Head and neck cutaneous melanoma: a retrospective observational study on 146 patients

Clinicopathological and prognostic value of Ki-67 expression in oral malignant melanoma: A systematic review and meta-analysis

Background. Ki-67 is one of the new biological markers with clinical value in the pathology and prognosis of oral melanoma. It is a nuclear protein involved in regulating cell proliferation. Some studies have suggested an association between Ki-67 and poor survival in patients with oral melanoma. This systematic review was undertaken to clarify this issue. Methods. Databases of PubMed, Scopus, and Web of Science were searched using relevant English keywords from 1988 to April 2022. STATA software version 16 and random models were used for meta-analysis. Results. Eleven articles were included in this systematic review, six of which were selected for meta-analysis. The mean expression of the Ki-67 index in patients with oral melanoma was estimated at 43.81% (28.66‒58.95 with 95% CI, I²=94.2, P<0.001). In addition, the results showed a significant relationship between Ki-67 expression and the prognosis of oral melanoma lesions. Increased expression of this marker weakens the prognosis and decreases the survival rate. Conclusion. High expression of Ki-67 may serve as a predictive biomarker for poor prognosis in patients with malignant oral melanoma. Therefore, classifying this malignancy by Ki-67 expression may be considered for therapy regimen selection and integrated management.

Compliance with sentinel lymph node biopsy guidelines for invasive melanomas treated with Mohs micrographic surgery

BACKGROUND

Sentinel lymph node biopsy (SLNB) has not been studied for invasive melanomas treated with Mohs micrographic surgery using frozen-section MART-1 immunohistochemical stains (MMS-IHC). The primary objective of this study was to assess the accuracy and compliance with National Comprehensive Cancer Network (NCCN) guidelines for SLNB in a cohort of patients who had invasive melanoma treated with MMS-IHC.

METHODS

This retrospective cohort study included all patients who had primary, invasive, cutaneous melanomas treated with MMS-IHC at a single academic center between March 2006 and April 2018. The primary outcomes were the rates of documenting discussion and performing SLNB in patients who were eligible based on NCCN guidelines. Secondary outcomes were the rate of identifying the sentinel lymph node and the percentage of positive lymph nodes.

RESULTS

In total, 667 primary, invasive, cutaneous melanomas (American Joint Committee on Cancer T1a-T4b) were treated with MMS-IHC. The median patient age was 69 years (range, 25-101 years). Ninety-two percent of tumors were located on specialty sites (head and/or neck, hands and/or feet, pretibial leg). Discussion of SLNB was documented for 162 of 176 (92%) SLNB-eligible patients, including 127 of 127 (100%) who had melanomas with a Breslow depth >1 mm. SLNB was performed in 109 of 176 (62%) SLNB-eligible patients, including 102 of 158 melanomas (65%) that met NCCN criteria to discuss and offer SLNB and 7 of 18 melanomas (39%) that met criteria to discuss and consider SLNB. The sentinel lymph node was successfully identified in 98 of 109 patients (90%) and was positive in 6 of those 98 patients (6%).

CONCLUSIONS

Combining SLNB and MMS-IHC allows full pathologic staging and confirmation of clear microscopic margins before reconstruction of specialty site invasive melanomas. SLNB can be performed accurately and in compliance with consensus guidelines in patients with melanoma using MMS-IHC.

Indocyanine Green Fluorescence Imaging with Lymphoscintigraphy Improves the Accuracy of Sentinel Lymph Node Biopsy in Melanoma

BACKGROUND

Despite advances in melanoma management, there remains room for improvement in the accuracy of sentinel lymph node biopsy. The authors analyzed a prospective cohort of patients with primary cutaneous melanoma who underwent sentinel lymph node biopsy with lymphoscintigraphy and indocyanine green fluorescence to evaluate the quality and accuracy of this technique.

METHODS

Consecutive primary cutaneous melanoma patients who underwent sentinel lymph node biopsy with radioisotope lymphoscintigraphy and indocyanine green fluorescence from 2012 to 2018 were prospectively enrolled. Analysis was performed of melanoma characteristics, means of identifying sentinel lymph nodes, sentinel lymph node status, and recurrence.

