Multi-institutional melanoma lymphatic mapping experience: the prognostic value of sentinel lymph node status in 612 stage I or II melanoma patients

A bibliometric analysis of sentinel lymph node biopsy in melanoma of the top 90 cited publications

BACKGROUND

This bibliometric analysis aims to describe research trends and assess the methodological quality of the highest-impact SLNB research in melanoma.

METHODS

We identified the 90 most cited publications on SLNB in melanoma using Web of Science, covering all available journal years (from 2005 to date). The Oxford Center for Evidence-Based Medicine (OCEBM) Levels of Evidence (LOE) were used to assess the methodological quality of each study.

RESULTS

The 90 most cited publications on SLNB in melanoma collectively garnered 10,314 citations. Citation counts per publication ranged from 44 to 1,405 (mean 114.6 ± 185.2), with the highest-cited study authored by Professor Donald Morton et al. The majority of publications was classified as LOE 3 (n = 36). The United States of America (USA) led in publication output with 43 articles. Professors Merrick Ross (USA) and John Thompson (Australia) were the leading authors by publication count. The University of Sydney (Australia), University of Texas System, and Anderson Cancer Center (USA) were the top contributing institutions. Annals of Surgical Oncology published most articles.

CONCLUSIONS

This bibliometric analysis provides a comprehensive overview and valuable reference for future researchers in the field of SLNB in melanoma.

Nodal Management in Melanoma: Is Nodal Staging Needed, What Is the Value, and What Is the Extent of Surgery?

Historical management of melanoma metastatic to draining nodal basins involved prophylactic lymphadenectomy, a morbid procedure without proven survival benefit. Over the last decade sentinel lymph node biopsy (SLNB) became a key prognostic tool, identifying patients with clinically occult nodal metastases with minimal morbidity. More recently, with the approval of adjuvant therapies for high-risk melanomas, the role of SLNB in the treatment of melanoma has been questioned. However, no robust alternative prognostic tool exists. SLNB therefore remains a critical staging procedure, informing clinical decision making when weighing the risks and benefits of adjuvant treatment and surveillance.

[Value of surgery for malignant melanoma in the context of current adjuvant and neoadjuvant treatment concepts]

The field of melanoma treatment is also dynamic with respect to surgical procedures. In the treatment of the primary tumor the safety margins have been reduced based on study data. In surgery of the regional lymph nodes elective lymph node dissection has been discontinued in favor of sentinel lymph node (SLN) extirpation. Whether SLN extirpation can even be dispensed with in view of adjuvant treatment, particularly in patients with thicker primary tumors, needs to be further investigated. In the stage of regional macrometastasis, neoadjuvant or perioperative drug treatment should be considered before surgical measures. In the case of distant metastasis and disseminated disease, systemic treatment is also the first choice and in the case of local complications or oligoprogression under systemic treatment, surgical measures can also be considered.

Critical evaluation of sentinel lymph node biopsy in pT1b and pT2a melanoma patients: A nationwide population-based study

INTRODUCTION

Sentinel lymph node biopsy (SLNB) aims to stage patients. According to the 8th edition of the American Joint Committee on Cancer(AJCC) staging manual, patients with pT1b or pT2a melanoma can be eligible for adjuvant immunotherapy, however, only if they have a sentinel node (SN) tumour burden > 1 mm. This study aims to determine the percentage of patients with pT1b or pT2a that will become eligible for adjuvant immunotherapy following SLNB.

METHODS

A nationwide, population-based study was conducted using data from the Dutch Pathology Databank. Patients diagnosed with pT1b and pT2a melanoma between 2002 and 2023 were included. The primary endpoint was the number of SNs with a tumour burden > 1 mm.

RESULTS

We identified 36,606 patients of who 16,042 underwent SLNB. SN positivity was 5 % for patients with pT1b melanoma, and 11 % for pT2a melanoma. A tumour burden > 1 mm was found in 1.5 % and 4.1 %, translating to a number needed to treat (NNT) of 69 for pT1b and 25 for pT2a.

CONCLUSION

This nationwide study demonstrated a low incidence of positive SNs and minimal likelihood of significant clinical outcomes following SLNB. Given the high NNT to be eligible for adjuvant immunotherapy, SLNB may no longer be justified for pT1b melanoma. For patients with pT2a melanoma, SLNB should be considered carefully, balancing limited clinical benefits against potential risks.

Risk stratification using the Merlin Assay (CP-GEP) in an independent cohort of 930 patients with clinical stage I/II melanoma who did not undergo sentinel lymph node biopsy

PURPOSE

More than 80 % of patients with melanoma are diagnosed without nodal metastasis, but most of those who relapse or die from melanoma are initially diagnosed as low risk early-stage. Here we investigate the ability of the Merlin Assay to stratify patients who did not undergo sentinel lymph node biopsy (SLNB) for their risk of recurrence.

PATIENTS AND METHODS

930 patients with clinical stage I/II primary cutaneous melanoma from the University of Tuebingen diagnosed between 2000 and 2020 were analyzed. None of the patients included underwent SLNB. The Merlin Assay combines patient age at diagnosis, Breslow thickness, and gene expression of eight specific genes from the primary tumor. Risk output labels are High Risk and Low Risk.

RESULTS

Clinicopathological gene expression profile (CP-GEP) identified 879 patients as Low Risk and 51 patients as High Risk. The 10-year RFS (HR 20.07; p < 0.001) and DMFS (HR 19.39; p < 0.001) were significantly higher in CP-GEP Low Risk versus High Risk patients. Similar results were observed in 10-year MSS (HR 35.85; p < 0.001). CP-GEP analysis of lentigo maligna melanoma and acral lentiginous melanoma showed that the performance of assay was independent of melanoma histological subtypes.

CONCLUSION

This study shows that CP-GEP has the potential to stratify patients with early-stage melanoma who did not undergo SLNB based on their risk of recurrence. Patients with CP-GEP Low Risk have a significantly better long-term survival. CP-GEP shows to be promising for guiding SLNB referral and may support melanoma care by optimizing personalized treatment plans and potential surveillance regimens.

Trends in sentinel lymph node evaluation for vulvar melanoma in the United States from 2012 to 2018

OBJECTIVE

To describe trends in type of lymph node assessment for vulvar melanoma over time and factors associated with sentinel lymph node biopsy (SLNB).

METHODS

This is a retrospective cohort study of patients in the National Cancer Database (NCDB) with vulvar melanoma from 2012 to 2018. Type of lymph node evaluation, demographic and clinical characteristics, and characteristics of the treating institution were abstracted. Chi square and multivariate logistic regression were used to evaluate predictors of SLNB compared to inguinofemoral lymph node dissection (IFLD) and no lymph node evaluation.

RESULTS

A total of 1828 patients with vulvar melanoma were identified. Of those, 925 (50.6 %) underwent lymph node evaluation, 357 (38.6 %) with SLNB alone, 97 (10.5 %) with SLNB and IFLD, and 471 (50.9 %) with IFLD alone. Year of diagnosis, age, T stage, insurance status, facility type, and facility volume were significant predictors of use of SLNB in univariate analyses. Age, year of diagnosis, T stage and facility type remained significant in multivariate analysis. SLNB was most often performed for T1 and T2 lesions (31.3 % and 36.2 %, respectively), while only 19.6 % of T3, 1.3 % of T4, and 25.8 % of those with unknown T stage underwent SLNB. Survival outcomes were similar regardless of mode of lymph node assessment, but worse in those who received no assessment.

CONCLUSIONS

Current practice in the United States for lymph node evaluation in vulvar melanoma differs from the recommended guidelines for cutaneous melanomas by T stage. Updated guidelines for vulvar melanoma aligned with those for cutaneous melanoma are needed.

Are Nomograms Useful for Predicting Sentinel Lymph Node Status in Melanoma Patients?

BACKGROUND AND OBJECTIVES

Clinical nomograms have been developed to predict sentinel lymph node (SLN) status in early-stage melanoma patients, but the clinical utility of these tools remains debatable. We created and validated a nomogram using data from a randomized clinical trial and assessed its accuracy against the well-validated Melanoma Institute Australia (MIA) nomogram.

METHODS

We developed our model to predict SLN status using logistic regression on clinicopathological patient data from the Multicenter Selective Lymphadenectomy Trial-I. The model was externally validated using the National Cancer Database (NCDB) data set, and its performance was compared to that of the MIA nomogram.

RESULTS

Our model had good discrimination between positive and negative SLNs, with a training set area under the curve (AUC) of 0.706 (0.661-0.751). Our model achieved an AUC of 0.715 (0.706-0.724) compared to 0.723 (0.715-0.731) with the MIA model, using the NCDB set.

