Revised American Joint Committee on Cancer staging criteria accurately predict sentinel lymph node positivity in clinically node-negative 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.

Predictive Values of Pathological and Clinical Risk Factors for Positivity of Sentinel Lymph Node Biopsy in Thin Melanoma: A Systematic Review and Meta-Analysis

Background

The indications for sentinel lymph node biopsy (SLNB) for thin melanoma are still unclear. This meta-analysis aims to determine the positive rate of SLNB in thin melanoma and to summarize the predictive value of different high-risk features for positive results of SLNB.

Methods

Four databases were searched for literature on SLNB performed in patients with thin melanoma published between January 2000 and December 2020. The overall positive rate and positive rate of each high-risk feature were calculated and obtained with 95% confidence intervals (CIs). Both unadjusted odds ratios (ORs) and adjusted ORs (AORs) of high-risk features were analyzed. Pooled effects were estimated using random-effects model meta-analyses.

Results

Sixty-six studies reporting 38,844 patients with thin melanoma who underwent SLNB met the inclusion criteria. The pooled positive rate of SLNB was 5.1% [95% confidence interval (CI) 4.9%-5.3%]. Features significantly predicted a positive result of SLNB were thickness≥0.8 mm [AOR 1.94 (95%CI 1.28-2.95); positive rate 7.0% (95%CI 6.0-8.0%)]; ulceration [AOR 3.09 (95%CI 1.75-5.44); positive rate 4.2% (95%CI 1.8-7.2%)]; mitosis rate >0/mm2 [AOR 1.63 (95%CI 1.13-2.36); positive rate 7.7% (95%CI 6.3-9.1%)]; microsatellites [OR 3.8 (95%CI 1.38-10.47); positive rate 16.6% (95%CI 2.4-36.6%)]; and vertical growth phase [OR 2.76 (95%CI 1.72-4.43); positive rate 8.1% (95%CI 6.3-10.1%)].

Conclusions

The overall positive rate of SLNB in thin melanoma was 5.1%. The strongest predictor for SLN positivity identified was microsatellites on unadjusted analysis and ulceration on adjusted analysis. Breslow thickness ≥0.8 mm and mitosis rate >0/mm² both predict SLN positivity in adjusted analysis and increase the positive rate to 7.0% and 7.7%. We suggest patients with thin melanoma with the above high-risk features should be considered for giving an SLNB.

The efficacy of 99mTc-rituximab as a tracer for sentinel lymph node biopsy in cutaneous melanoma patients

Background

The sentinel lymph node (SLN) status is a vital prognostic factor for malignant melanoma (MM) patients. There is increasing evidence that a radioactive agent, rather than its combination with blue dye, is sufficient for a SLN biopsy (SLNB). Thus, we discussed the efficacy of ^99mTc-rituximab as a tracer in MM patients.

Methods

A total of 502 consecutive patients with MM who underwent SLNB were enrolled in this study. All participants were peritumorally injected with ^99mTc-rituximab before imaging, and scanned with single-photon emission computed tomography-computed tomography (SPECT-CT) to detect the number and location of the SLN. A gamma detection probe was employed to detect radioactive SLNs in operation. Follow up was conducted to observe whether nodal or distant recurrence occurred.

Results

The SLNs were successfully imaged via SPECT-CT and harvested from all 502 participants. No drainage tube was indwelled and 32 (6.3%) participants experienced the following complications: seroma (n=26, 5.2%), wound infections or lymphangitis (n=6, 1.2%), sensory nerve injuries (n=4, 0.8%). There were 380 patients who were diagnosed as SLN-negative and 122 (24.2%) were SLN-positive. A total of 85 SLN-positive patients received complete lymph node dissection, and 28 (32.9%) had additional positive lymph nodes. During a median follow-up of 24 months, 28 participants were found to have a false negative (FN) SLN. The FN rate was 18.7%. A higher T stage was a predictive factor for FN [odds ratio (OR) 1.77; P<0.05]. There was no significant difference in the positive or FN rate between the acral and cutaneous groups.

Conclusions

The radiopharmaceutical ^99mTc-rituximab could be employed as a simple and safe tracer in acral and cutaneous melanoma SLN biopsies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Contemporary update of SPECT tracers and novelties in radioguided surgery: a perspective based on urology

Recent technical advances and implementation of novel radiotracers have further increased the potential of radioguided surgery for a broad variety of malignancies. Indeed, the possibilities for future applications of novel radiotracers in diverse oncological strategies has become more promising than ever. This literature review aims to provide a contemporary update on a selected group of radiotracers and evaluates the usability of radioguided surgery and sentinel node procedures, focusing on most promising advances. For example, the impact of targeted radiotracers on prostate specific membrane antigen (PSMA), CD206 receptor-targeted agents (^99mTc-tilmanocept), and hybrid tracers adding fluorescence to radioguidance (ICG-^99mTc-nanocolloid) as well as targeting hypoxia-induced carbonic anhydrase IX (CAIX) will be covered. Furthermore, future outlooks on the implementation of gold nanoparticles (AuNP's), but also technical advances in improved radiotracer detection by hybrid gamma devices will be discussed.

Mapping sentinel lymph nodes in cutaneous melanoma: a vast array of perioperative imaging modalities

Sentinel lymph node biopsy (SLNB) is a decisive step in the staging process of melanoma, critically impacting patients' oncological outcome and driving the decision-making process. SLNB limits the extent of the dissection in cases where no metastases are found. Conversely, when metastases are detected, SLNB has the potential to improve regional control of the disease when complete lymphadenectomy or early administration of adjuvant treatment are indicated. Thus, accurately identifying sentinel lymph nodes represents an important prognostic factor. Several strategies have been studied, including novel procedures that are not commonly used in the clinical setting. This review highlights the different tracers, preoperative and intraoperative imaging modalities studied to perform SLNB in cutaneous melanoma. The development of innovative modalities has been fueled by a need to optimize current approaches, offering new alternatives that can overcome some of the limitations of the standard method.

