1
|
The importance of mitosis ≥2 in selecting patients with T1 cutaneous melanomas for sentinel lymph node biopsy. Melanoma Res 2022; 32:469-476. [DOI: 10.1097/cmr.0000000000000851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
2
|
Huang H, Fu Z, Ji J, Huang J, Long X. Predictive Values of Pathological and Clinical Risk Factors for Positivity of Sentinel Lymph Node Biopsy in Thin Melanoma: A Systematic Review and Meta-Analysis. Front Oncol 2022; 12:817510. [PMID: 35155254 PMCID: PMC8829564 DOI: 10.3389/fonc.2022.817510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/10/2022] [Indexed: 11/25/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Hanzi Huang
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ziyao Fu
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiang Ji
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiuzuo Huang
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao Long
- Department of Plastic Surgery, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
3
|
Fröhlich SM, Cazzaniga S, Kaufmann LS, Hunger RE, Seyed Jafari SM. A Retrospective Cohort Study on Patients with Lentigo Maligna Melanoma. Dermatology 2019; 235:340-345. [PMID: 31112945 DOI: 10.1159/000499689] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 03/18/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND More epidemiological data about lentigo maligna melanoma (LMM) are required to define follow-up guidelines. The study focused on recurrence, progression, and overall survival of LMM managed with primary wide local excision. METHODS In a 23-year retrospective study (1994 to 2016), a cohort of patients with LMM was evaluated by collecting data about the tumor location, the Breslow depth, the presence of ulceration, and patients' age and sex. Local recurrences, locoregional and distant metastases, and disease-free and overall survival were additionally assessed. RESULTS Overall, 150 cases (84 male, 66 female, mean age 71.3 ± 11.3 years) of single, localized, primary LMM with a mean follow-up of 6.6 ± 4.4 years were included. A total of 33 (22.2%) patients underwent sentinel lymph node biopsy (SLNB) during surgical excision. However, positive SLNB was detected in none of them. The multivariable Cox analysis indicated that age of diagnosis and male gender significantly influenced the overall survival, while a shorter disease-free survival could be correlated with a greater Breslow thickness. The metastatic potential turned out to be low, entailing 7 deaths in the context of the LMM. CONCLUSION Male gender, age over 70 at diagnosis, and a Breslow thickness greater than 0.75 mm were associated with a statistically significant decrease in overall disease-free survival in the current study. The results of the study confirm the favorable outcome of LMM. However, diagnosed patients should undertake regular follow-ups. The intensity of follow-up in these patients can be individualized based on the probability of recurrence/metastasis and overall survival. Furthermore, the study showed that SLNB might not be a necessary staging procedure in patients with LMM.
Collapse
Affiliation(s)
- Selina M Fröhlich
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simone Cazzaniga
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Centro Studi GISED, Bergamo, Italy
| | - Lilian S Kaufmann
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Uniklinik Frankfurt, Frankfurt, Germany
| | - Robert E Hunger
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland,
| | - S Morteza Seyed Jafari
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
4
|
dos Santos FDM, da Silva FC, Pedron J, Furian RD, Fortes C, Bonamigo RR. Association between tumor-infiltrating lymphocytes and sentinel lymph node positivity in thin melanoma. An Bras Dermatol 2019; 94:47-51. [PMID: 30726463 PMCID: PMC6360962 DOI: 10.1590/abd1806-4841.20197414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/13/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Sentinel lymph node biopsy in thin invasive primary cutaneous melanoma (up to 1mm thick) is a controversial subject. The presence of tumor-infiltrating lymphocytes could be a factor to be considered in the decision to perform this procedure. OBJECTIVE To evaluate the association between the presence of tumor-infiltrating lymphocytes and lymph node metastases caused by thin primary cutaneous melanoma. METHODS Cross-sectional study with 137 records of thin invasive primary cutaneous melanoma submitted to sentinel lymph node biopsy from 2003 to 2015. The clinical variables considered were age, sex and topography of the lesion. The histopathological variables assessed were: tumor-infiltrating lymphocytes, melanoma subtype, Breslow thickness, Clark levels, number of mitoses per mm2, ulceration, regression and satellitosis. Univariate analyzes and logistic regression tests were performed as well the odds ratio and statistical relevance was considered when p <0.05. RESULTS Among the 137 cases of thin primary cutaneous melanoma submitted to sentinel lymph node biopsy, 10 (7.3%) had metastatic involvement. Ulceration on histopathology was positively associated with the presence of metastatic lymph node, with odds ratio =12.8 (2.77-59.4 95% CI, p=0.001). The presence of moderate/marked tumor-infiltrating lymphocytes was shown to be a protective factor for the presence of metastatic lymph node, with OR=0.20 (0.05-0.72 95% CI, p=0.014). The other variables - clinical and histopathological - were not associated with the outcome. STUDY LIMITATIONS The relatively small number of positive sentinel lymph node biopsy may explain such an expressive association of ulceration with metastatization. CONCLUSIONS In patients with thin invasive primary cutaneous melanoma, few or absent tumor-infiltrating lymphocytes, as well as ulceration, represent independent risk factors for lymph node metastasis.
Collapse
Affiliation(s)
| | - Felipe Correa da Silva
- Discipline of Pathology, Faculdade de Medicina da Universidade
Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS),
Brazil
| | - Julia Pedron
- Discipline of Pathology, Faculdade de Medicina da Universidade
Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS),
Brazil
| | | | - Cristina Fortes
- Department of Epidemiology, Istituto Dermopatico dell’Immacolata,
Rome, Italy
| | - Renan Rangel Bonamigo
- Service of Dermatology, Hospital de Clínicas de Porto
Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS), Brazil
- Pathology Post-Graduate Program, Universidade Federal de
Ciências da Saúde de Porto Alegre, Porto Alegre (RS), Brazil
| |
Collapse
|
5
|
Vertical Growth Phase as a Prognostic Factor for Sentinel Lymph Node Positivity in Thin Melanomas: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2018; 141:1529-1540. [PMID: 29579032 DOI: 10.1097/prs.0000000000004395] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
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.
Collapse
|
6
|
Joyce KM, McInerney NM, Piggott RP, Martin F, Jones DM, Hussey AJ, Kerin MJ, Kelly JL, Regan PJ. Analysis of sentinel node positivity in primary cutaneous melanoma: an 8-year single institution experience. Ir J Med Sci 2017; 186:847-853. [PMID: 28132159 DOI: 10.1007/s11845-017-1559-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 01/11/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is a standard method for determining the pathologic status of the regional lymph nodes. AIMS The aim of our study was to determine the incidence and clinicopathologic factors predictive of SLN positivity, and to evaluate the prognostic importance of SLNB in patients with cutaneous melanoma. METHODS We performed a retrospective analysis of a prospectively maintained database of all patients who underwent SLNB for primary melanoma at our institution from 2005 to 2012. Statistical analysis was performed using χ 2 and Fischer exact test. RESULTS In total, 318 patients underwent SLNB, of which 65 were for thin melanoma (≤1 mm). There were 36 positive SLNB, 278 negative SLNB and in four cases the SLN was not located. The incidence rate for SLNB was 11.3% overall and 1.5% in thin melanomas alone. Statistical analysis identified Breslow thickness >1 mm (P = 0.006), Clark level ≥ IV (P = 0.004) and age <75 years (P = 0.035) as the strongest predictors of SLN positivity. Our overall false negativity rate was 20% (9/45) with one case of false-negative SLNB in thin melanomas. CONCLUSION Breslow thickness of the primary tumour remains the strongest predictor of SLN positivity. Our findings point to a possible limited role for SLNB in thin melanoma due to its low positivity rate, associated false-negative rate and related morbidity.
