The impact of ultrasound scanning in the staging and follow-up of patients with clinical stage I cutaneous melanoma

Imaging Assessment of Interval Metastasis from Melanoma

Interval metastasis is a particular metastatic category of metastatic localizations in the lymph nodes in patients with melanoma. Interval nodes are generally located at nonregional lymphatic stations placed along the pathway of the spread of melanoma, such as the epitrochlear lymph node station, the popliteal fossa, and the retroareolar station. Imaging techniques for evaluation of patients with interval metastasis from melanoma diseases include ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), lymphoscintigraphy (LS), and positron emission tomography (PET). A literature review was conducted through a methodical search on the Pubmed and Embase databases. The evaluation of lymph node metastases represents a critical phase in the staging and follow-up of melanoma patients. Therefore, a thorough knowledge of the imaging methods available and the interactions between the clinician and the radiologist are essential for making the correct choice for individual patients, for a better management, and to improve treatment and survival.

Ultrasound Examination of the Lymphatic Drainage Area and Regional Lymph Nodes in Melanoma Patients with In-Transit Metastases

BACKGROUND

In-transit metastases (ITMs) are cutaneous or subcutaneous regional metastases that may occur in patients with melanoma. ITMs are often multiple and new lesions tend to appear over time. Ultrasonography can detect impalpable subcutaneous tumors.

OBJECTIVE

The aim of this study was to assess the value of ultrasound examination in detecting additional, non-palpable ITMs and to determine their relevance.

METHODS

Melanoma patients with ITMs who underwent regional ultrasound examination of the skin and subcutaneous tissue between the wide excision scar of the primary melanoma and the regional lymph node field were identified. In most, ultrasound assessment also included the regional lymph node field. Relevant data were collected and analyzed.

RESULTS

Twenty-eight patients presenting with a total of 40 ITMs were included. Ultrasound examination identified additional ITMs in 15 patients (54%). No nodal recurrences were detected. Most additional lesions were found closer to the regional lymph nodes than the original ITMs. Management was influenced by the ultrasound findings in nine patients (32%), five of whom had more extensive surgery, three received systemic drug therapy instead of surgery, and in one patient surgery was delayed and follow-up intensified. In one patient, only subcutaneous fat was found in the excised specimen and the ultrasound was classified as false-positive.

CONCLUSION

In melanoma patients with ITMs, ultrasonography of the lymphatic drainage area provided valuable information, as additional ITMs were identified in more than half of these patients and management was influenced in one-third.

Ultrasound, CT, MRI, or PET-CT for staging and re-staging of adults with cutaneous melanoma

BACKGROUND

Melanoma is one of the most aggressive forms of skin cancer, with the potential to metastasise to other parts of the body via the lymphatic system and the bloodstream. Melanoma accounts for a small percentage of skin cancer cases but is responsible for the majority of skin cancer deaths. Various imaging tests can be used with the aim of detecting metastatic spread of disease following a primary diagnosis of melanoma (primary staging) or on clinical suspicion of disease recurrence (re-staging). Accurate staging is crucial to ensuring that patients are directed to the most appropriate and effective treatment at different points on the clinical pathway. Establishing the comparative accuracy of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT imaging for detection of nodal or distant metastases, or both, is critical to understanding if, how, and where on the pathway these tests might be used.

OBJECTIVES

Primary objectivesWe estimated accuracy separately according to the point in the clinical pathway at which imaging tests were used. Our objectives were:• to determine the diagnostic accuracy of ultrasound or PET-CT for detection of nodal metastases before sentinel lymph node biopsy in adults with confirmed cutaneous invasive melanoma; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging in adults with cutaneous invasive melanoma:○ for detection of any metastasis in adults with a primary diagnosis of melanoma (i.e. primary staging at presentation); and○ for detection of any metastasis in adults undergoing staging of recurrence of melanoma (i.e. re-staging prompted by findings on routine follow-up).We undertook separate analyses according to whether accuracy data were reported per patient or per lesion.Secondary objectivesWe sought to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for whole body imaging (detection of any metastasis) in mixed or not clearly described populations of adults with cutaneous invasive melanoma.For study participants undergoing primary staging or re-staging (for possible recurrence), and for mixed or unclear populations, our objectives were:• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of nodal metastases;• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases; and• to determine the diagnostic accuracy of ultrasound, CT, MRI, or PET-CT for detection of distant metastases according to metastatic site.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included studies of any design that evaluated ultrasound (with or without the use of fine needle aspiration cytology (FNAC)), CT, MRI, or PET-CT for staging of cutaneous melanoma in adults, compared with a reference standard of histological confirmation or imaging with clinical follow-up of at least three months' duration. We excluded studies reporting multiple applications of the same test in more than 10% of study participants.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2)). We estimated accuracy using the bivariate hierarchical method to produce summary sensitivities and specificities with 95% confidence and prediction regions. We undertook analysis of studies allowing direct and indirect comparison between tests. We examined heterogeneity between studies by visually inspecting the forest plots of sensitivity and specificity and summary receiver operating characteristic (ROC) plots. Numbers of identified studies were insufficient to allow formal investigation of potential sources of heterogeneity.

