Evaluation of 107 therapeutic and elective parotidectomies for cutaneous melanoma

Intraparotid Sentinel Lymph Node Dissection for Melanoma: A Systematic Review and Meta-Analysis

BACKGROUND

Surgical management of head and neck cutaneous melanoma (HNCM) has evolved tremendously since sentinel lymph node biopsy (SLNB) has become the prominent tool of prognosis and staging. This meta-analysis aimed to evaluate the safety and efficiency of intraparotid SLNB compared with a more extensive surgery of superficial parotidectomy (SP).

METHODS

The electronic database of PubMed and Scopus were searched for publications until 10 March 2022. In addition, the study included data of patients from our institution who underwent cherry-picking procedures. Pooled estimates were calculated using the random-effects model. Heterogeneity was calculated using the I2 test.

RESULTS

The pooled result regarding the rate of SLNB excision success was 97 % (95 % confidence interval [CI], 0.95-0.99; p < 0.0001), and the pooled probability of a positive SLNB result was 16 % (95 % CI 0.12-0.20; p < 0.0001). Failure of SLNB had pooled results of 4 % (95 % CI 0.02-0.06; p < 0.0009). For SP, no study examining N0 HNCM patients has met the authors' inclusion criteria. Cherry-picking SLNB had temporary and permanent facial nerve paralysis relative risks (RRs) of 0.12 (95 % CI 0.06-0.27; p < 0.0001) and 0.46 (95 % CI 0.17-1.22; p < 0.0001), respectively, compared with historical data from four weighted meta-analyses of SP.

CONCLUSIONS

The data from this study suggest that intraparotid SLNB performed for N0 HNCM patients is a safe and reliable procedure, with very low complication rates. Failure of the procedure did not exceed 4 %. Therefore, intraparotid SLNB may be superior to an extensive surgery such as SP and should be examined in future prospective trials.

Role of neck dissection in management of patients with clinically apparent parotid metastatic melanoma - systematic review

Patients with cutaneous melanoma with metastatic deposits in the parotid gland have poor prognosis due to the high risk of developing distant metastasis. In the era of effective immunotherapy, there is no consensus amongst head and neck surgeons about the extent of neck dissection required for patients presenting with clinically apparent parotid metastasis. This review aims to determine the incidence and pattern of occult neck disease for patients with parotid metastasis reported in the literature to help guide clinicians on the extent of neck dissection required. The systematic review search was conducted using PubMed, EMBASE and Medline, using PRISMA guidelines. The inclusion criteria include cases treated with parotidectomy and neck dissection for patients with parotid melanoma metastasis. A narrative synthesis was carried out due to heterogeneity of studies. A total of 14 studies was included. We found no study reporting on outcomes with surgery and adjuvant immunotherapy in this cohort of patients. The incidence of distant metastasis reported was variable but remains high for patients with parotid metastasis. Patients with parotid and neck involvement have poorer prognosis than patients with parotid only metastatic disease. The effect and extent of neck dissection in patients with clinically apparent parotid nodes remains unclear in the era of effective immunotherapy. There is a need for further well-designed studies evaluating the outcomes for such patients following surgery and adjuvant immunotherapy.

Parotidectomy-related facial nerve lesions: proposal for a modified Sunnybrook Facial Grading System

OBJECTIVE

Facial nerve injury, affecting mainly the marginal mandibular branch, is the most frequent neurologic complication from parotidectomy. To test a modified Sunnybrook Facial Grading System as a new tool to assess the facial nerve function following parotidectomy, emphasizing the marginal mandibular branch.

METHODS

We reviewed the medical records of 73 post-parotidectomy patients (40 female, 18-84 years old, mean age 53.2 years) with facial nerve sparing, referred to the Department of Physical Therapy. All patients had parotid neoplasms or advanced skin cancer, and were followed by the principal author between 2006 and 2014.

RESULTS

The muscles innervated by the marginal mandibular branch were the most frequently affected (72.6%), particularly in patients undergoing neck dissection (p = 0.023). The voluntary movement scores obtained with the modified system were significantly lower compared with the original version (p < 0.001). The best and worst scores were observed in patients with benign parotid tumors and skin cancer, respectively. Patients requiring neck dissection (p = 0.031) and resection of other structures (p = 0.021) had the lowest scores, evidenced only with the modified version. Patients with malignant tumors had significantly worse ratings, regardless of the Sunnybrook system version. The post-physiotherapy analysis involved 50 patients. The worst facial rehabilitation outcomes were related to the marginal mandibular branch function.

