Using the Merlin assay for reducing sentinel lymph node biopsy complications in melanoma: a retrospective cohort study

BACKGROUND

The assessment of the sentinel lymph node is a cornerstone of melanoma staging. However, ~80% of sentinel lymph node biopsies (SLNB) are negative and nontherapeutic, and patients are unnecessarily exposed to surgery-related complications. Here, we gauged the potential of the Merlin assay to reduce SLNB-associated complications. The Merlin assay uses clinicopathologic variables and tumor gene expression profiling to identify low-risk patients who may forgo SLNB.

METHODS

We utilized the Merlin test development cohort to determine SLNB complication rates for procedures performed between 2004 and 2018 at Mayo Clinic. Complications evaluated were lymphedema, seroma, infection/cellulitis, hematoma, and wound dehiscence. Patients who underwent a completion lymph node dissection were excluded.

RESULTS

A total of 558 patients were included. The overall 90-day complication rate specific to SLNB (1 year for lymphedema) was 17.4%. The most common complications were seroma (9.3%), infection/cellulitis (4.8%), and lymphedema (4.3%). All three were more common in patients with a lower extremity primary tumor location versus other locations. With Merlin test results applied, SLNB-related complications would have decreased by 59%.

CONCLUSION

SLNB is a safe procedure but carries a significant complication rate. Merlin testing might reduce the need for SLNB and its associated complications.

Incidence and risk factor analysis of complications after sentinel node biopsy for penile cancer

BACKGROUND

Surgical staging is recommended in intermediate to high risk clinically node negative (cN0) penile cancer (PeCa). Because (modified) inguinal lymph node dissection (ILND) is associated with high morbidity, dynamic sentinel node biopsy (DSNB) was introduced with the aim to reduce morbidity while maintaining diagnostic accuracy.

OBJECTIVE

To determine the incidence and types of complications after DSNB and identify risk factors for the occurrence of postoperative complications.

PATIENTS AND METHODS

We evaluated 644 PeCa patients (1284 DSNB procedures) with at least one cN0 groin who underwent DSNB between 2011 and 2020 at a single high-volume centre. 30-day and 30-90-day postoperative complications were collected according to the modified Clavien Dindo classification and the standardized methodology proposed by the European Association of Urology panel. Univariable and multivariable generalized linear mixed models were used to identify risk factors for the occurrence of complications per groin.

RESULTS

A 30-day postoperative complication occurred in 14% of groins (n=186), of which 94% were mild to moderate. Wound infection and lymphocele formation were most common. 30-90-day postoperative complications occurred in 3.4% of the groins, all of which were mild or moderate (grade 1-2). The number of removed LNs per groin was the main independent predictor for any 30-day complications and grade≥2 complications (OR 1.40; p<0.001). An increase in the probability of postoperative complications with the number of LNs removed was observed after accounting for all confounders.

CONCLUSIONS

Despite being less morbid than (modified) ILND, DSNB is still associated with a considerable risk of mild to moderate postoperative complications. This risk increases with an increasing number of LNs removed. Further procedural refinement aimed at removing the true sentinel node(s) only, may help further reduce the morbidity of surgical staging in PeCa.

Absolute and relative differential blood count predicts survival of AJCC stage I-II melanoma patients scheduled for sentinel lymph node biopsy

BACKGROUND/OBJECTIVES

Elevated neutrophil-to-lymphocyte ratio (NLR) in peripheral blood is associated with poor overall survival (OS) in metastatic melanoma patients receiving immunotherapy. However, the impact of peripheral blood cells in patients undergoing sentinel lymph node biopsy (SLNB) is still unclear. This study was intended to characterize the impact of peripheral blood leukocytic cells on overall survival (OS) in melanoma patients undergoing SLNB.

METHODS

A total of 1412 AJCC stage I-II melanoma patients scheduled for SLNB at a single institution in the period 2010-2015 with available perioperative blood tests were randomly assigned to two independent cohorts. Associations of peripheral blood leukocytes with OS were analysed using Kaplan-Meier estimator and multivariate Cox proportional hazards model.

RESULTS

NLR >4.26, absolute neutrophil count >5800/µL, relative neutrophil count >69.7% and relative lymphocyte count ≤ 17.5% were significantly associated with reduced OS in both cohorts. Absolute monocytes >810/µL, absolute eosinophils ≤200/µL, relative monocytes >6.6%, relative eosinophils ≤2.7% and relative basophils ≤0.6% were significantly associated with reduced OS in one cohort each. On multivariate analysis, a combined score including absolute levels of neutrophils, lymphocytes, monocytes and eosinophils was significantly associated with OS in both cohorts. The hazard ratio of patients with a risk score of 3-4 was 5.42 (95% confidence interval: 1.52-19.42, P = 0.0094) in cohort 1 and 9.42 (2.06-43.06, P = 0.0038) in cohort 2, respectively.