MAIN RESULTS

We included a total of 39 publications reporting on 5204 study participants; 34 studies reporting data per patient included 4980 study participants with 1265 cases of metastatic disease, and seven studies reporting data per lesion included 417 study participants with 1846 potentially metastatic lesions, 1061 of which were confirmed metastases. The risk of bias was low or unclear for all domains apart from participant flow. Concerns regarding applicability of the evidence were high or unclear for almost all domains. Participant selection from mixed or not clearly defined populations and poorly described application and interpretation of index tests were particularly problematic.The accuracy of imaging for detection of regional nodal metastases before sentinel lymph node biopsy (SLNB) was evaluated in 18 studies. In 11 studies (2614 participants; 542 cases), the summary sensitivity of ultrasound alone was 35.4% (95% confidence interval (CI) 17.0% to 59.4%) and specificity was 93.9% (95% CI 86.1% to 97.5%). Combining pre-SLNB ultrasound with FNAC revealed summary sensitivity of 18.0% (95% CI 3.58% to 56.5%) and specificity of 99.8% (95% CI 99.1% to 99.9%) (1164 participants; 259 cases). Four studies demonstrated lower sensitivity (10.2%, 95% CI 4.31% to 22.3%) and specificity (96.5%,95% CI 87.1% to 99.1%) for PET-CT before SLNB (170 participants, 49 cases). When these data are translated to a hypothetical cohort of 1000 people eligible for SLNB, 237 of whom have nodal metastases (median prevalence), the combination of ultrasound with FNAC potentially allows 43 people with nodal metastases to be triaged directly to adjuvant therapy rather than having SLNB first, at a cost of two people with false positive results (who are incorrectly managed). Those with a false negative ultrasound will be identified on subsequent SLNB.Limited test accuracy data were available for whole body imaging via PET-CT for primary staging or re-staging for disease recurrence, and none evaluated MRI. Twenty-four studies evaluated whole body imaging. Six of these studies explored primary staging following a confirmed diagnosis of melanoma (492 participants), three evaluated re-staging of disease following some clinical indication of recurrence (589 participants), and 15 included mixed or not clearly described population groups comprising participants at a number of different points on the clinical pathway and at varying stages of disease (1265 participants). Results for whole body imaging could not be translated to a hypothetical cohort of people due to paucity of data.Most of the studies (6/9) of primary disease or re-staging of disease considered PET-CT, two in comparison to CT alone, and three studies examined the use of ultrasound. No eligible evaluations of MRI in these groups were identified. All studies used histological reference standards combined with follow-up, and two included FNAC for some participants. Observed accuracy for detection of any metastases for PET-CT was higher for re-staging of disease (summary sensitivity from two studies: 92.6%, 95% CI 85.3% to 96.4%; specificity: 89.7%, 95% CI 78.8% to 95.3%; 153 participants; 95 cases) compared to primary staging (sensitivities from individual studies ranged from 30% to 47% and specificities from 73% to 88%), and was more sensitive than CT alone in both population groups, but participant numbers were very small.No conclusions can be drawn regarding routine imaging of the brain via MRI or CT.

AUTHORS' CONCLUSIONS

Review authors found a disappointing lack of evidence on the accuracy of imaging in people with a diagnosis of melanoma at different points on the clinical pathway. Studies were small and often reported data according to the number of lesions rather than the number of study participants. Imaging with ultrasound combined with FNAC before SLNB may identify around one-fifth of those with nodal disease, but confidence intervals are wide and further work is needed to establish cost-effectiveness. Much of the evidence for whole body imaging for primary staging or re-staging of disease is focused on PET-CT, and comparative data with CT or MRI are lacking. Future studies should go beyond diagnostic accuracy and consider the effects of different imaging tests on disease management. The increasing availability of adjuvant therapies for people with melanoma at high risk of disease spread at presentation will have a considerable impact on imaging services, yet evidence for the relative diagnostic accuracy of available tests is limited.

Sentinel Node Biopsy in Cutaneous Melanoma Patients: Technical and Clinical Aspects

The role of the patent blue dye (PBD) technique and intraoperative probe-guided lymphoscintigraphy (LS) in detecting the sentinel node (SN) was investigated in a group of 130 consecutive stage I cutaneous melanoma patients. The preoperative workup included high-resolution US scanning and LS performed 15–18 hours before surgery. On the basis of preoperative LS, in the group of examined patients a total of 143 lymphatic drainage basins were identified and surgically explored: 41.6% in the axilla, 52.8% in the groin, and 5.6% in the head/neck. A total of 228 SNs were intraoperatively detected and removed; 110 lymphatic basins contained histologically negative SNs, while 33 basins had metastatic SNs. The sensitivity for SN detection using PBD alone was 93%, while it was 100% when PBD was combined with intraoperative LS. Preoperative and intraoperative LS appears to be a highly sensitive technique for SN detection in cutaneous melanoma patients. Furthermore, in view of the limited skin incision when radioguided surgery is performed, SN biopsy could be feasible under local anesthesia.

Lymph node dissection for melanoma: where do we stand?

The extent and timing of regional lymphadenectomy and its role in patients with clinically localized primary melanoma has been the subject of considerable debate. While therapeutic lymphadenectomy for clinically positive nodes is uniformly accepted, the benefit of regional lymphadenectomy in patients with clinically uninvolved lymph nodes potentially harboring micrometastatic disease is less clear. Efforts to better select patients for complete regional lymphadenectomy after sentinel lymph node biopsy are underway. The future holds the promise of more stringent selection criteria and perhaps the identification of subgroups of patients for which a therapeutic benefit may be realized. Moreover, novel sensitive radiological techniques for detecting in vivo micrometastatic nodal disease may improve surgical precision, further decreasing potential morbidities of lymphadenectomy.