RESULTS

Five hundred ninety-four melanomas and 1827 nodes were analyzed; 1556 nodes (85.2 percent) were identified by radioactivity/fluorescence, 255 (14 percent) by radioactivity only, and 16 (0.9 percent) with indocyanine green only. There were 163 positive sentinel nodes. One hundred forty-seven (90.2 percent) were identified by radioactivity/fluorescence, 13 (8 percent) by radioactivity only, and three (0.6 percent) with fluorescence only. Of the 128 patients with a positive biopsy, eight patients' (6.3 percent) nodes were identified by radioactivity only and four (3.4 percent) with fluorescence only. There were 128 patients with a positive biopsy, 454 with a negative biopsy, and 12 patients who had a negative biopsy with subsequent nodal recurrence. Mean follow-up was 2.8 years.

CONCLUSIONS

In the study of the largest cohort of patients with primary cutaneous melanoma who underwent a sentinel lymph node biopsy with radioisotope lymphoscintigraphy and indocyanine green-based technology, the quality and accuracy of this technique are demonstrated. This has important implications for melanoma patients, as the adoption of this approach with subsequent accurate staging, adjuvant workup, and treatment may improve survival outcomes. .

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

Sentinel lymph node biopsy in head and neck cutaneous melanomas: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Head and neck melanomas (HNMs) behave differently from cutaneous melanomas in other sites, and the efficacy of sentinel lymph node biopsy (SLNB) for patients with HNMs remains controversial.

METHODS

Studies on prognosis following SLNB were included. The prognostic role of SLNB and other potential predictors were analyzed using pooled relative risk (RR) or hazard ratio (HR).

RESULTS

Pooled statistics showed that SLNB improved overall survival of HNMs patients (HR = 0.845; 95% CI: 0.725-0.986; P = .032). The positive status of SN was proved as a risk factor of poor prognosis in HNMs (HR = 3.416; 95% CI: 1.939-6.021; P < .001). SLNB did not have significant correlation with lower recurrences (RR = .794; 95% CI: 0.607-1.038; P = .091).

CONCLUSIONS

SLNB is associated with better overall survival and the SN status is a promising risk factor of poor prognosis for HNMs patients.

Patterns of recurrence and retreatment outcomes among clinical stage I and II head and neck melanoma patients

BACKGROUND

The objective of this study was to determine survival outcomes in patients who underwent retreatment of recurrent cases of cutaneous melanoma of the head and neck (CMHN).

METHODS

Retrospective review of all patients who were treated for primary clinical stage I or II CMHN between January 1, 2000 and December 31, 2015.

RESULTS

Twenty percent (33/168) of the patients developed a recurrence. Sixty-six percent (4/6) of patients who developed local recurrence first and 50% (3/6) of patients who developed regional recurrence first were alive without evidence (NED) of disease at last follow-up, while 0% (0/21) of patients who developed distant or simultaneous recurrences first were NED at last follow-up. Among the 7 patients who were NED, the mean time from recurrence to last follow-up was 735 days.

CONCLUSIONS

Of patients with isolated local or regional recurrences, 58% (7/12) obtained durable curative treatment for recurrent melanoma.

Sentinel lymph node biopsy staging for cutaneous malignant melanoma of the head and neck

Conclusion Sentinel lymph node biopsies (SLNBs) can be performed safely and with reasonable accuracy in HNM patients. The outcome provides important prognostic information concerning DFS and further treatment. However, one must recognize that SLNB is a multidisciplinary procedure with a learning curve for all. Objectives To evaluate efficacy of performing SLNBs in a series of consecutive patients with cutaneous head and neck melanoma (HNM) ≥ T1b from introduction of the procedure and 10 years onward. Method End-points comprised of SLNB outcome, disease-free survival (DFS), and overall survival (OS). Results SNs were harvested in 128 of 160 patients (median Breslow = 2.0 mm, 29% ulcerated); success rate = 80.0%, or 92.1% if excluding patients where SLNBs were omitted due to non-localization on pre-operative imaging or because of SN-location in the parotid basin. Ten patients (7.8%) had positive SLNBs and were offered early completion neck dissections. Of the 146 patients available for follow-up (median = 27 months), 15.8% had recurrent disease. The risk of a regional nodal recurrence after a negative SLNB was 7.5%. SN-negative patients had improved DFS c.f. SN-positive patients (p < 0.001). A positive SLNB was the most important prognostic predictor of decreased DFS (hazard ratio = 5.70; p < 0.005), but had no significant impact on OS.

