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.

Lymphovenous Anastomoses and Microscopic Lymphatic Ligations for the Treatment of Persistent Lymphocele

Numerous approaches have been employed to treat chronic lymphocele and cutaneous lymphatic fistulas (LFs) with little success. Given a high incidence and substantial consequences for patients, there is an ongoing demand for effective therapeutic and preventive strategies. The aim of this study was to evaluate the results after microscopic lymphatic ligation (MLL) and lymphovenous anastomosis (LVA) as a therapeutic and preventive approach in this context.

Methods

Demographic data, surgical characteristics, complications, and the overall outcome of all patients undergoing surgery for postoperative LF from 2014 to 2019 were collected retrospectively. Patients were categorized in accordance with predefined inclusion/exclusion criteria and with their treatment. Statistical analysis was conducted using descriptive, summary statistics to identify a central tendency.

Results

Thirty-four patients underwent indocyanine-green-lymphangiography guided revision surgery for LF. Two patients were lost to follow-up at 6 months. LF was successfully treated in all patients (n = 32) with a multimodal approach. Only MLL was performed in 22 patients and MLL/LVA in 10 patients. LF resolved in 78% of all patients with MLL only or MLL/LVA. In the remaining 22%, LF resolved after additional sclerotherapy within 3 months.

Conclusions

Treatment of LF should follow a standardized staged surgical approach to optimize outcome. LF was treated successfully in all our patients. We therefore propose a multimodal interdisciplinary approach to this common clinical problem that includes adjunctive sclerotherapy.

Sentinel Lymph Node Biopsy for Melanoma: Comparison of Lymphocele Rates by Surgical Technique

Lymphocele is a common wound complication of sentinel lymph node biopsy (SLNB). The surgical technique may play a key role in lymphocele formation. This study compared rates of postoperative lymphocele formation by different surgical techniques (Harmonic Scalpel [HS], LigaSure [LS], and traditional electrocautery with clips) after SLNB in the groin or axilla for the staging of clinically node-negative cutaneous melanoma. Patients were selected by convenience sample from a single-institution, single-surgeon, prospectively collected melanoma database over a 27-month period. One hundred fifty consecutive patients underwent SLNB, 70 with clips, 37 with HS, and 43 with LS. The median number of nodes removed was two and did not vary significantly between groups. Twenty-three lymphoceles occurred for an overall rate of 15 per cent; rates were 9.9 and 26.5 per cent for the axilla and groin, respectively. Sixteen (70%) were aspirated for size or symptoms; lymphoceles after groin SLNB were significantly (P = 0.03) more likely to require aspiration. Lymphocele rates for the clip, HS, and LS groups were 20.0, 18.9, and 4.7 per cent, respectively. The differences between the LS and other groups were statistically significant. Use of the LS may lead to lower lymphocele rates after groin and axillary SLNB compared with electrocautery and clips.

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.

Sentinel lymph node biopsy in cutaneous melanoma of the head and neck using the indocyanine green SPY Elite system

PURPOSE

Lymph node status is the single most important prognostic factor for patients with early-stage cutaneous melanoma. Sentinel lymph node biopsy (SLNB) has become the standard of care for intermediate depth melanomas. Modern SLNB implementation includes technetium-99 lymphoscintigraphy combined with local administration of a vital blue dye. However, sentinel lymph nodes may fail to localize in some cases and false-negative rates range from 0 to 34%. Here we demonstrate the feasibility of a new sentinel lymph node biopsy technique using indocyanine green (ICG) and the SPY Elite near-infrared imaging system.

MATERIALS AND METHODS

Cases of primary cutaneous melanoma of the head and neck without locoregional metastasis, underwent SLNB at a single quaternary care institution between May 2016 and June 2017. Intraoperatively, 0.25 mL of ICG was injected intradermal in 4 quadrants around the primary lesion. 10-15 minute circulation time was permitted. SPY Elite identified the sentinel lymph node within the nodal basin marked by lymphoscintigraphy. Target first echelon lymph nodes were confirmed with a gamma probe and ICG fluorescence.

RESULTS

14 patients were included with T1a to T4b cutaneous melanomas. Success rates for sentinel lymph node identification using lymphoscintigraphy and the SPY Elite system were both 86%. Zero false negatives occurred. Median length of follow-up was 323 days.

CONCLUSIONS

In this pilot study, Indocyanine green near-infrared fluorescence demonstrates a safe, and facile method of sentinel lymph node biopsy for cutaneous melanoma of the head and neck compared with lymphoscintigraphy and vital blue dyes.

