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Hewitt DB, Merkow RP, DeLancey JO, Wayne JD, Hyngstrom JR, Russell MC, Gerami P, Balch CM, Bilimoria KY. National practice patterns of completion lymph node dissection for sentinel node-positive melanoma. J Surg Oncol 2018; 118:493-500. [DOI: 10.1002/jso.25160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 06/16/2018] [Indexed: 01/28/2023]
Affiliation(s)
- D. Brock Hewitt
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies; Feinberg School of Medicine, Northwestern University; Chicago Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology (NICER-Onc), Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Feinberg School of Medicine, Northwestern University; Chicago Illinois
- Department of Surgery; Thomas Jefferson University Hospital; Philadelphia Pennsylvania
| | - Ryan P. Merkow
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies; Feinberg School of Medicine, Northwestern University; Chicago Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology (NICER-Onc), Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Feinberg School of Medicine, Northwestern University; Chicago Illinois
| | - John Oliver DeLancey
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies; Feinberg School of Medicine, Northwestern University; Chicago Illinois
| | - Jeffrey D. Wayne
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies; Feinberg School of Medicine, Northwestern University; Chicago Illinois
| | - John R. Hyngstrom
- Division of General Surgery; Huntsman Cancer Institute, University of Utah Health Care; Salt Lake City Utah
| | - Maria C. Russell
- Division of Surgical Oncology, Department of Surgery; Emory University School of Medicine; Atlanta Georgia
| | - Pedram Gerami
- Northwestern Institute for Comparative Effectiveness Research in Oncology (NICER-Onc), Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Feinberg School of Medicine, Northwestern University; Chicago Illinois
| | - Charles M. Balch
- Division of Surgery; University of Texas MD Anderson Cancer Center; Houston Texas
| | - Karl Y. Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies; Feinberg School of Medicine, Northwestern University; Chicago Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology (NICER-Onc), Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Feinberg School of Medicine, Northwestern University; Chicago Illinois
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Chu BS, Koffi W, Hoehn RS, Ertel A, Shah SA, Ahmad SA, Sussman JJ, Neuman HB, Abbott DE. Improvement and persistent disparities in completion lymph node dissection: Lessons from the National Cancer Database. J Surg Oncol 2017; 116:1176-1184. [PMID: 28743173 DOI: 10.1002/jso.24766] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 06/21/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Completion lymph node dissection (CLND) is recommended for melanoma patients with positive sentinel lymph node biopsies (SLNB); however, 50% do not undergo CLND. We sought to determine CLND trends over time, and factors contributing to variability. METHODS The NCDB was queried for patients undergoing wide local excision (WLE), with or without SLNB and CLND. Cohorts were created based on demographic/socioeconomic variables and era of treatment (Era 1: 2003-07, Era 2: 2008-12). Univariate and multivariate analyses identified factors associated with performance of or trends in CLND. RESULTS 122 849 underwent WLE with SLNB. Of 24 267 (19.8%) with +SLNB, 13 594 (56.0%) continued to CLND. In multivariate analyses, Medicaid (OR 0.78; P = 0.04) or Medicare (OR 0.79; P < 0.01) in Era 1 and patients without insurance in Era 2 (OR 0.78; P = 0.01) underwent less CLND. In both eras, Blacks (OR 0.45; P < 0.01, OR 0.59; P < 0.01), head/neck lesions (OR 0.72; P < 0.01, OR 0.66; P < 0.01) and lower extremity lesions (OR 0.75; P < 0.01, OR 0.72; P < 0.01) underwent less CLND. However, Blacks experienced greatest increase in CLND usage (+9.2%). CONCLUSIONS CLND usage continues to be low and racial/socioeconomic disparities persist. Until the results of MSLT-2 become available, continued focus on understanding poor adherence to, and improving rates of CLND is necessary.
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Affiliation(s)
- Brian S Chu
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Wima Koffi
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Richard S Hoehn
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Audrey Ertel
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Heather B Neuman
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Nieweg OE, Cooper A, Thompson JF. Role of sentinel lymph node biopsy as a staging procedure in patients with melanoma: A critical appraisal. Australas J Dermatol 2017; 58:268-273. [PMID: 28707391 DOI: 10.1111/ajd.12655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 02/11/2017] [Indexed: 11/29/2022]
Abstract
Worldwide, sentinel node (SN) biopsy for accurate staging is now part of the standard work-up of patients with melanomas ≥1.0 mm Breslow thickness, as it is for staging patients with breast cancer. Nuclear medicine imaging and surgical techniques have evolved to such a degree that a SN can be identified and removed in virtually every patient. Nevertheless, some opposition to a routine SN biopsy remains, perhaps due to a failure to appreciate the serious implications of incomplete or inaccurate staging. Guided by a critical appraisal of the available evidence, this review elucidates the definition of an SN, discusses the sensitivity and specificity of the information it provides, emphasises that it is a minor staging procedure that can lead to improved survival when followed by appropriate therapy, and explains the necessarily unconventional and complex design of the only randomised trial that addresses this subject. It also describes other benefits and risks of an SN biopsy and outlines its role in current melanoma management.
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Affiliation(s)
- Omgo E Nieweg
- Melanoma Institute Australia, University of Sydney, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Alan Cooper
- Department of Dermatology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Sydney Medical School - Northern, University of Sydney, Sydney, New South Wales, Australia
| | - John F Thompson
- Melanoma Institute Australia, University of Sydney, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Madu M, Wouters M, van Akkooi A. Sentinel node biopsy in melanoma: Current controversies addressed. Eur J Surg Oncol 2017; 43:517-533. [DOI: 10.1016/j.ejso.2016.08.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 12/17/2022] Open
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5
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Oude Ophuis CMC, van Akkooi ACJ, Rutkowski P, Powell WEM, Robert C, Testori A, van Leeuwen BL, Siegel P, Eggermont AMM, Verhoef C, Grünhagen DJ. Timing of completion lymphadenectomy after positive sentinel node biopsy in patients with melanoma. Br J Surg 2017; 104:726-733. [DOI: 10.1002/bjs.10475] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 09/30/2016] [Accepted: 12/02/2016] [Indexed: 11/12/2022]
Abstract
Abstract
Background
Nodal staging with sentinel node biopsy (SNB) and completion lymph node dissection (CLND) provides prognostic information to patients with melanoma and their physicians. It is not known whether the timing of CLND is associated with survival outcome and/or CLND tumour load. This study investigated whether CLND timing is associated with CLND tumour load, disease-free survival (DFS) and/or melanoma-specific survival (MSS).
Methods
A retrospective cohort of patients with SNB-positive melanoma from nine European Organisation for Research and Treatment of Cancer (EORTC) Melanoma Group centres undergoing surgery between 1993 and 2009 were examined. Patients were selected based on availability of CLND and follow-up data. The CLND interval was defined as the number of days between diagnosis and CLND. Patient and tumour characteristics were collected. Five-year DFS and MSS rates were calculated. Cox and logistic regression analysis were performed, adjusting for known prognostic/predictive indicators.
Results
A total of 784 patients were included in the study. Their median age was 51 (i.q.r. 40–62) years, and 418 patients (53·3 per cent) were men. Median Breslow thickness was 3·0 (i.q.r. 2·0–5·0) mm, and 148 patients (18·9 per cent) had a residual tumour load. Median CLND interval was 84 (i.q.r. 65–105) days. Five-year DFS and MSS rates were not significantly different for patients operated on with a median CLND interval of less than 84 days and those with an interval of at least 84 days (DFS: 54·2 versus 53·3 per cent respectively; MSS: 66·9 versus 65·1 per cent). In a multivariable Cox model, CLND interval was not a significant prognostic indicator. CLND interval was negatively correlated with identification of positive non-sentinel nodes, but following adjustment for known risk factors this effect was no longer found.
Conclusion
The time interval between diagnosis of melanoma and CLND did not influence CLND tumour load, DFS or MSS.