Detecting near-the-injection-site sentinel nodes in head and neck melanomas with a high-resolution portable gamma camera

BACKGROUND

In head/neck melanomas, near-the-injection-site sentinel nodes (NIS-SNs) may be missed on planar lymphoscintigraphy and/or SPECT/CT. The aim of the present study is to establish the performance of a portable gamma camera (PGC) to detect NIS-SNs in a simulation phantom set-up, and subsequently in head/neck melanoma patients scheduled for a SN procedure.

METHODS

Five plastic Eppendorf tubes filled with technetium-99m-albumin nanocolloid were used to simulate 4 radiotracer deposit sites, as traditionally injected in melanoma patients, and 1 NIS-SN. A PGC was used with 2 pinhole collimators (2.5 and 4.0 mm). Image acquisition time was 1 minute with the camera positioned at various distances (range 1.5-15.5 cm). Results were compared with conventional lymphoscintigraphy and SPECT/CT acquired with a dual-head gamma camera as well with a gamma probe. Additionally, the same PGC setting was used in a case series of 3 patients with head/neck melanomas.

RESULTS

The simulated NIS-SN was differentiated from the injection site at a distance of 3 mm with the 2.5-mm pinhole and at 5 mm with the 4-mm pinhole when the PGC was positioned at 1.5 cm distance. Planar lymphoscintigraphy, SPECT/CT, and the gamma probe depicted the NIS-SN separated from the injection site at distances of 7, 10, and 22 mm, respectively. In all 3 patients, 6 NIS-SNs were depicted with the PGC.

CONCLUSION

A high-resolution PGC, positioned close to the skin, is able to detect SNs at distances of at least 3 mm from the injection site. A further clinical evaluation of this device to establish its added value in reducing false-negative procedures and potential recurrences is necessary.

Accuracy and prognostic value of sentinel lymph node biopsy in head and neck melanomas

BACKGROUND

Debate remains around the accuracy and prognostic implications of sentinel lymph node biopsy (SLNB) for melanoma arising in the head and neck (HN) areas because several analyses have shown discordances between clinically predicted lymphatic drainage pathways and those identified by lymphoscintigraphy. This study assesses the accuracy and prognostic value of SLNB in this critical anatomic region.

METHODS

Retrospective review of a prospectively collected melanoma database identified 331 patients with HN melanomas from January 2000 to December 2012. Primary end points included SLNB result, time to recurrence, site of recurrence, and survival. Multivariate models were constructed for analyses.

RESULTS

A sentinel lymph node (SLN) was identified in all 331 patients. There were 59 patients with a positive SLN (17.8%) with a recurrence rate of 88.1% compared with 22.4% in SLN-negative patients (P < 0.0001). The 5-y overall survival was 91.2% for SLN-negative patients and 48.7% for SLN-positive patients (P < 0.0001). Patients with scalp melanoma had thicker lesions and an elevated risk of SLN positivity, recurrence, and death compared with those with other sites. Among the 272 SLN-negative patients, four patients developed regional nodal disease in the same basin and had undergone a previous SLNB procedure for a false-omission rate of 1.45%. Risks for false-negative SLN occurrences included thick and scalp melanomas. Multivariate analysis on prognostic factors affecting relapse-free survival showed positive SLNB status to be the most prognostic clinicopathologic predictor of recurrence (hazard ratio, 20.56; P < 0.0001).