Neuropathic pain and quality of life after wide local excision and sentinel lymph node biopsy for melanoma: a multicentre study

Wide local excision and sentinel lymph node biopsy is the mainstay of treatment for patients with melanoma. As survival outcomes improve, longer term quality of life questions become more pertinent and this study aims to assess the factors which may play a role following surgery. A total of, 221 patients who underwent wide local excision and sentinel lymph node biopsy for melanoma (AJCC stage I and II) were recruited from three UK centres. These patients completed a patient outcome questionnaire, which included demographic and treatment data as well as quality of life and pain questionnaires. Pain was the only significant factor influencing the quality of life with a negative correlation seen between pain and quality of life scores (P<0.001). In total, 34% of patients reported pain at their surgical site and four (1.8%) patients scored as high risk for neuropathic pain. Patients experiencing pain were significantly younger that those not reporting pain (median 55.0 vs. 63.5 years, P<0.001). Length of time since surgery did not correlate with pain nor quality of life scores. Our results suggest that following this common procedure a sizeable proportion of patients experience pain and poorer quality of life which does not improve with time. The level of pain experienced is clinically significant and merits evaluation and treatment in this group of patients who are increasingly surviving their melanoma diagnosis. Further investigation into potential prophylactic measures is suggested.

Sentinel Lymph Node Biopsy and Management of Regional Lymph Nodes in Melanoma: American Society of Clinical Oncology and Society of Surgical Oncology Clinical Practice Guideline Update

PURPOSE

To update the American Society of Clinical Oncology (ASCO)-Society of Surgical Oncology (SSO) guideline for sentinel lymph node (SLN) biopsy in melanoma.

METHODS

An ASCO-SSO panel was formed, and a systematic review of the literature was conducted regarding SLN biopsy and completion lymph node dissection (CLND) after a positive sentinel node in patients with melanoma.

RESULTS

Nine new observational studies, two systematic reviews and an updated randomized controlled trial (RCT) of SLN biopsy, as well as two randomized controlled trials of CLND after positive SLN biopsy, were included.

RECOMMENDATIONS

Routine SLN biopsy is not recommended for patients with thin melanomas that are T1a (non-ulcerated lesions < 0.8 mm in Breslow thickness). SLN biopsy may be considered for thin melanomas that are T1b (0.8 to 1.0 mm Breslow thickness or <0.8 mm Breslow thickness with ulceration) after a thorough discussion with the patient of the potential benefits and risk of harms associated with the procedure. SLN biopsy is recommended for patients with intermediate-thickness melanomas (T2 or T3; Breslow thickness of >1.0 to 4.0 mm). SLN biopsy may be recommended for patients with thick melanomas (T4; > 4.0 mm in Breslow thickness), after a discussion of the potential benefits and risks of harm. In the case of a positive SLN biopsy, CLND or careful observation are options for patients with low-risk micrometastatic disease, with due consideration of clinicopathological factors. For higher risk patients, careful observation may be considered only after a thorough discussion with patients about the potential risks and benefits of foregoing CLND. Important qualifying statements outlining relevant clinicopathological factors, and details of the reference patient populations are included within the guideline.

Sentinel Lymph Node Biopsy and Management of Regional Lymph Nodes in Melanoma: American Society of Clinical Oncology and Society of Surgical Oncology Clinical Practice Guideline Update

Purpose To update the American Society of Clinical Oncology (ASCO)-Society of Surgical Oncology (SSO) guideline for sentinel lymph node (SLN) biopsy in melanoma. Methods An ASCO-SSO panel was formed, and a systematic review of the literature was conducted regarding SLN biopsy and completion lymph node dissection (CLND) after a positive sentinel node in patients with melanoma. Results Nine new observational studies, two systematic reviews, and an updated randomized controlled trial of SLN biopsy, as well as two randomized controlled trials of CLND after positive SLN biopsy, were included. Recommendations Routine SLN biopsy is not recommended for patients with thin melanomas that are T1a (nonulcerated lesions < 0.8 mm in Breslow thickness). SLN biopsy may be considered for thin melanomas that are T1b (0.8 to 1.0 mm Breslow thickness or < 0.8 mm Breslow thickness with ulceration) after a thorough discussion with the patient of the potential benefits and risk of harms associated with the procedure. SLN biopsy is recommended for patients with intermediate-thickness melanomas (T2 or T3; Breslow thickness of > 1.0 to 4.0 mm). SLN biopsy may be recommended for patients with thick melanomas (T4; > 4.0 mm in Breslow thickness), after a discussion of the potential benefits and risks of harm. In the case of a positive SLN biopsy, CLND or careful observation are options for patients with low-risk micrometastatic disease, with due consideration of clinicopathological factors. For higher-risk patients, careful observation may be considered only after a thorough discussion with patients about the potential risks and benefits of foregoing CLND. Important qualifying statements outlining relevant clinicopathological factors and details of the reference patient populations are included within the guideline. Additional information is available at www.asco.org/melanoma-guidelines and www.asco.org/guidelineswiki .