CONCLUSION

The modified Sunnybrook Facial Grading System improved the marginal mandibular branch assessment, preserving the evaluation of other facial nerve branches.

Parotidectomy for Primary Nonparotid Diseases

OBJECTIVE: To analyze the indications and results of parotid gland resections for patients with primary nonparotid diseases.

STUDY DESIGN AND SETTING: Retrospective analysis of 442 consecutive parotidectomies (76 for primary nonparotid disease) in a referral head and neck surgery service, tertiary care university hospital.

RESULTS: Skin cancer (mainly squamous cell and basal cell carcinomas) was the most common indication for parotidectomy. Superficial parotidectomy with preservation of the facial nerve was the most commonly performed operation (61.8%), with some form of nerve sacrifice necessary in 31.6%. Parotid gland parenchyma and/or lymph nodes were pathologically positive in 46 cases. Neck dissections were carried out in conjunction with parotidectomy in 42 patients (1 patient had had previous neck dissection), of which 16 turned out to be pN+.

CONCLUSION: Parotidectomy should be considered as part of the surgical treatment of tumors whenever oncologically necessary for appropriate margins, lymph node dissection, and for proper identification and preservation of the facial nerve.

Ear melanoma: influence of perichondrium involvement in evaluating surgical strategy

Adequate treatment of melanomas of the external ear offers unique surgical challenges because of the complex anatomical features of the auricle and the need for proper oncologic aggressiveness, as well as for valid aesthetic results. In this study, we evaluated nine different cases of melanoma of the auricle treated in our Institute between 1994 and 2008. Every enrolled patient underwent surgical excision, nonetheless reconstruction was performed with different surgical techniques. In accordance with histological reports, we could observe the absence of neoplastic cells in perichondral bone and in cartilagenous tissue, providing further assurance concerning the importance of preserving the outer ear in expectation of reconstruction. As a matter of fact, it has been proven that it is possible to reconstruct the auricle while guaranteeing oncologic safety in melanomas with a Breslow thickness >1 mm. Therefore, an excision preserving the cartilagenous tissue, thus allowing an efficient full-thickness cutaneous grafting may guarantee good functional and aesthetic results. In conclusion, the suggested therapeutic management may be considered in <1 mm melanomas without taking further unnecessary oncologic risks.

Multidisciplinary management of special melanoma situations: oligometastatic disease and bulky nodal sites

Potentially resectable, advanced stage melanoma in the form of extensive palpable adenopathy or limited systemic metastases presents a significant challenge but also offers the prospect of long-term disease control. Although surgical resection is the mainstay of therapy, involvement of a multidisciplinary team is required for optimal management of these special situations. These patients need to be evaluated preoperatively by the team, discussed at a multidisciplinary conference, and treated by experienced physicians with access to the full spectrum of modern surgical and oncologic therapy. Surgical resection is generally extensive and may require en bloc resection of important anatomic structures. Adjuvant radiation or systemic therapy is required in many patients to help achieve durable regional and systemic control of disease. In addition, novel therapies, such as neoadjuvant chemotherapy, targeted therapies, or investigational intralesional therapies, may ultimately play a role in the management of these difficult clinical situations and require further evaluation, as preliminary studies show some encouraging results.

Sentinel Lymph Node Biopsy for Cutaneous Head and Neck Melanoma: Mapping the Parotid Gland

BACKGROUND

Sentinel lymph node biopsy (SLNB) for primary cutaneous head and neck melanoma (CHNM) has been shown to be successful and is the current standard of care for intermediate-thickness melanoma. We evaluated our experience with CHNM associated with SLNB mapping to the region of the parotid gland.

METHODS

Retrospective review of a prospectively collected melanoma database identified 1014 CHNMs. Two-hundred twenty-three patients underwent SLNB, and 72 (32%) had mapping in the region of the parotid gland between May 1995 and June 2003.

RESULTS

The mean number of SLNs per patient was 2.5. A sentinel lymph node (SLN) was successfully identified in 94% of patients, and in 12%, the SLN was positive for metastatic disease. Biopsy of intraparotid SLNs was performed in 51.4% and of periparotid SLNs in 26.4%, and a superficial parotidectomy was performed in 22.2%. Ten patients were found to have lymph nodes in the parotid region with metastatic disease (eight identified by SLNB), and two (20%) patients developed intraparotid lymph node recurrence in the setting of a negative SLNB. Same-basin recurrence in SLN-negative patients was 3.3% with a median follow-up of 26 months. Facial nerve dysfunction was identified in seven (10%) patients. Facial nerve function returned to preoperative status in all patients.