Brazilian guidelines for diagnosis, treatment and follow-up of primary cutaneous melanoma - Part II

The last Brazilian guidelines on melanoma were published in 2002. Development in diagnosis and treatment made updating necessary. The coordinators elaborated ten clinical questions, based on PICO system. A Medline search, according to specific MeSH terms for each of the 10 questions was performed and articles selected were classified from A to D according to level of scientific evidence. Based on the results, recommendations were defined and classified according to scientific strength. The present Guidelines were divided in two parts for editorial and publication reasons. In this second part, the following clinical questions were answered: 1) which patients with primary cutaneous melanoma benefit from sentinel lymph node biopsy? 2) Follow-up with body mapping is indicated for which patients? 3) Is preventive excision of acral nevi beneficious to patients? 4) Is preventive excision of giant congenital nevi beneficious to patients? 5) How should stages 0 and I primary cutaneous melanoma patients be followed?

Outcome of Melanoma Patients Who Did Not Proceed to Sentinel Node Biopsy After Preoperative Lymphoscintigraphy

BACKGROUND

At our institution, a planned sentinel node biopsy (SNB) procedure is occasionally canceled after preoperative lymphoscintigraphy. This study reports the frequency of this, the reasons, and the management and outcomes of these patients.

METHODS

All patients with clinically localized cutaneous melanoma treated at Melanoma Institute Australia between 2000 and 2009 whose planned SNB procedure was not undertaken after lymphoscintigraphy were included in this retrospective study.

RESULTS

Of the 3148 patients in whom the procedure had been planned, 203 patients (6.4 %) did not have a SNB. The main reason for not proceeding with SNB (in 84 % of cases) was the lymphoscintigraphic demonstration of multiple drainage fields and/or multiple sentinel nodes (SNs). Patients who did not proceed to SNB were significantly older than those who did, more often had melanomas of the head or neck, and had more SNs and more nodal drainage fields. Of the 203 patients, 181 (89 %) were followed with high-resolution ultrasound of their SNs, which identified 33 % of the nodal recurrences before they were clinically apparent. Patients whose SNB was canceled had significantly worse recurrence-free survival and regional node disease-free survival, but melanoma-specific survival was similar. Compared to SN-positive patients, node-positive patients without SNB had significantly more involved nodes when a delayed lymphadenectomy was performed, but melanoma-specific survival was not significantly different after a median follow-up of 42 months.

CONCLUSIONS

Lymphoscintigraphy with ultrasound follow-up of previously identified SNs is an acceptable management strategy for patients in whom a SNB procedure is likely to be challenging.

The role of ultrasound and ultrasound-guided fine needle aspiration biopsy of lymph nodes in patients with skin tumours

Background

The primary aim of this study was to evaluate the diagnostic accuracy of ultrasound (US) in the study of superficial lymph nodes during the follow-up of patients surgically treated for skin tumours. The secondary objective was to compare positive cytological results with histological reports.

Patients and methods

From 2004 to 2011, 480 patients (male/female: 285/195; median age 57 years; prevalent skin tumour: melanoma) underwent US-guided fine-needle aspiration biopsy (FNAB) of suspicious recurrent lymph nodes. An expert radiologist first performed US testing of the lymph nodes, expressing either a negative or positive outcome of the test. Subsequently, US-guided FNAB was performed. FNAB positive patients were subjected to lymphadenectomy; the patients who tested negative underwent the follow-up.

Results

The size of lymph nodes was ≤ 2 cm in 90% of cases. Out of the 336 (70%) US “positive” patients, 231 (68.8%) were FNAB positives. Out of the 144 (30%) US “negatives”, 132 (91.7%) were FNAB negatives. The sensitivity and specificity of the US were 95% and 55.7%, respectively; the negative predictive value was 91.7% and the positive predictive value was 68.8%. Definitive histological results confirmed FNAB positivity in 97.5% of lymphadenectomies.

Conclusions

US is a sensitive method in the evaluation of superficial lymph nodes during the follow-up of patients with skin tumours. High positive predictive value of cytology was confirmed.

Preoperative ultrasound is not useful for identifying nodal metastasis in melanoma patients undergoing sentinel node biopsy: preoperative ultrasound in clinically node-negative melanoma

BACKGROUND

Sentinel lymph node biopsy (SLNB) is widely used in melanoma. Identifying nodal involvement preoperatively by high-resolution ultrasound may offer less invasive staging. This study assessed feasibility and staging results of clinically targeted ultrasound (before lymphoscintigraphy) compared to SLNB.

METHODS

From 2005 to 2009, a total of 325 patients with melanoma underwent ultrasound before SLNB. We reviewed demographics and histopathologic characteristics, then compared ultrasound and SLNB results. Sensitivity, specificity, and positive and negative predictive value were determined.

RESULTS

A total of 325 patients were included, 58% men and 42% women with a median age of 58 (range 18-86) years. A total of 471 basins were examined with ultrasound. Only six patients (1.8%) avoided SLNB by undergoing ultrasound-guided fine-needle aspiration of involved nodes, then therapeutic lymphadenectomy. Sixty-five patients (20.4%) had 69 SLNB positive nodal basins; 17 nodal basins from 15 patients with positive ultrasounds were considered truly positive. Forty-five SLNB positive basins had negative ultrasounds (falsely negative). Seven node-positive basins did not undergo ultrasound because of unpredicted drainage. A total of 253 patients with negative SLNBs had negative ultrasounds in 240 nodal basins (truly negative) but falsely positive ultrasounds occurred in 40 basins. Overall, sensitivity of ultrasound was 33.8%, specificity 85.7%, positive predictive value 36.5%, and negative predictive value 84.2%. Sensitivity and specificity improved somewhat with increasing Breslow depth. Sensitivity was highest for the neck, but specificity was highest for the groin.