CONCLUSION

Our model performed similarly to the MIA model, confirming that despite using different clinical features and data sets, no clinical nomogram is currently accurate enough for clinical use.

Surgical Management of Thick Primary Cutaneous Melanoma in the US

BACKGROUND

There remains significant variability in the surgical management of thick melanoma patients with clinically node-negative disease. We evaluated factors influencing overall survival (OS) in these patients, focusing on the surgical management of the primary tumor and nodal basin.

METHODS

Using the National Cancer Database, we identified 7647 patients diagnosed between 2012 and 2017 with thick melanoma (> 4 mm, T4) and clinically node-negative disease. 4332 patients had complete data and met all inclusion criteria. These patients were stratified into three groups based on nodal assessment: sentinel lymph node biopsy (SLNB), elective lymphadenectomy (ELND), or no nodal evaluation (NNE). OS was compared using Kaplan-Meier analyses and multivariable Cox proportional hazard regression.

RESULTS

In the cohort, 2851 (65.8%) had a SLNB, 799 (18.4%) had an ELND, and 682 (15.7%) had NNE. OS significantly decreased for each millimeter of increasing Breslow thickness. Ulceration, lymphovascular invasion, and tumor-positive SLN (+SLN) were associated with worse OS (all p < 0.001). The size of surgical margins was not significantly associated with OS. Five-year OS of patients with SLNB was 67.1% ± 1.2% compared to 57.9% ± 2.3% with ELND and 46.8% ± 2.5% with NNE (p < 0.001). Among +SLN patients, a complete lymph node dissection (CLND) was performed in 400 (62.3%) but was not associated with improved OS (p = 0.67) when compared to the nodal observation group.

CONCLUSION

Our results suggest that increasing Breslow thickness and nodal assessment provide important prognostic information regarding OS for thick melanoma patients, which emphasizes the importance of SLNB for staging and confirm the lack of benefit of CLND after +SLN in thick melanoma. The size of surgical margins did not affect OS.

Artificially Engineered Nanoprobes for Ultrasensitive Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is a noninvasive and radiation-free technique used for soft tissue. However, there are some limitations of the MRI modality, such as low sensitivity and poor image resolution. Artificially engineered magnetic nanoprobes have been extensively explored as a versatile platform for ultrasensitive MRI contrast agents due to their unique physiochemical characteristics and tunable magnetic properties. In this review, the emphasis is on recent progress in MRI nanoprobes with different structures and elements, including gadolinium-, iron-, manganese-based and metal-free nanoprobes. The key influencing factors and advanced engineering strategies for modulating the relaxation ratio of MRI nanoprobes are systematically condensed. Furthermore, the widespread and noninvasive visualization applications of MRI nanoprobes for real time monitoring of major organs and accurate disease diagnosing, such as cerebrovascular, ischemia, Alzheimer's disease, liver fibrosis, whole-body tumors, inflammation, as well as multi-mode imaging applications are summarized. Finally, the challenges and prospects for the future development of MRI nanoprobes are discussed, and promising strategies are specifically emphasized for improving biocompatibility, precisely engineering of optimal size, AI-driven prediction and design, and multifunctional self-assembly to enhance diagnostics. This review will provide new inspiration for artificial engineering and nanotechnology-based molecular probes for medical diagnosis and therapy with ultrasensitive MRI.

An artificial intelligence-based model exploiting H&E images to predict recurrence in negative sentinel lymph-node melanoma patients

BACKGROUND

Risk stratification and treatment benefit prediction models are urgent to improve negative sentinel lymph node (SLN-) melanoma patient selection, thus avoiding costly and toxic treatments in patients at low risk of recurrence. To this end, the application of artificial intelligence (AI) could help clinicians to better calculate the recurrence risk and choose whether to perform adjuvant therapy.

METHODS

We made use of AI to predict recurrence-free status (RFS) within 2-years from diagnosis in 94 SLN- melanoma patients. In detail, we detected quantitative imaging information from H&E slides of a cohort of 71 SLN- melanoma patients, who registered at Istituto Tumori "Giovanni Paolo II" in Bari, Italy (investigational cohort, IC). For each slide, two expert pathologists firstly annotated two Regions of Interest (ROIs) containing tumor cells alone (TUMOR ROI) or with infiltrating cells (TUMOR + INF ROI). In correspondence of the two kinds of ROIs, two AI-based models were developed to extract information directly from the tiles in which each ROI was automatically divided. This information was then used to predict RFS. Performances of the models were computed according to a 5-fold cross validation scheme. We further validated the prediction power of the two models on an independent external validation cohort of 23 SLN- melanoma patients (validation cohort, VC).

RESULTS

The TUMOR ROIs have revealed more informative than the TUMOR + INF ROIs. An Area Under the Curve (AUC) value of 79.1% and 62.3%, a sensitivity value of 81.2% and 76.9%, a specificity value of 70.0% and 43.3%, an accuracy value of 73.2% and 53.4%, were achieved on the TUMOR and TUMOR + INF ROIs extracted for the IC cohort, respectively. An AUC value of 76.5% and 65.2%, a sensitivity value of 66.7% and 41.6%, a specificity value of 70.0% and 55.9%, an accuracy value of 70.0% and 56.5%, were achieved on the TUMOR and TUMOR + INF ROIs extracted for the VC cohort, respectively.

CONCLUSIONS

Our approach represents a first effort to develop a non-invasive prognostic method to better define the recurrence risk and improve the management of SLN- melanoma patients.

Efficacy of indocyanine green fluoroscopy for sentinel node biopsy in head and neck melanoma: a systematic review and meta-analysis

The objective of this review was to conduct a systematic review and meta-analysis on the efficacy of ICG (indocyanine green) for sentinel lymph node (SLN) detection in head and neck melanoma. The Preferred Reporting Items for Systematic reviews and Meta-Analyses statement standards (PRISMA) were followed when conducting this review with a comprehensive search of the following online databases; Google Scholar, PubMed, MEDLINE, CINAHL, and CENTRAL, World Health Organization International Clinical Trials Registry (http://apps.who.int/trialsearch/), ClinicalTrials.gov (http://clinical-trials.gov/), and the ISRCTN registry (http://www.isrctn.com/). Nine studies met the inclusion criteria and results were reported with forest plots at 95% confidence intervals. Primary outcomes of interest included the localisation rate for sentinel node biopsies in head and neck melanoma using ICG and compared with other adjunct modalities. Secondary outcome measures included false negative rates as well as sensitivity rates for nodal detection with radiocolloid as well as blue dye. ICG reported an overall sensitivity rate of 95% with an untransformed proportion metric analysis (0.950, 0.922, 0.978 (95% CI)). It demonstrated a superior detection rate to blue dye (Odds ratio 15.417, 95% CI, 4.652 to 51.091, p < 0.001) and a comparable localisation efficacy to radiocolloid (Odds ratio 1.425, 95% CI, 0.535 to 3.794, p = 0.478). The sensitivity rate for radiocolloid utilisation in isolation was 90.6% (untransformed proportion metric, 0.906, 0.855, 0.957) and blue dye was 48.7% (untransformed proportion metric, 0.487, 0.364, 0.610). This is the first meta-analysis on the efficacy of ICG for sentinel node detection in head and neck melanoma. The authors advocate for a dual modality approach with ICG and radiocolloid to mitigate the inherent limitations of both methods when conducting sentinel node retrieval for head and neck melanoma. Further high-quality randomised trials are needed to improve the current evidence base.

How to objectively evaluate the impact of image-guided surgery technologies

PURPOSE

This manuscript aims to provide a better understanding of methods and techniques with which one can better quantify the impact of image-guided surgical technologies.

METHODS

A literature review was conducted with regard to economic and technical methods of medical device evaluation in various countries. Attention was focused on applications related to image-guided interventions that have enabled procedures to be performed in a minimally invasive manner, produced superior clinical outcomes, or have become standard of care.

RESULTS

The review provides examples of successful implementations and adoption of image-guided surgical techniques, mostly in the field of neurosurgery. Failures as well as newly developed technologies still undergoing cost-efficacy analysis are discussed.

CONCLUSION

The field of image-guided surgery has evolved from solely using preoperative images to utilizing highly specific tools and software to provide more information to the interventionalist in real time. While deformations in soft tissue often preclude the use of such instruments outside of neurosurgery, recent developments in optical and radioactive guidance have enabled surgeons to better account for organ motion and provide feedback to the surgeon as tissue is cut. These technologies are currently undergoing value assessments in many countries and hold promise to improve outcomes for patients, surgeons, care teams, payors, and society in general.