Genome-wide DNA methylation and RNA expression differences correlate with invasiveness in melanoma cell lines

Aims & objectives: The aim of this study was to investigate the role of DNA methylation in invasiveness in melanoma cells. Materials & methods: The authors carried out genome-wide transcriptome (RNA sequencing) and reduced representation bisulfite sequencing methylome profiling between noninvasive (n = 4) and invasive melanoma cell lines (n = 5). Results: The integration of differentially expressed genes and differentially methylated fragments (DMFs) identified 12 DMFs (two in AVPI1, one in HMG20B, two in BCL3, one in NTSR1, one in SYNJ2, one in ROBO2 and four in HORMAD2) that overlapped with either differentially expressed genes (eight DMFs and six genes) or cis-targets of lncRNAs (five DMFs associated with cis-targets and four differentially expressed lncRNAs). Conclusions: DNA methylation changes are associated with a number of transcriptional differences observed in noninvasive and invasive phenotypes in melanoma.

Relevance of sentinel lymph node biopsy for thick melanoma in the era of immunotherapy

BACKGROUND

Sentinel lymph node biopsy provides prognostic information in patients with thick melanoma but is often underutilized. We examine regional lymph node evaluation (RLNE) in patients with thick melanoma and the effect on treatment and overall survival (OS).

METHODS

Patients with clinical T4N0M0 melanoma were selected from the National Cancer Database (2004-2015). Binary logistic regression analysis was used to identify factors associated with RLNE and treatment. Overall survival analysis was performed.

RESULTS

A total of 14 286 patients with clinical T4N0M0 melanoma were identified; RLNE was performed in 70.2% of patients, and positive LNs were identified in 27.1%. RLNE was more likely in males (OR:1.44, 95%CI: 1.32-1.56, p < .001), and patients treated at academic centers (OR:1.58, 95%CI:1.46-1.71, p < .001). Immunotherapy was more commonly used in patients with RLNE (13.9% vs 3.4%, p < .001) and was associated with positive LNs (OR:2.50, 95%CI:2.19-2.86, p < .001). The 5-year OS for RLNE was 56.9% and for no RLNE was 32.7%. Independent factors associated with better OS were treatment at an academic center (HR:0.88, 95%CI:0.84-0.93, p < .001), and immunotherapy use (HR:0.86, 95%CI:0.76-0.96, p < .001).

CONCLUSION

The use of RLNE in patients with thick melanoma is important for prognosis and to risk stratify patients for selection of adjuvant therapies and clinical trials.

Clinicopathological Features, Staging, and Current Approaches to Treatment in High-Risk Resectable Melanoma

The incidence of melanoma in the United States has been increasing over the past several decades. Prognosis largely depends on disease stage, with 5-year melanoma-specific survival ranging from as high as 99% in patients with stage I disease to less than 10% for some patients with stage IV (distant metastatic) disease. Fortunately, in the last 5-10 years, there have been remarkable treatment advances for patients with high-risk resectable melanoma, including approval of targeted and immune checkpoint blockade therapies. In addition, results of recent clinical trials have confirmed the importance of sentinel lymph node biopsy and continue to refine the approach to regional lymph node basin management. Lastly, the melanoma staging system was revised in the eighth edition AJCC Cancer Staging Manual, which was implemented on January 1, 2018. Here we discuss these changes and the clinicopathological features that confer high risk for locoregional and distant disease relapse and poor survival. Implications regarding the management of melanoma in the metastatic and adjuvant settings are discussed, as are future directions for neoadjuvant therapies.

Is it Necessary to Perform Sentinel Lymph Node Biopsy in Thin Melanoma? A Retrospective Single Center Analysis

Sentinel lymph node biopsy (SLNB) is a standard procedure for regional lymph node staging and still has the most important prognostic value for the outcome of patients with thin melanoma. In addition to ulceration, SLNB had to be considered even for a single mitotic figure in thin (<1 mm) melanoma according to AJCC7th guideline, therefore, a retrospective review was conducted involving 403 pT1 melanoma patients. Among them, 152 patients suffered from pT1b ulcerated or mitotic rate ≥ 1/ mm2 melanomas according to the AJCC7th staging system. SLNB was performed in 78 cases, of which nine (11.5%) showed SLN positivity. From them, interestingly, we found a relatively high positive sentinel rate (6/78-8%) in the case of thin primary melanomas ˂0.8 mm. Moreover, the presence of regression increased the probability of sentinel positivity by 5.796 fold. After reassessing pT stage based on the new AJCC8th, 37 pT1b cases were reordered into pT1a category. There was no significant relation between other characteristics examined (age, gender, Breslow, Clark level, and mitosis index) and sentinel node positivity. Based on our data, we suggest that mitotic rate alone is not a sufficiently powerful predictor of SLN status in thin melanomas. If strict histopathological definition criteria are applied, regression might be an additional adverse feature that aids in identifying T1 patients most likely to be SLN-positive. After reassessing of pT1b cases according to AJCC8th regression proved to be independent prognostic factor on sentinel lymph node positivity. Our results propose that sentinel lymph node biopsy might also be considered at patients with regressive thin (˂0.8 mm) melanomas.

Biomarkers Predictive of Survival and Response to Immune Checkpoint Inhibitors in Melanoma

Immunotherapy has revolutionized the treatment of melanoma. Targeting of the immune checkpoints cytotoxic T-lymphocyte-associated protein 4 and programmed cell death protein 1 has led to improved survival in a subset of patients. Unfortunately, the use of immune checkpoint inhibitors is associated with significant side effects and many patients do not respond to treatment. Thus, there is an urgent need both for prognostic biomarkers to estimate risk and for predictive biomarkers to determine which patients are likely to respond to therapy. In this review, prognostic and predictive biomarkers that are an active area of research are outlined. Of note, certain transcriptomic signatures are already used in the clinic, albeit not routinely, to prognosticate patients. In the predictive setting, programmed cell death protein ligand 1 expression has been shown to correlate with benefit but is not precise enough to be used as an exclusionary biomarker. Future investigation will need to focus on biomarkers that are easily reproducible, cost effective, and accurate. The use of readily available clinical material, such as serum or hematoxylin and eosin-stained images, may offer one such path forward.