CONCLUSIONS

SLNB for patients with HN melanomas is an accurate procedure and has prognostic value.

Local lymph node micrometastasis in a patient with negative sentinel lymph node biopsies after lymphatic mapping with wide local excision of primary melanoma on the head/neck area

Sentinel lymph node biopsy is widely accepted as a staging procedure for patients with cutaneous melanoma who are at risk for metastases. The complex lymphatic drainage pattern on the head and neck makes sentinel lymph node mapping more challenging compared with other sites. Here, we report a patient who underwent reexcision of the primary tumor site with lymphatic mapping on the right posterior auricular area. Four sentinel nodes were negative for melanoma metastasis; however, step sectioning of the wide local excision of the primary tumor site revealed a small lymph node with histopathologic detection of micrometastasis. Our findings highlight the importance of a careful histopathologic approach that may have prognostic impact on outcome and survival.

Sentinel lymph node biopsy is accurate and prognostic in head and neck melanoma

BACKGROUND

Sentinel lymph node biopsy (SLNB) has emerged as a widely used staging procedure for cutaneous melanoma. However, debate remains around the accuracy and prognostic implications of SLNB for cutaneous melanoma arising in the head and neck, as previous reports have demonstrated inferior results to those in nonhead and neck regions. Through the largest single-institution series of head and neck melanoma patients, the authors set out to demonstrate that SLNB accuracy and prognostic value in the head and neck region are comparable to other sites.

METHODS

A prospectively collected database was queried for cutaneous head and neck melanoma patients who underwent SLNB at the University of Michigan between 1997 and 2007. Primary endpoints included SLNB result, time to recurrence, site of recurrence, and date and cause of death. Multivariate models were constructed for analyses.

RESULTS

Three hundred fifty-three patients were identified. A sentinel lymph node was identified in 352 of 353 patients (99.7%). Sixty-nine of the 353 (19.6%) patients had a positive SLNB. Seventeen of 68 patients (25%) undergoing completion lymphadenectomy after a positive SLNB result had at least 1 additional positive nonsentinel lymph node. Patients with local control and a negative SLNB failed regionally in 4.2% of cases. Multivariate analysis revealed positive SLNB status to be the most prognostic clinicopathologic predictor of poor outcome; hazard ratio was 4.23 for SLNB status and recurrence-free survival (P < .0001) and 3.33 for overall survival (P < .0001).

CONCLUSIONS

SLNB is accurate and its results are of prognostic importance for head and neck melanoma patients.

Sentinel Node Biopsy for Head and Neck Melanoma

Objective. This systematic review was conducted to examine the test performance of sentinel node biopsy in head and neck melanoma, including the identification rate and false-negative rate.

Data Sources. PubMed, EMBASE, ASCO, and SSO database searches were conducted to identify studies fulfilling the following inclusion criteria: sentinel node biopsy was performed, lesions were located on the head and neck, and recurrence data for both metastatic and nonmetastatic patients were reported.

Review Methods. Dual-blind data extraction was conducted. Primary outcomes included identification rate and test performance based on completion neck dissection or nodal recurrence.

Results. A total of 3442 patients from 32 studies published between 1990 and 2009 were reviewed. Seventy-eight percent of studies were retrospective and 22% were prospective. Trials varied from 9 to 755 patients (median 55). Mean Breslow depth was 2.53 mm. Median sentinel node biopsy identification rate was 95.2%. More than 1 basin was reported in 33.1% of patients. A median of 2.56 sentinel nodes per patient were excised. Sentinel node biopsy was positive in 15% of patients. Subsequent completion neck dissection was performed in almost all of these patients and revealed additional positive nodes in 13.67%. Median follow-up was 31 months. Across all studies, predictive value positive for nodal recurrence was 13.1% and posttest probability negative was 5%. Median false-negative rate for nodal recurrence was 20.4%.

Conclusion. Sentinel node biopsy of head and neck melanoma is associated with an increased false-negative rate compared with studies of non–head and neck lesions. Positive sentinel node status is highly predictive of recurrence.