A Systematic Quality Evaluation of Meta-Analyses Related to Plastic Surgery

INTRODUCTION

Meta-analyses are considered to be an important source of evidence. This review aims to systematically assess the quality of meta-analyses addressing topics in plastic surgery.

METHODS

Electronic databases were selected for systematic review. A search was performed focusing on communication addresses containing terms related to plastic surgery, and detailed inclusion criteria were used. Related data were extracted and recorded according to the items of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. To assess the quality of the meta-analyses over time, studies published before and after PRISMA were evaluated.

RESULTS

A total of 116 meta-analyses were included. There was 1 study that was fully in compliance with the PRISMA items. The main flaws impacting the overall quality of the included studies were in the following areas: structured summary (48%), protocol and registration (2%), full electronic search strategy (35%), risk of bias in individual studies (41%), additional analyses (27%), risk of bias within studies (47%), additional analysis (30%), and funding (47%). Study quality was evaluated using relative risks (RR) with a 95% confidence interval (95% CI); this revealed that there were few significant improvements in adherence to the PRISMA statement after its release, especially in selection (RR, 1.80; 95% CI, 1.08-2.99), results of individual studies (RR, 2.88; 95% CI, 1.41-5.91), synthesis of results (RR, 3.08; 95% CI, 1.32-7.17), and funding (RR, 1.65; 95% CI, 1.21-2.24).

CONCLUSIONS

There have been measurable improvements in the quality of meta-analyses over recent years. However, several serious deficiencies remain according to the PRISMA statement. Future reviewers should pay more attention to not only reporting the main findings but also encouraging compliance with proper standards.

Sentinel lymph node biopsy in early melanoma-comparison of two techniques for sentinel removal

BACKGROUND

Sentinel lymph node biopsy is an established technique for melanoma staging.

OBJECTIVE

There are no studies available comparing different techniques for the removal of sentinel lymph nodes related to safety and postsurgical complication rate.

METHODS

This is a retrospective single-center trial. We analyzed the postsurgical complications in 201 consecutive melanoma patients with ligature of lymphatic vessels by sutures (group A) and in 91 consecutive patients with occlusion of lymphatic vessels by bipolar tweezers (group B). We paid particular attention to complications related to disturbed lymphatic function, such as lymph edema, lymphatic fistula, and seroma.

RESULTS

The complication rate was 5.5 % (group A) and 9.6 % (group B) which is in the range of other published trials (p = 0.89). There was no increase of complications related to lymphatic vessels in group B, although the rate of patients with more than two sentinel lymph nodes removed was 5‑times higher than in group A.

CONCLUSIONS

Removal of sentinel lymph nodes with the use of bipolar tweezers does not increase the risk of postsurgical complications, and in particular it is not associated with a higher rate of complications related to lymphatic vessel dysfunction.

Impact of the 2009 AJCC staging guidelines for melanoma on the number of mitotic figures reported by dermatopathologists at one institution

BACKGROUND

In 2009 the revised seventh staging system for melanoma recommended the use of mitotic count to separate stage T1a from T1b. However, careful scrutiny of cases may lead to an inadvertent selection effect, with consequent increased reporting of mitotic counts.

METHODS

We investigated whether there is a significant increase in mitotic counts reported since 2009 for melanomas with a Breslow thickness of 1.0 mm or less. We conducted a retrospective, case-controlled study examining invasive melanoma cases at a large academic center. Mitotic counts were compared between pathology reports before 2009 (n = 61) and after 2009 (n = 125), with a subset of slides re-examined in a blinded fashion.

RESULTS

Before the 2009 staging guidelines, 51% of cases had one or more mitosis reported compared to 38% after 2009 (p = 0.113). Blinded re-counting did not yield a significant difference when compared with the original pathology reports in either group.

CONCLUSIONS

There was not a significant difference in the number of mitoses reported after the implementation of the new guidelines.