CONCLUSIONS

Routine preoperative ultrasound in clinically node-negative melanoma is impractical because of its low sensitivity. Selected patients with thick or ulcerated lesions may benefit. Because of variable lymphatic drainage patterns, preoperative ultrasound without lymphoscintigraphic localization will provide incomplete evaluation in many cases.

Fine needle aspiration cytology of palpable and nonpalpable lymph nodes to detect metastatic melanoma

BACKGROUND

Fine needle aspiration cytology (FNAC) is usually used to evaluate palpable nodes in patients with melanoma. The goal of our study is to review the sensitivity and specificity of this technique when applied to palpable but also to nonpalpable nodes.

METHODS

FNAC was performed during 1984-2007 in 1279 patients with suspicious lesions and/or lymph nodes. Indications for biopsy included increased size and/or palpability of nodes or abnormal ultrasound findings such as increased perfusion or focal lesions within the lymph nodes. The sensitivity, specificity, and positive and negative predictive values of FNACs guided by palpation or ultrasound were calculated for all patients and for subgroups of patients with palpable nodes or nonpalpable but sonomorphologically suspicious nodes.

RESULTS

A total of 2446 FNACs were performed in 1279 melanoma patients, of which 2011 (82.2%) FNACs had clinically or histologically confirmed results. Increased size and/or palpability of nodes was observed in 376 (29.4%) of 1279 patients, and abnormal ultrasound findings occurred for 903 (70.6%), indicating that a biopsy was needed. FNACs guided by palpation had sensitivity, specificity, and positive and negative predictive values similar to that of FNACs guided by ultrasound (sensitivity = 98.4% vs 97.2%, specificity = 100% vs 99.8%, positive predictive value = 100% vs 99.9%, and negative predictive value = 95.2% vs 96.4%, for palpation-guided FNACs vs ultrasound-guided FNACs, respectively). Results did not differ between patients with the palpable nodes and patients with nonpalpable but sonomorphologically suspicious nodes.

CONCLUSIONS

Ultrasound-guided FNAC of suspicious lymph nodes and lesions in melanoma patients has a high sensitivity and specificity, and FNAC should not be limited to palpable nodes. FNAC of normal-sized nodes and/or lymph nodes with abnormal ultrasound findings can be used to identify early metastatic disease.

Critical analysis of the ultrasonographic criteria for diagnosing lymph node metastasis in patients with cutaneous melanoma: a systematic review

The purpose of this systematic review of the literature was to evaluate the use of ultrasonography (US) in the assessment of lymph node metastasis in patients with cutaneous melanoma. A multimodal strategy was used, which was mainly based on a PubMed database search. Among the 201 cumulative articles collected (years 1989-2009), 31 were found to match all of the inclusion criteria and to provide a description of the use of US scanning in lymph node melanoma metastasis. Data extracted included the author's name and country, journal and year of publication, prospective or retrospective nature of the study, single-center or multicenter nature of the study, period when US studies were performed, US transducers used, gray scale and color Doppler criteria used for diagnosis, and data on US accuracy. The diagnostic criteria used in the 31 selected articles were critically reviewed, illustrating to the reader the discrepancies and unclear aspects identified. On the basis of this review, the need to establish definitive, clearly defined, and univocal diagnostic criteria to be applied in daily clinical practice as well as to be used in articles to be published is emphasized.

Sonography for locoregional staging and follow-up of cutaneous melanoma: how we do it

OBJECTIVE

Sonography is being used with increasing frequency in the assessment of locoregional tumor spread in patients with melanoma. Nevertheless, to maximize its practical impact, sonography should be performed with state-of-the-art equipment, by specifically trained operators, and using a careful exploration technique and well-defined diagnostic criteria. In this "how I do it"-type article, we illustrate our practical approach to sonography of cutaneous melanoma.

METHODS

We first illustrate the basic and advanced technical requirements; then we describe our exploration methods and our image interpretation approach; and finally, we report on our use of sonography as a guidance tool for interventional procedures. Special emphasis is given to methodological and interpretative clues, tricks, and pitfalls.

RESULTS

Sonography can be used in the initial staging of patients with melanoma, particularly in the screening of patients scheduled for a sentinel lymph node biopsy procedure. Additionally, sonography can be used during patient follow-up to detect locoregional recurrence earlier than palpation.

CONCLUSIONS

Sonography plays a growing role in the assessment of the superficial spread of melanoma. Nevertheless, state-of-the-art equipment and careful exploration by trained operators are necessary.

Ultrasound morphology criteria predict metastatic disease of the sentinel nodes in patients with melanoma

PURPOSE We have shown that ultrasound (US) -guided fine needle aspiration cytology (FNAC) can accurately identify the sentinel node (SN). Moreover, US-guided FNAC before the surgical SN procedure could identify up to 65% of all SN metastases. Herein we analyzed in detail the different US morphologic patterns of SN metastases. PATIENTS AND METHODS From July 2001 to December 2007, a total of 650 patients with melanoma scheduled for sentinel lymph node dissection were examined. We present the first 400 with sufficient follow-up (mean 40, median 39 months). Several morphologic characteristics were scored. In case of suspicious/clearly malignant US patterns a FNAC was performed. The final histology was considered the gold standard. Results Median Breslow was 1.8 mm. The sensitivity and positive predictive value of the most important factors were: peripheral perfusion (PP) present (77% and 52%, respectively), loss of central echoes (LCE; 60% and 65% respectively), and balloon shape (BS; 30% and 96% respectively). Together these factors have a sensitivity of 82% and PPV of 52% (P < .001). PP identified more patients with lower volume disease. PP and combined BS and LCE were independent prognostic factors for survival (hazard ratio, 2.19; P < .015; and hazard ratio, 5.50; P < .001, respectively). CONCLUSION Preoperative US and FNAC can identify 65% of SN metastases and thus reduce the need for surgical SN procedures. Peripheral perfusion is an early sign of involvement and of crucial importance to achieve a high identification rate. Balloon shape and loss of central echoes are late signs of metastases. We recommend US evaluation to identify those patients, who can directly proceed to a complete lymph node dissection after a positive US-guided FNAC of the SN.