CONCLUSIONS

We conclude that peripheral blood leukocytes are independently associated with OS in stage I-II melanoma patients and should be considered as prognostic markers in these patients. Eosinophils and basophils deserve more attention in future investigations.

Complications and Sequelae After Sentinel Lymph Node Biopsy in Melanoma: A Retrospective Cohort Study

BACKGROUND AND OBJECTIVE

Sentinel lymph node (SLN) biopsy is a staging, not a therapeutic, procedure. The benefits of SLN biopsy have been more modest than expected and could be outweighed by the risks, which remain unclear. The aim of this study was to describe complications and sequelae observed in patients with melanoma who underwent routine SLN biopsy at our hospital.

PATIENTS AND METHODS

In this retrospective cohort study, we performed a chart review of all patients with melanoma who underwent SLN biopsy at our hospital in Vigo, Spain, between January 2011 and July 2017.

RESULTS

In the period analyzed, 124 SLN biopsies were performed. Over a mean follow-up of 52.7 months (range 10.8-88.7 months). A percentage of 37.9 of the patients experienced complications. The complication rate after excluding patients who underwent lymph node dissection was 30.9%. In the full chort group, there were 14 scar-related complications (11.3%), 13 surgical wound infections (10.5%), 12 lymphedemas (9.7%), 11 seromas (8.9%), 4 hematomas (3.2%), 4 wound dehiscences (3.2%), 2 cases of lymphorrhagia (1.6%), 2 cases of sensitivity alteration (1.6%), and one urinary tract infection (0.8%). The most common sequela was lymphedema. Sequelae were on record for 15.3% of patients in the full cohort (7.5% of the patients who did not undergo lymphadenectomy). Smoking was associated with a 33 to 73% increased risk of complications. The main limitation of this study is the risk of information bias due to incomplete follow-up.

CONCLUSIONS

SLN biopsy is a melanoma staging procedure that causes complications and sequelae. Recommendations for its use in clinical practice guidelines should be revised and the risks and benefits carefully evaluated in each case. Smokers in particular seem to have a high risk of complications. Patients with melanoma could benefit greatly from the development of less invasive staging tools.

Assessment of morbidity following regional nodal dissection in the axilla and groin for metastatic melanoma

BACKGROUND

This study assessed and compared the morbidity of nodal dissection in the axilla and groin including sentinel lymph node biopsy (SLNB), completion lymph node dissection for a positive SLNB (CLND) and therapeutic lymph node dissection (TLND) with and without adjuvant radiotherapy (RT).

METHODS

Patients who had nodal dissection in the axilla or groin for cutaneous melanoma over an 18-year period (1995-2013) were prospectively documented on a database. The median follow-up was nearly 3 years. Early complications and clinically relevant lymphoedema were retrospectively analysed to assess the incidence and differences between the region and type of nodal surgery.

RESULTS

Included were 1521 patients following nodal dissection in the axilla (916 patients) and groin (605 patients). Less early complications occurred following SLNB in the axilla compared with the groin (5% versus 14%, P = 0.0001). Early complications were similar for CLND and TLND in the groin (49% versus 43%, P = 0.879) and axilla (28% versus 33%, P = 0.607). Moderate to severe lymphoedema rates were similar following axillary SLNB and CLND (6% versus 8%, P = 0.407). The lymphoedema rate for groin SLNB was lower than CLND (10% versus 20%, P = 0.063). No significant difference in lymphoedema rates followed CLND and TLND in each region. Following TLND, RT increased lymphoedema rates.

CONCLUSIONS

Morbidity may occur following SLNB with the groin having a higher rate of early complications and lymphoedema compared with the axilla. The morbidity following CLND and TLND were similar. Lymphoedema rates were increased following RT.

Clinical Usefulness of a Novel Freehand 3D Imaging Device for Radio-Guided Intraoperative Sentinel Lymph Node Detection in Malignant Melanoma

INTRODUCTION

Patients with invasive malignant melanoma are commonly referred for sentinel lymph node (SLN) detection. A recently proposed 3D tomographic imaging modality is freehand SPECT (declipseSPECT). This "bedside system" was originally developed to enable minimal-invasive image-guided surgery. The aim of this retrospective analysis was to assess the clinical use of this freehand detector device for image-guided lymphatic mapping in melanoma patients.

MATERIALS AND METHODS

Thirty-nine patients (12 female and 27 male subjects) were included (age, 30-79 years). All of them had at least one location of melanoma with tumoral stage pT1b or greater in 37 and pTx in 2 patients in different sites of the body (abdomen in 4, back in 14, head and neck in 5, lower extremity in 6, and upper extremity in 10 patients). Lymphoscintigraphy was performed with 65 to 127 MBq Tc-nanocolloid. A 2-day protocol was applied with SPECT-CT acquisition (Brightview XCT, Philips) at day 1 and surgery using radio-guided freehand SPECT at day 2. SPECT-CT data were integrated into the 3D navigation system to enable fast and direct localization of the SLN by displaying the depth of the node from the skin surface and lateral margins in relation to the gamma probe.