CONCLUSIONS

SLNB for patients with primary CHNM mapping to the parotid gland can be performed with a high degree of accuracy and a low morbidity consisting of temporary facial nerve paresis.

Primary and metastatic cancer of the parotid: comparison of clinical behavior in 232 cases

OBJECTIVES/HYPOTHESIS

Parotid malignancy may develop as a primary cancer of salivary tissue or by metastatic involvement of parotid lymph nodes. The aim of the study was to compare the clinical behavior of primary and metastatic parotid cancers by analyzing patterns of treatment failure and clinical outcomes.

STUDY DESIGN

Retrospective review of clinical and pathologic data prospectively accessioned onto a computerized database.

METHODS

A prospectively documented series of 232 parotidectomies carried out for treatment of cancer from 1988 to 1999 was reviewed. There were 177 male and 55 female patients with a median age of 65 years (age range, 17-97 y). Median follow-up time was 4 years. Pathological groups included 54 patients with primary parotid cancer, 101 with metastatic cutaneous squamous cell carcinoma, 69 with metastatic melanoma, and 8 with other metastatic cancers.

RESULTS

Neck nodes were clinically positive in 12 patients with primary cancer, 24 patients with squamous cell carcinoma, 16 with melanoma, and 2 with other metastatic malignancies. Conservative parotidectomy, preserving the main trunk of the facial nerve, was performed in 185 patients, and 47 patients had a radical parotidectomy sacrificing the facial nerve. There were 54 therapeutic and 110 elective neck dissections. Adjuvant radiotherapy was given to 39 patients with primary cancer, 86 with squamous cell carcinoma, 50 with melanoma, and 8 in the other metastatic group (78% of the patients in the series). Local control rates at 5 years in the four groups were 86%, 75%, 94%, and 100%, respectively (P <.01). Survival rates at 5 years were 77%, 65%, 46%, and 56%, respectively (P <.01).

CONCLUSIONS

The pattern of parotid malignancy is unique in Australia because of the high incidence of skin cancer, which can metastasize to the parotid gland. Metastatic cutaneous malignancy predominates. The pattern of failure and outcome varied depending on histological findings. Local failure occurred most often in metastatic squamous cell carcinoma, whereas patients with melanoma had the highest incidence of distant spread.

Treatment results of regional metastasis from cutaneous head and neck squamous cell carcinoma

AIMS

To investigate the results of our treatment policy, we present our institutional experience in the management of regional neck node metastases of cutaneous head and neck squamous cell carcinoma (CHNSCC).

METHODS

Between 1977 and 1997, 343 patients presented with CHNSCC, of whom 41 were treated for regional metastases, with parotidectomy and/or (selective) neck dissection. Histological analysis was performed on all operation specimens. Patients with multiple nodes and/or extra capsular rupture, at risk for recurrence, received adjuvant radiotherapy.

RESULTS

Seventy-six percent of the regional metastases occurred within the first 2 years, but a delay of more than 5 years was also observed. Parotid gland (56%), neck levels II (39%) and V (22%) were most frequently involved. Twenty-four percent of patients treated with curative intent failed at the regional site. Five years overall survival was 46%, with a median survival of 49 months. No survival differences emerged between patients treated by surgery alone and patients receiving adjuvant radiotherapy (P=0.14). Five patients died of disease, of whom three with distant metastases.

CONCLUSION

Regionally metastasized CHNSCC is a serious disease with a high risk of regional recurrence, calling for combined surgery and adjuvant radiotherapy. A small subset of patients with a long interval between completion of primary treatment and presence of regional nodes justifies a long follow-up.

Elective, therapeutic, and delayed lymph node dissection for malignant melanoma of the head and neck: analysis of 1444 patients from 1970 to 1998

OBJECTIVE

The purpose of this article is to evaluate the effects on survival, disease-free interval, and recurrence patterns for patients undergoing elective, therapeutic, and delayed lymph node dissection for malignant melanoma of the head and neck.