Adequacy of sentinel lymph node biopsy in malignant melanoma of the trunk and extremities: Clinical observations regarding prognosis

Background

Methods for identifying local lymph node metastasis in malignant melanoma include sentinel lymph node biopsy (SLNB) and lymph node dissection (LND). In particular, SLNB has been widely used in recent years. This study aimed to retrospectively confirm the adequacy of the current indication criteria for SLNB by applying those criteria to a mixed group of patients who previously received SLNB and LND.

Methods

This study included 77 patients with malignant melanoma of the extremities and trunk who were monitored for >24 months. The patients were classified according to whether the current indication criteria for SLNB were applicable. The sentinel lymph nodes were evaluated for each group. Patients for whom the indication criteria for SLNB and LND were applicable were analyzed according to whether SLNB or LND was performed. Finally, the outpatient records of these patients were reviewed to evaluate recurrence, metastasis, and prognosis.

Results

Of the 77 patients, SLNB was indicated according to the current criteria in 60 cases. Among the 60 patients for whom SLNB was indicated, 35 survived the follow-up period disease-free, 21 died during the follow-up period, and four experienced metastasis. The 17 patients for whom SLNB was not indicated had no recurrence or metastasis.

Conclusions

Patients for whom SLNB was not indicated had no recurrence or metastasis. In cases where SLNB is indicated, the possibility of metastasis and recurrence may be high even if SLNB is negative or LND is performed, so more aggressive treatment and careful follow-up are crucial.

Vertical Growth Phase as a Prognostic Factor for Sentinel Lymph Node Positivity in Thin Melanomas: A Systematic Review and Meta-Analysis

BACKGROUND

The 2010 American Joint Committee on Cancer guidelines recommended consideration of sentinel lymph node biopsy for thin melanoma (Breslow thickness <1.0 mm) with aggressive pathologic features such as ulceration and/or high mitotic rate. The therapeutic benefit of biopsy-based treatment remains controversial. The authors conducted a meta-analysis to estimate the risk and outcomes of sentinel lymph node positivity in thin melanoma, and examined established and potential novel predictors of positivity.

METHODS

Three databases were searched by two independent reviewers for sentinel lymph node positivity in patients with thin melanoma. Study heterogeneity, publication bias, and quality were assessed. Data collected included age, sex, Breslow thickness, mitotic rate, ulceration, regression, Clark level, tumor-infiltrating lymphocytes, and vertical growth phase. Positivity was estimated using a random effects model. Association of positivity and clinicopathologic features was investigated using meta-regression.

RESULTS

Ninety-three studies were identified representing 35,276 patients with thin melanoma who underwent sentinel lymph node biopsy. Of these patients, 952 had a positive sentinel lymph node biopsy, for an event rate of 5.1 percent (95 percent CI, 4.1 to 6.3 percent). Significant associations were identified between positivity and Breslow thickness greater than 0.75 mm but less than 1.0 mm, mitotic rate, ulceration, and Clark level greater than IV. Seven studies reported on vertical growth phase, which was strongly associated with positivity (OR, 4.3; 95 percent CI, 2.5 to 7.7).

CONCLUSIONS

To date, this is the largest meta-analysis to examine predictors of sentinel lymph node biopsy positivity in patients with thin melanoma. Vertical growth phase had a strong association with biopsy positivity, providing support for its inclusion in standardized pathologic reporting.

Recent advancement in the early detection of melanoma using computerized tools: An image analysis perspective

BACKGROUND

The paper reviews the advancement of tools and current technologies for the detection of melanoma. We discussed several computational strategies from pre- to postprocessing image operations, descriptors, and popular classifiers to diagnose a suspected skin lesion based on its virtual similarity to the malignant lesion with known histopathology. We reviewed the current state of smart phone-based apps as diagnostic tools for screening.

METHODS

A literature survey was conducted using a combination of keywords in the bibliographic databases: PubMed, AJCC, PH2, EDRA, and ISIC melanoma project. A number of melanoma detection apps were downloaded for two major mobile operating systems, iOS and Android; their important uses, key challenges, and various expert opinions were evaluated and also discussed.

RESULTS

We have provided an overview of research on the computer-aided diagnosis methods to estimate melanoma risk and early screening. Dermoscopic images are the most viable option for the advent of new image processing technologies based on which many of the skin cancer detection apps are being developed recently. We have categorized and explored their potential uses, evaluation criteria, limitations, and other details.

CONCLUSION

Such advancements are helpful in the sense they are raising awareness. Diagnostic accuracy is the major issue of smart phone-based apps and it cannot replace an adequate clinical experience and biopsy procedures.

Melanoma & nuclear medicine: new insights & advances

The contribution of nuclear medicine to management of melanoma patients is increasing. In intermediate-thickness N0 melanomas, lymphoscintigraphy provides a roadmap for sentinel node biopsy. With the introduction of single-photon emission computed tomography images with integrated computed tomography (SPECT/CT), 3D anatomic environments for accurate surgical planning are now possible. Sentinel node identification in intricate anatomical areas (pelvic cavity, head/neck) has been improved using hybrid radioactive/fluorescent tracers, preoperative lymphoscintigraphy and SPECT/CT together with modern intraoperative portable imaging technologies for surgical navigation (free-hand SPECT, portable gamma cameras). Furthermore, PET/CT today provides 3D roadmaps to resect 18F-fluorodeoxyglucose-avid melanoma lesions. Simultaneously, in advanced-stage melanoma and recurrences, 18F-fluorodeoxyglucose-PET/CT is useful in clinical staging and treatment decision as well as in the evaluation of therapy response. In this article, we review new insights and recent nuclear medicine advances in the management of melanoma patients.