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Affiliation(s)
- C M C Oude Ophuis
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - A C J van Akkooi
- Department of Surgery, The Netherlands Cancer Institute – Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - P Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
| | - W E M Powell
- Melanoma Unit, St George's Foundation University Hospital, London, UK
| | - C Robert
- Department of Dermatology and Allergology, Cancer Institute Gustave Roussy, Villejuif, France
| | - A Testori
- Division of Dermato-Oncological Surgery, European Institute of Oncology, Milan, Italy
| | - B L van Leeuwen
- Department of Surgical Oncology, Groningen University, University Medical Centre Groningen, Groningen, The Netherlands
| | - P Siegel
- Department of Dermatology and Allergology, Charité – University of Medicine Berlin, Berlin, Germany
| | - A M M Eggermont
- Board of Directors, Cancer Institute Gustave Roussy, Villejuif, France
| | - C Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - D J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Costa Svedman F, Spanopoulos D, Taylor A, Amelio J, Hansson J. Surgical outcomes in patients with cutaneous malignant melanoma in Europe - a systematic literature review. J Eur Acad Dermatol Venereol 2016; 31:603-615. [DOI: 10.1111/jdv.13950] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 08/11/2016] [Indexed: 02/03/2023]
Affiliation(s)
- F. Costa Svedman
- Karolinska Institutet; Karolinska University Hospital Solna; Stockholm Sweden
| | - D. Spanopoulos
- Centre for Observational Research; Amgen Ltd; Uxbridge UK
| | - A. Taylor
- Centre for Observational Research; Amgen Ltd; Uxbridge UK
| | - J. Amelio
- Centre for Observational Research; Amgen Ltd; Uxbridge UK
| | - J. Hansson
- Karolinska Institutet; Karolinska University Hospital Solna; Stockholm Sweden
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Lee DY, Lau BJ, Huynh KT, Flaherty DC, Lee JH, Stern SL, O'Day SJ, Foshag LJ, Faries MB. Impact of Completion Lymph Node Dissection on Patients with Positive Sentinel Lymph Node Biopsy in Melanoma. J Am Coll Surg 2016; 223:9-18. [PMID: 27236435 DOI: 10.1016/j.jamcollsurg.2016.01.045] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/13/2016] [Accepted: 01/13/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Whether patients with positive SLNB should undergo complete lymph node dissection (CLND) is an important unanswered clinical question. STUDY DESIGN Patients diagnosed with positive SLNB at a melanoma referral center from 1991 to 2013 were studied. Outcomes of patients who underwent CLND were compared with those who did not undergo immediate CLND (observation [OBS] group). RESULTS There were 471 patients who had positive SLNB; 375 (79.6%) in the CLND group and 96 (20.4%) in the OBS group. The groups were similar except that the CLND group was younger and had more sentinel nodes removed. Five-year nodal recurrence-free survival was significantly better in the CLND group compared with the OBS group (93.1% vs 84.4%; p = 0.005). However, 5-year (66.4% vs 55.2%) and 10-year (59.5% vs 45.0%) distant metastasis-free survival rates were not significantly different (p = 0.061). The CLND group's melanoma-specific survival (MSS) rate was superior to that of the OBS group; 5-year MSS rates were 73.7% vs 65.5% and 10-year MSS rates were 66.8% vs 48.3% (p = 0.015). On multivariate analysis, CLND was associated with improved MSS (hazard ratio = 0.60; 95% CI, 0.40-0.89; p = 0.011) and lower nodal recurrence (hazard ratio = 0.46; 95% CI, 0.24-0.86; p = 0.016). Increased Breslow thickness, older age, ulceration, and trunk melanoma were all associated with worse outcomes. On subgroup analysis, the following factors were associated with better outcomes from CLND: male sex, nonulcerated primary, intermediate thickness, Clark level IV or lower extremity tumors. CONCLUSIONS Treatment of positive SLNB with CLND was associated with improved MSS and nodal recurrence rates. Follow-up beyond 5 years was needed to see a significant difference in MSS rates.
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Affiliation(s)
- David Y Lee
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA
| | - Briana J Lau
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA
| | - Kelly T Huynh
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA
| | - Devin C Flaherty
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA
| | - Ji-Hey Lee
- Department of Biostatistics, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA
| | - Stacey L Stern
- Department of Biostatistics, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA
| | - Steve J O'Day
- Department of Medical Oncology, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA
| | - Leland J Foshag
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA
| | - Mark B Faries
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA.
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Evaluation of Melanoma Features and Their Relationship with Nodal Disease: The Importance of the Pathological Report. TUMORI JOURNAL 2015; 101:501-5. [DOI: 10.5301/tj.5000298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2015] [Indexed: 11/20/2022]
Abstract
Background The pathological features of melanoma biopsies can provide significant prognostic information that can help the surgeon evaluate the risk of nodal disease. The aim of this study was to attempt to determine the relationship between pathological features of primary melanoma and nodal disease, by sentinel node biopsy (SNB) and complete node dissection (CND). Methods A retrospective analysis was completed of patients who underwent SNB at AC Camargo Cancer Center, Sao Paulo, Brazil, between 2000 and 2010. Results A total of 697 patients were evaluated. By univariate analysis, it was found that histology, Clark level, Breslow depth, mitotic index, ulceration, regression, lymphatic and perineural invasion and satellitosis were significantly associated with SNB positivity. In the multivariate analysis, it was found that Breslow depth, mitotic index, ulceration, regression, lymphatic invasion and satellitosis were significant factors. In patients with a positive SNB, the primary tumor site, Clark level and Breslow depth greater than 2 mm were significantly related to non-sentinel node (NSN) positivity by univariate analysis. By multivariate analysis, Breslow depth greater than 2 mm was the only primary tumor feature that was significantly related (p = 0.038). Conclusions The indication of SNB should not be based solely on Breslow depth and ulceration or mitotic index. A complete evaluation of the pathological report should improve the identification of high-risk patients.
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Rutkowski P, Szydłowski K, Nowecki ZI, Sałamacha M, Goryń T, Mitręga-Korab B, Pieńkowski A, Dziewirski W, Zdzienicki M. The long-term results and prognostic significance of cutaneous melanoma surgery using sentinel node biopsy with triple technique. World J Surg Oncol 2015; 13:299. [PMID: 26462471 PMCID: PMC4603583 DOI: 10.1186/s12957-015-0701-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 09/03/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The sentinel lymph node biopsy (SLN) is a basic staging method in all primary cutaneous melanomas ≥pT1b. The standard technique is a triple technique consisting of preoperative lymphoscintigraphy, intraoperative blue-dye lymphography, and gamma-probe assessment. We performed the analysis of long-term results in a very large one-institution series of cutaneous melanoma patients. METHODS We have analyzed treatment results of a group of 1764 consecutive patients with cutaneous melanoma, who underwent SLN biopsy between 1997 and 2008 in one tertiary center. Additionally, we have analyzed the outcomes of a group of 473 patients with positive SLN biopsy undergoing completion lymph node dissection (CLND). Median follow-up time was 5.3 years. RESULTS Metastases to SLN (SLN+) were found in 19.9%. Eight-year overall survival (OS) rate in the entire group was 73.5%, 80% without SLN metastases (SLN-) and 50% in group with SLN+ (p < 0.001). Independent prognostic factors for OS were as follows: presence of metastases to SLN, primary tumor ulceration, and higher mitotic index (>5/mm(2)) of primary tumor. The nodal recurrences in the biopsied lymphatic basin were 5.4%. The metastases to non-sentinel lymph nodes (NSLN found in 27% of patients with SLN+) correlated (on multivariable logistic regression analysis) with primary tumor thickness >4 mm, SLN metastatic deposit size >1 mm, and extracapsular involvement of SLN. In an additionally analyzed SLN+ group, the NSLN involvement was related to poorer prognosis (8-year OS rate NSLN- vs NSLN+: 59.6 vs. 34.7%, respectively). The independent prognostic factors for OS in the SLN+ group were a higher Breslow thickness and ulceration of primary tumor, metastases to more than 1 lymph nodes. CONCLUSIONS The long-term results confirm crucial prognostic significance of SLN biopsy in cutaneous melanoma. We identified factors related to NSLN involvement, which in the future may limit indications for CLND.
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Affiliation(s)
- Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | | | - Zbigniew I Nowecki
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Maciej Sałamacha
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Tomasz Goryń
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Beata Mitręga-Korab
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Andrzej Pieńkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Wirginiusz Dziewirski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland
| | - Marcin Zdzienicki
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781, Warsaw, Poland.