Macroscopic tumor dimension, sentinel lymph node outcome, and survival analysis among cutaneous melanoma

BACKGROUND

Cutaneous melanoma is characterized by a high risk of metastasis to distant organs and a substantial mortality rate. For planning treatment and assessing outcomes, the Breslow micrometric measurement is critical. The tumor macroscopic dimension is not considered a prognostic parameter in cutaneous melanoma, although there are studies showing that tumor size is an independent prognostic factor for melanoma-specific survival. Therefore, this study aimed to evaluate the macroscopic dimension of melanoma and other known prognostic factors (i.e., Breslow index, mitoses, regression, and ulceration) as predictors of sentinel lymph node outcome and survival outcome.

METHODS

We performed a retrospective cross-sectional study of 227 melanoma lesions subjected to sentinel lymph node biopsy at two Brazilian referral centers.

RESULTS

On univariate analysis, there was a statistically significant correlation between the largest macroscopic tumor dimension and the sentinel lymph node result (P = 0.001); however, on multivariate analysis considering all evaluated parameters, there was no significant difference between the sentinel lymph node result and the tumor macroscopic dimension (P = 0.2689). Regarding melanoma-specific survival, the macroscopic dimension showed no significant correlation (P = 0.4632) in contrast to Breslow's dimension (P < 0.0001).

CONCLUSION

The Breslow thickness was the only significant factor related to both the sentinel lymph node outcome and melanoma specific survival among the evaluated variables.

Seizing the fate of lymph nodes in immunotherapy: To preserve or not?

Lymph node dissection has been a long-standing diagnostic and therapeutic strategy for metastatic cancers. However, questions over myriad related complications and survival outcomes are continuously debated. Immunotherapy, particularly neoadjuvant immunotherapy, has revolutionized the conventional paradigm of cancer treatment, yet has benefited only a fraction of patients. Emerging evidence has unveiled the role of lymph nodes as pivotal responders to immunotherapy, whose absence may contribute to drastic impairment in treatment efficacy, again posing challenges over excessive lymph node dissection. Hence, centering around this theme, we concentrate on the mechanisms of immune activation in lymph nodes and provide an overview of minimally invasive lymph node metastasis diagnosis, current best practices for activating lymph nodes, and the prognostic outcomes of omitting lymph node dissection. In particular, we discuss the potential for future comprehensive cancer treatment with effective activation of immunotherapy driven by lymph node preservation and highlight the challenges ahead to achieve this goal.

The Role of Sentinel Lymph Node Biopsy in the Management of Merkel Cell Carcinoma: A Systematic Review and Meta-analysis

Background

Merkel cell carcinoma (MCC) is a rare cutaneous malignancy with high metastatic potential. Sentinel lymph node biopsy (SLNB) is used to assess locoregional spread, facilitate staging, and inform prognosis. Positive nodal status is associated with higher recurrence rates and reduced overall survival.

Methods

A systematic search was conducted. Eligible articles included patients diagnosed with MCC, who would be candidates for or who had SLNB. The Covidence tool was used for screening and data extraction, including additional treatments, disease-free survival, overall survival, and recurrence. Methodological quality was assessed using the Newcastle-Ottowa Scale criteria.

Results

SLNB was associated with increased likelihood of completion lymphadenectomy (223 versus 41), regional radiotherapy (2167 versus 808), and systemic chemotherapy (138 versus 31). Overall survival for patients undergoing SLNB was 81% at 2 years, 75% at 3 years, and 72% at 5 years (odds ratio: 0.79). Hazard ratio for positive SLNB versus negative was 3.36 (P < 0.001). Five-year disease recurrence was 23.3% in patients undergoing SLNB.

Conclusions

Lymph node metastases are associated with reduced overall survival and increased recurrence of MCC. Determining nodal status early can inform prognosis, facilitate staging, and determine need for adjuvant treatment. Adjuvant treatments are associated with reduced mortality and improved overall survival; SLNB is an important influencer of their use. Early prophylactic intervention should be considered in MCC in both positive and negative nodal status to improve overall outcomes. Widespread use of SLNB will allow more accurate assessment of the role of nodal status on adjuvant treatment and long-term outcomes.

A Review of Contemporary Guidelines and Evidence for Wide Local Excision in Primary Cutaneous Melanoma Management

Surgical wide local excision (WLE) remains the current standard of care for primary cutaneous melanoma. WLE is an elective procedure that aims to achieve locoregional disease control with minimal functional and cosmetic impairment. Despite several prospective randomised trials, the optimal extent of excision margin remains controversial, and this is reflected in the persistent lack of consensus in guidelines globally. Furthermore, there is now the added difficulty of interpreting existing trial data in the context of the evolving role of surgery in the management of melanoma, with our increased understanding of clinicopathologic and genomic prognostic markers leading to the often routine use of sentinel node biopsy (SNB) as a staging procedure, in addition to the development of adjuvant systemic therapies for high-risk disease. An ongoing trial, MelMarT-II, has been designed with the aim of achieving a definitive answer to guide this fundamental surgical decision.

Sentinel lymph node biopsy for lentigo maligna melanoma under local anaesthesia

BACKGROUND

Lentigo maligna melanoma is mainly localized in the head and neck region in elderly patients. Due to its slow horizontal growth, it has a good prognosis compared to other melanoma subtypes, but specific data are rare.

OBJECTIVES

The aim of this study was to investigate sentinel lymph node biopsy in lentigo maligna melanoma under local anaesthesia and to discuss the benefit.

METHODS

Investigation of patients with lentigo maligna melanoma and tumour thickness ≥1 mm treated at the Department of Dermatology, University Medical Centre Tuebingen, between January 2008 and October 2019.

RESULTS

In total, 204 patients (126 SLNB, 78 non-SLNB) with a median age of 75.7 years (SLNB: 73.3 years, non-SLNB: 79.7 years) could be included. Sixteen of 126 (12.7%) sentinel lymph nodes were positive. Five-year overall survival was 87.9% (88.5% SLNB; 87.4% non-SLNB) and 5-year distant metastasis-free survival was 85.8% (85.4% SLNB; 86.7% non-SLNB). There was no significant difference for distant metastasis-free survival (p = 0.861) and overall survival (p = 0.247) between patients with and without sentinel lymph node biopsy.

CONCLUSIONS

Sentinel lymph node biopsy in lentigo maligna melanoma under local anaesthesia is a safe and simple method, even in very old patients. However, LMM has a very good 5-year overall survival. In high-risk patients with high tumour thickness and/or ulceration, adjuvant immunotherapy can now be offered without the need to perform this procedure.

Prediction of nonsentinel lymph node metastasis in acral melanoma with positive sentinel lymph nodes

BACKGROUND

Metastasis in a nonsentinel lymph node (non-SLN) is an unfavorable independent prognostic factor in cutaneous melanoma (CM). Recent data did suggest potential value of completion lymph node dissection (CLND) in CM patients with non-SLN metastasis. Prediction of non-SLN metastasis assists clinicians in deciding on adjuvant therapy without CLND. We analyzed risk factors and developed a prediction model for non-SLN status in acral melanoma (AM).

METHODS

This retrospective study enrolled 656 cases of melanoma who underwent sentinel lymph node biopsy at Fudan University Shanghai Cancer Center from 2009 to 2017. We identified 81 SLN + AM patients who underwent CLND. Clinicopathologic data, including SLN tumor burden and non-SLN status were examined with Cox and Logistics regression models.

RESULTS

Ulceration, Clark level, number of deposits in the SLN (NumDep) and maximum size of deposits (MaxSize) are independent risk factors associated with non-SLN metastases. We developed a scoring system that combines ulceration, the cutoff values of Clark level V, MaxSize of 2 mm, and NumDep of 5 to predict non-SLN metastasis with an efficiency of 85.2% and 100% positive predictive value in the high-rank group (scores of 17-24).

CONCLUSIONS

A scoring system that included ulceration, Clark level, MaxSize, and NumDep is reliable and effective for predicting non-SLN metastasis in SLN-positive AM.

Clinical evaluation of the clinicopathologic and gene expression profile (CP-GEP) in patients with melanoma eligible for sentinel lymph node biopsy: A multicenter prospective Dutch study

Sentinel lymph node biopsy (SLNB) is recommended for patients with >pT1b cutaneous melanoma, and should be considered and discussed with patients diagnosed with pT1b cutaneous melanoma for the purpose of staging, prognostication and determining eligibility for adjuvant therapy. Previously, the clinicopathologic and gene expression profile (CP-GEP, Merlin Assay®) model was developed to identify patients who can forgo SLNB because of a low risk for sentinel node metastasis. The aim of this study was to evaluate the clinical use and implementation of the CP-GEP model in a prospective multicenter study in the Netherlands. Both test performance and feasibility for clinical implementation were assessed in 260 patients with T1-T4 melanoma. The CP-GEP model demonstrated an overall negative predictive value of 96.7% and positive predictive value of 23.7%, with a potential SLNB reduction rate of 42.2% in patients with T1-T3 melanoma. With a median time of 16 days from initiation to return of test results, there was sufficient time left before the SLNB was performed. Based on these outcomes, the model may support clinical decision-making to identify patients who can forgo SLNB in clinical practice.