Sentinel node status prediction by four statistical models: results from a large bi-institutional series (n = 1132)

OBJECTIVE

To improve selection for sentinel node (SN) biopsy (SNB) in patients with cutaneous melanoma using statistical models predicting SN status.

SUMMARY BACKGROUND DATA

About 80% of patients currently undergoing SNB are node negative. In the absence of conclusive evidence of a SNBassociated survival benefit, these patients may be over-treated. Here, we tested the efficiency of 4 different models in predicting SN status.

METHODS

The clinicopathologic data (age, gender, tumor thickness, Clark level, regression, ulceration, histologic subtype, and mitotic index) of 1132 melanoma patients who had undergone SNB at institutions in Italy and Australia were analyzed. Logistic regression, classification tree, random forest, and support vector machine models were fitted to the data. The predictive models were built with the aim of maximizing the negative predictive value (NPV) and reducing the rate of SNB procedures though minimizing the error rate.

RESULTS

After cross-validation logistic regression, classification tree, random forest, and support vector machine predictive models obtained clinically relevant NPV (93.6%, 94.0%, 97.1%, and 93.0%, respectively), SNB reduction (27.5%, 29.8%, 18.2%, and 30.1%, respectively), and error rates (1.8%, 1.8%, 0.5%, and 2.1%, respectively).

DISCUSSION

Using commonly available clinicopathologic variables, predictive models can preoperatively identify a proportion of patients ( approximately 25%) who might be spared SNB, with an acceptable (1%-2%) error. If validated in large prospective series, these models might be implemented in the clinical setting for improved patient selection, which ultimately would lead to better quality of life for patients and optimization of resource allocation for the health care system.

Ultrasonography of the axilla in the follow-up of breast cancer patients who have a negative sentinel node biopsy and who avoid axillary clearance

The clinical value of ultrasonography of the axilla in detection of breast cancer recurrence is not known among patients who have a negative sentinel node biopsy and avoid axillary clearance. We studied a cohort of 205 such patients using ultrasonography one and three years after breast surgery. A recurrent tumour was found in the axilla in only two (0.5%) of the total of 383 ultrasound examinations performed during the study, and only one (0.3%) of the 369 examinations performed at the scheduled study visits revealed cancer. None of the ultrasound examinations was false positive, and no study participant was subjected to unnecessary surgery due to ultrasound monitoring. We conclude that the rate of breast cancer recurrence in the ipsilateral axilla is low following sparing of the axillary contents, and that monitoring of such patients with repeated ultrasound examinations is unlikely to be cost-effective.

Impact of Molecular Staging Methods in Primary Melanoma: Reverse-Transcriptase Polymerase Chain Reaction (RT-PCR) of Ultrasound-Guided Aspirate of the Sentinel Node Does Not Improve Diagnostic Accuracy, But RT-PCR of Peripheral Blood Does Predict Survival

Purpose

This study analyzes (1) the value of tyrosinase reverse-transcriptase polymerase chain reaction (RT-PCR) of aspirates obtained by ultrasound-guided fine-needle aspiration cytology (US-FNAC) of sentinel nodes (SNs) in patients with melanoma before sentinel lymph node biopsy (SLNB) and (2) the value of RT-PCR of blood samples of all SLNB patients.

Patients and Methods

Between 2001 and 2003, 127 patients with melanoma (median Breslow depth, 2.1 mm) underwent SLNB. FNAC was performed in all SNs of all patients pre- and post-SLNB. The aspirates were partly shock-frozen for RT-PCR and were partly used for standard cytology. Peripheral blood was collected at the time of SLNB and at every outpatient visit thereafter.

Results

Thirty-four (23%) of 120 SNs were positive for melanoma. SN involvement was predicted by US-FNAC with a sensitivity of 82% and a specificity of 72%. Additional tyrosinase RT-PCR revealed the same sensitivity of 82% and a specificity of 72%. At a median follow-up time of 40 months from first blood sample, peripheral-blood RT-PCR was a significant independent predictor of disease-free survival (DFS) and overall survival (OS; P < .001).

Conclusion

US-FNAC is highly accurate and eliminates the need for SLNB in 16% of all SLNB patients. RT-PCR of the aspirate or excised SN does not improve sensitivity or specificity. RT-PCR of blood samples predicts DFS and OS.

Ultrasound-guided fine needle aspiration cytology prior to sentinel lymph node biopsy in melanoma patients

BACKGROUND

Sentinel lymph node biopsy (SLNB) allows early detection of metastases, thereby enabling early treatment in melanoma patients likely to benefit from adjuvant therapies. This prospective study analyzes the possible benefits of additional ultrasound (US) and fine needle aspiration cytology (FNAC) of sentinel nodes (SN) prior to SLNB.

METHOD

Over a 2-year period 127 melanoma patients with 151 SN were scheduled for SLNB. All SN were initially identified with lymphoscintigraphy, then identified and evaluated by US and the cells aspirated for cytology (FNAC). US findings and FNAC results were compared to surgical findings.

