma. Various SN tumour burden parameters are assessed to determine the heterogeneity of SN-positivity. The aim of the present study was to validate the prognostic significance of various SN tumour burden micromorphometric features and classification schemes in a large cohort of SN-positive melanoma patients. METHODS In 1539 SN-positive patients treated between 1993 and 2008 at 11 melanoma treatment centres in Europe and Australia, indices of SN tumour burden (intranodal location, tumour penetrative depth (TPD) and maximum size of SN tumour deposits) were evaluated. RESULTS Non-subcapsular location, increasing TPD and increasing maximum size were all predictive factors for non-SN (NSN) status and were independently associated with poorer melanoma-specific survival (MSS). Patients with subcapsular micrometastases <0.1mm in maximum dimension had the lowest frequency of NSN metastasis (5.5%). Despite differences in SN biopsy protocols and clinicopathologic features of the patient cohorts (between centres), most SN parameters remained predictive in individual centre populations. Maximum SN tumour size>1mm was the most reliable and consistent parameter independently associated with higher non-SN-positivity, poorer disease-free survival (DFS) and poorer MSS. CONCLUSIONS In this large retrospective, multicenter cohort study, several parameters of SN tumour burden including intranodal location, TPD and maximum size provided prognostic information, but their prognostic significance varied considerably between the different centres. This could be due to sample size limitations or to differences in SN detection, removal and examination techniques.
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Affiliation(s)
| | | | | | | | - Rajmohan Murali
- Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Cornelis Verhoef
- Erasmus University Medical Center, Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
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Damsky WE, Theodosakis N, Bosenberg M. Melanoma metastasis: new concepts and evolving paradigms. Oncogene 2013; 33:2413-22. [PMID: 23728340 DOI: 10.1038/onc.2013.194] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Revised: 04/22/2013] [Accepted: 04/22/2013] [Indexed: 12/25/2022]
Abstract
Melanoma progression is typically depicted as a linear and stepwise process in which metastasis occurs relatively late in disease progression. Significant evidence suggests that in a subset of melanomas, progression is much more complex and less linear in nature. Epidemiologic and experimental observations in melanoma metastasis are reviewed here and are incorporated into a comprehensive model for melanoma metastasis, which takes into account the varied natural history of melanoma formation and progression.
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Affiliation(s)
- W E Damsky
- 1] Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA [2] Department of Pathology, University of Vermont College of Medicine, Burlington, VT, USA
| | - N Theodosakis
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
| | - M Bosenberg
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA
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Saadi A, Roulin D, Saiji E, Bouzourene H, Demartines N, Matter M. The Prognostic Value of Minimally Involved Melanoma Sentinel Lymph Nodes. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/jct.2013.410180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Vollmer RT. The dynamics of death in melanoma. J Cutan Pathol 2012; 39:1075-82. [DOI: 10.1111/cup.12031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 02/29/2012] [Accepted: 03/19/2012] [Indexed: 11/28/2022]
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Riber-Hansen R, Hastrup N, Clemmensen O, Ramsing M, Hamilton-Dutoit SJ, Steiniche T. Increased sampling will lead to an increase in detection, but is it clinically relevant? Eur J Cancer 2012. [DOI: 10.1016/j.ejca.2012.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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van Akkooi AC, Cook MG, Eggermont AM. Increased sampling will lead to an increase in detection, but is it clinically relevant? Eur J Cancer 2012; 48:2488-9; author reply 2486-7. [DOI: 10.1016/j.ejca.2012.02.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 02/29/2012] [Indexed: 11/25/2022]
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van der Ploeg APT, van Akkooi ACJ, Rutkowski P, Cook M, Nieweg OE, Rossi CR, Testori A, Suciu S, Verhoef C, Eggermont AMM. Prognosis in patients with sentinel node-positive melanoma without immediate completion lymph node dissection. Br J Surg 2012; 99:1396-405. [DOI: 10.1002/bjs.8878] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Abstract
Background
The therapeutic value of immediate completion lymph node dissection (CLND) for sentinel node (SN)-positive melanoma is unknown. The aim of this study was to evaluate the impact of immediate CLND on the outcome of patients with SN-positive melanoma.
Methods
Patients with SN metastases treated between 1993 and 2008 at ten cancer centres from the European Organization for Research and Treatment of Cancer Melanoma Group were included in this retrospective study. Maximum tumour size, intranodal location and penetrative depth of SN metastases were measured. Outcome in those who had CLND was compared with that in patients who did not undergo completion lymphadenectomy.