Collapse
Affiliation(s)
- K M Joyce
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland.
| | - N M McInerney
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - R P Piggott
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - F Martin
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - D M Jones
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - A J Hussey
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - M J Kerin
- Department of Surgery, Clinical Science Institute, Galway University Hospital, Galway, Ireland
| | - J L Kelly
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| | - P J Regan
- Department of Plastic and Reconstructive Surgery, Galway University Hospital, Galway, Ireland
| |
Collapse
|
7
|
Puleo CA, Messina JL, Riker AI, Glass LF, Nelson C, Cruse CW, Johnson TM, Sondak VK. Sentinel Node Biopsy for Thin Melanomas: Which Patients Should be Considered? Cancer Control 2017; 12:230-5. [PMID: 16258494 DOI: 10.1177/107327480501200404] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND As the incidence of melanoma increases, thin melanomas are being diagnosed at an increasingly frequent rate. Currently available prognostic factors are limited in their ability to reliably discriminate which patients will manifest regional nodal metastasis and would be identified early through sentinel node biopsy. METHODS We summarized our experience with sentinel node biopsy for patients with cutaneous melanomas less than 1.00 mm in Breslow thickness, with evaluation of Clark level as a predictor of positive sentinel node metastasis. RESULTS Among the 409 patients identified, micrometastases were found in the sentinel node in 20 patients, for an overall incidence of nodal progression of 4.9%. A total of 252 (62%) were Clark level II or III (11 of whom had a positive sentinel node) and 157 (38%) were Clark level IV (9 of whom had a positive sentinel node). We reviewed the literature to identify reliable indicators that might be helpful in determining which patients with "thin melanomas" would be likely to manifest regional progression to warrant routinely undergoing a preoperative lymphoscintigraphy followed by a sentinel node biopsy. CONCLUSIONS Based on available data, patients with melanomas between 0.75 and 1.00 mm are appropriate candidates to be considered for sentinel node biopsy after discussing the likelihood of finding evidence of nodal progression, the risks of sentinel node biopsy (including the risk of a false-negative result), and the lack of proven survival benefit from any form of surgical nodal staging.
Collapse
Affiliation(s)
- Christopher A Puleo
- Cutaneous Oncology Division, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | | | | | | | | | | | | | | |
Collapse
|
8
|
|
9
|
Cordeiro E, Gervais MK, Shah PS, Look Hong NJ, Wright FC. Sentinel Lymph Node Biopsy in Thin Cutaneous Melanoma: A Systematic Review and Meta-Analysis. Ann Surg Oncol 2016; 23:4178-4188. [PMID: 26932710 DOI: 10.1245/s10434-016-5137-z] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Indexed: 12/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Erin Cordeiro
- Division of General Surgery, The Ottawa Hospital, Ottawa, ON, Canada.
| | - Mai-Kim Gervais
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Prakesh S Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Nicole J Look Hong
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Frances C Wright
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| |
Collapse
|
10
|
Vollmer RT. Probabilistic issues with sentinel lymph nodes in malignant melanoma. Am J Clin Pathol 2015; 144:464-72. [PMID: 26276777 DOI: 10.1309/ajcp50dkltiuazte] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES To address issues of probability for sentinel lymph node results in melanoma and provide details about the probabilistic nature of the numbers of sentinel nodes as well as to address how these issues relate to tumor thickness and patient outcomes. METHODS Analysis of the probability of observing sentinel node metastases uses the discrete exponential probability distribution to address the number of observed positive sentinel nodes. In addition, mathematical functions derived from survival analysis are used. Data are then chosen from the literature to illustrate the approach and to derive results. RESULTS Observations about the numbers of positive and negative sentinel nodes closely follow discrete exponential probability distributions, and the relationship between the probability of a positive sentinel node and tumor thickness follows closely a function derived from survival analysis. Sentinel node results relate to tumor thickness as well as to the total number of nodes harvested but fall short of identifying all those who eventually develop metastatic melanoma. CONCLUSIONS Probability analyses provide useful insight into the success and failure of the sentinel node biopsy procedure in patients with melanoma.
Collapse
|
11
|
A review of sentinel lymph node biopsy for thin melanoma. Ir J Med Sci 2014; 184:119-23. [PMID: 25366817 DOI: 10.1007/s11845-014-1221-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 10/27/2014] [Indexed: 01/19/2023]
Abstract
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.
Collapse
|
12
|
Validation of a nomogram predicting sentinel lymph node status in melanoma in an Irish population. Ir J Med Sci 2014; 184:769-73. [PMID: 24997756 DOI: 10.1007/s11845-014-1166-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 06/29/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Sentinel lymph node (SLN) positivity is an important prognostic factor in cutaneous melanoma. A nomogram has been developed at Memorial Sloan-Kettering Cancer Centre (MSKCC) to predict SLN positivity and this may be useful to select patients for SLN biopsy. AIMS We aimed to determine whether this nomogram would be of clinical use in an Irish population. METHODS Age, Breslow thickness, Clark's level, presence of ulceration and tumour location indices were used to calculate the probability of SLN positivity with the MSKCC nomogram in 124 patients who underwent SLN biopsy in Beaumont Hospital between 2006 and 2012. Discrimination and calibration of the nomogram were evaluated. Negative predictive value (NPV) of the nomogram was calculated, using a cut-off of nomogram predicted probability of <9%. RESULTS SLN biopsy was positive in 25 patients (20.16%). Overall predictive accuracy of the nomogram was found to be significant with an area under the curve of 0.805 (95% confidence interval 0.710-0.899). The mean predicted probability correlated well with observed risk (r = 0.887). The NPV was 92.86% with an error rate of 3.23%. This would lead to a reduction in SLN biopsy rate of 45.16%. CONCLUSIONS This nomogram is valid and accurate at predicting SLN positivity in an Irish population. This may facilitate the clinical decision to perform a SLN biopsy in malignant melanoma.
Collapse
|
13
|
Han D, Zager JS, Shyr Y, Chen H, Berry LD, Iyengar S, Djulbegovic M, Weber JL, Marzban SS, Sondak VK, Messina JL, Vetto JT, White RL, Pockaj B, Mozzillo N, Charney KJ, Avisar E, Krouse R, Kashani-Sabet M, Leong SP. Clinicopathologic predictors of sentinel lymph node metastasis in thin melanoma. J Clin Oncol 2013; 31:4387-93. [PMID: 24190111 DOI: 10.1200/jco.2013.50.1114] [Citation(s) in RCA: 169] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
PURPOSE Indications for sentinel lymph node biopsy (SLNB) for thin melanoma are continually evolving. We present a large multi-institutional study to determine factors predictive of sentinel lymph node (SLN) metastasis in thin melanoma. PATIENTS AND METHODS Retrospective review of the Sentinel Lymph Node Working Group database from 1994 to 2012 identified 1,250 patients who had an SLNB and thin melanomas (≤ 1 mm). Clinicopathologic characteristics were correlated with SLN status and outcome. RESULTS SLN metastases were detected in 65 (5.2%) of 1,250 patients. On univariable analysis, rates of Breslow thickness ≥ 0.75 mm, Clark level ≥ IV, ulceration, and absence of regression differed significantly between positive and negative SLN groups (all P < .05). These four variables and mitotic rate were used in multivariable analysis, which demonstrated that Breslow thickness ≥ 0.75 mm (P = .03), Clark level ≥ IV (P = .05), and ulceration (P = .01) significantly predicted SLN metastasis with 6.3%, 7.0%, and 11.6% of the patients with these respective characteristics having SLN disease. Melanomas < 0.75 mm had positive SLN rates of < 5% regardless of Clark level and ulceration status. Median follow-up was 2.6 years. Melanoma-specific survival was significantly worse for patients with positive versus negative SLNs (P = .001). CONCLUSION Breslow thickness ≥ 0.75 mm, Clark level ≥ IV, and ulceration significantly predict SLN disease in thin melanoma. Most SLN metastases (86.2%) occur in melanomas ≥ 0.75 mm, with 6.3% of these patients having SLN disease, whereas in melanomas < 0.75 mm, SLN metastasis rates are < 5%. By using a 5% metastasis risk threshold, SLNB is indicated for melanomas ≥ 0.75 mm, but further study is needed to define indications for SLNB in melanomas < 0.75 mm.