Emerging Biomarkers in Cutaneous Melanoma

Earlier identification of aggressive melanoma remains a goal in the field of melanoma research. With new targeted and immune therapies that have revolutionized the care of patients with melanoma, the ability to predict progression and monitor or predict response to therapy has become the new focus of research into biomarkers in melanoma. In this review, promising biomarkers are highlighted. These biomarkers have been used to diagnose melanoma as well as predict progression to advanced disease and response to therapy. The biomarkers take various forms, including protein expression at the level of tissue, genetic mutations of cancer cells, and detection of circulating DNA. First, a brief description is provided about the conventional tissue markers used to stage melanoma, including tumor depth. Next, protein biomarkers, which provide both diagnostic and prognostic information, are described. This is followed by a discussion of important genetic mutations, microRNA, and epigenetic modifications that can provide therapeutic and prognostic material. Finally, emerging serologic biomarkers are reviewed, including circulating melanoma cells and exosomes. Overall the goal is to identify biomarkers that aid in the earlier identification and improved treatment of aggressive melanoma.

Stratifying SLN incidence in intermediate thickness melanoma patients

BACKGROUND

Guidelines for melanoma recommend sentinel lymph node biopsy (SLNB) in patients with melanomas ≥1 mm thickness. Recent single institution studies have found tumors <1.5 mm a low-risk group for positive SLNB.

METHODS

A retrospective review of the Sentinel Lymph Node Working Group multicenter database identified patients with intermediate thickness melanoma (1.01-4.00 mm) who had SLNB, and assessed predictors for positive SLNB.

RESULTS

3460 patients were analyzed, 584 (17%) had a positive SLNB. Univariate factors associated with a positive SLNB included age <60 (p < .001), tumor on the trunk/lower extremity (p < .001), Breslow depth ≥2 mm (p < .001), ulceration (p < .001), mitotic rate ≥1/mm² (p = .01), and microsatellitosis (p < .001). Multivariate analysis revealed age, location, and Breslow depth as significant predictors. Patients ≥75 with lesions 1.01-1.49 mm on the head/neck/upper extremity and 1.5-1.99 mm without high-risk features had <5% risk of SLN positivity.

CONCLUSIONS

Intermediate thickness melanoma has significant heterogeneity of SLNB positivity. Low-risk subgroups can be found among older patients in the absence of high-risk features.

Transected thin melanoma: Implications for sentinel lymph node staging

BACKGROUND AND OBJECTIVES

Indications for sentinel lymph node (SLN) biopsy in patients with thin melanoma (≤1 mm thick) are controversial. We asked whether deep margin (DM) positivity at initial biopsy of thin melanoma is associated with SLN positivity.

METHODS

Cases were identified using prospectively maintained databases at two melanoma centers. Patients who had undergone SLN biopsy for melanoma ≤1 mm were included. DM status was assessed for association with SLN metastasis in univariate and multivariate analyses.

RESULTS

1413 cases were identified, but only 1129 with known DM status were included. 39% of patients had a positive DM on original biopsy. DM-positive and DM-negative patients did not differ significantly in primary thickness, ulceration, or mitotic activity. DM-positive and DM-negative patients had similar incidence of SLN metastasis (5.7% vs 3.5%; P = 0.07). Positive DM was not associated with SLN metastasis on univariate analysis (OR 1.69, 95% CI: 0.95-3.00, P = 0.07) or on multivariate analysis adjusted for Breslow depth, Clark level, mitotic rate, and ulceration (OR = 1.59, 95% CI: 0.89-2.85; P = 0.12).

CONCLUSIONS

For patients with thin melanoma, a positive DM on initial biopsy is not associated with risk of SLN metastasis, so DM positivity should not be considered an indication for SLN staging in an otherwise low-risk patient.

Melanoma staging: Evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual

Answer questions and earn CME/CNE To update the melanoma staging system of the American Joint Committee on Cancer (AJCC) a large database was assembled comprising >46,000 patients from 10 centers worldwide with stages I, II, and III melanoma diagnosed since 1998. Based on analyses of this new database, the existing seventh edition AJCC stage IV database, and contemporary clinical trial data, the AJCC Melanoma Expert Panel introduced several important changes to the Tumor, Nodes, Metastasis (TNM) classification and stage grouping criteria. Key changes in the eighth edition AJCC Cancer Staging Manual include: 1) tumor thickness measurements to be recorded to the nearest 0.1 mm, not 0.01 mm; 2) definitions of T1a and T1b are revised (T1a, <0.8 mm without ulceration; T1b, 0.8-1.0 mm with or without ulceration or <0.8 mm with ulceration), with mitotic rate no longer a T category criterion; 3) pathological (but not clinical) stage IA is revised to include T1b N0 M0 (formerly pathologic stage IB); 4) the N category descriptors "microscopic" and "macroscopic" for regional node metastasis are redefined as "clinically occult" and "clinically apparent"; 5) prognostic stage III groupings are based on N category criteria and T category criteria (ie, primary tumor thickness and ulceration) and increased from 3 to 4 subgroups (stages IIIA-IIID); 6) definitions of N subcategories are revised, with the presence of microsatellites, satellites, or in-transit metastases now categorized as N1c, N2c, or N3c based on the number of tumor-involved regional lymph nodes, if any; 7) descriptors are added to each M1 subcategory designation for lactate dehydrogenase (LDH) level (LDH elevation no longer upstages to M1c); and 8) a new M1d designation is added for central nervous system metastases. This evidence-based revision of the AJCC melanoma staging system will guide patient treatment, provide better prognostic estimates, and refine stratification of patients entering clinical trials. CA Cancer J Clin 2017;67:472-492. © 2017 American Cancer Society.

Expression of Ki-67 and Estrogen Receptor Beta in Primary Cutaneous Melanoma as a Potential Indicator of Regional Lymph Node Positivity

In the early stages of cutaneous malignant melanoma (MM), it is extremely difficult to predict adequately the risk from hematogenic and lymphatic metastasis. We investigate whether the immunohistochemical expression of Ki-67 and estrogen receptor beta (ERβ) in cells of MM could predict the status of regional lymph nodes. A total of 55 tissue samples of primary cutaneous melanomas with known status of regional lymph nodes were retrospectively evaluated for Ki-67 and ERβ expression by quantitative immunohistochemistry and then correlated with the status of regional lymph nodes and relevant clinicopathologic parameters. The ERβ-positive expression was detected in 38 of 55 tumors (69.09%). The Clark level showed a strong correlation with ERβ expression, as well as pT stage. All cases of MM showed Ki-67-positive expression and an elevated Ki-67 expression was strongly associated with increased Breslow thickness, Clark level, ulceration, lymphovascular invasion, number of mitosis, and pT stage. Logistic regression analysis showed that when ERβ levels increase by 1%, the risk of positive lymph nodes decreases by 7% (odds ratio=0.930; 95% confidence interval, 0.87-0.99; P=0.036), and, when the Ki-67 expression increases by 1%, the risk of lymph nodes' positivity increases by 10% (odds ratio=1.108; 95% confidence interval, 1.02-1.19; P=0.009). Correlation between expression of Ki-67 and ERβ and the status of lymph nodes has better prognostic significance than the relationship between melanoma thickness and the status of lymph nodes. Our study showed a significant prognostic value of Ki-67 expression in predicting the behavior of MM and the potential prognostic significance of ERβ.