A retrospective study of sentinel lymph node biopsy for skin cancer in Japan: Comparison with breast cancer and evaluation of factors related to its use

BACKGROUND

Sentinel lymph node biopsy (SLNB) underuse has been reported for skin cancers; however, actual performance rates have not been compared. The objective of this study was to investigate the SLNB performance rate in skin cancers covered by health insurance in Japan and compare it with that in breast cancer.

METHODS

This was a retrospective study of the SLNB performance rate in SLNB-eligible patients with breast or skin cancer from 2018 to 2019, utilizing a database linked to the Hospital-Based Cancer Registry and Diagnosis Procedure Combination survey. Demographic and tumor characteristics were analyzed using logistic regression.

RESULTS

A total of 71,652 patients were included in this study. SLNB was performed in 86.4% (57,904/67,036) of the patients with breast cancer, 44.7% (694/1552) with melanomas, 3.1% (89/2849) with squamous cell carcinomas (SCCs), and 13.5% (29/215) with Merkel cell carcinomas (MCCs). The performance rate of SLNB was significantly lower for skin cancers than for breast cancers (odds ratio [OR], 0.03; p < 0.001). In addition, the performance rates of SLNB were significantly lower for SCCs and MCCs than for melanomas (SCC: OR, 0.04; p < 0.001; MCC: OR, 0.19; p < 0.001). Factors associated with SLNB performance included age, sex, year of incidence, primary tumor site, T stage, and number of hospital beds.

CONCLUSIONS

SLNB is underutilized for skin cancer. Further investigation is required to explore the reasons for its underutilization so that it may be implemented more universally.

Lymph nodes: at the intersection of cancer treatment and progression

Metastasis to lymph nodes (LNs) is a common feature of disease progression in most solid organ malignancies. Consequently, LN biopsy and lymphadenectomy are common clinical practices, not only because of their diagnostic utility but also as a means of deterring further metastatic spread. LN metastases have the potential to seed additional tissues and can induce metastatic tolerance, a process by which tumor-specific immune tolerance in LNs promotes further disease progression. Nonetheless, phylogenetic studies have revealed that distant metastases are not necessarily derived from nodal metastases. Furthermore, immunotherapy efficacy is increasingly being attributed to initiation of systemic immune responses within LNs. We argue that lymphadenectomy and nodal irradiation should be approached with caution, particularly in patients receiving immunotherapy.

Sentinel lymph node assessment in melanoma: current state and future directions

Assessment of sentinel lymph node status is an important step in the evaluation of patients with melanoma for both prognosis and therapeutic management. Pathologists have an important role in this evaluation. The methodologies have varied over time, from the evaluation of dimensions of metastatic burden to determination of the location of the tumour deposits within the lymph node to precise cell counting. However, no single method of sentinel lymph node tumour burden measurement can currently be used as a sole independent predictor of prognosis. The management approach to sentinel lymph node-positive patients has also evolved over time, with a more conservative approach recently recognised for selected cases. This review gives an overview of past and current status in the field with a glimpse into future directions based on prior experiences and clinical trials.

Primary Melanoma Histopathologic Predictors of Sentinel Lymph Node Positivity: A Proposed Scoring System for Risk Assessment and Patient Selection in a Clinical Setting

Background and Objectives: The careful selection of adequate SLNB candidates not only aims at reducing the surgical risk while identifying SLN metastasis, but also plays a crucial role in identifying the patients eligible for adjuvant therapy. Objectives: The purpose of our study was to investigate the clinical and histologic aspects of primary melanomas that correlate with the likelihood of a positive SLNB result. Materials and Methods: A total of 101 primary melanoma patients who underwent sentinel lymph node biopsies were included in the study. General patient demographics were obtained as well as localization and melanoma-specific characteristics of primary melanoma from histologic reports in addition to data derived from SLNB melanoma histopathology reports. Results: The patients with positive SLN results had a statistically significant increased Breslow thickness (3.8 mm vs. 1.97 mm, p = 0.002), higher mitotic index rate (5/mm2 vs. 2/mm2, p = 0.009), as well as the presence of ulceration (68.4% vs. 31.6%, p = 0.007). Univariate regression analysis showed the Breslow thickness (p = 0.008), the mitotic index rate (p = 0.054), the presence of ulceration (p = 0.009), as well as the pT3-4 stage (p = 0.009) to be significant predictors of SLN positivity. The optimal cut-off values for Breslow thickness and the number of mitoses scores were determined based on ROC curve analysis. Using the Breslow thickness, mitotic index rate, presence of ulceration, and pT3-4 stage significant coefficients from the univariate regression model, a chance prediction score was developed. Conclusions: The newly developed and proposed scoring system can aid in patient selection for SLN biopsy by facilitating a more efficient risk assessment in the detection of lymph node metastases in melanoma patients.

Cutaneous melanoma

Cutaneous melanoma is a malignancy arising from melanocytes of the skin. Incidence rates are rising, particularly in White populations. Cutaneous melanoma is typically driven by exposure to ultraviolet radiation from natural sunlight and indoor tanning, although there are several subtypes that are not related to ultraviolet radiation exposure. Primary melanomas are often darkly pigmented, but can be amelanotic, with diagnosis based on a combination of clinical and histopathological findings. Primary melanoma is treated with wide excision, with margins determined by tumour thickness. Further treatment depends on the disease stage (following histopathological examination and, where appropriate, sentinel lymph node biopsy) and can include surgery, checkpoint immunotherapy, targeted therapy, or radiotherapy. Systemic drug therapies are recommended as an adjunct to surgery in patients with resectable locoregional metastases and are the mainstay of treatment in advanced melanoma. Management of advanced melanoma is complex, particularly in those with cerebral metastasis. Multidisciplinary care is essential. Systemic drug therapies, particularly immune checkpoint inhibitors, have substantially increased melanoma survival following a series of landmark approvals from 2011 onward.

Evaluation of tumor load in sentinel lymph node in patients with cutaneous melanoma

INTRODUCTION

cutaneous melanoma (MC) is a malignant neoplasm derived from melanocytic cells with an aggressive behavior. It is usually associated with the multifactorial interaction of genetic susceptibility and environmental exposure, usually ultraviolet radiation. Despite advances in treatment, the disease remains relentless with poor prognosis. Sentinel lymph node (SLN) biopsy is a technique used to screen patients in need of lymph node dissection.

OBJECTIVES

to correlate the tumor burden in the SLN with the mortality of patients undergoing SLN biopsy.

METHODOLOGY

the medical records and histological slides of patients with MC who underwent SLN biopsy treated at HC-Unicamp from 2001 to 2021 were retrospectively analyzed. The positive SLN were measured according to the size of the tumor infiltration area, for analysis of the depth of invasion (DI), closest proximity to the capsule (CPC) and tumor burden (TB). For statistical analysis, associations between variables were analyzed using Fishers exact test, with post Bonferroni test and Wilcoxon test.

RESULTS

105 records of patients who underwent SLN biopsy of MC were identified. Of these, nine (8.6%) had positive SLN and 81 (77.1%) had negative SLN. The performed lymphadenectomies resulted in 55.6% (n=5) affected, 22.2% (n=2) without disease and 22.2% (n=2) were not performed. Mean CPC, TB, and DI were 0.14mm, 32.10mm and 2.33mm, respectively. Patients with T2 and T3 tumors were more likely to show the SLN affected (p=0.022). No patient with positive SLN died during follow-up.

CONCLUSION

patients who presented T3 staging are the ones who most presented positive SLN.

Evaluation of Preoperative and Intraoperative Mobile Gamma Camera Imaging in Sentinel Lymph Node Biopsy for Melanoma Independent of Preoperative Lymphoscintigraphy

INTRODUCTION

Sentinel lymph node biopsy (SLNB) is a standard practice for staging cutaneous melanoma. High false-negative rates have an increased interest in adjunctive techniques for localizing SLNs. Mobile gamma cameras (MGCs) represent potential tools to enhance SLNB performance.