Collapse
Affiliation(s)
- Dale Han
- Dale Han, Jonathan S. Zager, Sanjana Iyengar, Mia Djulbegovic, Jaimie L. Weber, Suroosh S. Marzban, Vernon K. Sondak, and Jane L. Messina, Moffitt Cancer Center, Tampa; Eli Avisar, University of Miami, Miami, FL; Yu Shyr, Heidi Chen, and Lynne D. Berry, Vanderbilt University School of Medicine, Nashville, TN; John T. Vetto, Oregon Health and Science University, Portland, OR; Richard L. White, Carolinas Medical Center, Charlotte, NC; Barbara Pockaj, Mayo Clinic, Scottsdale; Robert Krouse, Southern Arizona Veterans Administration Health Care System, Tucson, AZ; Nicola Mozzillo, Istituto Nazionale dei Tumori-Fondazione Pascale, Naples, Italy; Kim James Charney, St Joseph Hospital, Orange; and Mohammed Kashani-Sabet and Stanley P. Leong, California Pacific Medical Center and Research Institute, San Francisco, CA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Bartlett EK, Gimotty PA, Sinnamon AJ, Wachtel H, Roses RE, Schuchter L, Xu X, Elder DE, Ming M, Elenitsas R, Guerry D, Kelz RR, Czerniecki BJ, Fraker DL, Karakousis GC. Clark level risk stratifies patients with mitogenic thin melanomas for sentinel lymph node biopsy. Ann Surg Oncol 2013; 21:643-9. [PMID: 24121883 DOI: 10.1245/s10434-013-3313-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND The role for sentinel lymph node biopsy (SLNB) in patients with thin melanoma (≤1 mm) remains controversial. We examined a large cohort of patients with thin melanoma to better define predictors of SLN positivity. METHODS From 1995 to 2011, 781 patients with thin primary melanoma and evaluable clinicopathologic data underwent SLNB at our institution. Predictors of SLN positivity were determined using univariate and multivariate regression analyses, and patients were risk-stratified using a classification and regression tree (CART) analysis. RESULTS In the study cohort (n = 781), 29 patients (3.7%) had nodal metastases. In the univariate analysis, mitotic rate [odds ratio (OR) = 8.11, p = 0.005], Clark level (OR 4.04, p = 0.003), and thickness (OR 3.33, p = 0.011) were significantly associated with SLN positivity. In the multivariate analysis, MR (OR 7.01) and level IV-V (OR 3.45) remained significant predictors of SLN positivity. CART analysis initially stratified lesions by mitotic rate; nonmitogenic lesions (n = 273) had a 0.7% SLN positivity rate versus 5.6% in mitogenic lesions (n = 425). Mitogenic lesions were further stratified by Clark level; patients with level II-III had a 2.9% SLN positivity rate (n = 205) versus 8.2% with level IV-V (n = 220). With median follow-up of 6.3 years, five SLN-negative patients developed nodal recurrence and four SLN-positive patients died of disease. CONCLUSIONS SLN positivity is low in patients with thin melanoma (3.7%) and exceedingly so in nonmitogenic lesions (0.7%). Appreciable rates of SLN positivity can be identified in patients with mitogenic lesions, particularly with concurrent level IV-V regardless of thickness. These factors may guide appropriate selection of patients with thin melanoma for SLNB.
Collapse
Affiliation(s)
- Edmund K Bartlett
- Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA,
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Mozzillo N, Pennacchioli E, Gandini S, Caracò C, Crispo A, Botti G, Lastoria S, Barberis M, Verrecchia F, Testori A. Sentinel node biopsy in thin and thick melanoma. Ann Surg Oncol 2013; 20:2780-6. [PMID: 23720068 DOI: 10.1245/s10434-012-2826-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although sentinel node biopsy (SNB) has become standard of care in patients with melanoma, its use in patients with thin or thick melanomas remains a matter of debate. METHODS This was a retrospective analysis of patients with thin (≤1 mm) or thick (≥4 mm) melanomas who underwent SNB at two Italian centers between 1998 and 2011. The associations of clinicopathologic features with sentinel lymph node positive status and overall survival (OS) were analyzed. RESULTS In 492 patients with thin melanoma, sentinel node was positive for metastatic melanoma in 24 (4.9 %) patients. No sentinel node positivity was detected in patients with primary tumor thickness <0.3 mm. Mitotic rate was the only factor significantly associated with sentinel node positivity (p = 0.0001). Five-year OS was 81 % for patients with positive sentinel node and 93 % for negative sentinel node (p = 0.001). In 298 patients with thick melanoma, 39 % of patients had positive sentinel lymph nodes (median Breslow thickness 5 mm). In patients with positive sentinel node, 93 % had mitotic rate >1/mm(2). Five-year OS was 49 % for patients with positive sentinel lymph nodes and 56 % for patients with negative sentinel nodes (p = 0.005). CONCLUSIONS The rate of sentinel node positivity in patients with thin melanoma was 4.9 %. The only clinicopathologic factor related to node positivity was mitotic rate. Given its prognostic importance, SNB should be considered in such patients. SNB should also be the standard method for melanoma ≥4 mm, not only for staging, but also for guiding therapeutic decisions.
Collapse
Affiliation(s)
- Nicola Mozzillo
- Istituto Nazionale per lo Studio e la cura dei tumori Fondazione G.Pascale IRCCS, Naples, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Venna SS, Thummala S, Nosrati M, Leong SP, Miller JR, Sagebiel RW, Kashani-Sabet M. Analysis of sentinel lymph node positivity in patients with thin primary melanoma. J Am Acad Dermatol 2013. [DOI: 10.1016/j.jaad.2012.08.045] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
17
|
Sentinel lymph node status as most important prognostic factor in patients with high-risk cutaneous melanomas (tumour thickness >4.00 mm): outcome analysis from a single institution. Eur J Nucl Med Mol Imaging 2012; 39:1316-25. [DOI: 10.1007/s00259-012-2139-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Accepted: 04/11/2012] [Indexed: 12/19/2022]
|
18
|
Abstract
OBJECTIVES To determine the rate and clinicopathologic factors predictive of sentinel lymph node (SLN) positivity, regional lymph node recurrence, and survival in a large series of patients with thin primary cutaneous melanoma who underwent SLN biopsy (SLNB). METHODS Patients with thin (≤1 mm) melanomas who underwent SLNB between 1992 and 2009 at Melanoma Institute Australia were identified from the Melanoma Institute Australia database. The association of clinicopathologic features with SLN status, lymph node recurrence, and survival was analyzed. RESULTS In 432 patients [226 men, 206 women; median age 49.5 years (range: 14.4-85.0 years)], SLNB was positive for metastatic melanoma in 29 (6.7%) patients. No SLN positivity was detected in 37 patients with primary tumor thickness 0.50 mm or less. Breslow thickness (P = 0.012) and presence of lymphovascular invasion (P = 0.018) were the only factors significantly associated with SLN positivity. Regional lymph node recurrence was significantly more common in tumors located in the head/neck region (4/33, 12%) than in extremities (3/245, 1.2%) and trunk (2/154, 1.3%) (P < 0.001). Primary tumor mitotic rate was a significant predictor of melanoma-specific survival (Hazard Ratio [HR] = 1.2, 95% confidence interval: 1.09-1.35, P < 0.001). CONCLUSIONS There is a low but significant rate of SLN positivity in patients with primary melanomas 0.51 to 1.0 mm in thickness. Given its prognostic importance, SLNB should be considered in such patients, particularly if there is lymphatic permeation by melanoma at the primary tumor site. More frequent regional node field recurrences in patients with head/neck primary tumors may be a consequence of complex lymphatic drainage patterns in this region.
Collapse
|
19
|
Hinz T, Ahmadzadehfar H, Wierzbicki A, Höller T, Wenzel J, Biersack HJ, Bieber T, Schmid-Wendtner MH. Prognostic value of sentinel lymph node biopsy in 121 low-risk melanomas (tumour thickness <1.00 mm) on the basis of a long-term follow-up. Eur J Nucl Med Mol Imaging 2011; 39:581-8. [DOI: 10.1007/s00259-011-2009-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 11/17/2011] [Indexed: 10/14/2022]
|
20
|
Lowe M, Hill N, Page A, Chen S, Delman KA. The Impact of Shave Biopsy on The Management of Patients with Thin Melanomas. Am Surg 2011. [DOI: 10.1177/000313481107700826] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Disagreement persists regarding the role that various biopsy methods should play in the diagnosis of primary cutaneous melanoma. We analyzed the indications for sentinel lymph node (SLN) biopsy and the rates of SLN involvement among biopsy techniques and deep margin status to attempt to determine impact of shave biopsy on surgical management of patients with thin melanoma. All patients who underwent SLN biopsy for melanoma with Breslow thickness less than 1 mm between 1998 and 2006 were identified. Patient and tumor characteristics were compared using χ2 tests for categorical variables. Continuous variables were reported as a mean ± standard deviation and analyzed using t test. Of the 260 patients diagnosed with thin melanomas, 159 (61.2%) were diagnosed by shave biopsy; 101 (38.8%) were diagnosed by other techniques. Of the 159 patients diagnosed by shave biopsy, 18.2 per cent (n = 29) underwent SLN biopsy with the only indication being positive deep margin. The frequency of SLN positivity did not differ between the biopsy groups (3.1% vs 4.0%, P = 0.726) or between groups that had positive or negative deep margins (3.0% vs 3.3%, P = 0.839, respectively). For patients unable to undergo general anesthesia, the increased rate of performing SLN biopsy resulting from shave biopsy should limit its use in these patients. However, shave biopsy is a reasonable diagnostic method for patients at low risk for general anesthesia, particularly because it results in comparably low rates of positive SLN. Thus each patient's unique clinical situation should be considered when deciding which biopsy technique is appropriate.
Collapse
Affiliation(s)
- Michael Lowe
- Departments of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Nikki Hill
- Departments of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew Page
- Departments of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Suephy Chen
- Departments of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Keith A. Delman
- Departments of Surgery, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
21
|
Abstract
This article reviews melanoma and nonmelanoma cutaneous malignancies.