Melanoma long non-coding RNA signature predicts prognostic survival and directs clinical risk-specific treatments

BACKGROUND

Various studies have demonstrated that the Breslow thickness, tumor ulceration and mitotic index could serve as prognostic markers in patients with cutaneous melanoma. Recently, however, as these clinicopathological biomarkers lack efficient interpretation of endogenous mechanism of melanoma, the emphasis on the prognosis of melanoma has transformed to molecular tumor markers.

OBJECTIVE

This study was designed to identify survival-related long non-coding RNAs (lncRNAs), and based on the different expressions of these lncRNAs, clinical risk-specific diagnosis and adjuvant therapy could be employed on melanoma patients, especially patients in the early course of disease or patients with a Breslow thickness no more than 2mm.

METHODS

The clinical information and corresponding RNA expression data were obtained from The Cancer Genome Atlas dataset and Gene Expression Omnibus dataset (GSE65904). All samples were categorized into one training dataset and two validation datasets. Cox proportional hazard regression analysis was then used to identify survival-related lncRNAs and risk assessment signature was constructed in training dataset. Kaplan-Meier method was used to estimate the utility of this signature in predicting the duration of survival of patients both in the training dataset and two validation datasets. Meanwhile receiver operating characteristic analyses were used to evaluate the predictive effectiveness of this signature in two validation datasets.

RESULTS

It was found that the signature was effective while used for risk stratification, and Kaplan-Meier analyses indicated that the duration of survival of patients in high-risk groups were significantly shorter than that of low-risk groups. Moreover, areas under the receiver operating characteristic curve were 0.711 (95% confidence interval: 0.618-0.804) and 0.698 (95% confidence interval: 0.614-0.782) when this signature was used to predict the patients' duration of survival in two validation datasets respectively, indicating the superior specificity and sensitivity of this signature.

CONCLUSION

We identified a four-lncRNA prognostic signature with the ability of risk stratification for melanoma patients. Risk score acquired from this signature, combining with differential diagnosis and differential adjuvant therapy, could potentially improve the prognosis quality of life for patients, especially patients in the early course of disease or patients with a Breslow thickness no more than 2mm.

Association of sentinel lymph node diameter with melanoma metastasis

BACKGROUND

Lymph nodes are an important part of the immune system and the size of the lymph node reflects local immunologic activity. The purpose of this study was to examine the association between sentinel lymph node (SLN) size and the presence of nodal metastasis in patients with melanoma.

METHODS

Retrospective review of a prospectively maintained database of patients undergoing SLN biopsy for cutaneous melanoma between February 1995 and January 2013. The maximum pathologic diameter and the volume of the largest node was used. A nodal diameter of 1.5 cm, included in 2 interquartile ranges of both positive and negative SLNs, was used as the cutoff for multivariate regression.

RESULTS

Of 1,017 SLN biopsies, 826 (81%) had complete size measurements and were included in the analysis. Patients with a positive SLN were younger (median 50 vs 53 years, P = .032), had deeper primary lesions (2 vs 1.4 mm, P < .001), and had larger SLN volume (.8 vs .6 cc, P = .009) or maximum diameter (1.9 vs. 1.6 cm, P = .03). Sex, pathologic ulceration, mitosis, and the type or location of the primary was not statistically different. On multivariate analysis; age, depth of primary, and both SLN volume and maximum diameter remained significant. An SLN greater than 1.5 cm in maximum diameter has a 60% increased odds ratio of being positive after adjusting for age, sex, and depth of primary lesion (P = .046).

CONCLUSIONS

Larger SLN maximum diameter is associated with nodal positivity independent of age, sex, depth of primary lesion, and location of SLN biopsy. The etiology and significance of larger SLNs warrant further analysis.

Sentinel Lymph Node Biopsy in Thin Cutaneous Melanoma: A Systematic Review and Meta-Analysis

BACKGROUND

Most patients with melanoma have a thin (≤1.00 mm) lesion. There is uncertainty as to which patients with thin melanoma should undergo sentinel lymph node (SN) biopsy. We sought to quantify the proportion of SN metastases in patients with thin melanoma and to determine the pooled effect of high-risk features of the primary lesion on SN positivity.

METHODS

Published literature between 1980 and 2015 was searched and critically appraised. Primary outcome was the proportion of SN metastases in patients with thin cutaneous melanoma. Secondary outcomes included the effect of high-risk pathological features of the primary lesion on the proportion of SN metastases. Summary measures were estimated by Mantel-Haenszel method using random effects meta-analyses.

RESULTS

Sixty studies (10,928 patients) met the criteria for inclusion. Pooled SN positivity was 4.5 % [95 % confidence interval (CI) 3.8-5.2 %]. Predictors of a positive SN were: thickness ≥0.75 mm [adjusted odds ratio (AOR) 1.90 (95 % CI 1.08-3.34); with a likelihood of SN metastases of 8.8 % (95 % CI 6.4-11.2 %)]; Clark level IV/V [AOR 2.24 (95 % CI 1.23-4.08); with a likelihood of 7.3 % (95 % CI 6.2-8.4 %)]; ≥1 mitoses/mm² [AOR 6.64 (95 % CI 2.77-15.88); pooled likelihood 8.8 % (95 % CI 6.2-11.4 %)]; and the presence of microsatellites [unadjusted OR 6.94 (95 % CI 2.13-22.60); likelihood 26.6 % (95 % CI 4.3-48.9 %)].