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Oude Ophuis CMC, van Akkooi ACJ, Hoekstra HJ, Bonenkamp JJ, van Wissen J, Niebling MG, de Wilt JHW, van der Hiel B, van de Wiel B, Koljenović S, Grünhagen DJ, Verhoef C. Risk Factors for Positive Deep Pelvic Nodal Involvement in Patients with Palpable Groin Melanoma Metastases: Can the Extent of Surgery be Safely Minimized? : A Retrospective, Multicenter Cohort Study. Ann Surg Oncol 2015; 22 Suppl 3:S1172-80. [PMID: 26014150 PMCID: PMC4686555 DOI: 10.1245/s10434-015-4602-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Indexed: 11/29/2022]
Abstract
Background Patients with palpable melanoma groin metastases have a poor prognosis. There is debate whether a combined superficial and deep groin dissection (CGD) is necessary or if superficial groin dissection (SGD) alone is sufficient. Aim The aim of this study was to analyze risk factors for deep pelvic nodal involvement in a retrospective, multicenter cohort of palpable groin melanoma metastases. This could aid in the development of an algorithm for selective surgery in the future. Methods This study related to 209 therapeutic CGDs from four tertiary centers in The Netherlands (1992–2013), selected based on complete preoperative imaging and pathology reports. Analyzed risk factors included baseline and primary tumor characteristics, total and positive number of inguinal nodes, inguinal lymph node ratio (LNR) and positive deep pelvic nodes on imaging (computed tomography [CT] ± positron emission tomography [PET], or PET − low-dose CT). Results Median age was 57 years, 54 % of patients were female, and median follow-up was 21 months (interquartile range [IQR] 11–46 months). Median Breslow thickness was 2.10 mm (IQR 1.40–3.40 mm), and 26 % of all primary melanomas were ulcerated. Positive deep pelvic nodes occurred in 35 % of CGDs. Significantly fewer inguinal nodes were positive in case of negative deep pelvic nodes (median 1 [IQR 1–2] vs. 3 [IQR 1–4] for positive deep pelvic nodes; p < 0.001), and LNR was significantly lower for negative versus positive deep pelvic nodes [median 0.15 (IQR 0.10–0.25) vs. 0.33 (IQR 0.14–0.54); p < 0.001]. A combination of negative imaging, low LNR, low number of positive inguinal nodes, and no extracapsular extension (ECE) could accurately predict the absence of pelvic nodal involvement in 84 % of patients. Conclusions Patients with negative imaging, few positive inguinal nodes, no ECE, and low LNR have a low risk of positive deep pelvic nodes and may safely undergo SGD alone.
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Affiliation(s)
- C M C Oude Ophuis
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - A C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - H J Hoekstra
- Department of Surgical Oncology, Groningen University Medical Center, Groningen, The Netherlands
| | - J J Bonenkamp
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J van Wissen
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - M G Niebling
- Department of Surgical Oncology, Groningen University Medical Center, Groningen, The Netherlands
| | - J H W de Wilt
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - B van der Hiel
- Department of Nuclear Medicine, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - B van de Wiel
- Department of Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - S Koljenović
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - D J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Leiter U, Eigentler TK, Häfner HM, Krimmel M, Uslu U, Keim U, Weide B, Breuninger H, Martus P, Garbe C. Sentinel Lymph Node Dissection in Head and Neck Melanoma has Prognostic Impact on Disease-Free and Overall Survival. Ann Surg Oncol 2015; 22:4073-80. [DOI: 10.1245/s10434-015-4439-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Indexed: 11/18/2022]
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12
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Ribero S, Osella-Abate S, Sanlorenzo M, Balagna E, Senetta R, Fierro MT, Macripò G, Macrì L, Sapino A, Quaglino P. Sentinel Lymph Node Biopsy in Thick-Melanoma Patients (N=350): What is Its Prognostic Role? Ann Surg Oncol 2014; 22:1967-73. [PMID: 25388059 DOI: 10.1245/s10434-014-4211-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is currently recommended for patients with intermediate-thickness melanomas (T2-T3). Historically, T4 melanoma patients have not been considered good candidates for SLNB because of the high risk of distant progression. However, some authors suggest that T4 melanoma patients could be considered as a heterogeneous group that could benefit from SLNB. METHODS We retrospectively analyzed 350 patients with thick (>4 mm) melanomas between 1999 and 2011. Patients were stratified into three groups depending on the results of SLNB: (1) 94 SLNB-negative; (2) 84 SLNB-positive; and (3) 172 SLNB not performed (observation group). The associations of clinical-pathologic features with the result of SLNB, disease-free interval (DFI), and disease-specific survival (DSS) were analyzed. RESULTS Multivariate analyses confirmed a better prognosis for SLN-negative patients compared with patients in the observation group (DSS hazard ratio [HR] 0.62, p = 0.03; DFI HR 0.47, p < 0.001). The observation group was shown to have the same prognosis as the positive-sentinel lymph node group, when adjusted for principal confounders in the model. CONCLUSIONS We confirmed that thick-melanoma patients are a heterogeneous group with different prognosis. In our experience, SLNB allowed for an appropriate stratification of patients in different survival groups. On the basis of our results, we strongly recommend the routine execution of SLNB in cases of primary melanoma thicker than 4 mm.
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Affiliation(s)
- S Ribero
- Section of Dermatology, Department of Medical Sciences, University of Turin, Turin, Italy,
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Kachare SD, Brinkley J, Wong JH, Vohra NA, Zervos EE, Fitzgerald TL. The influence of sentinel lymph node biopsy on survival for intermediate-thickness melanoma. Ann Surg Oncol 2014; 21:3377-85. [PMID: 25063010 DOI: 10.1245/s10434-014-3954-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND The Multicenter Selective Lymphadenectomy Trial-1 (MSLT-1) failed to demonstrate a survival advantage for sentinel lymph node biopsy (SNB) in melanoma. This may have been secondary to inadequate statistical power. This study was designed to determine the impact of SNB on melanoma-specific survival (MSS) in a larger patient cohort. METHODS From 2003-2008, patients with tumors 1-4 mm in thickness and clinically negative nodes were identified within the SEER registry. Propensity score was used to create two matched cohorts: those who underwent a wide excision with SNB or wide excision alone. RESULT A total of 15,274 met inclusion criteria and 7,910 comprised the match cohort. Average age was 67.4 years. The majority were male (62.3 %) and white (97.2 %). Primary tumors were most frequently nonulcerated (77.1 %), located on the extremity (42.3 %), and T2 (64.1 %). There were 3,955 patients in both the SNB and observation groups. There was no significant difference in gender, ethnicity, ulceration status, primary site, or T-classification between the groups. Improved 5-year MSS was associated with SNB (85.7 vs. 84.0 %), female gender (88.3 vs. 82.7 %), absence of ulceration (87.5 vs. 75.7 %), extremity location (87.4 %), T2 disease (88.6 vs. 77.9 %), and a negative SNB (88.9 vs. 64.8 %). The relationships between observation [hazard ratio (HR) 1.18], male gender (HR 1.33), ulceration (HR 1.77), head-and-neck location (HR 1.34), and T3 disease (HR 1.82) persisted on multivariate analysis. CONCLUSIONS Status of the sentinel node is the strongest predictor of survival in patients with intermediate thickness melanoma. SNB compared with observation was associated with a modest survival advantage.