RESULTS

Of 127 patients, 114 had one SN each, 12 had two, and one had three. In vivo US achieved a sensitivity of 79% (95% CI: 62-91%) and a specificity of 72% (95% CI: 62-81%). FNAC showed a sensitivity of 59% (95% CI: 41-76%) and a specificity of 100% (95% CI: 95-100%). The combination of these two in vivo methods achieved an overall sensitivity of 82% (95% CI: 65-93%) and an overall specificity of 72% [95% CI: 62-81%].

CONCLUSION

Combined US and FNAC provides important information prior to SLNB in that both procedures identify metastases in the lymph nodes (sensitivity > 80%). Patients with positive FNAC may proceed directly to complete lymph node dissection (cLND) instead of having initial SLNB. Thus, combined US and FNAC may prevent unnecessary anesthesia and surgical management as well reduce costs. In our study 16% (19/121) fewer SLNB procedures were carried out, subsequently replaced by cLND. For patients with a negative combination of in vivo US and FNAC, SLNB remains the best diagnostic option.

Ultrasound Mapping of Lymph Node and Subcutaneous Metastases in Patients with Cutaneous Melanoma: Results of a Prospective Multicenter Study

BACKGROUND

Ultrasound (sonography, B-mode sonography, ultrasonography) examination improves the sensitivity in more than 25% compared to the clinical palpation, especially after surgery on the regional lymph node area.

OBJECTIVE

To evaluate the distribution of metastases during follow-up in the draining lymph node areas from the scar of primary to regional lymph nodes (head and neck, supraclavicular, axilla, infraclavicular, groin) in patients with cutaneous melanoma with or without sentinel lymph node biopsy (SLNB) or former elective or consecutive complete lymph node dissection in case of positive sentinel lymph node (CLND). cv: Prospective multicenter study of the Departments of Dermatology of the Universities of Homburg/Saar, Tubingen and Munich (Germany) in which the distribution of lymph node and subcutaneous metastases were mapped from the scar of primary to the lymphatic drainage region in 53 melanoma patients (23 women, 30 men; median age: 64 years; median tumor thickness: 1.99 mm) with known primary, visible lymph nodes or subcutaneous metastases proven by ultrasound and histopathology during the follow-up.

RESULTS

Especially in the axilla, infraclavicular region and groin the metastases were not limited to the anatomic lymph node regions. In 5 patients (9.4%) (4 of them were in stage IV) lymph node metastases were not located in the corresponding lymph node area. 32 patients without former SLNB had a time range between melanoma excision and lymph node metastases of 31 months (median), 21 patients with SLNB had 18 months (p < 0.005). In 11 patients with positive SLNB the time range was 17 months, in 10 patients with negative SLNB 21 months (p < 0.005); in 32 patients with CLND the time range was 31 months and in 21 patients without CLND 18 months (p<0.005). In thinner melanomas lymph node metastases occurred later (p<0.05).

CONCLUSIONS

After surgery of cutaneous melanoma, SLNB and CLND the lymphatic drainage can show significant changes which should be considered in clinical and ultrasound follow-up examinations. Especially for high-risk melanoma patients follow-up examinations should be performed at intervals of 3 months in the first years. Patients at stage IV should be examined in all regional lynph node areas clinically and by ultrasound.

Follow-up in patients with localised primary cutaneous melanoma

Follow-up services for patients with localised cutaneous melanoma are widely discussed but there is no international consensus. Our aim was to discuss frequency and duration of follow-up, type of health professional involved, optimum intensity of routine investigation, and patients' satisfaction with follow-up. Searches of the published work were directed at publications between January, 1985, and February, 2004 on recurrences, subsequent primary melanoma, routine tests, and patients' satisfaction. In a selection of 72 articles, 2142 (6.6%) recurrences were reported, 62% of which were detected by the patients themselves. 2.6% of patients developed a subsequent primary melanoma. Most investigators do not support high-intensity routine follow-up investigations. Of the various follow-up investigations requested by physicians, only medical history and physical examination seem to be cost effective. Lymph-node sonography seems to be a promising method for detection, although survival benefit remains to be proven. Patients were found to be anxious about follow-up visits, although other research showed that provision of information to patients was much appreciated. Published work on the follow-up of patients with cutaneous melanoma has mainly been retrospective and descriptive. Recommendations can be given with only a low grade of evidence. For meaningful guidelines to be developed, prospective, high-quality methodological research is needed.

Ultrasonography or palpation for detection of melanoma nodal invasion: a meta-analysis

Because treatment of distant melanoma metastases is not very effective, nodal spread should be diagnosed early so that therapeutic lymphadenectomy can be started as early as possible. Physical examination alone often does not detect nodal metastases and palpable nodes cannot be clasified unambiguously. Whether lymph-node ultrasonography-an inexpensive procedure-improves detection of nodal invasion during the initial staging and follow-up of patients with melanoma is controversial. We used meta-analysis techniques for diagnostic tests to assess the merit of ultrasonography and palpation in detection of nodal invasion in patients with melanoma. Five databases were screened until December, 2003. 12 studies, including 6642 patients and 18?610 paired palpation and ultrasound examinations, were eligible. The main limitations were variations in the definition of false negatives, and verification bias. Ultrasonography had a higher discriminatory power (odds ratio 1755; 95% CI 726-4238) than did palpation (21 [4-111]; p=0.0001). Furthermore, positive-likelihood ratios were 41.9 (95% CI 29-75) for ultrasonography and 4.55 (2-18) for palpation; negative-likelihood ratios were 0.024 (0.01-0.03) and 0.22 (0.06-0.31), respectively. Our results showed clearly that ultrasonography detects lymph-node invasion more accurately than palpation, and should therefore probably be used routinely in patients with melanoma.