CONCLUSIONS

The pooled proportion of SN metastases in thin melanoma is 4.5 %. Thickness ≥0.75 mm, Clark level IV/V, mitoses, and microsatellites significantly increased the odds of SN positivity and should prompt strong consideration of SN biopsy.

Prognostic factors in melanoma patients with tumor-negative sentinel lymph nodes

BACKGROUND

Sentinel lymph node (SLN) biopsy for melanoma results in accurate nodal staging, which guides treatment decisions. Patients with a negative SLN biopsy in general have a favorable prognosis, but certain subsets are at increased risk for recurrence and death. This study aimed to identify risk factors predictive of prognosis in patients with a tumor-negative SLN biopsy for cutaneous melanoma.

METHODS

In this post-hoc analysis of data from a multicenter prospective randomized trial, clinicopathologic data of patients with cutaneous melanoma ≥1.0 mm Breslow thickness and tumor-negative SLN were analyzed. Disease-free survival, overall survival (OS), and local and in-transit recurrence-free survival were compared by Kaplan-Meier analysis. Risk factors for worse survival were identified with Cox proportional hazard models.

RESULTS

This analysis included 1,998 patients with tumor-negative SLN with a median follow-up of 70 months. Ulceration, Breslow thickness, nonextremity tumor location, and age ≥45 years were independent risk factors for worse disease-free survival and OS. Breslow thickness and ulceration were the only factors on multivariate analysis that predicted local and in-transit recurrence-free survival. Estimated 5-year OS rates ranged from 55.5 to 95.4% on the basis of the defined risk factors.

CONCLUSION

There is a wide range of prognosis among patients with tumor-negative SLN. Breslow thickness, ulceration, age, and anatomic location of the primary melanoma are important independent factors predicting survival and recurrence among such patients. These factors can be used to stratify prognosis among patients with tumor-negative SLN to formulate rational long-term follow-up strategies as well as identify high-risk, SLN-negative patients for clinical trials of adjuvant therapy.

Dermal melanoma: A report on prognosis, outcomes, and the utility of sentinel lymph node biopsy

INTRODUCTION

Historically dermal melanoma (DM) has been labeled as either stage IIIB (in-transit) or stage IV (M1a) disease. We sought to investigate the natural history of DM and the utility and prognostic significance of sentinel lymph node biopsy (SLNB).

METHODS

Patients with DM undergoing SLNB at a single center from 1998 to 2009 were identified.

RESULTS

Eighty-three patients met criteria, 10 (12%) patients had a positive SLNB. Of those, 5 (50%) recurred (all with distant disease). Twenty-one (29%) of the 73 SLNB negative patients recurred and of those, 15 (71%) developed distant metastases, whereas 6 (29%) developed local or regional recurrence, including two false-negative regional nodal recurrences. No in-transit recurrences were recorded. Five-year recurrence-free and disease-specific survival was significantly better for patients with a negative SLNB versus positive SLNB (56.8% vs. 22.2% P = 0.02, 81.1% vs. 61.0%, P = 0.05, respectively).

CONCLUSION

SLNB has prognostic significance for RFS and DSS, and should be utilized in the management of DM based on a >10% yield and low false-negative rate. Our data demonstrate patients with DM do not recur in an in-transit fashion, which along with the survival outcomes suggest the behavior of DM is consistent with primary cutaneous melanoma of similar thickness rather than an isolated in-transit or distant dermal metastasis from a regressed cutaneous primary.

Prognostic factors for Taiwanese patients with cutaneous melanoma undergoing sentinel lymph node biopsy

BACKGROUND/PURPOSE

Sentinel lymph node biopsy (SLNB) is a standard procedure in the management of clinically node-negative melanoma. However, few studies have been performed on SLNB in Asia, which is an acral melanoma-prevalent area. This study evaluated the clinicopathologic prognostic factors of disease-free survival (DFS) and overall survival (OS) in Taiwanese patients with cutaneous melanoma who received wide excision and SLNB. The prognosis of patients with false-negative (FN) SLNB was also evaluated.

METHODS

Malignant melanoma cases were reviewed for 518 patients who were treated between January 2000 and December 2011. Of these patients, 127 patients with node-negative cutaneous melanoma who received successful SLNB were eligible for inclusion in the study.

RESULTS

The SLNB-positive rate was 34.6%. The median DFS was 51.5 months, and the median OS was 90.9 months at the median follow-up of 36.6 months. Multivariate analysis revealed that patients whose melanoma had a Breslow thickness greater than 2 mm had a significantly shorter DFS than patients whose melanoma had a Breslow thickness of 2 mm or less [hazard ratio (HR), 3.421; p = 0.005]. Independent prognostic factors of OS were a Breslow thickness greater than 2 mm (HR, 4.435; p = 0.002); nonacral melanoma (HR, 3.048; p = 0.001); and an age older than 65 years (HR, 2.819; p = 0.036). During the follow-up period, 13 of 83 SLN-negative patients developed a regional nodal recurrence. The SLNB failure rate was 15.7% and the FN rate was 22.8%. Compared to patients with a true-positive SLNB, patients with FN SLNB had a significantly shorter DFS (p = 0.001) but no significant difference in OS (p = 0.262).

CONCLUSION

Except for the pathologic subtypes, prognostic factors in Taiwan are similar to those used in other melanoma-prevalent countries. Identifying and closely monitoring patients at risk of nodal recurrence after a negative SLNB is important.

Clinical and prognostic factors for melanoma of the skin using SEER registries: collaborative stage data collection system, version 1 and version 2

BACKGROUND

The objectives of this article are to assess the completeness of the data collected on site-specific factors (SSFs) as a part of Collaborative Stage (CS) version 2 and the impact of the transition from the American Joint Committee on Cancer's (AJCC) 6th to 7th edition guidelines on stage distribution.

METHODS

Incidence data for melanomas of the skin from 18 Surveillance, Epidemiology, and End Results (SEER) registries (SEER-18) were analyzed. Percentages of unknown cases for 7 SSFs were examined, along with staging trends from 2004 to 2010 and differences in AJCC 6th and 7th edition stage distributions for 2010 cases.