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Affiliation(s)
- Swapnil D Kachare
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, NC, USA
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Niebling MG, Wevers KP, Suurmeijer AJH, van Ginkel RJ, Hoekstra HJ. Deep lymph node metastases in the groin significantly affects prognosis, particularly in sentinel node-positive melanoma patients. Ann Surg Oncol 2014; 22:279-86. [PMID: 25008028 DOI: 10.1245/s10434-014-3854-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND In order to define patients eligible for only a superficial groin dissection or a combined superficial and deep groin dissection, this study aimed to determine the incidence of deep lymph node metastases (LNM) in patients with melanoma metastasized to the groin, to identify patient and melanoma factors that predict deep nodal involvement, and to analyze the impact of deep nodal involvement on survival and recurrence. METHODS Patients who underwent a combined superficial (inguinal) and deep (iliac and obturator) complete (CLND) or therapeutic lymph node dissection (TLND) of the groin between 1994 and 2012 were analyzed. RESULTS QueryDeep LNM were found in 8 of 62 CLND patients (13 %) and in 21 of 67 TLND patients (31 %). More than three superficial LNM was the only independent predictor for deep LNM in both CLND and TLND patients. The 5-year melanoma-specific survival (MSS) for CLND and TLND patients with deep LNM was 14.3 and 16.6 %, respectively, and was significantly worse (hazard ratio [HR] 3.39, 95 % CI 1.34-8.58, p = 0.010; and HR 2.01, 95 % CI 1.04-3.88, p = 0.039) compared with CLND and TLND patients without deep LNM (5-year MSS: 54.1 and 37.2 %, respectively). Distant recurrence was significantly associated with deep LNM in CLND patients (p = 0.032). CONCLUSIONS The present study showed that LNM in the deep area of the groin are fairly common in both CLND and TLND patients and significantly affect prognosis, especially in CLND patients. The number of superficial LNM is the only factor that was found to predict a finding of deep nodal metastases.
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Affiliation(s)
- M G Niebling
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700, Groningen, The Netherlands
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van der Ploeg APT, Haydu LE, Spillane AJ, Quinn MJ, Saw RP, Shannon KF, Stretch JR, Uren RF, Scolyer RA, Thompson JF. Outcome following sentinel node biopsy plus wide local excision versus wide local excision only for primary cutaneous melanoma: analysis of 5840 patients treated at a single institution. Ann Surg 2014; 260:149-57. [PMID: 24633018 DOI: 10.1097/sla.0000000000000500] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Worldwide, sentinel node biopsy (SNB) is now a standard staging procedure for most patients with melanomas 1 mm or more in thickness, but its therapeutic benefit is not clear, pending randomized trial results. This study sought to assess the therapeutic benefit of SNB in a large, nonrandomized patient cohort. METHODS Patients with primary melanomas 1.00 mm or more thick or with adverse prognostic features treated with wide local excision (WLE) at a single institution between 1992 and 2008 were identified. The outcomes for those who underwent WLE plus SNB (n = 2909) were compared with the outcomes for patients in an observation (OBS) group who had WLE only (n = 2931). Median follow-up was 42 months. RESULTS Melanoma-specific survival (MSS) was not significantly different for patients in the SNB and OBS groups. However, a stratified univariate analysis of MSS for different thickness subgroups indicated a significantly better MSS for SNB patients with T2 and T3 melanomas (>1.0 to 4.0 mm thick) (P = 0.011), but this was not independently significant in multivariate analysis. Compared with OBS patients, SNB patients demonstrated improved disease-free survival (DFS) (P < 0.001) and regional recurrence-free survival (P < 0.001). There was also an improvement in distant metastasis-free survival (DMFS) for SNB patients with T2 and T3 melanomas (P = 0.041). CONCLUSIONS In this study, the outcome for the overall cohort after WLE alone did not differ significantly from the outcome after additional SNB. However, the outcome for the subgroup of patients with melanomas more than 1.0 to 4.0 mm in thickness was improved if they had a SNB, with significantly improved disease-free and DMFS.
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Affiliation(s)
- Augustinus P T van der Ploeg
- *Melanoma Institute Australia †Sydney Medical School, The University of Sydney, Sydney ‡Nuclear Medicine and Diagnostic Ultrasound, RPAH Medical Centre, Newtown, New South Wales, Australia
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Leilabadi SN, Chen A, Tsai S, Soundararajan V, Silberman H, Wong AK. Update and Review on the Surgical Management of Primary Cutaneous Melanoma. Healthcare (Basel) 2014; 2:234-49. [PMID: 27429273 PMCID: PMC4934469 DOI: 10.3390/healthcare2020234] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 04/17/2014] [Accepted: 05/06/2014] [Indexed: 01/07/2023] Open
Abstract
The surgical management of malignant melanoma historically called for wide excision of skin and subcutaneous tissue for any given lesion, but has evolved to be rationally-based on pathological staging. Breslow and Clark independently described level and thickness as determinant in prognosis and margin of excision. The American Joint Committee of Cancer (AJCC) in 1988 combined features from each of these histologic classifications, generating a new system, which is continuously updated and improved. The National Comprehensive Cancer Network (NCCN) has also combined several large randomized prospective trials to generate current guidelines for melanoma excision as well. In this article, we reviewed: (1) Breslow and Clark classifications, AJCC and NCCN guidelines, the World Health Organization's 1988 study, and the Intergroup Melanoma Surgical Trial; (2) Experimental use of Mohs surgery for in situ melanoma; and (3) Surgical margins and utility and indications for sentinel lymph node biopsy (SLNB) and lymphadenectomy. Current guidelines for the surgical management of a primary melanoma of the skin is based on Breslow microstaging and call for cutaneous margins of resection of 0.5 cm for MIS, 1.0 cm for melanomas ≤1.0 mm thick, 1-2 cm for melanoma thickness of 1.01-2 mm, 2 cm margins for melanoma thickness of 2.01-4 mm, and 2 cm margins for melanomas >4 mm thick. Although the role of SLNB, CLND, and TLND continue to be studied, current recommendations include SLNB for Stage IB (includes T1b lesions ≤1.0 with the adverse features of ulceration or ≥1 mitoses/mm²) and Stage II melanomas. CLND is recommended when sentinel nodes contain metastatic deposits.
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Affiliation(s)
- Solmaz Niknam Leilabadi
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St., Suite 415, Los Angeles, CA 90015, USA.
| | - Amie Chen
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St., Suite 415, Los Angeles, CA 90015, USA.
| | - Stacy Tsai
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St., Suite 415, Los Angeles, CA 90015, USA.
| | - Vinaya Soundararajan
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St., Suite 415, Los Angeles, CA 90015, USA.
| | - Howard Silberman
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St., Suite 412, Los Angeles, CA 90015, USA.
| | - Alex K Wong
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo St., Suite 415, Los Angeles, CA 90015, USA.
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Rutkowski P, Gos A, Jurkowska M, Switaj T, Dziewirski W, Zdzienicki M, Ptaszyński K, Michej W, Tysarowski A, Siedlecki JA. Molecular alterations in clinical stage III cutaneous melanoma: Correlation with clinicopathological features and patient outcome. Oncol Lett 2014; 8:47-54. [PMID: 24959217 PMCID: PMC4063661 DOI: 10.3892/ol.2014.2122] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 04/24/2014] [Indexed: 11/06/2022] Open
Abstract
The aim of the present study was to evaluate the frequency and type of oncogenic v-raf murine sarcoma viral oncogene homolog B1 (BRAF)/neuroblastoma RAS viral (v-ras) oncogene homolog (NRAS) mutations in cutaneous melanoma with clinically detected nodal metastases (stage IIIB and C) in relation to clinicopathological features and outcome. The clinicopathological data of 250 patients following therapeutic lymphadenectomy (LND) between 1995 and 2010, as well as BRAF/NRAS mutational status in corresponding nodal metastases, were analyzed. The median follow-up time was 53 months. BRAF mutations were detected in 154 (62%) cases (141 p.V600E, nine p.V600K and four others) and mutually exclusive NRAS mutations were detected in 42 (17%) cases. The presence of a BRAF mutation was found to correlate with patients of a younger age. The five-year overall survival (OS) rate was 33 and 43% for LND and primary tumor excision, respectively, and the five-year disease-free survival (DFS) rate for LND was 25%. No correlation was identified between BRAF/NRAS mutational status and RFS or OS (calculated from the date of the LND and primary tumor excision); for BRAF- and NRAS-mutated melanoma, the prognosis was the same for patients with wild-type (WT) melanoma. The important factors which had a negative impact on OS and DFS were as follows: Male gender, >1 metastatic lymph node and extracapsular extension of nodal metastases. The interval between the diagnosis of the initial melanoma to regional nodal metastasis (median, 10 months) was not significantly different between BRAF-mutant and -WT patients. Our largest comprehensive molecular analysis of clinical stage III melanoma revealed that BRAF and NRAS mutational status is not a prognostic marker in stage III melanoma patients with macroscopic nodal involvement, but may have implications for potential adjuvant therapy.
