Lymph node dissection for stage III melanoma

Locoregional spread of melanoma to its draining lymph node basin is the strongest negative prognostic factor for patients. Exclusive of clinical trials, patients with sentinel lymph node-positive (microscopic) or clinically palpable (macroscopic) nodal disease should undergo lymphadenectomy. This article reviews the management and technical aspects of surgical care for regional metastases. Adjunct therapies (immunotherapy, targeted therapy, and radiation) may supplement lymphadenectomy in certain patient populations. Surgical morbidity after lymphadenectomy can be substantial, creating opportunities for improvement via minimally invasive techniques or refined patient selection.

In-transit melanoma metastases: incidence, prognosis, and the role of lymphadenectomy

PURPOSE

To analyze a large, single-institution database to further understanding of melanoma in-transit metastases (ITM) with regard to incidence, prognosis, and the role of lymphadenectomy.

METHODS

A total of 11,614 patients with single primary cutaneous melanomas were treated at Melanoma Institute Australia between January 1994 and December 2009. Of these, 505 developed ITM. Clinicopathologic characteristics, sentinel node (SN) status, patterns of disease progression, and outcomes were analyzed.

RESULTS

In the 505 patients with ITM, the median primary tumor thickness was 2.95 mm, and 39.4 % were ulcerated. The ITM rates for patients with primary melanomas <1 or ≥1 mm in size and in those who underwent sentinel node biopsy were 0.4, 7.8, and 7.2 %, respectively. The ITM rates for SN-positive and SN-negative patients were 21.6 and 4.7 %, respectively. The median time from primary diagnosis to the development of ITM was 17.9 months. After ITM diagnosis, the median survival time was 19.9 months, 5-year survival was 32.8 %, and 10-year survival was 27.5 %. After ITM diagnosis, primary tumor site (head/neck, trunk) and ulceration were predictors of poorer survival. Five-year survival from the time of ITM ranged from 47.9 % for nonulcerated limb primary lesions to only 13.6 % for ulcerated trunk primary lesions. Elective lymph node dissection in clinically node-negative patients with ITM did not significantly alter overall survival.

CONCLUSIONS

This large study demonstrates that the diagnosis of melanoma ITM carries serious adverse prognostic implications and will assist in improving the accuracy of staging and prognostic estimates as well as treatment in these patients.

Reliability and cost-effectiveness of complete lymph node dissection under tumescent local anaesthesia vs. general anaesthesia: a retrospective analysis in patients with malignant melanoma AJCC stage III

BACKGROUND

Complete lymph node dissection (CLND) in melanoma patients with a positive sentinel lymph node (SLN) is currently being debated, as it is a cost-intensive surgical intervention with potentially high morbidity.

OBJECTIVE

This clinical study seeks to clarify the effectiveness, reliability and cost-effectiveness of CLND performed under tumescent local anaesthesia (TLA) compared with procedures under general anaesthesia (GA).

METHODS

We retrospectively analysed the data from 60 patients with primary malignant melanoma American Joint Committee on Cancer stage III who underwent CLND.

RESULTS

Altogether 26 (43.3%) patients underwent CLND under TLA and 34 (56.7%) patients underwent CLND under GA. Fifteen of 43 (34.9%) patients had a complication, such as development of seromas and/or wound infections. The rate of complications was 25.0% (3/12) in the axilla subgroup and 28.6% (4/14) in the groin subgroup of the TLA group. In the GA group, the complication rate was 31.3% (5/16) in the axilla subgroup and 44.4% (8/18) in the groin subgroup. The costs for CLND were significantly less for the CLND in a procedure room performed under TLA (mean €67.26) compared with CLND in an operating room under GA (mean €676.20, P < 0.0001).

CONCLUSIONS

In conclusion, this study confirms that TLA is an excellent, safe, effective and cost-efficient alternative to GA for CLND in melanoma patients.