Lymphatic mapping and selective lymphadenectomy as an alternative to elective lymph node dissection in patients with malignant melanoma

Population-Based Assessment of Surgical Treatment Trends for Patients With Melanoma in the Era of Sentinel Lymph Node Biopsy

Purpose

The surgical staging of melanoma dramatically changed with the introduction of sentinel lymph node (SLN) biopsy. In this study, Surveillance, Epidemiology, and End Results (SEER) data were examined to determine how surgical treatment is being carried out and whether SLN biopsy is being performed in melanoma patients in conformance with National Comprehensive Cancer Network (NCCN) guidelines.

Patients and Methods

The SEER database (1998 to 2001) was searched for all patients with invasive melanoma. NCCN guidelines were used to define optimal stage-specific surgical treatment. Treatment trends in patients with stages I to III disease were summarized, and multivariate analyses were performed to identify factors associated with nonadherence with treatment guidelines.

Results

A total of 21,867 melanoma patients were identified; 18,499 of these patients met the inclusion criteria. The number of patients diagnosed with stage III melanoma increased by 55.7% over the study period, and this corresponded to a 53% increase in the number of SLN biopsies performed annually. The odds ratios for nonadherence were 2.32, 2.27, and 1.54 for stages IB, II, and III disease, respectively, compared with stage IA melanoma. Multivariate analyses revealed that age more than 65 years, marital status, minority populations, and primary tumor location were associated with nonadherence with guidelines. Treatment patterns among tumor registries also varied significantly.

Conclusion

Stage migration is evident in the SEER registries in consort with increasing use of SLN biopsy. Although treatment trends are improving, SLN biopsy continues to be underused, particularly in the elderly and minority populations, in patients with truncal and head/neck melanomas, and also in some geographic regions of the United States.

Lymphoscintigraphy and sentinel node biopsy accurately stage melanoma in patients presenting after wide local excision

BACKGROUND

Patients have traditionally been considered candidates for sentinel node biopsy (SNBx) only at the time of wide local excision (WLE). We hypothesized that patients with prior WLE may also be staged accurately with SNBx.

METHODS

Seventy-six patients, including 18 patients from the University of Virginia and 58 from a multicenter study of SNBx led by investigators at the University of Vermont, who had previous WLE for clinically localized melanoma underwent lymphoscintigraphy with SNBx. Median follow-up time was 38 months.

RESULTS

Intraoperative identification of at least 1 sentinel node was accomplished in 75 patients (98.6%). The mean number of sentinel nodes removed per patient was 2.0. Eleven patients (15%) had positive sentinel nodes. Among the 64 patients with negative SNBx, 3 (4%) developed nodal recurrences in a sentinel node-negative basin simultaneous with systemic metastasis, and 1 (1%) developed an isolated first recurrence in a lymph node.

CONCLUSIONS

This multicenter study more than doubles the published experience with SNBx after WLE and provides much-needed outcome data on recurrence after SNBx in these patients. These outcomes compare favorably with the reported literature for patients with SNBx at the time of WLE, suggesting that accurate staging of the regional lymph node bed is possible in patients after WLE.

Anaphylactic reaction to isosulfan blue used for sentinel node biopsy: case report and literature review

Isosulfan blue is a commonly used agent in the detection of sentinel lymph nodes during cancer surgery. Similar to any drug, it is possible to have an allergic reaction to this increasingly popular chemical during breast cancer operations. We present one case of anaphylactic shock in response to injection of isosulfan blue for the purpose of localizing the sentinel node and review the medical literature. A thorough knowledge of possible isosulfan blue side effects, including their presentation and subsequent therapy, is essential for the modern breast surgeon.

Value of frozen-section analysis of sentinel lymph nodes for primary cutaneous malignant melanoma

OBJECTIVE

To analyze a large, single-institution experience with routine frozen section (FS) of the sentinel lymph node (SLN) in patients with primary cutaneous melanoma.

SUMMARY BACKGROUND DATA

Controversy exists over the utility of intraoperative FS analysis of the SLN in patients with primary cutaneous melanoma.

METHODS

All patients with clinically node-negative cutaneous melanoma undergoing SLN biopsy from 1991 to 1999 were identified from a prospective database. All SLNs were examined by FS. Step-sectioning and immunohistochemistry of permanent section were performed for SLNs negative by FS.

RESULTS

At least one SLN was identified in 98% (360/368) of patients. There were 74 (20%) SLNs positive on permanent section; FS was positive in 59% of these. The accuracy, sensitivity, and specificity of FS were 92%, 59%, and 100%. Because isolated recurrence developed in six patients in the nodal basin in which the SLN was negative, the failure rate was 1.7%. The false-negative rate for SLN biopsy was 7.5%.

CONCLUSIONS

Because the prevalence of metastases within the SLN and sensitivity of FS analysis are low, routine use of FS for all patients undergoing SLN biopsy is not recommended.

[Contribution of radioguided detection and selective biopsy of the sentinel lymph node to staging in 100 patients with cutaneous melanoma]

OBJECTIVE

A selective sentinel node (SN) biopsy appears to be an alternative to conventional lymph node dissection for staging patients with cutaneous melanoma. This study has aimed to analyze our experience in the localization of the sentinel node with a probe detector and lymphoscintigraphy and its utility in the staging of this disease.

MATERIAL AND METHODS

100 patients, 56 female and 44 male, 51.5 31.5 mean age, diagnosed of cutaneous melanoma were studied. The lymphoscintigraphy was performed in all cases to detect the area of lymphatic drainage after peritumoral intradermal administration of 600 uCi of 99mTc-colloidal sulfur, and planar images were acquired every 10 minutes until activity was detected in these areas. Afterwards, the intraoperative localization of the sentinel node with a probe detector was performed and the selective biopsy of the node was sent to the Pathology Department for its histologic study.