METHODS

An institutional review board approval was obtained for this study (ClinicalTrials.gov ID NCT01531608). After obtaining informed consent, 20 eligible melanoma patients underwent 99mTc sulfur colloid injection and standard lymphoscintigraphy with a fixed gamma camera (FGC). A survey using a 20 cm square MGC, performed immediately preoperatively by the study surgeon, was used to establish an operative plan while blinded to the FGC results. Subsequently, SLNB was performed using a gamma probe and a novel 6 cm diameter handheld MGC.

RESULTS

A total of 24 SLN basins were detected by FGC. Prior to unblinding, all 24 basins were identified with the preoperative MGC and the operative plan established by preoperative MGC imaging was confirmed accurate by review of the FGC images. All individual sentinel lymph nodes were identified during intraoperative MGC imaging, and in 5/24 (21%) cases, surgeon-reported additional clinically useful information was obtained from the MGC.

CONCLUSIONS

Preoperative MGC images provide information consistent with FGC images for planning SLNB and in some cases provide additional information that aided in surgical decision-making.

Nonvisualized sentinel node on preoperative lymphoscintigraphy in primary cutaneous melanoma: an 11-year retrospective survey

BACKGROUND

Sentinel lymph node (SLN) biopsy in cutaneous melanoma patients evaluates the regional draining basin for occult micrometastatic disease. Occasionally, nonidentification of SLN impairs the acquisition of this important prognostic factor.

OBJECTIVES

To investigate the outcomes of melanoma patients with negative lymphoscintigraphic findings and patients who underwent SLN biopsy from 2004 to 2015 ( n  = 1200) were retrospectively reviewed for tumor characteristics and clinical outcomes.

METHODS

Patients with nonvisualized lymph nodes (NV group) who underwent only preoperative lymphoscintigraphy were separated and compared with a cohort drawn from all melanoma patients who completed the surgical procedure within the same period (V group).

RESULTS

A negative lymphoscintigraphic scan was observed in 38 cases (3.2% of all patients). The NV group showed a significantly older age (median 66.0 vs. 48.3 years; P  < 0.0001). Head and neck melanomas were more frequent in the NV group compared to the control group (25.1 vs. 7.8%; P  = 0.009). Tumor characteristics such as ulceration and Breslow thickness do not influence the lymphoscintigraphy result. No differences were found in overall survival (OS) and disease-free survival (DFS) between the groups.

CONCLUSIONS

The nonvisualization of regional lymph nodes by lymphoscintigraphy is more frequent in older patients with head and neck melanomas. From the clinical point of view, no specific recommendation emerged for patients' management because the nonvisualization of the SLN did not show a significant influence on DFS and OS rates. However, lack of knowledge of lymph node status suggests performing a tighter follow-up eventually by ultrasound evaluation of all potential lymph node drainage basins.

Prognostic Significance and Management of Sentinel Nodes in the Triangular Intermuscular Space of Patients with Melanoma

BACKGROUND

The clinical significance of sentinel nodes (SNs) in the triangular intermuscular space (TIS) of patients with melanoma is poorly understood. This study aimed to determine their incidence and positivity rate, and to report their management and patient outcomes.

METHODS

This was a single-institution retrospective cohort study of patients with unilateral or bilateral TIS SNs on lymphoscintigraphy treated between 1992 and 2017. Recurrence-free survival was analyzed.

RESULTS

Lymphoscintigraphy identified TIS SNs in 266 patients. They were bilateral in 17 patients. Of the 2296 patients with a melanoma on the upper back, 259 (11%) had TIS SNs. Procurement of SNs was not attempted in 122 (43%) of the 283 cases and failed in 11 cases (7%). An SN was successfully retrieved from the TIS in 145 patients (53%) and contained metastasis in 18 of 150 TIS SNs. This was the only positive SN in 12 patients (8%), upstaging all of them. Of the 18 patients with a positive SN in the TIS, 9 (50%) underwent completion axillary lymph node dissection, but no additional involved nodes were found in any of these patients. Recurrence in the TIS was observed in six patients (5%), none of whom had their TIS SN surgically pursued previously.

CONCLUSIONS

Lymphoscintigraphy showed TIS SNs in 11% of patients with melanomas on their upper back. In such cases, retrieval of TIS SNs is required for accurate staging and to minimize the risk of TIS recurrence.

Practice patterns for positive sentinel lymph node in head and neck melanoma

BACKGROUND

An international survey was conducted to investigate the preferences for completion lymph node dissection (CLND) in head and neck melanomas.

METHODS

A questionnaire was sent through the American Society of Head & Neck Surgery (AHNS) and Canadian Society of Otolaryngology-Head and Neck Surgery (CSO).

RESULTS

Hundred and forty-nine surgeons completed the survey. Response rate was 6.3% and 9.7% from AHNS and CSO members, respectively. When presented the scenario of a 47-year-old male with a clinical T3bN0 cheek melanoma, with 1/1 positive sentinel lymph node (SLN) with nodal deposit <2 mm, 72 of respondents (48.3%) would perform a CLND. Reasons for CLND included multiples positive SLN (64.1%), size of nodal deposits (54.2%), and perceived lack of compliance to follow-up (54.2%). Surgeons with access to immunotherapy treatment were less likely to recommend CLND (p = 0.025).

CONCLUSIONS

Following SLN biopsy, nearly half of the surveyed head and neck surgeons would recommend CLND, which contrasts with the current melanoma practice patterns in other anatomic locations. However, compared with an earlier study in the literature it does seem that there has been a shift away from completion neck dissection. Further investigation into understanding practice variations is warranted.

Lymphoscintigraphy Using Tilmanocept Detects Multiple Sentinel Lymph Nodes in Melanoma Patients

BACKGROUND

Technetium-99m-labeled Tilmanocept, a multivalent mannose, is readily internalized by the CD206 surface receptor on macrophages and dendritic cells which are abundantly present in lymph nodes. We want to examine the drainage patterns of Technetium-99m-labeled Tilmanocept to sentinel lymph nodes (SLNs) in melanoma patients following the 10% rule.

METHODS

Multi-center retrospective review of patients with cutaneous melanoma undergoing SLN biopsy using Technetium-99m-labeled Tilmanocept between 2008 and 2014 was conducted. Statistical methods were used for data analyses.

RESULTS

Of the 564 patients (mean age of 60.3 and 62% male) with preoperative lymphoscintigraphy showing at least one SLN, several primary tumor sites were included: 27% head/neck, 33% trunk, 21% upper extremity and 19% lower extremity. For the head/neck primary site, 36.5% of patients had multiple draining basins; for the trunk site, 36.4% of patients; for the upper extremity site, 13% of patients; and for the lower extremity, 27.4% of patients. A median of 3 (range 1-18) SLNs were identified and resected. Overall, 78% of patients had >1 SLN identified by Technetium-99m-labeled Tilmanocept. In a multivariate model, patients with >1 SLN were significantly associated with age, Breslow depth, tumor location and higher AJCC tumor stage. A total of 17.7% of patients (100/564) had a positive SLN identified. A total of 145 positive SLNs were identified out of 1,812 SLNs with a positive SLN rate of 8%. Positive SLN status was significantly associated with younger age, greater Breslow depth, mitosis rate, higher AJCC tumor stage, presence of ulceration and angiolymphatic invasion.

CONCLUSIONS

Using the 10% rule, Technetium-99m-labeled Tilmanocept detects multiple SLNs in most melanoma patients.

Influencing factors associated with lymph node status in patients with cutaneous melanoma: An Asian population study

BACKGROUND

Sentinel lymph node (SLN) status is the predominant prognostic factor in patients diagnosed with clinically localized melanoma. The significance of completion lymph node dissection in patients with SLN metastasis is debatable. Not many studies have been conducted on acrallentiginous melanoma (ALM). This study aimed to characterize the prognostic factors of nodal positive ALM and confirm whether ALM patients can undergo the same treatment strategy as non-ALM patients in the Asian population.

METHODS

This is a retrospective review of patients who underwent surgery for cutaneous melanoma (CM) at Taipei Veterans General Hospital between January 1993 and December 2019. We investigated the risk factors for lymph node status. The association between clinicopathological factors and lymph node status of ALM and non-ALM patients was analyzed. Outcomes of completion lymph node dissection (CLND) performed following sentinel lymph node biopsy (SLNB) in the CM and ALM groups were compared.

RESULTS

A total of 197 patients were included in this study. ALM was the most common histological subtype, accounting for 66.5% of all the cases. Patients in the CM and ALM subgroups with metastatic SLN ( p = 0.012) or lymph nodes ( p < 0.001 and p = 0.001) exhibited higher mortality rate. Multivariate analysis showed that patients with clinical presentation of T4 category tumor ( p = 0.012) and lymphovascular invasion ( p = 0.012) had a significantly higher risk of positive lymph nodes. The overall survival of patients with lymph nodes metastasis was not associated with the performance of CLND.