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Affiliation(s)
- Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw 02-781, Poland
| | - Aleksandra Gos
- Department of Molecular Biology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw 02-781, Poland
| | - Monika Jurkowska
- Department of Biochemistry and Molecular Biology, Institute of Rheumatology, Warsaw 02-637, Poland
| | - Tomasz Switaj
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw 02-781, Poland
| | - Wirginiusz Dziewirski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw 02-781, Poland
| | - Marcin Zdzienicki
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw 02-781, Poland
| | - Konrad Ptaszyński
- Department of Pathology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw 02-781, Poland ; Department of Pathology, Center of Postgraduate Medical Education, Warsaw 01-809, Poland
| | - Wanda Michej
- Department of Pathology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw 02-781, Poland
| | - Andrzej Tysarowski
- Department of Molecular Biology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw 02-781, Poland
| | - Janusz A Siedlecki
- Department of Molecular Biology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw 02-781, Poland
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de Oliveira Filho RS, da Silva AM, de Oliveira DA, Oliveira GG, Nahas FX. Sentinel node biopsy should not be recommended for patients with thick melanoma. Rev Col Bras Cir 2014; 40:127-9. [PMID: 23752639 DOI: 10.1590/s0100-69912013000200008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 08/11/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To ascertain whether there is any relationship between the state of the sentinel lymph node histopathology, recurrence and mortality from thick melanoma in patients undergoing SLNB over a long follow-up. METHODS Eighty-six patients with thick melanoma undergoing SLNB were selected from a prospective database. Lymphoscintigraphy, lymphatic mapping and intraoperative gamma probe detection were performed in all patients. The sentinel lymph node (SLN) was analyzed by HE and immunohistochemistry. Complete lymphadenectomy was indicated for patients with positive sentinel node. The histopathological SLN status was related to the rate of recurrence and mortality from melanoma. RESULTS One hundred and sixty-six SLNs were taken from the 86 patients. Ages ranged from 18 to 73 years. There were 47 women and 39 men. Micrometastases were found in 44 patients. Forty-two patients underwent complete lymphadenectomy. Seven other patients had positive lymph node. Among the 44 patients with positive sentinel node, there were 20 recurrences and 15 deaths. There were 18 recurrences and 12 deaths in the group with negative SLN. The Breslow thickness was not correlated with the histopathological SLN status. The histopathological SLN status did not affect the rates of recurrence and mortality (Fisher test, p = 1.00). The median follow-up was 69 months. CONCLUSION Considering the lack of evidence of benefit, SLNB should not be indicated for patients with thick melanoma outside of clinical studies.
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Khosrotehrani K, van der Ploeg APT, Siskind V, Hughes MC, Wright A, Thomas J, Barbour A, Allan C, Bayley G, Eggermont A, Verhoef C, Smithers BM, Green AC. Nomograms to predict recurrence and survival in stage IIIB and IIIC melanoma after therapeutic lymphadenectomy. Eur J Cancer 2014; 50:1301-9. [PMID: 24613127 DOI: 10.1016/j.ejca.2014.02.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 01/24/2014] [Accepted: 02/11/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Current staging algorithms in melanoma patients undergoing therapeutic lymph node dissection (LND) fail to accurately distinguish long-term survivors from those at risk of rapid relapse. Our goal was to establish and validate nomograms for predicting both recurrence and survival after LND. METHODS A prospective cohort of stage IIIB and IIIC melanoma patients was ascertained from a tertiary hospital in Brisbane, Australia. Failure-time multivariate analysis identified key factors that, in adjusted combinations, generated nomograms to predict 2-year recurrence and 5-year melanoma-specific survival. The predictive value of these nomograms was further validated in a patient cohort from Rotterdam, The Netherlands. RESULTS In 494 Australian patients, number of positive lymph nodes, extra-capsular extension and nodular histopathological subtype were the main independent predictors of 2-year recurrence while age, number of positive nodes and extra-capsular extension were the independent predictors of survival. Predictive value was confirmed in The Netherlands cohort of 331 patients. The nomograms were able to classify patients according to their 2-year recurrence and 5-year survival rates even within each stage III sub-class. CONCLUSIONS Models that include extra-capsular extension predict outcomes in patients with clinically involved lymph nodes. This tool may help tailor treatment and monitoring of this group of patients.
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Affiliation(s)
- Kiarash Khosrotehrani
- The University of Queensland, UQ Centre for Clinical Research, Experimental Dermatology Group, Brisbane, QLD, Australia; The University of Queensland, UQ Diamantina Institute, Translational Research Institute, Woolloongabba, QLD, Australia.
| | | | - Victor Siskind
- QIMR Berghofer Medical Research Institute, Cancer and Population Studies Group, Brisbane, Australia
| | - Maria Celia Hughes
- QIMR Berghofer Medical Research Institute, Cancer and Population Studies Group, Brisbane, Australia
| | - Annaliesa Wright
- The University of Queensland, UQ Centre for Clinical Research, Experimental Dermatology Group, Brisbane, QLD, Australia
| | - Janine Thomas
- Queensland Melanoma Project, Discipline of Surgery, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Andrew Barbour
- Queensland Melanoma Project, Discipline of Surgery, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Christopher Allan
- Queensland Melanoma Project, Discipline of Surgery, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Gerard Bayley
- Queensland Melanoma Project, Discipline of Surgery, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Alexander Eggermont
- Erasmus MC Cancer Institute, Rotterdam, The Netherlands; Institut de Cancérologie Gustave Roussy, Villejuif-Paris, France
| | | | - B Mark Smithers
- Queensland Melanoma Project, Discipline of Surgery, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Adele C Green
- QIMR Berghofer Medical Research Institute, Cancer and Population Studies Group, Brisbane, Australia; Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
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Adjuvant vaccination with melanoma antigen-pulsed dendritic cells in stage III melanoma patients. Med Oncol 2013; 29:2966-77. [PMID: 22302285 DOI: 10.1007/s12032-012-0168-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 01/14/2012] [Indexed: 12/27/2022]
Abstract
Dendritic cells may be successfully used to induce in vivo-specific anti-tumor responses when combined with the appropriate antigen in the appropriate context. The purpose of this study was to evaluate efficacy of peptide-loaded DC vaccine in high-risk stage III melanoma patients after lymph node dissection (LND). HLA-A2+, -A1+, or -A3+ melanoma patients (N=22), stage III, N1b-N3, received 5–16 (median: 11) DC vaccines loaded with MHC class-I-restricted melanoma peptides respective to the patient’s haplotype, and with autologous tumor lysate, if available. Vaccinated patients were matched to unvaccinated stage III controls (22 of 869) by sex, number of metastatic lymph nodes, extracapsular involvement, LND type, Breslow stage, and ulceration. Vaccination elicited cutaneous delayed-type hypersensitivity (DTH) or/and IFN-γ-producing CD8+ cell response to melanoma peptides in 15 of 22 patients. Three-year overall survival (OS) rate was 68.2% in the vaccinated group versus 25.7% in the control group, P value accounting for matching: 0.0290. In a Cox regression model, hazard ratio (HR) for death of vaccinated patients was 0.31 [95% confidence interval (CI): 0.10–0.94]. The corresponding values for 3-year disease-free survival rate were 40.9 versus 14.5%, P=0.1083; HR of recurrence for vaccinated, 0.46 (95% CI: 0.18–1.22). There was no grade>1 toxicity. The DC/peptide vaccine was well tolerated and elicited immune responses to melanoma antigens. Vaccinated patients had significantly longer OS after LND than the matched controls, but a significant improvement in the primary endpoint DFS was not achieved.