STUDY DESIGN AND METHODS

A retrospective computer-aided analysis was performed comparing 1444 patients treated from 1970 to 1998 at Duke University Medical Center. A total of 446 of the 1444 (32%) of patients with head and neck melanoma underwent some form of lymph node dissection. Survival, disease-free interval, and recurrence rates for patients having 1) no initial lymph node dissection (no LND), 2) elective lymph node dissection (ELND) within 2 months of date of diagnosis, 3) therapeutic lymph node dissection (TLND) for metastatic regional disease at diagnosis, or 4) delayed lymph node dissection (DLND) for patients developing regional lymph node metastasis later than 3 months from the date of diagnosis were compared.

RESULTS

A total of 246 patients undergoing ELND demonstrated 11% with occult disease. DLND for regional lymph node recurrence was reported at a median time interval of 1.2 years from diagnosis. Multivariate analysis indicated a significant improvement in survival for DLND when compared with patients undergoing ELND plus sign in circle or TLND (P =.01). Distant metastasis was the site of first recurrence in 12% of patients undergoing no initial LND. Five-year survival after DLND and TLND was 56% and 36%, respectively.

CONCLUSION

Patients undergoing DLND had an overall better survival than patients undergoing TLND or ELND with positive nodes. The progression of metastatic disease following regional node disease occurred in 35% to 45% of cases, underscoring the need for effective adjunctive therapy.

Parotid region lymphatic mapping and sentinel lymphadenectomy for cutaneous melanoma

BACKGROUND

Routine elective superficial parotidectomy for patients with primary cutaneous melanomas of the scalp, auricle, or face has been questioned. We evaluated an alternative, i.e., lymphatic mapping and sentinel lymphadenectomy, for patients with primary cutaneous melanomas draining to the region of the parotid gland.

PATIENTS

Retrospective review of our large (>8000 patients) melanoma database identified 39 patients with primary melanomas (American Joint Committee on Cancer stage I or II) of the scalp (n = 19), auricle (n = 11), or face (n = 9) who underwent intraoperative lymphatic mapping to identify a sentinel node (SN) in the region of the parotid gland, between June 1985 and July 1997.

RESULTS

A SN was identified in the parotid region of 37 patients (94.9%), four of whom had SN metastases. The mean number of SN obtained was 2.3/patient (range, 1-4/patient). The two patients (5.1%) for whom a parotid-region SN could not be identified underwent superficial parotidectomy during the same operation. Among the 33 patients with tumor-free SN, with a median follow-up period of 33.2 months (range, 1-121 months), there was one (3.1%) intraparotid recurrence; thus, the false-negative rate was 3.1%. The procedure-related surgical morbidity rate was only 2.6% (one case of temporary facial nerve paresis).

CONCLUSIONS

For patients with primary melanomas of the scalp, auricle, or face, sentinel lymphadenectomy can be performed accurately in the parotid region and offers a low-morbidity alternative to routine elective superficial parotidectomy.

Cervical lymph-node metastasis from cutaneous melanoma of the head and neck: a search for prognostic factors

AIMS

To identify prognostic factors determining overall survival in patients with surgically treated neck node metastases of cutaneous melanoma.

METHODS

A retrospective study was carried out in 70 patients who were surgically treated with curative intent for cervical lymph-node metastasis from cutaneous head and neck melanoma at our institution between 1960 and 1986.

RESULTS

Median follow-up of the 14 patients still alive was 10 years. Of the 70 patients, 64 underwent a radical neck dissection, four a modified radical neck dissection and two a postero-lateral neck dissection. In 63 patients, the node dissection was for palpable involved nodes and in seven for microscopic disease. Survivals after 5 and 10 years were 23% (SE 5%) and 20% (SE 5%), respectively. Five-year survival was 62% (SE 17%) for patients with a melanoma less than 1.5 mm thick and 16% for lesions thicker than 1.5 mm. A regional recurrence in the neck occurred in 16 (23%) patients, of whom 14 were found also to have distant metastases. All patients with regional recurrence died from disease.

CONCLUSIONS

Of the 15 patient-, tumour- and treatment-related factors tested, only the Breslow thickness of the primary lesion carried prognostic significance for survival (Bonferroni corrected P-value: 0.026).

Adjuvant radiotherapy following neck dissection and parotidectomy for metastatic malignant melanoma

BACKGROUND

Regional recurrence remains a problem in the management of patients with metastatic malignant melanoma in the cervical lymph nodes and parotid. In this study, the influence of the number of positive nodes, extracapsular spread, and the use of adjuvant radiotherapy on regional control and survival were analyzed.