Managing malignant melanoma

The incidence of melanoma is increasing worldwide. Melanomas represent 3 percent of all skin cancers but 65 percent of skin cancer deaths. Melanoma is now the fifth most common cancer diagnosed in the United States. Excisional biopsy should be performed for lesions suspicious for melanoma. The pathologist's report provides essential information for surgical treatment; the most important information is the Breslow depth of the lesion. In addition to wide surgical excision of the primary lesion, sentinel lymph node biopsy is the standard of care for early identification of regional metastasis. Nodal metastasis found in the sentinel lymph node biopsy should be followed with a complete lymph node dissection. Although surgery remains the primary treatment of melanoma, recent advances in chemotherapy may offer further survival benefits to patients with metastatic disease.

In vivo and in silico pharmacokinetics and biodistribution of a melanocortin receptor 1 targeted agent in preclinical models of melanoma

The melanocortin 1 receptor (MC1R) is overexpressed in most melanoma metastases, making it a promising target for imaging of melanomas. In this study, the expression of MC1R in a large fraction of patients with melanoma was confirmed using mRNA and tissue microarray. Here, we have characterized the in vivo tumor and tissue distribution and pharmacokinetics (PK) of uptake and clearance of a MC1R specific peptidomimetic ligand conjugated to a near-infrared fluorescent dye. We propose an interdisciplinary framework to bridge the different time and space scales of ligand-tumor-host interactions: intravital fluorescence microscopy to quantify probe internalization at the cellular level, a xenograft tumor model for whole body pharmacokinetics, and a computational pharmacokinetic model for integration and interpretation of experimental data. Administration of the probe into mice bearing tumors with high and low MC1R expression demonstrated normalized image intensities that correlated with expression levels (p < 0.05). The biodistribution study showed high kidney uptake as early as 30 min postinjection. The PK computational model predicted the presence of receptors in the kidneys with a lower affinity, but at higher numbers than in the tumors. As the mouse kidney is known to express the MC5R, this hypothesis was confirmed by both coinjection of a ligand with higher MC5R affinity compared to MC1R and by injection of lower probe concentrations (e.g., 1 nmol/kg), both leading to decreased kidney accumulation of the MC1R ligand. In addition, through this interdisciplinary approach we could predict the rates of ligand accumulation and clearance into and from organs and tumors, and the amount of injected ligand required to have maximum specific retention in tumors. These predictions have potential to aid in the translation of a targeted agent from lab to the clinic. In conclusion, the characterized MC1R-specific probe has excellent potential for in vivo detection of melanoma metastases. The process of cell-surface marker validation, targeted imaging probe development, and in vitro, in vivo, and in silico characterization described in this study can be generally applied to preclinical development of targeted agents.

Advocacy for survivors with or at risk for lymphedema

OBJECTIVES

To discuss various advocates and advocacy roles integral to the multidisciplinary oncology lymphedema care team.

DATA SOURCES

Review and research articles, and Web sites.

CONCLUSION

The professional and lay awareness of lymphedema, risk profiles, patient education, and treatment have improved significantly over the past two decades, although gaps are still present that require attention.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must be familiar with the common concepts related to lymphedema, risk profiles, recognition of symptoms, and referral options for the treatment of oncology patients with or at risk for lymphedema.

Synthesis and characterization of a melanoma-targeted fluorescence imaging probe by conjugation of a melanocortin 1 receptor (MC1R) specific ligand

The incidence of malignant melanoma is rising more rapidly than that of any other cancer in the United States. The melanocortin 1 receptor (MC1R) is overexpressed in most human melanoma metastases, thus making it a promising target for imaging and therapy of melanomas. We have previously reported the development of a peptidomimetic ligand with high specificity and affinity for MC1R. Here, we have conjugated near-infrared fluorescent dyes to the C-terminus of this ligand via lysine-mercaptopropionic acid linkers to generate MC1R specific optical probes (MC1RL-800, 0.4 nM K(i); and MC1RL-Cy5, 0.3 nM K(i)). Internalization of the imaging probe was studied in vitro by fluorescence microscopy using engineered A375/MC1R cells and B16F10 cells with endogenous MC1R expression. The in vivo tumor targeting of MC1RL-800 was evaluated by intravenous injection of probe into nude mice bearing bilateral subcutaneous A375 xenograft tumors with low MC1R expression and engineered A375/MC1R tumors with high receptor expression. Melanotic B16F10 xenografts were also studied. Fluorescence imaging showed that the agent has higher uptake values in tumors with high expression compared to low (p < 0.05), demonstrating the effect of expression levels on image contrast-to-noise. In addition, tumor uptake was significantly blocked by coinjection of excess NDP-α-MSH peptide (p < 0.05). In conclusion, the MC1R-specific imaging probe developed in this study displays excellent potential for the intraoperative detection of regional node involvement and for margin detection during melanoma metastasis resection.