RESULTS

Comparable preoperative imaging and intraoperative localization was observed in 18 patients. In 14 cases, more lymph nodes were resected than detected by SPECT-CT including 1 patient without evidence of an SLN because this node was located close to the primary right ear tumor. In 10 of these patients, intraoperative freehand SPECT revealed additional sites of lymph nodes. In 7 cases, more findings were detected by SPECT-CT than surgically removed. The procedure was safe and easy to perform, and the time of surgical intervention using freehand SPECT was in the range of 36 to 133 minutes (mean time, 66.56 minutes).

CONCLUSIONS

Freehand SPECT detected more SLN compared with SPECT-CT, and the tracking system provided precise anatomical localization of the radioactive-labeled SLNs.

High expression of FOXP3 in primary melanoma is associated with tumour progression

BACKGROUND

The antitumour immune response plays an important role in the prognosis of melanoma. High numbers of circulating regulatory T cells have been associated with rapid disease progression.

OBJECTIVES

To assess the influence of forkhead box protein (FOXP)3, CD1a and langerin expression on the prognosis of primary melanoma.

METHODS

We analysed 185 primary melanomas by immunohistochemical staining for expression of the regulatory T-cell marker FOXP3 and the dendritic cell markers langerin and CD1a, and correlated marker expression with clinical outcome.

RESULTS

Disease-free survival and overall survival were significantly longer in patients expressing low levels of FOXP3 in the primary melanoma, whereas they were associated with high expression of CD1a. The negative prognostic value of FOXP3 expression was independent of the Breslow tumour thickness. Langerin expression did not correlate with the clinical outcome.

CONCLUSIONS

High expression of FOXP3 in the primary melanoma may be used as an additional independent prognostic marker for early tumour progression in patients with melanoma.

Melanoma of the Hand: Current Practice and New Frontiers

Melanoma of the hand represents a complicated clinical entity. Anatomic features of the hand create challenges in successful management of melanoma not encountered elsewhere in the body. The objectives of this article are to outline current standards for managing melanoma of the hand including diagnosis, surgical, and chemotherapeutic management. Particular emphasis will be placed on currently debated topics of the role of sentinel lymph node biopsy, the role of Mohs micrographic surgery, tissue sparing management of subungual melanoma, and the consideration of melanoma of the hand as a distinct entity based on clinical and molecular studies.

Transferring innovative freehand SPECT to the operating room: first experiences with sentinel lymph node biopsy in malignant melanoma

PURPOSE

The purpose of this study was to report on the first experiences with freehand single-photon emission-computed tomography (freehand SPECT) in sentinel lymph node biopsy (SLNB) in patients with malignant melanoma. Freehand SPECT is a novel imaging modality combining gamma probes, surgical navigation systems, and emission tomography algorithms, designed to overcome some of the limitations of conventional gamma probes.

METHODS

In this study 20 patients with malignant melanoma underwent conventional planar scintigraphy prior to surgery. In the operating room, the number and location of separable SLNs were detected first by a pre-incisional scan with freehand SPECT to render a 3D-image of the target site and afterwards by a scan with a conventional gamma probe. After SLNB another scan was performed to document the removal of all targeted SLNs.

RESULTS

Planar scintigraphy identified 40 SLNs in 26 nodal basins. Pre-incisional freehand SPECT mapped 38 of these nodes as well as one additional node in one patient (95.0% node based sensitivity). The results of freehand SPECT were identical to those of planar scintigraphy in 25 basins, while it missed one basin (96.2% basin based sensitivity). In comparison, the gamma probe failed to detect 7 nodes in 4 basins (82.5% node based sensitivity and 84.6% basin based sensitivity). After resection freehand SPECT detected 9 remaining radioactive spots, two of whichwere resected as they matched the position of SLNs detected on preoperative planar scintigraphy.

CONCLUSIONS

Freehand SPECT provides a real-time, intraoperative 3D-image of the radioactive labelled SLNs, facilitating their detection and resection.

First Experiences with Navigated Radio-Guided Surgery Using Freehand SPECT

Background

Sentinel lymph node biopsy (SLNB) in melanoma using one-dimensional gamma probes is a standard of care worldwide. Reports on the performance are claimed by most groups to successfully detect the SLNs during the surgical procedure in almost 100% of the patients. In clinical practice, however, several issues remain which are usually not addressed: the difficulty of intraoperative detection of deeply located nodes, SLN detection in obese patients or in the groin and the impossibility to make a scan of the entire wound after SLN resection to avoid false negative testing for eventually remaining SLNs.

Materials and Methods

The concept behind freehand SPECT is to combine a gamma probe as used for conventional radio-guided surgery with a tracking system as used in neurosurgical navigation. From this combination and a proper algorithm framework the 3D reconstruction of radioactivity distributions and displaying these intraoperatively is possible.

Conclusion

In summary, the feasibility of freehand SPECT could be shown and provides an image-guided SLNB and a truly minimally invasive and optimized surgical procedure.