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Abstract
PURPOSE OF REVIEW Sentinel node biopsy (SNB) for primary melanoma is accepted worldwide as a diagnostic procedure. When sentinel node positive, the invasive completion lymph node dissection (CLND) is usually performed. Approximately 20% of CLND patients have nonsentinel node (NSN) metastases. The therapeutic benefit is unknown. This review analyzed the necessity of CLND in sentinel node positive patients. RECENT FINDINGS Prognosis of sentinel node positive patients is highly heterogeneous. The Rotterdam and Dewar criteria and S-classification are important sentinel node tumor burden criteria to stratify melanoma patients for prognosis and risk of NSN metastases. Patients with less than 0.1 mm metastases seem to have similar prognosis as sentinel node negative patients, especially when located in the subcapsular area. This depends on the use of an extensive sentinel node pathology protocol identifying possibly clinically irrelevant micrometastases. SUMMARY Consensus on the sentinel node pathology work-up and analysis protocols are crucial for correct risk stratification and for clinical decision-making. Primary and sentinel node tumor burden parameters and patient comorbidities should be taken into consideration when offering CLND to an individual patient. In the future, prospective studies such as the MSLT-II and the EORTC 1208 (Minitub) will provide answers to whether CLND has a therapeutic benefit and to which patients might safely be spared CLND.
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Melanoma patients with unknown primary site or nodal recurrence after initial diagnosis have a favourable survival compared to those with synchronous lymph node metastasis and primary tumour. PLoS One 2013; 8:e66953. [PMID: 23825594 PMCID: PMC3692543 DOI: 10.1371/journal.pone.0066953] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 05/13/2013] [Indexed: 11/19/2022] Open
Abstract
Background A direct comparison of prognosis between patients with regional lymph node metastases (LNM) detected synchronously with the primary melanoma (primary LNM), patients who developed their first LNM subsequently (secondary LNM) and those with initial LNM in melanoma with unknown primary site (MUP) is missing thus far. Patients and Methods Survival of 498 patients was calculated from the time point of the first macroscopic LNM using Kaplan Meier and multivariate Cox hazard regression analysis. Results Patients with secondary LNM (HR = 0.67; p = 0.009) and those with initial LNM in MUP (HR = 0.45; p = 0.008) had a better prognosis compared to patients with primary LNM (median survival time 52 and 65 vs. 24 months, respectively). A high number of involved nodes, the presence of in-transit/satellite metastases and male gender had an additional independent unfavourable effect. Conclusions Survival of patients with LNM in MUP and with secondary LNM is similar and considerably more favourable compared to those with primary LNM. This difference needs to be considered during patient counselling and for stratification purposes in clinical trials. The assumption of an immune privilege of patients with MUP which is responsible for rejection of the primary melanoma, and results in a favourable prognosis is not supported by our data.
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Nagaraja V, Eslick GD. Is complete lymph node dissection after a positive sentinel lymph node biopsy for cutaneous melanoma always necessary? A meta-analysis. Eur J Surg Oncol 2013; 39:669-80. [PMID: 23571104 DOI: 10.1016/j.ejso.2013.02.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 02/04/2013] [Accepted: 02/20/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The current recommendation for patients with cutaneous melanoma and a positive sentinel lymph node (SLN) biopsy is a complete lymph node dissection (CLND). However, metastatic melanoma is not present in approximately 80% of CLND specimens. A meta-analysis was performed to identify the clinicopathological variables most predictive of non-sentinel node (NSN) metastases when the sentinel node is positive in patients with melanoma. METHODS A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google scholar, Science Direct, and Web of Science. The search identified 54 relevant articles reporting the frequency of NSN metastases in melanoma. Original data was abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI). FINDINGS The pooled estimates that were found to be significantly associated with the high likelihood of NSN metastases were: ulceration (OR: 1.88, 95% CI: 1.53-2.31), satellitosis (OR: 3.25, 95% CI: 1.86-5.66), neurotropism (OR: 2.51, 95% CI: 1.39-4.53), >1 positive SLN (OR: 1.77, 95% CI: 1.2-2.62), Starz 3 (old) (OR: 1.83, 95% CI: 0.89-3.76), Angiolymphatic invasion (OR: 2.46, 95% CI: 1.34-4.54), extensive location (OR: 2.22, 95% CI: 1.74-2.81), macrometastases >2 mm (OR: 1.95, 95% CI: 1.61-2.35), extranodal extension (OR: 3.38, 95% CI: 1.79-6.40) and capsular involvement (OR: 3.16, 95% CI: 1.37-7.27). There were 3 characteristics not associated with NSN metastases: subcapsular location (OR: 0.51, 95% CI: 0.38-0.67), Rotterdam Criteria <0.1 mm (OR: 0.29, 95% CI: 0.17-0.50) and Starz I (new) (OR: 0.44, 95% CI: 0.22-0.91). Other variables including gender, Breslow thickness 2-4 mm and extremity as primary site were found to be equivocal. INTERPRETATION This meta-analysis provides evidence that patients with low SLN tumor burden could probably be spared the morbidity associated with CLND. We identified 9 factors predictive of non-SLN metastases that should be recorded and evaluated routinely in SLN databases. However, further studies are needed to confirm the standard criteria for not performing CLND.
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Affiliation(s)
- V Nagaraja
- The Whiteley-Martin Research Centre, Discipline of Surgery, The University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
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The analysis of the outcomes and factors related to iliac–obturator involvement in cutaneous melanoma patients after lymph node dissection due to positive sentinel lymph node biopsy or clinically detected inguinal metastases. Eur J Surg Oncol 2013; 39:304-10. [DOI: 10.1016/j.ejso.2012.12.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 09/30/2012] [Accepted: 12/12/2012] [Indexed: 11/17/2022] Open
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Cukier M, Wright FC, McCready DR. Advocating Sentinel Node Biopsy in the Management of Cutaneous Melanoma. CURRENT DERMATOLOGY REPORTS 2012. [DOI: 10.1007/s13671-012-0008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Martinez SR, Tseng WH, Young SE. Outcomes for lymph node-positive cutaneous melanoma over two decades. World J Surg 2011; 35:1567-72. [PMID: 21559997 PMCID: PMC3109242 DOI: 10.1007/s00268-010-0903-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Our aim was to demonstrate that, despite advances in treatment and surveillance of node-positive cutaneous melanoma, rates of overall survival (OS) and melanoma-specific survival (MSS) have not changed over the last two decades. METHODS We used the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute to identify patients with node-positive cutaneous melanoma. Patients were categorized by treatment era; the first era encompassed patients diagnosed from 1988 to 1999 and the second era 2000 to 2006. Multivariate Cox proportional hazards models compared rates of OS and MSS between treatment eras while controlling for known prognostic factors. We reported risks of death as hazard ratios (HR) with 95% confidence intervals (CI) and set significance at P≤0.05. RESULTS Entrance criteria were met by 6,868 patients, 1,631 (23.8%) treated in era I and 5,237 (76.3%) treated in era II. On multivariate analysis, era II patients did not demonstrate a significantly different risk of death from any cause (HR 0.89, CI 0.79-1.01; P<0.08), but they did have a lower risk of melanoma-specific mortality (HR 0.81, CI 0.71-0.93; P=0.003) relative to their era I counterparts. CONCLUSIONS Over nearly two decades, MSS but not OS has improved for AJCC stage III melanoma patients. Stage migration is likely responsible for any improvement in MSS among patients in the most recently diagnosed era.
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Affiliation(s)
- Steve R Martinez
- Department of Surgery, Division of Surgical Oncology Sacramento, University of California at Davis, 4501 X Street, Suite 3010, Sacramento, CA 95817, USA.
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Bichakjian CK, Halpern AC, Johnson TM, Foote Hood A, Grichnik JM, Swetter SM, Tsao H, Barbosa VH, Chuang TY, Duvic M, Ho VC, Sober AJ, Beutner KR, Bhushan R, Smith Begolka W. Guidelines of care for the management of primary cutaneous melanoma. American Academy of Dermatology. J Am Acad Dermatol 2011; 65:1032-47. [PMID: 21868127 DOI: 10.1016/j.jaad.2011.04.031] [Citation(s) in RCA: 243] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Revised: 04/16/2011] [Accepted: 04/20/2011] [Indexed: 12/29/2022]
Abstract
The incidence of primary cutaneous melanoma has been increasing dramatically for several decades. Melanoma accounts for the majority of skin cancer-related deaths, but treatment is nearly always curative with early detection of disease. In this update of the guidelines of care, we will discuss the treatment of patients with primary cutaneous melanoma. We will discuss biopsy techniques of a lesion clinically suspicious for melanoma and offer recommendations for the histopathologic interpretation of cutaneous melanoma. We will offer recommendations for the use of laboratory and imaging tests in the initial workup of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, we will provide recommendations for surgical margins and briefly discuss nonsurgical treatments. Finally, we will discuss the value and limitations of sentinel lymph node biopsy and offer recommendations for its use in patients with primary cutaneous melanoma.