Melanoma - what is new in sentinel node biopsy and locoregional treatments in 2003? Report of a workshop at the Third Research Meeting on Melanoma, Milan, Italy, May 2003

This paper reports on the scientific session on sentinel node biopsy, surgery and locoregional treatments that took place during the Third Research Meeting on Melanoma, Milan, Italy, held in May 2003. It provides an overview of contributions presented at the meeting grouped according to subject - ultrasound scanning, sentinel node biopsy, mini-invasive surgery and stop-flow limb perfusion. The main comments made by the respective rapporteurs are also summarized.

Molecular detection of circulating tumor cells is an independent prognostic factor in patients with high-risk cutaneous melanoma

Detection of circulating tumor cells (CTCs) might improve current staging procedures by identifying a subgroup of patients with minimal residual disease and thus a higher risk of disease recurrence. Forty patients with > or =2-mm-thick cutaneous melanoma with or without lymph node metastasis were enrolled. After standard radical surgery and adjuvant therapy in case of lymph node metastasis, patients were followed up with routine physical and radiologic assessments as well as serial PCR-based analysis of CTCs using 2 melanoma markers (tyrosinase and Melan-A/Mart-1). After a median follow-up of 30 months, 18 patients had disease recurrence and 28 were PCR-positive before the disease became clinically evident. The sensitivity of the molecular test was 83%. Median time to PCR positivity and median PCR-to-relapse time were 12 and 8 months, respectively. At multivariate analysis, PCR positivity was an independent predictor of disease recurrence (hazard ratio=2.06, 95% CI 1.07-3.35; p=0.03). Among high-risk melanoma patients, serial PCR-based analysis of CTCs can identify a subgroup at higher risk of disease recurrence, with clinically significant advance. Therefore, CTC detection might be employed for the selection of patients for adjuvant treatment and during follow-up for early indication of therapeutic failure.

Malignant melanoma

In the European Community cutaneous melanoma accounts for 1 and 1.8% of cancers occurring in men and women, respectively. The incidence rate is increasing faster than that of any other tumour. Sun exposure, patient's phenotype, family history, and history of a previous melanoma are the major risk factors. The change over a period of months is the main sign of a skin lesion turned into a melanoma. The ABCDE scheme for early detection of melanoma is commonly accepted. A new staging classification will be published in the next AJCC/UICC Cancer Staging System Manual in 2002. The clinical course of melanoma is determined by its dissemination and depends on thickness, ulceration, localisation, gender and histology of the primary tumour. Tumour stage at diagnosis remains the major prognostic factor. Surgery is the standard treatment option for operable local-regional disease. Sentinel node biopsy represents a promising experimental approach in the clinical detection and early treatment of occult lymph node involvement. For metastatic inoperable patients systemic chemotherapy can be attempted, while radiation therapy has to be considered as palliative treatment. No studies concerning frequency of follow-up are currently available, but common procedures may be performed.

Value of ultrasonography compared with physical examination for the detection of locoregional metastases in patients with cutaneous melanoma

In several studies the early detection of locoregional metastases in patients with cutaneous melanomas has been shown to be of prognostic value. Physical examination alone often fails to detect locoregional metastases or cannot unambiguously classify palpable lymph nodes. This study aimed to evaluate the usefulness of high resolution ultrasonography for the early detection of locoregional metastases and to compare the sensitivity and specificity of ultrasound and physical examination. A prospective study was performed between January 1997 and June 1999 in 1395 patients (721 men and 674 women) with invasive cutaneous melanoma, treated and followed up at the Department of Dermatology and Allergology, Ludwig-Maximilian-University, Munich, Germany. A total of 2650 physical and ultrasound examinations of lymphatic drainage areas were performed, and lesions suspicious for metastases were excised and diagnosed by histopathology. The results of physical and ultrasound examinations were compared. Of the 2650 ultrasound examinations, metastases were suspected in 153, whereas 290 of the 2650 physical examinations were suspicious for metastatic disease. A total of 168 patients with suspicious lesions underwent surgery; histopathological examination revealed 112 melanoma metastases and 56 other diagnoses, including one second malignancy, one neurinoma, one haemangioma and 54 reactive lymph nodes. Ultrasonographic diagnosis of melanoma metastases had a sensitivity of 92.2% and a specificity of 98.2%, whereas diagnosis by physical examination had a sensitivity of only 51.3% and a specificity of 90.9%. Thus ultrasound examination was found to be highly effective and superior to physical examination for the early detection of locoregional melanoma metastases.

The role of ultrasound in detection and management of regional disease in melanoma patients

Melanoma follow-up programs are directed towards early detection of tumor recurrence. Because the majority of first relapses occur in the regional lymph node area, special focus is placed on this region using various techniques in addition to physical examination. During the last several years, particularly ultrasound B-scan has evolved as a technique of major importance for detection of such regional melanoma recurrences. The technique shows high sensitivity and specificity, discriminating regional or subcutaneous melanoma metastases from nonspecific nodes. Furthermore, suspicious findings can be evaluated quickly and reliably by the minimally invasive technique of ultrasound-guided fine-needle aspiration cytology (FNAC). For regional metastases located deeply or close to vulnerable structures, the new method of ultrasound-guided anchor-wire-marking facilitates subsequent surgery. In summary, ultrasound B-scan has become an essential technique in the follow-up of melanoma patients.

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.

Sentinel node biopsy and ultrasound scanning in cutaneous melanoma: clinical and technical considerations

1.5 mm and in all cases with two metastatic SNs, further positive additional nodes were found. The mean counts per 10 s (CP10S) ratio for SN and non-SN values was 5.62 (1.29-23.51) and 3.09 (1.03-10.99) in the intra-operative and extra-operative phases, respectively. US scanning and preoperative lymphoscintigraphy associated with PBD allows preoperative patient selection and accurate SN(s) identification. Breslow thickness and the number of metastatic SN(s), but not their type, are correlated with disease spread; CP10S contributed to the differentiation amongst the nodes and the determining of procedure's completion.