Collapse
|
22
|
Jaber JJ, Clark JI, Muzaffar K, Ruggiero FP, Feustel PJ, Frett MJ, Zender CA. Evolving treatment strategies in thin cutaneous head and neck melanoma: 1 institution's experience. Head Neck 2011; 33:7-12. [DOI: 10.1002/hed.21403] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
23
|
Silva FB, Oliveira Filho RSD, Iared W, Atallah ÁN, Santos IDDAO, Ferreira LM. Indications of Sentinel Node Biopsy in Thin Melanoma. EINSTEIN-SAO PAULO 2010; 8:235-40. [PMID: 26760011 DOI: 10.1590/s1679-45082010rw1424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Accepted: 04/12/2010] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To assess data on survival, recurrence and histological factors in positive and negative sentinel lymph nodes in thin melanoma cases. METHODS A systematic review was conducted on observational studies in four databases (Cochrane Library, Medline, Embase and Lilacs). Positive and negative micrometastases in sentinel lymph node biopsy were compared regarding the clinical outcomes - death and recurrence - and six histological factors - vertical growth phase, Breslow thickness, Clark level, ulceration, regression and mitosis rate. RESULTS Positive sentinel lymph node is statistically associated with greater risk of death in six studies (OR: 7.2; 95%CI [2.37-21.83]; I2 0%) and also to recurrence in three studies (OR: 30.7; 95%CI [12.58-74.92]; I2 36%). Comparing positive and negative groups, the histological factors predicting positive sentinel nodes and poor prognosis were: mitosis rate ≥ 5/mm2 (OR: 16.29; 95%CI [3.64-72.84]; I2 40%); VGP (OR: 2.93; 95%CI [1.08-7.93]; I2 59%); Breslow thickness ≥ 0.75mm (OR: 2.23; 95%CI [1.29-3.86]; I2 0%); and Clark level IV-V (OR: 1.61; 95%CI [1.06-2.44]; I234%). CONCLUSIONS The statistically significant results associated with the presence of micrometastases in thin melanomas were Breslow thickness ≥ 0.75 mm, Clark level IV-V and mitoses ≥ 5/mm2, absence of regression. This histological factor of ulceration was associated, but not statistically significant.
Collapse
Affiliation(s)
- Fernanda Braga Silva
- Resident in Dermatology, Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, BR
| | | | | | | | | | - Lydia Masako Ferreira
- Department of Surgery, Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, BR
| |
Collapse
|
24
|
Yao K, Balch G, Winchester DJ. Multidisciplinary treatment of primary melanoma. Surg Clin North Am 2009; 89:267-81, xi. [PMID: 19186240 DOI: 10.1016/j.suc.2008.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article covers the multidisciplinary treatment of primary melanoma. Excision margins and the need for sentinel lymphadenectomy are mainly dictated by the Breslow thickness although exceptions to this dictum do exist. Interferon is the only FDA approved adjuvant therapy for high risk melanoma although its overall survival benefit is minimal. Trials examining different doses or duration of interferon therapy have not demonstrated any promising survival data so far. There have been several randomized vaccine trials for melanoma but none have shown an overall survival benefit. Research into T-cell regulation continues and will hopefully bring promise for the future of melanoma treatment.
Collapse
Affiliation(s)
- Katharine Yao
- Department of Surgery, Northwestern University Feinberg School of Medicine, NorthShore University HealthSystem, Evanston Hospital-Walgreen Bldg Suite 2507, 2650 Ridge Ave, Evanston, IL 60201, USA.
| | | | | |
Collapse
|
25
|
Warycha MA, Zakrzewski J, Ni Q, Shapiro RL, Berman RS, Pavlick AC, Polsky D, Mazumdar M, Osman I. Meta-analysis of sentinel lymph node positivity in thin melanoma (<or=1 mm). Cancer 2009; 115:869-79. [PMID: 19117354 PMCID: PMC3888103 DOI: 10.1002/cncr.24044] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Despite the lack of an established survival benefit of sentinel lymph node (SLN) biopsy, this technique has been increasingly applied in the staging of thin ( METHODS MEDLINE, EMBASE, and Cochrane databases were searched for rates of SLN positivity in patients with thin melanoma. The methodologic quality of included studies was assessed using the Methodological Index for Non-Randomized Studies criteria. Heterogeneity was assessed using the Cochran Q statistic, and publication bias was examined through funnel plot and the Begg and Mazumdar method. Overall SLN positivity in thin melanoma patients was estimated using the DerSimonial-Laird random effect method. RESULTS Thirty-four studies comprising 3651 patients met inclusion criteria. The pooled SLN positivity rate was 5.6%. Significant heterogeneity among studies was detected (P = .005). There was no statistical evidence of publication bias (P = .21). Eighteen studies reported select clinical and histopathologic data limited to SLN-positive patients (n = 113). Among the tumors from these patients, 6.1% were ulcerated, 31.5% demonstrated regression, and 47.5% were Clark level IV/V. Only 4 melanoma-related deaths were reported. CONCLUSIONS Relatively few patients with thin melanoma have a positive SLN. To the authors' knowledge, there are no clinical or histopathologic criteria that can reliably identify thin melanoma patients who might benefit from this intervention. Given the increasing diagnosis of thin melanoma, in addition to the cost and potential morbidity of this procedure, alternative strategies to identify patients at risk for lymph node disease are needed.
Collapse
Affiliation(s)
- Melanie A. Warycha
- Department of Dermatology, New York University School of Medicine, New York, NY
| | - Jan Zakrzewski
- Department of Dermatology, New York University School of Medicine, New York, NY
| | - Quanhong Ni
- Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY
| | - Richard L. Shapiro
- Department of Surgery, New York University School of Medicine, New York, NY
| | - Russell S. Berman
- Department of Surgery, New York University School of Medicine, New York, NY
| | - Anna C. Pavlick
- Department of Dermatology, New York University School of Medicine, New York, NY
- Department of Medicine, New York University School of Medicine, New York, NY
| | - David Polsky
- Department of Dermatology, New York University School of Medicine, New York, NY
- Department of Pathology, New York University School of Medicine, New York, NY
| | - Madhu Mazumdar
- Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY
| | - Iman Osman
- Department of Dermatology, New York University School of Medicine, New York, NY
- Department of Medicine, New York University School of Medicine, New York, NY
| |
Collapse
|
26
|
Wright BE, Scheri RP, Ye X, Faries MB, Turner RR, Essner R, Morton DL. Importance of sentinel lymph node biopsy in patients with thin melanoma. ACTA ACUST UNITED AC 2008; 143:892-9; discussion 899-900. [PMID: 18794428 DOI: 10.1001/archsurg.143.9.892] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
HYPOTHESIS The status of the sentinel node (SN) confers important prognostic information for patients with thin melanoma. DESIGN, SETTING, AND PATIENTS We queried our melanoma database to identify patients undergoing sentinel lymph node biopsy for thin (< or =1.00-mm) cutaneous melanoma at a tertiary care cancer institute. Slides of tumor-positive SNs were reviewed by a melanoma pathologist to confirm nodal status and intranodal tumor burden, defined as isolated tumor cells, micrometastasis, or macrometastasis (< or =0.20, 0.21-2.00, or >2.00 mm, respectively). Nodal status was correlated with patient age and primary tumor depth (< or = 0.25, 0.26-0.50, 0.51-0.75, or 0.76-1.00 mm). Survival was determined by log-rank test. MAIN OUTCOME MEASURES Disease-free and melanoma-specific survival. RESULTS Of 1592 patients who underwent sentinel lymph node biopsy from 1991 to 2004, 631 (40%) had thin melanomas; 31 of the 631 patients (5%) had a tumor-positive SN. At a median follow-up of 57 months for the 631 patients, the mean (SD) 10-year rate of disease-free survival was 96% (1%) vs 54% (10%) for patients with tumor-negative vs tumor-positive SNs, respectively (P < .001); the mean (SD) 10-year rate of melanoma-specific survival was 98% (1%) vs 83% (8%), respectively (P < .001). Tumor-positive SNs were more common in patients aged 50 years and younger (P = .04). The SN status maintained importance on multivariate analysis for both disease-free survival (P < .001) and melanoma-specific survival (P < .001). CONCLUSIONS The status of the SN is significantly linked to survival in patients with thin melanoma. Therefore, sentinel lymph node biopsy should be considered to obtain complete prognostic information.