METHODS

A non-randomized, prospectively documented series of 143 patients with histologically positive nodes in the neck or parotid was analyzed. There were 152 dissected necks or parotids: 45 of these received postoperative radiotherapy, 6 x 5.5 Gy fractions over 3 weeks; 107 were not irradiated.

RESULTS

The regional recurrence rate was 6.5% in the irradiated group, compared with 18.7% in the non-irradiated group (p = .055). The irradiated group, however, had more extensive nodal involvement than the non-irradiated group: 65% had two or more positive nodes, and 48% had extracapsular spread, compared with 40% and 19%, respectively, in the non-irradiated group. Survival was significantly worse when there was extracapsular spread (p < .05) or multiple node involvement (p < .01). By multivariate analysis, the use of adjuvant radiotherapy was associated with a trend toward improved regional control (p = .065), but survival was not improved.

CONCLUSIONS

Adjuvant radiotherapy was associated with improved control of metastatic malignant melanoma in the neck and parotid; however, statistical significance was not reached. A prospective trial should be supported to clarify this question.

Prediction of potential metastatic sites in cutaneous head and neck melanoma using lymphoscintigraphy

BACKGROUND

The technique of lymphoscintigraphy may allow a more selective approach to the management of clinically negative neck nodes among patients with cutaneous head and neck melanoma.

PATIENTS AND METHODS

A group of 97 patients with cutaneous head and neck melanoma had preoperative lymphoscintigraphy using intradermal injections of technetium 99m antimony trisulfide colloid to identify sentinel nodes. Fifty-one patients were eligible for clinical analysis after initial definitive treatment by wide excision only (n = 11), wide excision and elective dissection of the neck (n = 19) or axilla (n = 1), or wide excision and a sentinel node biopsy procedure (n = 20).

RESULTS

Sentinel nodes were identified in 95 of 97 lymphoscintigrams, and 85% of patients had multiple sentinel nodes. In 21 patients (22%), sentinel nodes were identified outside the parotid region and the 5 main neck levels, mostly in postauricular nodes (n = 13). Lymphoscintigrams were discordant with clinical predictions in 33 patients (34%). Lymph nodes were positive in 4 elective dissections and 4 sentinel node biopsies. Among 16 patients evaluable after wide excision and a negative sentinel node biopsy, 4 patients subsequently developed metastatic nodes; however, confident identification of all nodes marked as sentinel nodes on lymphoscintigraphy was not achieved at the original biopsy procedure in 3 of these patients.

CONCLUSIONS

Lymphoscintigraphy and sentinel node biopsy are more difficult to perform in the head and neck than in other parts of the body. The reliability of sentinel node biopsy based on lymphoscintigraphy may be improved by identifying and marking all nodes that are considered to receive direct lymphatic drainage from the primary melanoma, and by use of a gamma probe intraoperatively.

Radical, modified, and selective neck dissection for cutaneous malignant melanoma

BACKGROUND

The roles of modified and selective neck dissections in treating patients with clinical metastatic melanoma and the place of adjuvant radiotherapy are unclear. In the elective setting, the efficacy of various selective dissections also requires clarification.

METHODS

The prospectively documented experience of the senior author (COB) was analyzed. A total of 175 patients had 183 neck dissections and 92 parotidectomies in 6 years. There were 75 therapeutic and 108 elective operations. Modified or selective neck dissections were performed in 58% of patients with clinical neck metastases. Ali but two elective operations were modified or selective dissections. Postoperative radiotherapy was given to 27 dissected necks. Minimum follow-up was 12 months, and 86% of patients were followed up for 2 years or to neck recurrence.

RESULTS

Nodes were histologically positive in 80 dissections. The cumulative rate of control of metastatic melanoma in the neck was 86% at 5 years. Neck recurrence developed in 14% of radical dissections, 0% of modified, and 23% of selective dissections performed for clinical disease. Neck recurrence occurred after 5% of elective dissections. Recurrence was 7% among irradiated necks compared to 23% in nonirradiated (p-value not significant). The 5-year survival rate was 50%, and this was significantly worsened by increasing node involvement.

CONCLUSIONS

Modified radical neck dissection is highly effective in controlling metastatic melanoma in selected patients. Selective dissections are less effective and need further study. Adjuvant radiotherapy appears to decrease the risk of neck recurrence. In the elective setting, recurrence is uncommon following the selective neck dissections described.