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).

Classification and staging of melanoma

Although a standardized and uniformly accepted cancer staging system is an essential and fundamental requirement to enable meaningful comparisons across patient populations, the sometimes capricious biologic behavior of melanoma makes developing such a staging system particularly difficult. Since the earliest well-documented attempts at classifying patients with cutaneous melanoma were described more than 50 years ago, the identification of increasingly powerful prognostic factors has led to sequential modifications of the cutaneous melanoma staging system. The current AJCC staging system is based on relatively well-established prognostic factors; however, several recent reports have identified additional prognostic factors not included in the current system, and other studies support the re-evaluation of some of the currently employed staging criteria. Some of the more controversial areas include the relevance of level of invasion versus tumor thickness, optimal cutoffs for tumor thickness, importance of ulceration, the grouping of satellites with in-transit metastases, the inclusion of microsatellites and local recurrences as a separate staging criterion, the replacement of size of nodal mass with number of positive nodes, the importance of nodal metastases in more than one nodal basin, and the prognostic significance of distant metastases. Therefore, future modifications of the staging system are anticipated to better incorporate these observations. Stage-specific staging recommendations for the patient with melanoma provide the clinician with a framework to most efficiently assess extent of disease in an era of cost-conscious clinical practice. In the asymptomatic patient with primary melanoma (stage I or II), we recommend a chest roentgenogram and evaluation of alkaline phosphatase and LDH levels; extensive radiologic evaluations are not indicated, because the rate of detection in this population is extremely low. Additional staging information should also be obtained by the technique of lymphatic mapping and sentinel lymphadenectomy. For patients with local-regional disease (stage III, satellites, and local recurrence), a selective approach to imaging studies is warranted. For this patient population, we recommend complete blood count, liver function tests including alkaline phosphatase and LDH, a chest roentgenogram, and a CT scan of the abdomen. Although the yield of these tests, particularly CT of the abdomen, in detecting distant metastases in asymptomatic patients is low, they may identify false-positive abnormalities and provide an important baseline for future studies in this high-risk population. For patients with disease below the waist or in the head and neck region, we recommend CT of the pelvis and CT of the neck, respectively. Additional studies should be done only if clinically indicated. Finally, patients with known systemic disease (stage IV) should be more comprehensively evaluated, because the likelihood of detecting asymptomatic metastases is higher. Accordingly, in addition to the work-up outlined previously for stage III patients, we also perform a CT scan of the chest and MR imaging of the brain; other studies (e.g., bone scan, gastrointestinal series) are performed on the basis of symptoms.

Computed tomography for the detection of neck node metastases in melanoma patients

AIMS

To assess the value of CT scanning for detection of lymph node metastases in the neck.

METHODS

The appearance and site of the metastases was studied, as well as the sensitivity and specificity of CT.

RESULTS

Nodal metastases did not always show a high contrast uptake and nodal density therefore cannot be used as a criterion for metastasis. Irregular contrast enhancement was seen in seven of the 21 tumour-positive necks. Frequently, metastases in the parotids, superficial nodes in the neck and in the posterior triangle were seen. The sensitivity and specificity of palpation and CT scanning were 87 and 100%, respectively.

CONCLUSIONS

However, because small, clinically occult, melanoma metastases were frequently overlooked on CT, the role of this imaging modality in assessing occult metastases remains limited. Based on recent data from literature it is reasonable to speculate that ultrasound guided fine needle aspiration cytology (FNAC) will prove to be more effective than a non-invasive staging procedure of the neck in melanoma patients.

Principles and guidelines for surgeons: management of cutaneous malignant melanoma. European Society of Surgical Oncology Brussels

This article outlines and discusses the principles of the guidelines for the management of malignant melanoma by surgeons. The guidelines are based, in large part, on the consensus of the Dutch Melanoma Working Party that was revised in 1997. The article reflects internationally accepted treatment principles that have arisen both from critical assessment of existing evidence and data, and from the outcome of randomized studies.

Management of cutaneous melanoma M0: state of the art and trends

This article reviews the epidemiology, diagnosis and treatment of cutaneous melanoma, including the most recent developments. The combination of positive family history, fair complexion, number of nevi, exposure to sun and/or chromosomal alterations seem to be implicated in the pathogenesis of cutaneous melanoma. Melanomas can be classified according to their growth patterns, and tumour microstaging is of straightforward predictive value for survival and risk of metastasis, although new factors are also being investigated. As yet, surgical excision is the only effective treatment available for primary tumours, resection margins varying according to tumour thickness. Elective node dissection is, however, no longer advocated for melanomas thinner than 1.5 mm, and there is disagreement as to its role for thicker lesions. In contrast, selective node dissection at the time of definitive surgery is becoming more widely accepted, with regional node dissection being restricted to positive cases. Therapeutic dissection is required for lymph node involvement, the most common pattern of recurrence from melanoma, which affects nearly 30% of all patients. Complete remission rates from isolated limb perfusion, which has been employed in patients with multiple recurrences or in-transit metastases, range from 40 to 90%, depending on drugs and techniques used in different series; the best responses so far have been obtained with tumour necrosis factor in combination with melphalan. Patients with thick lesions (> 4 mm) or lymph node metastases have a high risk of micrometastases that would warrant adjuvant therapy. The only agent found to affect survival is interferon alpha-2.