Collapse
Affiliation(s)
- Byron E Wright
- Department of Surgical Oncology, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California 90404, USA
| | | | | | | | | | | | | |
Collapse
|
27
|
Roulin D, Matter M, Bady P, Liénard D, Gugerli O, Boubaker A, Bron L, Lejeune FJ. Prognostic value of sentinel node biopsy in 327 prospective melanoma patients from a single institution. Eur J Surg Oncol 2008; 34:673-9. [PMID: 17825518 DOI: 10.1016/j.ejso.2007.07.197] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2007] [Accepted: 07/23/2007] [Indexed: 10/22/2022] Open
Abstract
AIM To confirm the accuracy of sentinel node biopsy (SNB) procedure and its morbidity, and to investigate predictive factors for SN status and prognostic factors for disease-free survival (DFS) and disease-specific survival (DSS). MATERIALS AND METHODS Between October 1997 and December 2004, 327 consecutive patients in one centre with clinically node-negative primary skin melanoma underwent an SNB by the triple technique, i.e. lymphoscintigraphy, blue-dye and gamma-probe. Multivariate logistic regression analyses as well as the Kaplan-Meier were performed. RESULTS Twenty-three percent of the patients had at least one metastatic SN, which was significantly associated with Breslow thickness (p<0.001). The success rate of SNB was 99.1% and its morbidity was 7.6%. With a median follow-up of 33 months, the 5-year DFS/DSS were 43%/49% for patients with positive SN and 83.5%/87.4% for patients with negative SN, respectively. The false-negative rate of SNB was 8.6% and sensitivity 91.4%. On multivariate analysis, DFS was significantly worsened by Breslow thickness (RR=5.6, p<0.001), positive SN (RR=5.0, p<0.001) and male sex (RR=2.9, p=0.001). The presence of a metastatic SN (RR=8.4, p<0.001), male sex (RR=6.1, p<0.001), Breslow thickness (RR=3.2, p=0.013) and ulceration (RR=2.6, p=0.015) were significantly associated with a poorer DSS. CONCLUSION SNB is a reliable procedure with high sensitivity (91.4%) and low morbidity. Breslow thickness was the only statistically significant parameter predictive of SN status. DFS was worsened in decreasing order by Breslow thickness, metastatic SN and male gender. Similarly DSS was significantly worsened by a metastatic SN, male gender, Breslow thickness and ulceration. These data reinforce the SN status as a powerful staging procedure.
Collapse
Affiliation(s)
- D Roulin
- Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Abstract
In patients with melanoma, surgery is pivotal not only for the primary tumor but also for regional and often distant metastases. The minimally invasive technique of sentinel node (SN) biopsy has become standard for detection of occult regional node metastasis in patients with intermediate-thickness primary melanoma; in these patients it has a central role in determining prognosis and a significant impact on survival when biopsy results are positive. Its role in thin melanoma remains under evaluation. The regional tumor-draining SN also is a useful model for studies of melanoma-induced immunosuppression. Although completion lymphadenectomy remains the standard of care for patients with SN metastasis, results of ongoing phase III trials will indicate whether SN biopsy without further lymph node surgery is adequate therapy for certain patients with minimal regional node disease.
Collapse
Affiliation(s)
- Mark B Faries
- Division of Surgical Oncology and the Roy E. Coats Research Laboratories, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, CA 90404, USA.
| | | |
Collapse
|
29
|
Abstract
The aim of the present study is to report our experience with lymphatic mapping (LM) and sentinel lymph node biopsy (SLNB) in a selected group of patients with thin primary cutaneous melanomas. Fifty patients (22 females and 28 males; mean age, 57.8 years; range, 30-77 years) with a mean tumor thickness of 0.63 mm (range, 0.24-1.00 mm) underwent LM/SLNB. Twenty-eight (56%) of them had Clark level II, 20 (40%) had Clark level III, and two (4%) had Clark level IV. Tumor ulceration was present in two patients (4%) and histological regression in 35 patients (70%). Sentinel lymph node (SLN) metastases occurred in two of 50 patients (4%). The first case was a 0.88-mm thick, Clark level III, non-ulcerated superficial spreading melanoma of the trunk, without any regression. The second case was a 0.95-mm thick, Clark level IV, non-ulcerated superficial spreading melanoma of the neck, with regression. Both patients were disease-free 76 and 50 months after the SLNB procedure and followed complete lymph node dissection, respectively. The patients with negative SLN were disease-free after a median follow up of 44 months (mean, 43.2; range, 15-84 months). Published data and our experience suggest that LM/SLNB is not routinely indicated for melanomas less than 0.75 mm. Our results confirmed the accuracy of the new American Joint Committee on Cancer/International Union Against Cancer criteria, in which SLNB is required for thin melanomas less than 1.0 mm when they have ulceration or Clark level IV and V invasion.
Collapse
Affiliation(s)
- Roberto Cecchi
- Department of Dermatology, Pistoia Hospital, Pistoia, Italy.
| | | | | | | |
Collapse
|
30
|
Kruper LL, Spitz FR, Czerniecki BJ, Fraker DL, Blackwood-Chirchir A, Ming ME, Elder DE, Elenitsas R, Guerry D, Gimotty PA. Predicting sentinel node status in AJCC stage I/II primary cutaneous melanoma. Cancer 2007; 107:2436-45. [PMID: 17058288 DOI: 10.1002/cncr.22295] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Sentinel lymph node (SLN) status is an important prognostic factor for survival for patients with primary cutaneous melanoma. To address the issue of selecting patients at high and low risk for a positive SLN, prognostic factors were sought that predict SLN involvement by examining characteristics of both the primary tumor and the patient within the context of a biological model of melanoma progression. METHODS The study included 682 patients with primary vertical growth phase (VGP) melanoma and no clinical evidence of metastatic disease who underwent SLN biopsy (1995-2003). Logistic regression and classification tree analyses were used to investigate the association between SLN positivity and Breslow thickness, Clark level, tumor infiltrating lymphocytes (TIL), ulceration, mitotic rate (MR), lesion site, gender, and age. RESULTS.: In all, 88 of the 682 patients had > or =1 positive SLN (12.9%). In the multivariate analysis, MR, TIL, and thickness were found to be independent prognostic factors for SLN positivity. In the classification tree, four different risk groups were defined, ranging from minimal risk (2.1%) to high risk (40.4%). In lesions < r =2.0 mm, MR was important in risk-stratifying patients, and in lesions >2.0 mm TIL was important. CONCLUSIONS By incorporating biologically based variables such as VGP, TIL, and MR along with thickness into a prognostic model, both patients at high risk and minimal risk for SLN positivity can be identified. If validated, this model can be used in patient management and trial design to select patients to undergo or be spared SLN biopsy.
Collapse
Affiliation(s)
- Laura L Kruper
- Melanoma Program of the Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Chan FM, O'Donnell BA, Whitehead K, Ryman W, Sullivan TJ. Treatment and Outcomes of Malignant Melanoma of the Eyelid. Ophthalmology 2007; 114:187-92. [PMID: 17140665 DOI: 10.1016/j.ophtha.2006.08.043] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2004] [Revised: 07/10/2006] [Accepted: 08/16/2006] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To review the treatment and outcomes of malignant melanoma (MM) of the eyelid skin. DESIGN Retrospective case series review. PARTICIPANTS All consecutive patients who had MM arising from eyelid skin treated by 2 regional tertiary referral oculoplastic surgeons were included. METHODS Patient charts were reviewed to collect information on the main outcome measures. MAIN OUTCOME MEASURES Demographics, clinical and histological features of the lesion, treatment, and outcomes. RESULTS Twenty-nine patients between 22 and 88 years old (mean, 65) were included. The most common site of MM occurrence was the lower eyelid. Seventeen cases arose in an area of pigmentation, 4 arose de novo, and 8 were of unknown origin. The most common histopathological types were lentigo maligna melanoma (19 cases), followed by superficial spreading MM (8 cases). Fourteen patients had in situ disease and therefore had no Breslow thickness. Another 7 patients had Breslow thickness of <0.76 mm. Thirteen patients had Clark level II or higher. According to the American Joint Committee on Cancer staging system for cutaneous melanoma, 14 patients were clinically stage 0 and 6 patients were stage IA, with thickness < or = 1 mm and no ulceration. Treatment included wide excision in all cases, one of which underwent anterior exenteration. Pathological techniques used included mapped serial excision with standard or overnight paraffin sections or Mohs' micrographic surgery. Most patients had a good outcome, although 2 died of the disease. Five patients had local recurrence, and 4 had distant metastases. Median postoperative follow-up was 3 years (range, 1 month-9 years, 9 months). CONCLUSIONS Lentigo maligna melanoma compared with other forms of MM was relatively more common in the periocular region than in other body locations. Our pathologists preferred paraffin sections to frozen section for accurate assessment of melanocytic atypia and margin status. Initial wide excision margins of 10 mm from the macroscopic edge of the tumor are suggested, as histological margins may be less than this. Margin control by mapped serial excision or a modified Mohs' micrographic surgery using paraffin sections is a useful technique to ensure complete excision and minimization of local recurrence.