Results
Of 1174 patients with SN-positive melanoma, 1113 (94·8 per cent) underwent CLND and 61 (5·2 per cent) did not. Median follow-up for the two groups was 34 and 48 months respectively. In univariable survival analysis, CLND did not significantly influence disease-specific survival (hazard ratio (HR) 0·89, 95 per cent confidence interval 0·58 to 1·37; P = 0·600). However, patients who did not undergo CLND had more favourable prognostic factors. Matched-pair analysis, with matching for age, Breslow thickness, tumour ulceration and SN tumour burden, showed that CLND had no influence on survival (HR 0·86, 0·46 to 1·61; P = 0·640). After adjusting for prognostic factors in multivariable survival analyses, no difference in survival was found.
Conclusion
In these two cohorts of patients with SN-positive melanoma and prognostic heterogeneity, outcome was not influenced by CLND.
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Affiliation(s)
| | - A P T van der Ploeg
- Erasmus University Medical Centre—Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
| | - A C J van Akkooi
- Erasmus University Medical Centre—Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
| | - P Rutkowski
- M. Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
| | - M Cook
- Royal Surrey County Hospital, Guildford, UK
| | - O E Nieweg
- Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - C R Rossi
- Veneto Institute of Oncology—Istituto di Ricovero e Cura a Carattere Scientifico and University of Padua, Padua, Italy
| | - A Testori
- European Institute of Oncology, Milan, Italy
| | - S Suciu
- European Organization for Research and Treatment of Cancer, Headquarters, Brussels, Belgium
| | - C Verhoef
- Erasmus University Medical Centre—Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
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Pasquali S, Spillane AJ, de Wilt JHW, McCaffery K, Rossi CR, Quinn MJ, Saw RP, Shannon KF, Stretch JR, Thompson JF. Surgeons' opinions on lymphadenectomy in melanoma patients with positive sentinel nodes: a worldwide web-based survey. Ann Surg Oncol 2012; 19:4322-9. [PMID: 22805861 DOI: 10.1245/s10434-012-2483-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Indexed: 11/18/2022]
Abstract
PURPOSE A worldwide web-based survey was conducted among melanoma surgeons to investigate opinions about completion lymph node dissection (CLND) in patients with positive sentinel nodes (SN). METHODS A questionnaire was designed following input from a group of melanoma surgeons. Cognitive interviews and pilot testing were performed. Surgeons identified through a systematic-review of the SN and CLND literature were invited by email. RESULTS Of 337 surgeons, 193 (57.2 %) from 25 countries responded (January-July 2011). Most respondents work in melanoma (30.1 %) and surgical oncology (44.6 %) units. In patients with a positive SN, 169 (91.8 %) recommend CLND; the strength of the recommendation is mostly influenced by patient comorbidities (64.7 %) and SN tumor burden (59.2 %). Seventy-one responders enroll patients in the second Multicenter Selective-Lymphadenectomy Trial (MSLT-2), and 64 of them (76 %) suggest entering the trial to majority of patients. In cases requiring neck CLND, level 1-5 dissection is recommended by 35 % of responders, whereas 62 % base the extent of dissection on primary site and lymphatic mapping patterns. Only inguinal dissection or ilioinguinal dissection is performed by 36 and 30 % of surgeons, respectively. The remaining 34 % select either procedure according to number of positive SNs, node of Cloquet status, and lymphatic drainage patterns. Most surgeons (81 %) perform full axillary dissections in positive SN cases. CONCLUSIONS The majority of melanoma surgeons recommend CLND in SN-positive patients. Surgeons participating in the MSLT-2 suggest entering the trial to the majority of patients. More evidence is needed to standardize the extent of neck and groin CLND surgeries.
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Affiliation(s)
- Sandro Pasquali
- Melanoma Institute Australia, 40 Rocklands Road, North Sydney, NSW, Australia
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41
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Treatment influencing down-staging in EORTC Melanoma Group sentinel node histological protocol compared with complete step-sectioning: A national multicentre study. Eur J Cancer 2012; 48:347-52. [DOI: 10.1016/j.ejca.2011.08.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 08/16/2011] [Accepted: 08/30/2011] [Indexed: 11/22/2022]
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Riber-Hansen R, Vainer B, Steiniche T. Digital image analysis: a review of reproducibility, stability and basic requirements for optimal results. APMIS 2011; 120:276-89. [PMID: 22429210 DOI: 10.1111/j.1600-0463.2011.02854.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Digital image analysis (DIA) is increasingly implemented in histopathological research to facilitate truly quantitative measurements, decrease inter-observer variation and reduce hands-on time. Originally, efforts were made to enable DIA to reproduce manually obtained results on histological slides optimized for light microscopy and the human eye. With improved technical methods and the acknowledgement that computerized readings are different from analysis by human eye, recognition has been achieved that to really empower DIA, histological slides must be optimized for the digital 'eye', with reproducible results correlating with clinical findings. In this review, we focus on the basic expectations and requirements for DIA to gain wider use in histopathological research and diagnostics. With a reference to studies that specifically compare DIA with conventional methods, this review discusses reproducibility, application of stereology-based quantitative measurements, time consumption, optimization of histological slides, regions of interest selection and recent developments in staining and imaging techniques.