RESULTS

Fewer than 10% of cases were coded as unknown for SSFs 1 (measured thickness), 2 (ulceration), and 3 (lymph node metastasis). For the remaining SSFs, 36-81% of cases were coded as unknown. Stage distributions were relatively consistent across time and between the AJCC 6th and 7th editions, with the exception of stage IA and stage INOS (not otherwise specified), for which a shift in cases was observed between the AJCC 6th and 7th edition guidelines fOR 2010 cases.

CONCLUSIONS

A shift of cases out of stage IA and into stage INOS was observed between the AJCC 6th and 7th edition guidelines for 2010 cases. This was attributed to the high number of cases coded as unknown for SSF7 (primary tumor mitotic count/rate). The percentage of cases coded as unknown varied by SSF. Data completeness presents an issue for SSFs introduced in CS version 2.

A review of sentinel lymph node biopsy for thin melanoma

INTRODUCTION

Although there is a lack of established survival benefit of sentinel lymph node biopsy (SLNB), this technique has been increasingly applied in the staging of patients with thin (≤1.00 mm) melanoma (T1Nx), without clear supportive evidence.

METHODS

We review the guidelines and available literature on the indications and rationale for performing SLNB in thin melanoma.

RESULTS

As a consequence of the paucity of evidence of SLNB in thin melanoma, there is considerable variability in the guidelines. It is difficult to define clinicopathologic factors that reliably predict the presence of nodal metastasis. SLNB does not yet inform management in thin melanoma to improve survival outcome.

CONCLUSION

Based on available evidence, high risk patients with melanomas between 0.75 and 1.00 mm may be appropriate candidates to be considered for SLN biopsy after discussing the likelihood of finding evidence of nodal progression, the risks of sentinel node biopsy, and the lack of proven survival benefit from any form of surgical nodal staging.

Melanoma and nuclear medicine

Supported by a large body of published work, the contribution of nuclear medicine technologies to the assessment of melanoma has been increasing in recent years. Lymphoscintigraphy-assisted sentinel lymph node biopsy and PET are in continuous evolution with the aid of technological imaging advances, making it possible to fuse functional and anatomic images (e.g., with SPECT/CT, PET/CT and 3D rendering systems). The development of hybrid fluorescent-radioactive tracers that enable high-quality preoperative lymphoscintigraphy and SPECT/CT, and the optimization of modern intraoperative portable imaging technologies, such as free-hand SPECT and portable γ-cameras, are important innovations that have improved sentinel lymph node identification in complex anatomical areas, such as the pelvis and head and neck. Concurrently, ¹⁸F-fluorodeoxyglucose-PET has proved its usefulness in the clinical staging and treatment decision-making process, and there is also emerging evidence regarding its utility in the evaluation of therapeutic response. The potential uses of other novel PET radiotracers could open up a new field of use for this technique. In this article, we review the current and future role of nuclear medicine in the management of melanoma.

Breslow thickness, clark index and ulceration are associated with sentinel lymph node metastasis in melanoma patients: a cohort analysis of 612 patients

BACKGROUND

Sentinel lymph node biopsy (SLNB) is the most sensitive procedure for assessing nodal status in patients with primary melanoma.

OBJECTIVE

To evaluate the predictive ability of usual primary melanoma prognosis factors of detecting sentinel lymph node (SLN) metastasis in patients with melanoma.

PATIENTS AND METHODS

A cohort of 612 consecutive patients presenting with primary skin melanoma who underwent a SLNB was evaluated. Assessment of the determinants of SLN metastasis was based on general linear model analysis. The model performance was studied using the concordance statistic and the net reclassification index. The calibration was estimated using the Hosmer-Lemeshow test.

RESULTS

The discrimination ability did not differ significantly between Breslow thickness (0.57), Clark index (0.61), ulceration (0.57) and histological subtype (0.55). Clark index, ulceration and Breslow thickness were all significant and independent determinants of SLN metastasis. The predictive ability of the final model was 0.657.

CONCLUSION

Breslow thickness, Clark index and ulceration are independent predictors of a SLN metastasis.

Principles of surgical treatment of malignant melanoma

Although melanoma represents less than 5% of all skin cancers, it is responsible for the bulk of skin cancer-related deaths. Nevertheless, despite this aggressive reputation, most patients with cutaneous melanoma will be surgically cured of their disease. Early detection allows for curative resection, and 5-year survival for all stages of melanoma is 91%. This review outlines the surgical treatment of melanoma, including principles of wide local excision and management of the regional lymph nodes.

Sentinel node biopsy improves prognostic stratification in patients with thin (pT1) melanomas and an additional risk factor

BACKGROUND

Sentinel lymph node (SLN) biopsy (SLNB) for pT1 melanomas is not generally recognized as a clinical standard. We studied the value of SLNB for pT1 melanoma patients having at least one additional risk factor.

PATIENTS

Among 931 patients with SLNB, 210 had pT1 melanomas. All of the latter showed at least one of the following risk factors: ulceration (4 %) Clark level IV (44 %), nodular growth pattern (11 %), mitoses (59 %), regression (38 %) or age ≤ 40 years (27 %).

RESULTS

In this selected pT1 population, we observed a surprisingly high SLN positivity rate of 18 %. The melanoma-specific overall survival significantly depended on SLN status. Compared with Clark IV, a lower invasion level (Clark II/III) was associated with a higher proportion of positive SLNs (25 vs. 10 %; p < 0.01). There was a trend towards a higher SLN positivity rate in younger patients (p = 0.06). Breslow, ulceration, mitoses, nodular growth pattern, and sex did not reach significance. Regression was significantly more frequently found in very thin melanomas (≤ 0.75 mm) and tended to be significant in this subgroup (p = 0.075).

CONCLUSIONS

SLNB improves prognostic stratification in patients with thin melanomas having an additional risk factor. Clark level IV most likely does not belong to these risk factors. The impact of regression deserves further consideration. Our data suggest that SLNB should be offered to patients with thin melanomas, if ulceration, nodular growth pattern, mitoses, or regression are present, or if the patient is younger than 40 years of age.