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Affiliation(s)
- Christopher K Bichakjian
- Department of Dermatology, University of Michigan Health System and Comprehensive Cancer Center, Ann Arbor, Michigan, USA
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Rondelli F, Vedovati M, Becattini C, Tomassini G, Messina S, Noya G, Simonetti S, Covarelli P. Prognostic role of sentinel node biopsy in patients with thick melanoma: a meta-analysis. J Eur Acad Dermatol Venereol 2011; 26:560-5. [DOI: 10.1111/j.1468-3083.2011.04109.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Pilko G, Besic N, Zgajnar J, Hocevar M. Prognostic heterogeneity after the excision of lymph node metastases in patients with cutaneous melanoma. Surg Oncol 2011; 20:26-34. [DOI: 10.1016/j.suronc.2009.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 09/12/2009] [Accepted: 09/19/2009] [Indexed: 10/20/2022]
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Prieto VG. Sentinel lymph nodes in cutaneous melanoma: handling, examination, and clinical repercussion. Arch Pathol Lab Med 2011; 134:1764-9. [PMID: 21128773 DOI: 10.5858/2009-0502-rar.1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Within the last 15 years, evaluation of sentinel lymph nodes (SLNs) has become the most popular method of early staging of several malignancies, including melanoma. Sentinel lymph nodes are usually examined on formalin-fixed, paraffin-embedded sections and by routine histology/immunohistochemistry (research protocols have used other techniques such as polymerase chain reaction). Approximately 20% of patients with cutaneous melanoma have metastasis in the SLN. In most studies, detection of positive SLN conveys a poorer prognosis for patients with cutaneous melanoma. OBJECTIVE To review the morphologic patterns of melanoma metastasis in the SLN, the differential diagnosis, and the quantification of tumor burden as a prognostic factor. DATA SOURCES Personal observations and review of the pertinent literature. CONCLUSIONS Evaluation of sentinel lymph nodes is certainly becoming a widespread technique and most authors agree on its prognostic power for staging patients with cutaneous melanoma. Current studies are evaluating the possible therapeutic value of removal of positive SLNs.
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Affiliation(s)
- Victor G Prieto
- Departments of Pathology and Dermatology, University of Texas M. D. Anderson Cancer Center, Houston, 77030, USA.
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Rutkowski P, Nowecki ZI, Zdzienicki M, Michej W, Symonides M, Rosinska M, Dziewirski W, Bylina E, Ruka W. Cutaneous melanoma with nodal metastases in elderly people. Int J Dermatol 2010; 49:907-13. [DOI: 10.1111/j.1365-4632.2009.04386.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Rutkowski P, Nowecki ZI, van Akkooi ACJ, Kulik J, Wanda M, Siedlecki JA, Eggermont AMM, Ruka W. Multimarker reverse transcriptase-polymerase chain reaction assay in lymphatic drainage and sentinel node tumor burden. Ann Surg Oncol 2010; 17:3314-23. [PMID: 20607422 PMCID: PMC2995879 DOI: 10.1245/s10434-010-1142-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Indexed: 12/29/2022]
Abstract
PURPOSE We assessed molecular (presence of melanoma cells markers in lymph fluid [LY]) and pathological features (sentinel lymph node [SN] tumor burden according to Rotterdam criteria, metastases microanatomic location) and correlated them with survival and melanoma prognostic factors in a group of patients with positive SN biopsy. METHODS We analyzed 368 consecutive SN-positive patients after completion lymph node dissection (CLND). In 321 patients we obtained data on SLN microanatomic location/tumor burden (only 7 cases had metastases <0.1 mm); in 137 we additionally analyzed 24-hour collected LY after CLND (multimarker reverse transcriptase-polymerase chain reaction [MM-RT-PCR] with primers for tyrosinase, MART1 (MelanA), and uMAGE mRNA (27.7% positive samples)]. Median follow-up time was 41 months. RESULTS According to univariate analysis, the following factors had a negative impact on overall survival (OS): higher Breslow thickness (P = .0001), ulceration (P < .0001), higher Clark level (P = .008), male gender (P = .0001), metastatic lymph nodes >1 (P < .0001), nodal metastases extracapsular extension (P < .0001), metastases to additional non-SNs (P = .0004), micrometastases size ≥ 0.1 mm (P = .0006), and positive LY MM-RT-PCR (P = .0007). SN tumor burden showed linear correlation with increasing Breslow thickness (P = .01). The 5-year OS rates for SLN tumor burden <0.1 mm, 1-1.0 mm, and >1.0 mm were 84%/66%/44%, respectively, and for positive and negative LY MM-RT-PCR 47%/0%, respectively. The independent factors for shorter OS (multivariate analysis): male gender, primary tumor ulceration, number of involved nodes ≥ 4, micrometastases size >1.0 mm, and, in additional model including molecular analysis-positive MM-RT-PCR results (hazard ratio [HR] 3.2), micrometastases size >1.0 mm (HR 1.13), and primary tumor ulceration (HR 2.17). Similar results were demonstrated for disease-free survival (DFS) data. CONCLUSIONS SN tumor burden categories according to Rotterdam criteria and the positive result of LY MM-RT-PCR assay demonstrated additional, independent prognostic value in SN-positive melanoma patients, showing significant correlation with shorter DFS and OS.
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Affiliation(s)
- Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland.
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Balch CM, Gershenwald JE, Soong SJ, Thompson JF, Ding S, Byrd DR, Cascinelli N, Cochran AJ, Coit DG, Eggermont AM, Johnson T, Kirkwood JM, Leong SP, McMasters KM, Mihm MC, Morton DL, Ross MI, Sondak VK. Multivariate analysis of prognostic factors among 2,313 patients with stage III melanoma: comparison of nodal micrometastases versus macrometastases. J Clin Oncol 2010; 28:2452-9. [PMID: 20368546 PMCID: PMC2982783 DOI: 10.1200/jco.2009.27.1627] [Citation(s) in RCA: 309] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Accepted: 01/25/2010] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To determine the survival rates and independent predictors of survival using a contemporary international cohort of patients with stage III melanoma. PATIENTS AND METHODS Complete clinicopathologic and follow-up data were available for 2,313 patients with stage III disease in an updated and expanded American Joint Committee on Cancer (AJCC) melanoma staging database. Kaplan-Meier and Cox multivariate survival analyses were performed. RESULTS Among all 2,313 patients with stage III disease, 81% had micrometastases, and 19% had clinically detectable macrometastases. The 5-year overall survival was 63%; it was 67% for patients with nodal micrometastases, and it was 43% for those with nodal macrometastases (P < .001). Tremendous heterogeneity in survival was observed, particularly in the microscopically detected nodal metastasis subset (from 23% to 87% for 5-year survival). Multivariate analysis demonstrated that in patients with nodal micrometastases, number of tumor-containing lymph nodes, primary tumor thickness, patient age, ulceration, and anatomic site of the primary independently predicted survival (all P < .01). When added to the model, primary tumor mitotic rate was the second-most powerful predictor of survival after the number of tumor-containing nodes. In contrast, for patients with nodal macrometastases, the number of tumor-containing nodes, primary ulceration, and patient age independently predicted survival (P < .01). CONCLUSION In this multi-institutional analysis, we demonstrated remarkable heterogeneity of prognosis among patients with stage III melanoma, especially among those with nodal micrometastases. These results should be incorporated into the design and interpretation of future clinical trials involving patients with stage III melanoma.
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Affiliation(s)
- Charles M Balch
- Department of Surgery, Johns Hopkins Medical Institutions, 600 N Wolfe St, Osler 624, Baltimore, MD 21287, USA.