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Riber-Hansen R, Nyengaard JR, Hamilton-Dutoit SJ, Sjoegren P, Steiniche T. Automated digital volume measurement of melanoma metastases in sentinel nodes predicts disease recurrence and survival. Histopathology 2011; 59:433-40. [DOI: 10.1111/j.1365-2559.2011.03960.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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van der Ploeg AP, van Akkooi AC, Verhoef C, Eggermont AM. Reply to I. Satzger et al. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.37.4702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Cornelis Verhoef
- Erasmus University Medical Center–Daniel den Hoed Cancer Center, Rotterdam, the Netherlands
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de Vries M, Speijers M, Bastiaannet E, Plukker J, Brouwers A, van Ginkel R, Suurmeijer A, Hoekstra H. Long-term follow-up reveals that ulceration and sentinel lymph node status are the strongest predictors for survival in patients with primary cutaneous melanoma. Eur J Surg Oncol 2011; 37:681-7. [DOI: 10.1016/j.ejso.2011.05.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Revised: 03/10/2011] [Accepted: 05/05/2011] [Indexed: 10/18/2022] Open
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Erman AB, Collar RM, Griffith KA, Lowe L, Sabel MS, Bichakjian CK, Wong SL, McLean SA, Rees RS, Johnson TM, Bradford CR. Sentinel lymph node biopsy is accurate and prognostic in head and neck melanoma. Cancer 2011; 118:1040-7. [PMID: 21773971 DOI: 10.1002/cncr.26288] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 04/25/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) has emerged as a widely used staging procedure for cutaneous melanoma. However, debate remains around the accuracy and prognostic implications of SLNB for cutaneous melanoma arising in the head and neck, as previous reports have demonstrated inferior results to those in nonhead and neck regions. Through the largest single-institution series of head and neck melanoma patients, the authors set out to demonstrate that SLNB accuracy and prognostic value in the head and neck region are comparable to other sites. METHODS A prospectively collected database was queried for cutaneous head and neck melanoma patients who underwent SLNB at the University of Michigan between 1997 and 2007. Primary endpoints included SLNB result, time to recurrence, site of recurrence, and date and cause of death. Multivariate models were constructed for analyses. RESULTS Three hundred fifty-three patients were identified. A sentinel lymph node was identified in 352 of 353 patients (99.7%). Sixty-nine of the 353 (19.6%) patients had a positive SLNB. Seventeen of 68 patients (25%) undergoing completion lymphadenectomy after a positive SLNB result had at least 1 additional positive nonsentinel lymph node. Patients with local control and a negative SLNB failed regionally in 4.2% of cases. Multivariate analysis revealed positive SLNB status to be the most prognostic clinicopathologic predictor of poor outcome; hazard ratio was 4.23 for SLNB status and recurrence-free survival (P < .0001) and 3.33 for overall survival (P < .0001). CONCLUSIONS SLNB is accurate and its results are of prognostic importance for head and neck melanoma patients.
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Affiliation(s)
- Audrey B Erman
- Department of Otolaryngology Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan 48109-5312, USA
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Kretschmer L. Comments and Notes. J Dtsch Dermatol Ges 2011. [DOI: 10.1111/j.1610-0387.2011.07678.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Decoding melanoma metastasis. Cancers (Basel) 2010; 3:126-63. [PMID: 24212610 PMCID: PMC3756353 DOI: 10.3390/cancers3010126] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 12/22/2010] [Accepted: 12/23/2010] [Indexed: 12/18/2022] Open
Abstract
Metastasis accounts for the vast majority of morbidity and mortality associated with melanoma. Evidence suggests melanoma has a predilection for metastasis to particular organs. Experimental analyses have begun to shed light on the mechanisms regulating melanoma metastasis and organ specificity, but these analyses are complicated by observations of metastatic dormancy and dissemination of melanocytes that are not yet fully malignant. Additionally, tumor extrinsic factors in the microenvironment, both at the site of the primary tumor and the site of metastasis, play important roles in mediating the metastatic process. As metastasis research moves forward, paradigms explaining melanoma metastasis as a step-wise process must also reflect the temporal complexity and heterogeneity in progression of this disease. Genetic drivers of melanoma as well as extrinsic regulators of disease spread, particularly those that mediate metastasis to specific organs, must also be incorporated into newer models of melanoma metastasis.
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