CONCLUSION

Patients in the CM or ALM subgroups with metastatic SLNs or lymph nodes exhibited significantly poorer overall survival. Advanced Breslow thickness and lymphovascular invasion were independent predictive factors for CM and ALM patients with positive lymph node status. There was no significant difference in survival between CM and ALM patients following SLNB, regardless of CLND being performed.

Sentinel lymph node biopsy in desmoplastic melanoma - the percent desmoplastic component matters: A systematic review

BACKGROUND

Desmoplastic melanoma (DM) is a less common form of cutaneous melanoma that has been described for decades; however, controversy remains regarding the management and use of sentinel lymph node biopsy (SLNB). The purpose of this study is to identify whether SLNB is indicated in all cases of DM, including the pure subtype.

METHODS

A systematic review was conducted using PubMed (with access to MEDLINE) along with the Cochrane Central Register of Controlled Trials from 2001 to 2019. Case series and case-control studies were included.

RESULTS

Eighteen studies were included for a total population of 3,914 patients. SLNB was performed in 2229 patients. The percentage of positive SLNB results was 8.5%. However, patients with pure DM (>90% desmoplastic component) were found to have a significantly lower rate of occult metastatic node positivity when compared with that of mixed DM (4.9% and 14.8%, respectively).

CONCLUSIONS

Our findings underscore the importance of the pathologist reporting percentage of desmoplastic component in melanoma. SLNB should be strongly considered for patients with mixed DM. However, the low rate of occult metastatic node positivity in pure DM is beneath the threshold for using SLNB as a staging procedure.

SUMMARY

Previous studies have suggested that desmoplastic melanoma is less likely to metastasize to regional lymph nodes when compared with conventional melanoma. This review suggests that it is imperative to distinguish the histologic subtype of desmoplastic melanoma to determine if staging procedure is indicated.

Sentinel Lymph Node Biopsy in Cutaneous Melanoma, a Clinical Point of View

Sentinel lymph node biopsy (SLNB) is a surgical procedure that has been used in patients with cutaneous melanoma for nearly 30 years. It is used for both staging and regional disease control with minimum morbidity, as proven by numerous worldwide prospective studies. It has been incorporated in the recommendations of national and professional guidelines. In this article, we provide a summary of the general information on SLNB in the clinical guidelines for the management of cutaneous malignant melanoma (American Association of Dermatology, European Society of Medical Oncology, National Comprehensive Cancer Network, and Cancer Council Australia) and review the most relevant literature to provide an update on the existing recommendations for SLNB.

Ulceration vs Mitosis in Cutaneous Melanoma: which is Superior for Predicting Prognosis Across Clinical Stages?

Ulceration and high mitosis are considered among the major unfavorable prognostic factors in the survival of cutaneous melanoma patients. The aim of this study was to investigate the clinical significance of these parameters and to compare them to see which one is superior to predicting prognosis across all clinical stages of melanoma. A total of 1,074 melanomas were analyzed retrospectively. Tumor ulceration was found to be limited to the local stage for predicting survival, whereas, mitosis maintained its prognostic strength for predicting survival across all clinical stages. Furthermore, no survival differences were observed between ulceration and mitosis across clinical stages.

Intermediate-thickness melanoma: A population-based study of surgical quality metrics

BACKGROUND

Variability in guideline compliance for melanoma lymph node surgery is partially attributable to controversy about patient selection. Prior data has indicated suboptimal practice of sentinel lymph node biopsy and undertreatment of clinically node-positive disease, predating Multicenter Selective Lymphadenectomy Trial II publication. To minimize bias, we studied compliance with lymph node surgery guidelines in T2/T3 (intermediate-thickness) melanoma patients, where the greatest agreement exists.

METHODS

T2/T3 and metastasis 0 melanoma cases were identified from 2004 to 2018 Surveillance, Epidemiology, and End Results data. Analysis used Cochran-Armitage test for trends, multivariable logistic regression, and Kaplan-Meier survival estimates.

RESULTS

Of 66,319 eligible T2/T3 patients, 57,211 were clinically node negative; 2,191 were clinically node positive; 6,197 were clinical node unreported; and 19,044/66,319 (28.8%) had no lymph node surgery. Among clinically node-negative patients, 36,433 (63.7%) underwent sentinel lymph node biopsy and 31,026 (85.2%) were pathologically node negative; 1,499 clinically node-positive patients (68.4%) had a lymph node dissection. Lymph node dissection rates declined from 2004 to 2018, 79.8% to 32.0% for clinically node-negative/pathologically node-positive patients and 80.4% to 61.2% for clinically node-positive/pathologically node-positive patients (both P < .0001). For clinically node-negative patients, lymph node surgery compliance improved from 63.7% (2004) to 70.4% (2018) (P < .0001). Compliance correlated with younger age, male sex, tumor mitotic rate, and site (extremity > trunk/head/neck) in multivariable analysis and improved 5-year cancer-specific survival (90.0% vs 83.4%) (all P < .0001).

CONCLUSIONS

Despite clear guidelines, one-third of intermediate-thickness melanoma patients in a recent cohort did not have recommended lymph node surgery. Lymph node status is a key determinant of the relative benefit of adjuvant systemic therapy and the need for active surveillance of pathologically node-positive/clinically node-negative patients. These data highlighted a clinical care gap. Efforts to improve guideline compliance are a logical strategy to improve cancer outcomes for intermediate-thickness melanoma patients.

Sentinel Lymph Node Biopsy and Formal Lymphadenectomy for Soft Tissue Sarcoma: A Single Center Experience of 86 Consecutive Cases

BACKGROUND

Lymph node metastases (LNMs) are rare in patients with soft tissue sarcoma (STS), and there is limited evidence to guide clinical management. We describe our experience with sentinel lymph node biopsy (SLNB) and lymphadenectomy in STS patients.

METHODS

A single-center, retrospective review was performed for patients with STS treated with SLNB and/or lymphadenectomy from 1994 to 2018. Clinicopathologic characteristics, multimodality treatment, regional/distant recurrence-free survival (RFS), and overall survival (OS) were examined.

RESULTS

Eighty-six patients underwent SLNB (n = 34) and/or lymphadenectomy (n = 60) for STS. The most frequent histologic subtypes were epithelioid, clear cell, and undifferentiated pleomorphic sarcoma. Eight of 34 (23.5%) patients had a positive SLNB with 5-year OS of 71.4% compared with 71.9% for those with a negative SLNB. Eight of the 26 SLN-negative patients (30.8%) eventually developed nodal recurrence (n = 2) and/or (n = 6) distant metastasis with an estimated 5-year OS of 50%. Of patients undergoing lymphadenectomy, estimated 5-year OS was 44.6% and median RFS was 12 months. Eight (13.3%) had distant disease at time of lymphadenectomy, 20 (33.3%) developed distant recurrence after lymphadenectomy, and 6 (10%) developed regional-only recurrence. Patients with regional-only recurrence after lymphadenectomy had an estimated 5-year OS of 66.7% compared with 29.1% for those who recurred distantly.

CONCLUSIONS

Patients with positive SLNB had similar survival to those with negative SLNB. Lymphadenectomy for isolated nodal disease is associated with poor RFS but reasonable 5-year OS when recurrence is regional-only. In STS, regional disease appears clinically distinct from distant metastatic disease and has better outcomes.

Fifty years of progress in surgical oncology: Melanoma

This paper outlines the scientific and clinical advances in the treatment of melanoma over the past 50 years. Among the highlights of progress, the dominant themes include evidence-based reduction in the extent and morbidity of surgical procedures in patients with local or regional melanoma without compromising end results, and the introduction of effective systemic therapy, specifically targeted therapy matched to patients based on specific tumor mutations, and immune checkpoint blockade. Management of advanced disease has also changed dramatically, due to improved understanding of the genomic variability of the disease as well as continuing improvements in imaging.

Incidence and patterns of lymphatic drainage to the epitrochlear and popliteal sentinel lymph nodes in malignant melanoma of the distal extremities: a single-institution retrospective study

BACKGROUND

In most cutaneous melanomas of the distal extremity, sentinel lymph nodes (SLNs) are identified in the axillary or inguinal basin; however, they may be occasionally found in the epitrochlear or popliteal basins. The incidence and patterns of lymphatic drainage to the epitrochlear or popliteal SLNs are unclear.

METHODS

To clarify the incidence and clinical characteristics of melanoma draining to these ectopic SLNs, we performed a retrospective study of the patients with distal extremity melanoma who underwent SLN biopsy at the National Cancer Center Hospital between April 2010 and December 2017.