RESULTS

The lymphoscintigraphy study was positive in 99 of the 100 cases and it was identified intraoperatively in 98 cases. The histologic analysis was negative in 78.9% and positive in 21.1% of the nodes.

CONCLUSIONS

Radioisotopic lymphography and intraoperative probe detection are two very useful techniques for locating the sentinel node and staging patients with cutaneous melanoma. Many patients are benefiting from the selective biopsy of the sentinel node because of the decreased post-surgical morbidity and better staging of the cutaneous melanoma.

Pediatric melanoma: confirming the diagnosis with sentinel node biopsy

Many pediatric melanoma lesions present at a more advanced stage than those in the adult population. Clinical and histological melanoma mimics, including a subset of Spitz nevi, are difficult to discriminate from melanoma. When dealing with a childhood melanoma, the clinician is likely to be faced with a thick lesion, and one in which the actual diagnosis may even be in doubt. There is a paucity of data to guide the physician in his management of melanoma in this age group, particularly with respect to node status and adjuvant therapy. The authors present two cases of pediatric melanoma in which the novel use of sentinel node biopsy helped confirm the diagnosis of melanoma, determined the need for full lymph node dissection, and guided the use of adjuvant interferon therapy.

Ultrasound examination of regional lymph nodes significantly improves early detection of locoregional metastases during the follow-up of patients with cutaneous melanoma: results of a prospective study of 1288 patients

BACKGROUND

In regional lymph node metastasis of cutaneous melanoma, the number and volume of involved lymph nodes are the most important prognostic factors. Several studies have revealed that palpation of the lymphatic drainage area(s) and regional lymph nodes has a high rate of false-negative results during follow-up. The aim of the current study was to assess the sensitivity and specificity of ultrasound versus clinical diagnosis in the detection of subcutaneous and regional metastases.

METHODS

During a period of 42 months, a total of 6328 lymphatic drainage areas were examined clinically and by ultrasound (7.5-10 MHz) in 1288 melanoma patients at 4435 follow-up consultations. When an ultrasound finding was suggestive of metastasis, surgery and histopathologic evaluation were performed. The results of clinical examination, ultrasound examination, and histopathologic findings were compared.

RESULTS

In 504 ultrasound examinations performed on 235 patients, metastatic disease was diagnosed in 263 examinations following surgery (179 patients). Due to advanced disease or rejection, an additional 56 patients did not undergo surgery. In 239 of the 263 positive findings (90.9%), metastases from melanoma were histopathologically confirmed. In 8 cases (3%) a second malignancy and in 16 cases (6. 1%) benign lymphadenopathy was histopathologically diagnosed. Palpation of subcutaneous lymph nodes and lymph nodes gave false-negative results in 68 of the 238 cases of histopathologically proven metastases (28.6%). Clinical examination was least sensitive in the supraclavicular, axillary, and infraclavicular regions. The sensitivity and specificity for ultrasound examination were 89.2% and 99.7%, respectively, and 71.4% and 99.7% for clinical examination, respectively.

CONCLUSIONS

For early diagnosis of in-transit and regional lymph node metastases in cutaneous melanoma, ultrasound scanning is distinctly superior to clinical examination. Controlled follow-up studies are proposed to examine the possible beneficial effects on survival time resulting from the ultrasound examinations of the lymphatic drainage area(s) and regional lymph nodes.

Melanoma. A multidisciplinary approach for the general surgeon

Advances in the understanding of the biology and treatment of melanoma have moved the care of melanoma patients into an increasingly multidisciplinary environment. Surgeons must understand these advances because they will often be responsible for directing the overall care of these patients. Most patients with melanomas more than 1 mm in diameter and no evidence of metastatic disease should be offered SLNB to more accurately stage them and direct decisions about participation in postoperative adjuvant therapy trials. Until the results of the MSLT are known, the effect of SLNB and ELND on outcome remains unknown. SLNs should be analyzed with serial sectioning and immunohistochemistry to avoid missing micro-metastatic disease. Based on the results of the ECOG-1684 trial, the FDA approved IFN-alpha 2b for the adjuvant treatment of melanoma patients with thick primary tumors (> 4 mm) or resected nodal disease. IFN-alpha 2b treatment is expensive and potentially toxic. The data from ECOG-1684 do not support the use of IFN-alpha 2b in patients with node-negative disease. In light of the ECOG-1690 trial results, the role of high-dose IFN-alpha 2b in the management of patients with resected nodal disease is considerably less clear. Any recommendations for treatment with high-dose IFN-alpha 2b should be made only after weighing the costs, side effects, and potential benefits for individual patients. Numerous, less toxic, promising, adjuvant immunotherapeutic strategies have been developed and are being tested in multicenter, prospective, randomized trials. These strategies include GMK, PMCV, and Melacine. If the results of any of these trials show a survival advantage compared with placebo or equivalent survival compared with IFN-alpha 2b, these immunotherapeutic agents will become the adjuvant treatment of choice for patients with resected high-risk melanoma. RT-PCR detection of tyrosinase in SLNs can identify patients with submicroscopic nodal disease who may be at increased risk for recurrence or death from melanoma. An ongoing, prospective, randomized trial will determine whether patients with histologically negative but RT-PCR-positive SLNs will benefit from lymphadenectomy or adjuvant IFN-alpha 2b therapy. RT-PCR can also identify minimal residual disease in peripheral blood and bone marrow from patients with high-risk melanoma, but RT-PCR analysis of peripheral blood and bone marrow is still experimental, and procedural details need to be standardized and prospectively validated in large patient groups before its use can be considered the standard of care.