Age as a predictor of sentinel node metastasis among patients with localized melanoma: an inverse correlation of melanoma mortality and incidence of sentinel node metastasis among young and old patients

PURPOSE

We have previously reported that older patients with clinical stage I and II primary cutaneous. Melanoma had lower survival rates compared to younger patients. We postulated that the incidence of nodal metastasis would therefore be higher among older melanoma patients.

METHODS

The expanded American Joint Committee on Cancer melanoma staging database contains a cohort of 7,756 melanoma patients who presented without clinical evidence of regional lymph node or distant metastasis and who underwent a sentinel node biopsy procedure as a component of their staging assessment.

RESULTS

Although older patients had primary melanoma features associated with more aggressive biology, we paradoxically observed a significant decrease in the incidence of sentinel node metastasis as patient age increased. Overall, the highest incidence of sentinel node metastasis was 25.8 % in patients under 20 years of age, compared to 15.5 % in patients 80 years and older (p < 0.001). In contrast, 5-year mortality rates for clinical stage II patients ranged from a low of 20 % for those 20-40 years of age up to 38 % for those over 70 years of age. Patient age was an independent predictor of sentinel node metastasis in a multifactorial analysis (p < 0.001).

CONCLUSIONS

Patients with clinical stage I and II melanoma under 20 years of age had a higher incidence of sentinel lymph node metastasis but, paradoxically, a more favorable survival outcome compared to all other age groups. In contrast, patients >70 years had the most aggressive primary melanoma features and a higher mortality rate compared to all other age groups but a lower incidence of sentinel lymph node metastasis.

Sentinel node biopsy for melanoma. Analysis of our experience (125 patients)

INTRODUCTION

The objective of this study is to analyze our experience in the use of sentinel node biopsy (SNB) in melanoma and identify the predictive factors of positive SNB and multiple drainage.

MATERIAL AND METHODS

Retrospective study of patients who underwent SNB for melanoma between August of 2000 and February of 2013.

RESULTS

SNB was performed in 125 patients with a median of age of 55,6 (±15) years. The anatomic distribution was: 44 (35,2%) in legs, 24 (19,2%) in arms, 53 (42,4%) trunk and 3 (2,4%) in head and neck. The median Breslow index was 1,81 (0,45-5). Between 1 and 6 nodes were isolated. The drainage was unique in 98 (78,4%) and multiple in 27 (21,6%). The trunk was the localization of 25 (92,6%) nodes with multiple drainage. The definitive result of sentinel node (SN) was positive in 18 cases (7,1%). Breslow thickness (p=0,01) was statistically significant predictor of a positive SNB.

CONCLUSIONS

The SNB allows patients to be selected for lymphadenectomy. Melanoma of the trunk was the principle location of multiple drainage. The only predictive factor of positive SNB was Breslow thickness.

Surgery and adjuvant radiotherapy for cutaneous melanoma considered high-risk for local-regional recurrence

PURPOSE

To assess the efficacy of postoperative radiotherapy (RT) in the treatment of cutaneous melanoma.

MATERIALS

Between August 1981 and December 2009, 82 patients were treated with surgery and postoperative RT for cutaneous melanoma. Patients were thought to be high risk for local-regional recurrence after surgery alone because of the presence of one or more risk factors including recurrence after prior surgery, positive lymph nodes, extracapsular extension, incomplete regional node dissection, microscopically positive margins, gross residual disease, and in-transit metastases. The primary site was located in the head and neck in 64 patients and elsewhere in the remainder. Forty-two patients (47%) were treated with hypofractionated RT and the remainder with conventional fractionation. Median age was 62 years (range, 21 to >89 years). Median follow-up overall and for survivors was 3.0 years (range, 0.1 to 17.4 years) and 6.4 years (1.6 to 17.4 years), respectively.

RESULTS

The 5-year outcomes were: in-field local-regional control 82%; local-regional control, 76%; distant metastasis-free survival, 48%; cause-specific survival, 56%; and overall survival, 43%. In-field local-regional control at 5 years was 87% after hypofractionated RT and 78% after conventionally fractionated RT.

CONCLUSIONS

Postoperative adjuvant RT likely reduces the risk of local-regional recurrence after surgery for patients with high risk cutaneous melanoma. Hypofractionated RT is as effective as conventional fractionation and is logistically advantageous, particularly for patients with a relatively poor prognosis. The risk of RT complications is low.

Is head and neck melanoma different from trunk and extremity melanomas with respect to sentinel lymph node status and clinical outcome?

BACKGROUND

Previous studies showed conflicting and inconsistent results regarding the effect of anatomic location of the melanoma on sentinel lymph node (SLN) positivity and/or survival. This study was conducted to evaluate and compare the effect of the anatomic locations of primary melanoma on long-term clinical outcomes.

METHODS

All consecutive cutaneous melanoma patients (n=2,079) who underwent selective SLN dissection (SLND) from 1993 to 2009 in a single academic tertiary-care medical center were included. SLN positive rate, disease-free survival (DFS), and overall survival (OS) were determined. Kaplan-Meier survival, univariate, and multivariate analyses were performed to determine predictive factors for SLN status, DFS, and OS.

RESULTS

Head and neck melanoma (HNM) had the lowest SLN-positive rate at 10.8% (16.8% for extremity and 19.3% for trunk; P=0.002) but had the worst 5-year DFS (P<0.0001) and 5-year OS (P<0.0001) compared with other sites. Tumor thickness (P<0.001), ulceration (P<0.001), HNM location (P=0.001), mitotic rate (P<0.001), and decreasing age (P<0.001) were independent predictive factors for SLN-positivity. HNM with T3 or T4 thickness had significantly lower SLN positive rate compared with other locations (P≤0.05). Also, on multivariate analysis, HNM location versus other anatomic sites was independently predictive of decreased DFS and OS (P<0.001). By Kaplan-Meier analysis, HNM was associated significantly with the worst DFS and OS.

CONCLUSIONS

Primary melanoma anatomic location is an independent predictor of SLN status and survival. Although HNM has a decreased SLN-positivity rate, it shows a significantly increased risk of recurrence and death as compared with other sites.