Collapse
Affiliation(s)
- Fiona M Chan
- Department of Ophthalmology, Royal Brisbane Hospital, Brisbane, Australia
| | | | | | | | | |
Collapse
|
32
|
Ranieri JM, Wagner JD, Wenck S, Johnson CS, Coleman JJ. The prognostic importance of sentinel lymph node biopsy in thin melanoma. Ann Surg Oncol 2006; 13:927-32. [PMID: 16788753 DOI: 10.1245/aso.2006.04.023] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2004] [Accepted: 12/19/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is prognostically useful in patients with cutaneous melanoma with Breslow thickness > 1 mm. The objective of this study was to determine whether sentinel node histology has similar prognostic importance in patients with thin melanomas (< or = 1 mm). METHODS This was a retrospective study of patients who underwent SLNB for clinically localized melanoma at Indiana University Medical Center between 1994 and 2003. SLNB results and traditional melanoma prognostic indicators were studied in univariate log-rank tests. RESULTS One hundred eighty-four patients with melanomas < or = 1 mm thick underwent SLNB. SLNB was tumor positive in 12 patients (6.5%). Univariate analysis of SLNB results revealed that Breslow thickness, Clark level of invasion, and mitotic index were associated with SLNB status. Tumor positivity was observed at different rates in tumor thickness subsets: < .75 mm, 2.3%; and .75 to 1.0 mm, 10.2% (P = .0372). Disease-free survival and overall survival were significantly associated with SLNB results in melanomas < or = 1 mm (log-rank test: P < .0001 and P = .0125, respectively) at a median follow-up of 26.3 months. CONCLUSIONS SLNB histology in melanomas < or = 1.0 mm deep is a significant predictor of outcome. SLNB should be considered for selected patients with melanomas .75 to 1.0 mm.
Collapse
Affiliation(s)
- Jaime M Ranieri
- Department of Surgery/Plastic and Reconstructive Surgery, Indiana University School of Medicine, Indiana University-Purdue University, Indianapolis, Indiana 46202, USA
| | | | | | | | | |
Collapse
|
33
|
Abstract
Accurate risk assessment is central to the process of making rational surgical and systemic treatment recommendations for melanoma patients and in establishing appropriate clinical trial stratification criteria. The current American Joint Commission on Cancer melanoma staging system incorporated relevant prognostic variables to provide a framework for the estimation of risk for recurrence; however, significant prognostic heterogeneity exists within the stage groupings. In the stage I/II group, survival rates range from 40% to 95% as defined by the combination of tumor thickness and ulceration. The use of novel prognostic factors, such as mitotic rate, sentinel node biopsy, and prognostic modeling using a variety of factors, can minimize this prognostic heterogeneity and provide a more accurate and individualized prognostic profile. Recent modifications in the stage III criteria include the number of positive nodes, whether the nodal disease is microscopic or clinically apparent, and the presence of an ulcerated primary. Through these factors, survival estimates can be provided, but like the stage I/II group, wide ranges in prognosis exist. The complexion of the stage III population is in evolution as a result of increasing numbers of patients being diagnosed as having microscopic sentinel node disease. Contemporary efforts are focused on defining the prognosis and natural history of this group. Through prognostic modeling using the number of nodes involved, ulceration status, and a measure of disease burden--disease in the sentinel node--relatively homogeneous subgroups can be identified. Long-term follow-up of patients staged with PCR molecular techniques on sentinel nodes shows conflicting value in assessing prognosis and therefore cannot be routinely used outside a clinical trial. The combination of genomic profiling using microarray analyses and the development of targeted therapy holds the future promise of individualizing prognosis and therapy.
Collapse
Affiliation(s)
- Merrick I Ross
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
| |
Collapse
|
34
|
Ross MI. New American Joint Commission on Cancer Staging System for Melanoma: Prognostic Impact and Future Directions. Surg Oncol Clin N Am 2006; 15:341-52. [PMID: 16632219 DOI: 10.1016/j.soc.2005.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Accurate melanoma staging is critical in establishing management strategies and estimating disease relapse. Combined with assessment of comorbidities and understanding treatment toxicities, risk assessment is central to offering appropriate surgical or systemic therapies. The American Joint Commission on Cancer (AJCC) melanoma staging system provides survival estimates within anatomically defined disease categories. Newer prognostic factors and methods of prognostic analyses can augment predictions for the presence of micro-metastatic disease and further define the risk for relapse. This article highlights relevant changes, evidence supporting future incorporation of more recently defined prognostic variables, novel approaches used as adjuncts to the current staging system, and future directions of the AJCC staging committee.
Collapse
Affiliation(s)
- Merrick I Ross
- Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, 1400 Holcombe Boulevard, Unit #444, Houston, TX 77030, USA.
| |
Collapse
|
35
|
Karakousis GC, Gimotty PA, Botbyl JD, Kesmodel SB, Elder DE, Elenitsas R, Ming ME, Guerry D, Fraker DL, Czerniecki BJ, Spitz FR. Predictors of regional nodal disease in patients with thin melanomas. Ann Surg Oncol 2006; 13:533-41. [PMID: 16523360 DOI: 10.1245/aso.2006.05.011] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2005] [Accepted: 10/12/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Most melanoma patients present with thin (<or=1.0 mm) lesions. Indications for sentinel lymph node (SLN) biopsy are not well defined for this group. Previously, we reported an association between mitotic rate (MR) and SLN positivity in these patients. The study was limited by a relatively small sample size and low statistical power. In this study, we evaluated a large population of patients with thin melanoma from the pre-SLN era to identify predictors of regional nodal disease (RND) that may serve as a surrogate for SLN positivity. METHODS Eight hundred eighty-two patients evaluated between 1972 and 1991 were included in the study. Univariate and multivariate regression analyses were performed by using clinical and histological data to identify factors associated with RND. A multivariate logistic regression model was developed and applied to the previously reported group of patients with thin melanomas who underwent SLN biopsy between 1996 and 2004 for validation. RESULTS Thirty-eight patients (4.3%) had evidence of RND. In the multivariate analysis, a MR>0, vertical growth phase (VGP), male sex, and ulceration were statistically significant predictors of RND. Patients at the highest risk according to a classification tree analysis (VGP and MR>0) had an RND rate of 11.9%. The regression model developed predicted well the SLN status in the validation sample. CONCLUSIONS Investigation of a large pre-SLN population identified MR>0, ulceration, VGP, and male sex as independently predictive of RND in patients with thin melanomas. These factors may help to identify subgroups of these patients that have clinically significant risks of SLN positivity.
Collapse
Affiliation(s)
- Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania Health System, Abramson Cancer Center, Philadelphia, Pennsylvania 19104, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Abstract
PURPOSE OF REVIEW It is now well established that sentinel lymph node biopsy is a powerful test to predict prognosis for melanoma patients. Controversy exists, however, regarding the appropriate selection of patients for sentinel lymph node biopsy, especially among patients with thin melanomas (< 1 mm Breslow thickness), thick melanomas (> 4 mm Breslow thickness), or locally recurrent melanoma. RECENT FINDINGS The majority of the studies in the past 2 years regarding sentinel lymph node biopsy have been concerned with identifying factors that can better predict regional nodal metastasis and survival. Other studies have proposed a better risk stratification model, which includes these factors, to best select those patients at increased risk of nodal positivity. SUMMARY Although much research has been done to select appropriate patients for sentinel lymph node biopsy based on multiple prognostic factors, further studies are necessary to completely define the indications for this procedure in patients with thin, thick and locally recurrent melanomas.
Collapse
Affiliation(s)
- Jin Hee Ra
- Department of Surgery, Hospital of the University of Pennsylvania, PA 19104, USA
| | | | | |
Collapse
|
37
|
Wong SL, Brady MS, Busam KJ, Coit DG. Results of Sentinel Lymph Node Biopsy in Patients With Thin Melanoma. Ann Surg Oncol 2006; 13:302-9. [PMID: 16485151 DOI: 10.1245/aso.2006.02.021] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2005] [Accepted: 09/11/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sentinel lymph node (SLN) biopsy has been shown to be a highly accurate method of staging nodal basins in melanoma patients. Although this technique is widely accepted in patients with intermediate-thickness tumors, it is unclear what the indications are for thin (< or = 1 mm) melanoma. METHODS From May 1991 to October 2004, 223 patients with thin melanoma underwent SLN biopsy at Memorial Sloan-Kettering Cancer Center. Most patients with thin melanoma were selected for the procedure because of high-risk clinicopathologic features. RESULTS Nodal metastases were found in eight patients (3.6%) who underwent SLN biopsy. All positive SLNs were found in patients with > or = .75 mm-thick and Clark level IV melanoma (8 of 114; 7%). Age, sex, tumor location, thickness, Clark level, ulceration, regression, tumor-infiltrating lymphocytes, mitotic rate, and number of mapped nodal basins were not predictive of positive SLNs (chi(2); P = not significant). With a median follow-up of 25 months, there have been no recurrences or deaths in patients with melanoma < .75 mm. Six patients have had regional and/or systemic recurrences (2.7%), only one of whom had a positive SLN. Three patients have died of melanoma; all had negative SLNs. CONCLUSIONS Nodal metastasis in thin melanoma is uncommon, especially in patients with < .75 mm and Clark level II or III melanoma. In our experience, no single clinicopathologic factor was predictive of nodal metastases. The prognostic implications of positive SLNs in thin melanoma remain undefined.