RESULTS

We identified 27 patients with melanoma of the distal upper extremity and 113 patients with melanoma of the distal lower extremity. All patients with distal upper and lower extremity melanomas had SLNs in the axillary and inguinal basins. Epitrochlear SLNs were found in 14.8% (4/27) of the patients with upper extremity melanoma, and the frequency increased by 36.4% (4/11) when the primary melanoma was located in the basilic vein area (P = 0.00188). Popliteal SLNs were found in 21.2% (24/113) of the patients with lower extremity melanoma, and the frequency increased by 37.9% (22/58) when the primary melanoma was located in the lesser saphenous vein area (P < 0.0001).

CONCLUSION

The incidence of SLNs identified in the epitrochlear or popliteal basin is not uncommon, and physicians need to be aware of these ectopic SLNs, especially when the primary melanoma is located in the basilic vein or lesser saphenous vein areas accordingly.

Prognostic value of ulceration varies across Breslow thicknesses and clinical stages in acral melanoma: a retrospective study

BACKGROUND

Ulceration is regarded as an adverse prognostic factor and is used together with tumour thickness to subcategorize patients with cutaneous melanoma. However, the prognostic impact of ulceration in acral melanoma (AM) is controversial.

OBJECTIVES

To assess the prognostic impact of ulceration in AM and the variability across different Breslow thicknesses and clinical stages.

METHODS

A multicentre retrospective study of patients diagnosed with AM between January 2000 and December 2017. Differences in melanoma-specific survival (MSS) between patients with and without ulceration were assessed using the multivariable Cox proportional hazards model and log-rank test.

RESULTS

Among 1053 enrolled patients, 62.6% had ulceration. After a median follow-up of 61 months, patients with ulceration had a lower median MSS than those without: 66.1 months, 95% confidence interval (CI) 60.0-86.0 vs. not reached; hazard ratio 1.41, 95% CI 1.09-1.82; P = 0.012. Among patients with thin (≤ 1 mm) melanoma, the survival curves of patients with vs. without ulceration clearly separated over time (P < 0.001). No association between ulceration and MSS was observed for melanomas of thickness > 1 mm (subgroups of T2, T3 and T4; all P-values > 0.05) or patients with stage III disease (hazard ratio 1.09, 95% CI 0.71-1.68, P = 0.39).

CONCLUSIONS

Ulceration is an independent negative prognostic factor for patients with AM, but the impact varies across Breslow thicknesses and clinical stages. Ulceration has a significant effect on prognosis for patients with thin (≤ 1 mm) melanoma, but there was no association between ulceration and survival in intermediate/thick AM or stage III AM. What is already known about this topic? Ulceration status is used together with Breslow tumour thickness to subcategorize patients into different stages according to the America Joint Committee on Cancer melanoma staging system. As one distinctive subtype of cutaneous melanoma, acral melanoma (AM) is characterized by poor survival outcomes due to delayed diagnosis and a high prevalence of negative prognostic and genetic features. The prognostic impact of ulceration in AM is still controversial. What does this study add? This was the first large-scale study to assess the prognostic and staging values of ulceration in patients with AM. Ulceration has a significant effect on prognosis for patients with thin (≤1 mm) melanoma, but no association between ulceration and survival was found in intermediate/thick or stage III AM. These findings should be considered when using ulceration-based staging systems.

Lymph node colonization induces tumor-immune tolerance to promote distant metastasis

For many solid malignancies, lymph node (LN) involvement represents a harbinger of distant metastatic disease and, therefore, an important prognostic factor. Beyond its utility as a biomarker, whether and how LN metastasis plays an active role in shaping distant metastasis remains an open question. Here, we develop a syngeneic melanoma mouse model of LN metastasis to investigate how tumors spread to LNs and whether LN colonization influences metastasis to distant tissues. We show that an epigenetically instilled tumor-intrinsic interferon response program confers enhanced LN metastatic potential by enabling the evasion of NK cells and promoting LN colonization. LN metastases resist T cell-mediated cytotoxicity, induce antigen-specific regulatory T cells, and generate tumor-specific immune tolerance that subsequently facilitates distant tumor colonization. These effects extend to human cancers and other murine cancer models, implicating a conserved systemic mechanism by which malignancies spread to distant organs.

Phantom study of SPECT/CT augmented reality for intraoperative localization of sentinel lymph nodes in head and neck melanoma

OBJECTIVE

To show that augmented reality (AR) visualization of single-photon emission computed tomography (SPECT)/computed tomography (CT) data in 3D can be used to accurately localize targets in the head and neck region.

MATERIALS AND METHODS

Eight head and neck styrofoam phantoms were painted with a mixture of radioactive solution (Tc-99m) detectable with a handheld gamma probe and fluorescent ink visible only under ultraviolet (UV) light to create 10-20 simulated lymph nodes on their surface. After obtaining SPECT/CT images of these phantoms, virtual renderings of the nodes were generated from the SPECT/CT data and displayed using a commercially available AR headset. For each of three physician evaluators, the time required to localize lymph node targets was recorded (1) using the gamma probe alone and (2) using the gamma probe while wearing the AR headset. In addition, the surface localization accuracy when using the AR headset was evaluated by measuring the misalignment between the locations visually marked by the evaluators and the ground truth locations identified using UV stimulation of the ink at the site of the nodes.

RESULTS

For all three evaluators, using the AR headset significantly reduced the time to detect targets (P = 0.012, respectively) compared to using the gamma probe alone. The average misalignment between the location marked by the evaluators and the ground truth location was 8.6 mm.

CONCLUSION

AR visualization of SPECT/CT data in 3D allows for accurate localization of targets in the head and neck region, and may reduce the localization time of targets.

Sentinel Lymph Node Biopsy Positivity in Patients With Acral Lentiginous and Other Subtypes of Cutaneous Melanoma

IMPORTANCE

Acral lentiginous melanoma (ALM) is a rare subtype of malignant melanoma typically occurring on the palmar and plantar surfaces. Although it has distinctive genetic, prognostic, and behavioral characteristics relative to cutaneous melanomas overall, owing to its rarity, treatment is largely guided by data extrapolated from more common subtypes. Although sentinel lymph node (SLN) status has been shown to be a significant prognostic factor for ALM, the independent effect of ALM-subtype disease on the likelihood of SLN positivity and the stage-specific positivity rates for ALM are not well characterized.

OBJECTIVE

To evaluate the association of ALM with SLN status as well as to characterize the clinical stage-specific rates of SLN positivity for ALM based on the AJCC Cancer Staging Manual, 8th edition (AJCC-8).

DESIGN, SETTING, AND PARTICIPANTS

The National Cancer Database (NCDB) includes all reportable cases from Commission on Cancer accredited facilities and represents approximately 50% of all newly diagnosed melanoma cases in the US. This retrospective cohort study included cases of AJCC-8 clinical stage I to II melanomas from the NCDB diagnosed from 2012 to 2015. The analysis took place between April 2021 and September 2021.

EXPOSURES

Melanoma histopathologic subtype.

MAIN OUTCOMES AND MEASURES

Sentinel lymph node status.

RESULTS

We identified 60 148 patients with malignant melanomas, 959 of whom had ALM-subtype disease. Among patients in the cohort, 25 550 (42.5%) were women and the mean (SD) age was 64 (16) years. Multivariable logistic regression controlling for demographic and histopathologic characteristics revealed that ALM was independently associated with the highest risk for SLN positivity among included subtypes (vs superficial spreading melanoma: odds ratio, 1.91; 95% CI, 1.59-2.28). Subgroup analysis by AJCC clinical stage demonstrated that ALM was independently associated with the highest risk for SLN positivity for both stage IB and II disease. The rate of SLN positivity for patients with stage IB and II ALM was 18.39% (95% CI, 13.82%-24.03%) and 39.53% (34.98%-44.26%), respectively.

CONCLUSIONS AND RELEVANCE

In this cohort study ALM was independently associated with SLN positivity and had relatively high positivity rates at clinical stage IB and II. This suggests that SLNB should be encouraged for all patients with clinical stage IB and II ALM, and such patients should receive appropriate counseling about the higher regional metastatic risk of their cancers. Future work with a larger cohort is required to elucidate the risk of SLN positivity for stage IA ALM.