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Rutkowski P, Nowecki ZI, Dziewirski W, Zdzienicki M, Pieñkowski A, Salamacha M, Michej W, Trepka S, Bylina E, Ruka W. Melanoma without a detectable primary site with metastases to lymph nodes. Dermatol Surg 2010; 36:868-76. [PMID: 20482725 DOI: 10.1111/j.1524-4725.2010.01562.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To compare outcomes of patients with clinical nodal melanoma metastases that occurred without a detectable primary tumor (melanoma of unknown primary site; MUP) with those with a known primary site (KPM). METHODS We included data from 459 consecutive patients treated from 1994 to 2007 with radical therapeutic lymph node dissection (LND; stage IIIB, C) due to clinically palpable and pathologically confirmed lymph node metastases (229 axillary; 230 ilioinguinal). The median follow-up was 49 months. RESULTS LND was performed in 59 cases (12.9%; 29 men, 30 women) due to MUP nodal metastases, including 33 axillary (14.4%) and 26 ilioinguinal (11.3%). In the MUP group, the 3- and 5-year survival rates were 48% and 41%, respectively. Similar rates were observed in patients with KPM, even with matched-pair analyses. Established prognostic factors (number of metastatic nodes, p=.005; extracapsular extension of metastases, p=.002) influenced survival in the MUP group. Relapses occurred in 31 (53%) and 299 (74.7%) cases in the MUP and KPM groups, respectively. CONCLUSIONS Survival rates in the MUP and KPM groups were similar, and the same prognostic factors affected both. Thus, all MUP cases should be treated as standard stage III melanomas.
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Affiliation(s)
- Piotr Rutkowski
- Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland.
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Stebbins WG, Garibyan L, Sober AJ. Sentinel lymph node biopsy and melanoma: 2010 update Part II. J Am Acad Dermatol 2010; 62:737-48;quiz 749-50. [PMID: 20398811 DOI: 10.1016/j.jaad.2009.11.696] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Revised: 11/11/2009] [Accepted: 11/16/2009] [Indexed: 11/19/2022]
Abstract
UNLABELLED This article will discuss the evidence for and against the therapeutic efficacy of early removal of potentially affected lymph nodes, morbidity associated with sentinel lymph node biopsy and completion lymphadenectomy, current guidelines regarding patient selection for sentinel lymph node biopsy, and the remaining questions that ongoing clinical trials are attempting to answer. The Sunbelt Melanoma Trial and the Multicenter Selective Lymphadenectomy Trials I and II will be discussed in detail. LEARNING OBJECTIVES At the completion of this learning activity, participants should be able to discuss the data regarding early surgical removal of lymph nodes and its effect on the overall survival of melanoma patients, be able to discuss the potential benefits and morbidity associated with complete lymph node dissection, and to summarize the ongoing trials aimed at addressing the question of therapeutic value of early surgical treatment of regional lymph nodes that may contain micrometastases.
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Affiliation(s)
- William G Stebbins
- Massachusetts General Hospital, Department of Dermatology, 55 Fruit St, Bartlett Hall 616, Boston, MA 02114, USA.
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Early (sentinel lymph node biopsy-guided) versus delayed lymphadenectomy in melanoma patients with lymph node metastases. Cancer 2010; 116:1201-9. [DOI: 10.1002/cncr.24852] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Rueth NM, Groth SS, Tuttle TM, Virnig BA, Al-Refaie WB, Habermann EB. Conditional survival after surgical treatment of melanoma: an analysis of the Surveillance, Epidemiology, and End Results database. Ann Surg Oncol 2010; 17:1662-8. [PMID: 20165985 DOI: 10.1245/s10434-010-0965-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Survival curves following surgical treatment of cutaneous melanoma are heavily influenced by early deaths. Therefore, survival estimates may be misleading for long-term cancer survivors. We examined whether conditional survival (CS) is more accurate in predicting long-term melanoma survival. METHODS We used the Surveillance, Epidemiology, and End Results database (1992-2005) to identify patients who underwent surgical treatment for melanoma. We included patients with T2-T4 disease and with known nodal status. Patients were stratified into low-risk (T2-3N0M0) and high-risk (T4N0M0 or T2-4N1-3M0) categories. We defined CS as time-specific estimates conditioned on living to a certain point in follow-up, and calculated 10-year cancer-specific survival curves conditioned on annual survival. We adjusted for potential confounders using a Cox proportional hazards regression model (alpha = 0.05). RESULTS A total of 8647 patients met inclusion criteria (low-risk, 5987 [69.2%]; high-risk, 2660 [30.8%]). At diagnosis, low-risk patients had a significantly better 10-year survival rate (low-risk, 79.6%; high-risk, 41.2%; P < 0.001). On CS analysis, survival differences remained until 8 years after treatment, after which 10-year cancer-specific survival rates were no longer significantly different (P = 0.51) for low-risk (95.4%) and high-risk (91.7%) groups. Multivariate analysis demonstrated that age, gender, location, and ulceration (initial predictors of survival) were no longer predictive after 8 years of survival. CONCLUSIONS For patients who survive 8 years after surgical treatment of melanoma, CS data become discordant with traditionally used estimates. Our findings have important implications for patient counseling, as high-risk melanoma survivors may require no more intensive surveillance than low-risk survivors 8 years after treatment.
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Affiliation(s)
- Natasha M Rueth
- Division of Surgical Oncology, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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Petitt M, Allison A, Shimoni T, Uchida T, Raimer S, Kelly B. Lymphatic invasion detected by D2-40/S-100 dual immunohistochemistry does not predict sentinel lymph node status in melanoma. J Am Acad Dermatol 2009; 61:819-28. [DOI: 10.1016/j.jaad.2009.04.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Revised: 04/07/2009] [Accepted: 04/13/2009] [Indexed: 12/01/2022]
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Abstract
BACKGROUND/AIM Skin melanoma is one of the most malignant diseases with increasing incidence rate. Sentinel node biopsy (SNB) is very important for early detection of metastatic spread. The aim of the study was to analyze the first 40 patients with skin melanoma of 1 to 4 mm Breslow thickness when SNB was indicated. METHODS The patient characteristics, localization of the primary melanoma as well as histology grade were analyzed. SNB with intraoperative radiocolloid and methylene blue dye detection was performed. RESULTS Complication rate after SNB was analyzed and seroma was found in 5% of the patients. The therapeutic node dissection was performed in 10 patients with positive sentinel biopsy. The follow-up lasted two years. In five patients the false negative SNB was defined after the mean time of 11 months and the therapeutic dissection was performed. CONCLUSION SNB in melanoma patients is a useful diagnostic procedure. It is advised for melanoma of 1 to 4 mm Breslow thickness.
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Haerle SK, Hany TF, Strobel K, Sidler D, Stoeckli SJ. Is there an additional value of SPECT/CT over planar lymphoscintigraphy for sentinel node mapping in oral/oropharyngeal squamous cell carcinoma? Ann Surg Oncol 2009; 16:3118-24. [PMID: 19636629 DOI: 10.1245/s10434-009-0632-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 07/01/2009] [Accepted: 07/02/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Lymphatic mapping for sentinel node biopsy (SNB) has been shown to be crucial for detection of sentinel lymph nodes (SLN). Previous reports suggested a benefit of single photon emission computed tomography with CT (SPECT/CT) over dynamic planar lymphoscintigraphy (LS) alone. The aim was to assess whether there is an additional value of SPECT/CT over LS alone for lymphatic mapping of SLNs in oral/oropharyngeal SCC. METHODS A consecutive cohort of 58 patients was evaluated using SNB with additional SPECT/CT to preoperative LS. RESULTS In the entire cohort of 58 patients undergoing LS and SPECT/CT, hot spots could be revealed in all but 4 cases. The guidance of the handheld gamma probe was able to reveal 9 additional SLNs within 3 patients not detected by either modality. Lymphoscintigraphy showed full concordance with SPECT/CT in 81% of the cases. SPECT/CT was able to detect additional HS in 11 patients, in 1 case even with additional metastatic disease. The false negative rate for SNB was 6%, and the negative predictive value 98%. CONCLUSIONS SPECT/CT has the potential to detect more SLNs, which might harbor occult disease, than LS alone. With regard to the excellent results achieved with LS and the intraoperative use of the gamma probe, SPECT/CT is not indispensable for successful SNB. Both imaging modalities have difficulties in detecting level I sentinel nodes close to the injection site.
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Affiliation(s)
- Stephan K Haerle
- Department of Otolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
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