Collapse
Affiliation(s)
- Sandra L Wong
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10021, USA
| | | | | | | |
Collapse
|
38
|
Vaquerano J, Kraybill WG, Driscoll DL, Cheney R, Kane JM. American Joint Committee on Cancer Clinical Stage as a Selection Criterion for Sentinel Lymph Node Biopsy in Thin Melanoma. Ann Surg Oncol 2006; 13:198-204. [PMID: 16418885 DOI: 10.1245/aso.2006.03.092] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Accepted: 08/25/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND A significant proportion of newly diagnosed melanomas are thin lesions (< or = 1.00 mm). Because tumor thickness correlates with the risk for nodal metastases, sentinel lymph node (SLN) biopsy in this subset is controversial. Incorporating other prognostic factors (Clark level and ulceration), we evaluated the 6th edition American Joint Committee on Cancer (AJCC) clinical stage as a simple and widely applicable guideline for offering SLN biopsy for thin melanoma. METHODS This study was a review of a prospective melanoma SLN database from 1993 to 2003 with emphasis on SLN positivity rates based on the 6th edition AJCC primary tumor thickness intervals and clinical stage. RESULTS Three hundred five patients underwent SLN biopsy, with an overall positivity rate of 17.7%. By the 6th edition AJCC, lesions < or = 1.00 mm had an SLN positivity rate of 6.6%. By 6th edition clinical stage, SLN positivity rates were 4.9% for stage IA and 10.4% for stage IB. By using stage IA as the criterion for not offering SLN biopsy, this procedure would have been avoided in 46% (39 of 85) of < or = 1.00-mm melanoma patients with a negative SLN. CONCLUSIONS Sixth edition AJCC clinical stage IB as a selection criterion for performing SLN biopsy in thin melanoma identifies most patients with a positive SLN while also avoiding a negative SLN biopsy in many patients. Until additional widely accepted and validated selection criteria are available, SLN biopsy for clinical stage IB, but not stage IA, thin melanomas is a reasonable approach.
Collapse
Affiliation(s)
- Julio Vaquerano
- Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, New York 14263, USA
| | | | | | | | | |
Collapse
|
39
|
Hershko DD, Robb BW, Lowy AM, Ahmad SA, Ramadas GH, Soldano DA, Sussman JJ. Sentinel lymph node biopsy in thin melanoma patients. J Surg Oncol 2006; 93:279-85. [PMID: 16496355 DOI: 10.1002/jso.20415] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND We sought to determine the incidence of positive sentinel lymph nodes in thin melanoma (<or=1.0 mm) patients and if subgroups could be identified with a higher risk of occult nodal disease. METHODS Patients with <or=1.0 mm lesions treated between 1997 and 2003 were reviewed. Sentinel nodes underwent microscopic analysis including step sectioning and immunohistochemical examination. Some nodes underwent reverse transcriptase-polymerase chain reaction (RT-PCR) evaluation for melanoma markers. RESULTS Sixty-four of 107 thin melanoma patients underwent sentinel node biopsy (SNB). Mapped patients were more likely to have Clark >or= III and thicker lesions (mean 0.77 mm vs. 0.47 mm), but were not different in regards to age, sex, or lesion location. Eight percent and 58% of sentinel nodes were positive by routine histology and RT-PCR, respectively. Among mapped patients, younger age was the only significant prognostic factor for node positivity. With a median follow-up of 18 months among all patients, one regional recurrence (at 2 years) has been identified. CONCLUSIONS Given the low morbidity of sentinel lymph node biopsy, this procedure should be discussed with selected thin melanoma patients to detect microscopic disease, however PCR positivity by our methods is too commonly seen to be clinically significant in thin melanoma patients and requires additional study.
Collapse
Affiliation(s)
- Dan D Hershko
- Department of Surgery, A. Rambam Medical Center, Technion-Israel Institute of Technology, Haifa, Israel
| | | | | | | | | | | | | |
Collapse
|
40
|
Kretschmer L, Bertsch HP, Meller J. [Sentinel lymph node biopsy in malignant melanoma--an update]. J Dtsch Dermatol Ges 2005; 1:777-84. [PMID: 16281813 DOI: 10.1046/j.1439-0353.2003.03048.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Ten years after the introduction of the sentinel lymph node biopsy technique in the management of malignant melanoma, it is time to take stock. The complex method has proved itself sufficiently sensitive, although a certain percentage of false-negative histological results have to be taken into account. Presently, it is still a point at issue whether sentinel lymph node biopsy should be regarded as the standard of care in high-risk patients. Three prospective multicentre trials have failed to demonstrate a survival benefit resulting from elective lymph node dissection. In contrast, a retrospective multicentre study has recently shown that patients with node metastases diagnosed by the sentinel procedure benefit from early excision of their nodal disease in terms of overall survival, as compared to patients with delayed dissection of palpable nodes. Studies worldwide have established the pathologic status of the sentinel lymph node biopsy as the most important prognostic factor for recurrence and survival after the excision of primary melanoma. As with any invasive staging procedure, sentinel lymph node biopsy should have demonstrated therapeutic consequences. Unfortunately, an unequivocally acknowledged adjuvant therapy is lacking. Moreover, the impact of complete lymph node dissection after positive sentinel biopsy on survival or local disease control has not yet been clarified.
Collapse
Affiliation(s)
- Lutz Kretschmer
- Abteilung Dermatologie und Venerologie, Georg-August-Universität Göttingen, Germany.
| | | | | |
Collapse
|
41
|
Nelson BM. Sentinel lymph node biopsies in cancers of the skin, colon, head and neck, and breast. Proc (Bayl Univ Med Cent) 2005; 17:99-103. [PMID: 16200094 PMCID: PMC1200646 DOI: 10.1080/08998280.2004.11927962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Bridget M Nelson
- Department of Surgery, Baylor University Medical Center, Dallas, Texas 75246, USA
| |
Collapse
|
42
|
Castro LGM, Duprat JP, Landman G. Dupla drenagem para cadeias linfonodais distintas, detectada por técnica de biópsia de linfonodo sentinela em pacientes com melanoma cutâneo: relato de dois casos. An Bras Dermatol 2005. [DOI: 10.1590/s0365-05962005000600008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Os principais méritos da biópsia de linfonodo sentinela em pacientes com melanoma cutâneo residem na possibilidade de serem evitadas linfadenectomias radicais desnecessárias e de permitir a correta identificação da cadeia de drenagem linfática, principalmente quando o tumor se localiza em áreas de drenagem ambígua. Atualmente já foi incorporada como fator prognóstico, sendo importante dado para o correto estadiamento do paciente. No presente relato são apresentados dois casos em que a utilização desta técnica foi extremamente útil, sobretudo por ter identificado a presença de drenagem linfática para duas cadeias linfáticas distintas. é importante que o dermatologista esteja consciente da correta indicação da técnica, para poder orientar da melhor forma possível seus pacientes.
Collapse
|
43
|
Koskivuo I, Suominen E, Niinikoski J, Talve L. Sentinel node metastasectomy in thin ≤1-mm melanoma. Langenbecks Arch Surg 2005; 390:403-7. [PMID: 16052368 DOI: 10.1007/s00423-005-0572-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2005] [Accepted: 06/28/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Sentinel lymph node biopsy (SLNB) has been widely accepted as a precise tool to stage melanoma. In thin T1 melanomas (<or=1 mm), the indication of SLNB is controversial since the risk of nodal metastasis is low. The aim of this study was to assess if SLNB detects occult nodal metastases among patients with thin melanomas. PATIENTS AND METHODS SLNB was performed prospectively in 135 patients with invasive melanoma in any depth category, including 56 T1 melanomas. RESULTS Nodal metastases were detected in 18% by SLNB, and there were three sentinel-positive thin melanomas, constituting 5% of the T1 cases. Histopathologically, there were no factors of the primary tumors that would have predicted these metastases. CONCLUSION SLNB is a precise method to detect clinically silent nodal metastases in thin invasive melanoma. Certain histopathologic features of a thin primary lesion may correlate with the predictive probability of the sentinel node status. We were unable to identify these predictors, but the conclusions from this study are limited by the small sample size. Advanced melanoma is a lethal disease, and accurate staging is essential also in the T1 group. For stage III patients with occult nodal metastases, metastasectomy is a better option for cure than observation.