RIPK3 and AXL Expression Study in Primary Cutaneous Melanoma Unmasks AXL as Predictor of Sentinel Node Metastasis: A Pilot Study

Malignant melanoma (MM) is the most lethal skin cancer. AXL is a tyrosine kinase receptor involved in several oncogenic processes and might play a role in blocking necroptosis (a regulated cell death mechanism) in MM through the downregulation of the necroptotic-related driver RIPK3. The aim of this study was to evaluate the clinical impact of the expression of AXL and RIPK3 in 108 primary cutaneous MMs. Association between AXL and RIPK3 immunoreactivity and clinical-pathological variables, sentinel lymph node status, and tumor-infiltrating lymphocytes (TILs) was assessed. Immunoreaction in tumor cells was detected in 30 cases (28%; range, 5%-80%) and in 17 cases (16%; range, 5%-50%) for AXL and RIPK3, respectively. Metastases in the sentinel lymph nodes were detected in 14 out of 61 patients, and these were associated with AXL-positive immunoreactivity in the primary tumor (p < 0.0001). No association between AXL and TILs was found. RIPK3 immunoreactivity was not associated with any variables. A final logistic regression analysis showed Breslow and AXL-positive immunoreactivity as the stronger predictor for positive sentinel node status [area under the receiver operating characteristic curve (AUC) of 0.96]. AXL could be a potential new biomarker for MM risk assessment, and it deserves to be further investigated in larger studies.

Does the pattern of lymphatic drainage influence the risk of nodal recurrence in trunk melanoma patients with negative sentinel lymph node biopsy?

Background

There are conflicting data regarding the prognostic value of the lymphatic basin drainage pattern in melanoma patients and the evidence is scant in the setting of negative sentinel lymph node biopsy.

Objective

To investigate whether the pattern of lymphatic basin drainage influences the risk of nodal disease in patients with melanoma of the trunk and negative sentinel lymph node biopsy.

Methods

A case series of patients with trunk melanoma and negative sentinel lymph node biopsy was retrospectively evaluated. Clinicopathological features, the pattern of lymphatic drainage and nodal, metastatic, and overall recurrence-free survival were reviewed.

Results

Of the 135 patients included, multiple lymphatic basin drainage was identified in 61 (45.2%). Ten of the 74 (13.5%) patients with single drainage developed nodal recurrence, compared with 2 of the 61 (3.6%) patients with multiple drainages (p = 0.04). Nodal recurrence-free survival was significantly longer in the group with multiple drainages than in the group with single drainage (175.6 vs. 138.7 months; p = 0.04). In multivariate analysis, single drainage was associated with a higher risk of nodal recurrence (HR = 4.54; p = 0.05). No significant differences in metastatic and overall recurrence-free survival were found between groups.

Study limitations

Retrospective analysis, single-center study, small sample, detailed histopathologic information not always present.

Conclusions

In patients with trunk melanoma and negative sentinel lymph node biopsy, multiple lymphatic basin drainage may be an independent risk factor for nodal disease recurrence. This factor may help to identify patients with negative sentinel lymph node biopsy with a higher risk of nodal recurrence.

Integrating additional factors into the TNM staging for cutaneous melanoma by machine learning

BACKGROUND

Integrating additional factors into the TNM staging system is needed for more accurate risk classification and survival prediction for patients with cutaneous melanoma. In the present study, we introduce machine learning as a novel tool that incorporates additional prognostic factors to improve the current TNM staging system.

METHODS AND FINDINGS

Cancer-specific survival data for cutaneous melanoma with at least a 5 years follow-up were extracted from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute and split into the training set (40,781 cases) and validation set (5,390 cases). Five factors were studied: the primary tumor (T), regional lymph nodes (N), distant metastasis (M), age (A), and sex (S). The Ensemble Algorithm for Clustering Cancer Data (EACCD) was applied to the training set to generate prognostic groups. Utilizing only T, N, and M, a basic prognostic system was built where patients were stratified into 10 prognostic groups with well-separated survival curves, similar to 10 AJCC stages. These 10 groups had a significantly higher accuracy in survival prediction than 10 stages (C-index = 0.7682 vs 0.7643; increase in C-index = 0.0039, 95% CI = (0.0032, 0.0047); p-value = 7.2×10-23). Nevertheless, a positive association remained between the EACCD grouping and the AJCC staging (Spearman's rank correlation coefficient = 0.8316; p-value = 4.5×10-13). With additional information from A and S, a more advanced prognostic system was established using the training data that stratified patients into 10 groups and further improved the prediction accuracy (C-index = 0.7865 vs 0.7643; increase in C-index = 0.0222, 95% CI = (0.0191, 0.0254); p-value = 8.8×10-43). Both internal validation using the training set and temporal validation using the validation set showed good stratification and a high predictive accuracy of the prognostic systems.

CONCLUSIONS

The EACCD allows additional factors to be integrated into the TNM to create a prognostic system that improves patient stratification and survival prediction for cutaneous melanoma. This integration separates favorable from unfavorable clinical outcomes for patients and improves both cohort selection for clinical trials and treatment management.

The utility of ICG fluorescence for sentinel lymph node identification in head and neck melanoma

PURPOSE

Perform an evidence-based review to determine the utility of indocyanine green fluorescence (ICG) to detect sentinel lymph nodes (SLN) in patients with head and neck melanoma compared to blue dye or radiocolloid injection (RI).

MATERIALS AND METHODS

A systematic review of the literature was performed to identify patients with head and neck melanoma managed with ICG fluorescence. PubMed, Embase, and Cochrane Library databases were searched. Included studies were assessed for level of evidence. Patient demographics and data on SLN identification were determined.

RESULTS

Twenty-two studies encompassing 399 patients (75% male, 25% female, average age 57.1 years) met inclusion criteria. Publications comprised of two case reports, four retrospective case series, twelve cohort studies, and four clinical trials. Most common site of melanoma was scalp/temple/forehead (35%), cheek/midface (22%), and ear (17%) with an average Breslow thickness of 3.32 mm. SLN was identified in 80.7% (n = 201/249) of patients using ICG-RI, 85.2% (n = 75/88) using RI alone, and 63.4% (n = 52/82) using blue dye-RI.

CONCLUSIONS

ICG-^99mTc-nanocolloid hybrid tracer may be a superior alternative to blue dye + adiocolloid and has theoretical advantages compared to RI alone. Additional prospective randomized controlled trials are needed to further compare these methods and obtain data on false negative rates, operating room time, and cost effectiveness to fully elucidate the utility of ICG-^99mTc-nanocolloid over current methods used for SLN identification in this patient population.

Sentinel Lymph Node Tumor Burden Using Digital Cell Count Estimation Predicts Outcomes in Melanoma

BACKGROUND

Cutaneous melanoma often metastasizes in primis to sentinel lymph nodes (SLNs). Currently, there is no standardized method of characterizing micrometastatic tumor burden in SLN biopsies for melanoma. Different criteria have been developed to evaluate SLN biopsies, yet none consider the number of cells identified.

AIM

Here, we used software analysis to digitally quantify metastatic tumor burden within SLNs and correlated these data with clinicopathologic and prognostic information.

METHODS

We identified 246 cases of SLN biopsies, including 63 positive (26%) and 183 (74%) negative for metastatic melanoma. Digital cell counting was performed within the greatest metastatic focus and the entire metastatic tumor burden within the same SLN.

RESULTS

Increasing cell count in the largest metastatic deposit correlated with the previously described Rotterdam (Spearman's r = 0.91; 95% CI: 0.84, 0.94), Starz (Spearman's r = 0.78; 95% CI: 0.68, 0.87), and Dewar criteria (p < 0.01), validating our method of using cell count to define SLN tumor burden. Additionally, increasing cell count was associated with decreased metastasis free survival (HR = 2.29; 95% CI: 1.22, 4.31).

CONCLUSION

These data support the use of computerized cell count analysis for prognostication of outcomes in patients undergoing SLN biopsy.

Contemporary management of locoregionally advanced melanoma in Australia and New Zealand and the role of adjuvant systemic therapy

Australia and New Zealand have the highest incidence and mortality rates for melanoma in the world. Local surgery is still the standard treatment of primary cutaneous melanoma, and it is therefore important that surgeons understand the optimal care pathways for patients with melanoma. Accurate staging is critical to ensure a reliable assessment of prognosis and to guide treatment selection. Sentinel node biopsy (SNB) plays an important role in staging and the provision of reliable prognostic estimates for patients with cutaneous melanoma. Patients with stage III melanoma have a substantial risk of disease recurrence following surgery, leading to poor long-term outcomes. Systemic immunotherapies and targeted therapies, known to be effective for stage IV melanoma, have now also been shown to be effective as adjuvant post-surgical treatments for resected stage III melanoma. These patients should be made aware of this and preferably managed in an integrated multidisciplinary model of care, involving the surgeon, medical oncologists and radiation oncologists. This review considers the impact of a recent update to the American Joint Committee on Cancer (AJCC) staging system, the role of SNB for patients with high-risk primary melanoma and recent advances in adjuvant systemic therapies for high-risk patients.