Collapse
Affiliation(s)
- Ilkka Koskivuo
- Department of Surgery, Turku University Hospital, P.O. Box 52, 20521, Turku, Finland.
| | | | | | | |
Collapse
|
44
|
MacNeill KN, Ghazarian D, McCready D, Rotstein L. Sentinel lymph node biopsy for cutaneous melanoma of the head and neck. Ann Surg Oncol 2005; 12:726-32. [PMID: 16041473 DOI: 10.1245/aso.2005.11.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2004] [Accepted: 04/17/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Lymph node status is the most important prognostic factor for patients with cutaneous melanoma. Sentinel lymph node biopsy (SLNB) is now the standard of care for staging clinically node-negative patients. It is accurate with low morbidity, yet SLNB for head and neck melanoma is challenging because of unpredictable lymphatic drainage and risk of complications. METHODS A retrospective analysis of prospectively collected data identified patients with cutaneous melanoma of the head and neck > or =.76 mm. Sentinel lymph nodes were identified by using a standardized protocol of preoperative lymphoscintigrams, intraoperative blue dye injections, and handheld gamma probes. Clinical, surgical, and pathologic data were collected and analyzed. RESULTS A sentinel lymph node was removed in 41 (94%) of 44 patients. Seven (17%) of 41 had at least 1 positive sentinel lymph node. Three of seven had primary tumors <1 mm (two of the three were not ulcerated). The sites of lymphatic drainage of the primary lesion were discordant, with historical anatomically predicted sites in 24.4% of cases. None of the 34 patients with negative SLNB has had a nodal recurrence (false-negative rate, 0%; sensitivity and negative predictive value, 100%). The mean follow-up is 22.4 months (range, <1-69 months). Seven (17%) of 41 patients had minor complications. CONCLUSIONS SLNB in the head and neck area is challenging; however, combined preoperative, intraoperative, and histological techniques produce a sensitive procedure with a high negative predictive value. The lack of false-negative results obviates the need for prophylactic neck dissections.
Collapse
Affiliation(s)
- Karen Nicole MacNeill
- Department of Laboratory Medicine and Pathobiology, Banting Institute, 100 College Street, Room 110, Toronto, Ontario, M9G 1L5, Canada.
| | | | | | | |
Collapse
|
45
|
Kesmodel SB, Karakousis GC, Botbyl JD, Canter RJ, Lewis RT, Wahl PM, Terhune KP, Alavi A, Elder DE, Ming ME, Guerry D, Gimotty PA, Fraker DL, Czerniecki BJ, Spitz FR. Mitotic rate as a predictor of sentinel lymph node positivity in patients with thin melanomas. Ann Surg Oncol 2005; 12:449-58. [PMID: 15864482 DOI: 10.1245/aso.2005.04.027] [Citation(s) in RCA: 185] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2004] [Accepted: 01/12/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Lymphatic mapping and sentinel lymphadenectomy (LM/SL) provide important prognostic information for patients with early-stage melanoma. Although the use of this technique in patients with thin melanomas (< or =1.00 mm) is not routine, risk factors that may predict sentinel lymph node (SLN) positivity in this patient population are under investigation. We sought to determine whether mitotic rate (MR) is associated with SLN positivity in thin-melanoma patients and, therefore, whether it may be used to risk-stratify and select patients for LM/SL. METHODS Clinical and histopathologic variables were reviewed for 181 patients with thin melanomas who underwent LM/SL from January 1996 through January 2004. Univariate and multivariate logistic regression analyses were performed to identify factors associated with SLN positivity. Risk groups were defined on the basis of the development of a classification tree. RESULTS The overall SLN positivity rate was 5%. All patients with positive SLNs had an MR of >0. By univariate analysis, MR and thickness were significant predictors of SLN positivity. The association between MR and SLN positivity remained significant controlling for each of the other variables evaluated. On the basis of a classification tree, patients with an MR >0 and tumor thickness > or =.76 mm were identified as a higher-risk group, with an SLN positivity rate of 12.3%. CONCLUSIONS In patients with thin melanomas, MR >0 seems to be a significant predictor of SLN positivity that may be used to risk-stratify and select patients for LM/SL. To confirm these results, the predictive value of MR for SLN positivity needs to be validated in other populations of thin-melanoma patients.
Collapse
Affiliation(s)
- Susan B Kesmodel
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Wong SL, Kattan MW, McMasters KM, Coit DG. A nomogram that predicts the presence of sentinel node metastasis in melanoma with better discrimination than the American Joint Committee on Cancer staging system. Ann Surg Oncol 2005; 12:282-8. [PMID: 15827679 DOI: 10.1245/aso.2005.05.016] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2004] [Accepted: 11/19/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND The threshold and indications for sentinel lymph node (SLN) biopsy in patients with melanoma remain somewhat arbitrary. Many variables associated with SLN positivity have previously been identified, including a significant association between the American Joint Committee on Cancer (AJCC) staging system and SLN status. We developed a user-friendly nomogram that takes several characteristics into account simultaneously to more accurately predict the presence of SLN metastasis for an individual patient. METHODS A total of 979 patients who underwent successful SLN biopsy for cutaneous melanoma at a single institution between February 1991 and November 2003 were included in the analysis. Predictors were used to develop a nomogram, based on logistic regression analysis, to predict the probability of SLN positivity. A large multi-institutional trial with 3108 patients was used to validate the predictive accuracy of the nomogram compared with the AJCC staging system. RESULTS The nomogram was developed and found to be accurate and discriminating. The concordance index of the nomogram, a measure of predictive ability, was .694 when evaluated with the validation dataset. In contrast, the concordance index of the AJCC staging system was lower (.663; P < .001). CONCLUSIONS Using commonly available clinicopathologic information, we developed a nomogram to accurately predict the probability of a positive SLN in patients with melanoma. This tool takes several characteristics into account simultaneously. This model should enable improved patient counseling and treatment selection.
Collapse
Affiliation(s)
- Sandra L Wong
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York 10021, USA
| | | | | | | |
Collapse
|
47
|
Stitzenberg KB, Groben PA, Stern SL, Thomas NE, Hensing TA, Sansbury LB, Ollila DW. Indications for lymphatic mapping and sentinel lymphadenectomy in patients with thin melanoma (Breslow thickness < or =1.0 mm). Ann Surg Oncol 2004; 11:900-6. [PMID: 15383424 DOI: 10.1245/aso.2004.10.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients with thin (Breslow thickness < or =1.0 mm) melanoma have a good prognosis (5-year survival >90%). Consequently, the added benefit of lymphatic mapping and sentinel lymphadenectomy (LM/SL) in these patients is controversial. We hypothesize that LM/SL with a focused examination of the sentinel node (SN) will detect a significant number of SN metastases in patients with thin melanoma and that certain clinical or histopathologic factors may serve as predictors of SN tumor involvement. METHODS Over 6 years, 349 patients with melanoma underwent LM/SL and were prospectively entered into an institutional review board (IRB)-approved database. LM/SL was performed with a combined radiotracer and blue dye technique. SNs were serially sectioned, and each section was examined by a dermatopathologist at multiple levels with hematoxylin and eosin as well as immunohistochemical stains. RESULTS One hundred forty-six patients (42%) had a melanoma with Breslow thickness < or =1.0 mm; six (4%) of these 146 patients had a tumor-involved SN. On multivariate analysis, none of the clinical or histopathologic factors examined were significantly associated with SN tumor involvement in patients with thin melanoma. Completion lymphadenectomy was performed on all patients with a tumor-involved SN. None of the patients had non-SN tumor involvement. CONCLUSIONS The incidence of SN tumor involvement in patients with thin melanoma is considerable. Although we were unable to identify predictors of SN tumor involvement in patients with thin melanoma, efforts to identify predictors of SN tumor involvement should continue. Until better predictors are identified, we continue to advocate offering LM/SL to patients with thin melanomas who demonstrate clinical or histopathologic characteristics that have historically been associated with an increased risk of recurrence and mortality.
Collapse
Affiliation(s)
- Karyn B Stitzenberg
- Division of Surgical Oncology, Department of Surgery, 3010 Old Clinic Building, CB#7213, University of North Carolina, Chapel Hill, NC 27599-7213, USA
| | | | | | | | | | | | | |
Collapse
|
48
|
|