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Moncrieff MD, Lo SN, Scolyer RA, Heaton MJ, Nobes JP, Snelling AP, Carr MJ, Nessim C, Wade R, Peach AH, Kisyova R, Mason J, Wilson ED, Nolan G, Pritchard Jones R, Sondak VK, Thompson JF, Zager JS. Evaluation of the Indications for Sentinel Node Biopsy in Early-Stage Melanoma with the Advent of Adjuvant Systemic Therapy: An International, Multicenter Study. Ann Surg Oncol 2022; 29:5937-5945. [PMID: 35562521 PMCID: PMC9356930 DOI: 10.1245/s10434-022-11761-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/23/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients presenting with early-stage melanoma (AJCC pT1b-pT2a) reportedly have a relatively low risk of a positive SNB (~5-10%). Those patients are usually found to have low-volume metastatic disease after SNB, typically reclassified to AJCC stage IIIA, with an excellent prognosis of ~90% 5-year survival. Currently, adjuvant systemic therapy is not routinely recommended for most patients with AJCC stage IIIA melanoma. The purpose was to assess the SN-positivity rate in early-stage melanoma and to identify primary tumor characteristics associated with high-risk nodal disease eligible for adjuvant systemic therapy METHODS: An international, multicenter retrospective cohort study from 7 large-volume cancer centers identified 3,610 patients with early primary cutaneous melanomas 0.8-2.0 mm in Breslow thickness (pT1b-pT2a; AJCC 8th edition). Patient demographics, primary tumor characteristics, and SNB status/details were analyzed. RESULTS The overall SNB-positivity rate was 11.4% (412/3610). Virtually all SNB-positive patients (409/412; 99.3%) were reclassified to AJCC stage IIIA. Multivariate analysis identified age, T-stage, mitotic rate, primary site and subtype, and lymphovascular invasion as independent predictors of sentinel node status. A mitotic rate of >1/mm2 was associated with a significantly increased SN-positivity rate and was the only significant independent predictor of high-risk SNB metastases (>1 mm maximum diameter). CONCLUSIONS The new treatment paradigm brings into question the role of SNB for patients with early-stage melanoma. The results of this large international cohort study suggest that a reevaluation of the indications for SNB for some patients with early-stage melanoma is required.
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Affiliation(s)
- Marc D Moncrieff
- Department of Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK.
- Norwich Medical School, University of East Anglia, Norwich, UK.
| | - Serigne N Lo
- Melanoma Institute of Australia, University of Sydney, Sydney, Australia
| | - Richard A Scolyer
- Melanoma Institute of Australia, University of Sydney, Sydney, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- NSW Health Pathology, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Martin J Heaton
- Department of Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Jenny P Nobes
- Department of Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Andrew P Snelling
- Department of Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | | | | | - Ryckie Wade
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | | | | | - Grant Nolan
- St. Helens and Knowsley NHS Trust, Liverpool, UK
| | | | | | - John F Thompson
- Melanoma Institute of Australia, University of Sydney, Sydney, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
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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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Meves A, Nikolova E, Heim JB, Squirewell EJ, Cappel MA, Pittelkow MR, Otley CC, Behrendt N, Saunte DM, Lock-Andersen J, Schenck LA, Weaver AL, Suman VJ. Tumor Cell Adhesion As a Risk Factor for Sentinel Lymph Node Metastasis in Primary Cutaneous Melanoma. J Clin Oncol 2015; 33:2509-15. [PMID: 26150443 DOI: 10.1200/jco.2014.60.7002] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Less than 20% of patients with melanoma who undergo sentinel lymph node (SLN) biopsy based on American Society of Clinical Oncology/Society of Surgical Oncology recommendations are SLN positive. We present a multi-institutional study to discover new molecular risk factors associated with SLN positivity in thin and intermediate-thickness melanoma. PATIENTS AND METHODS Gene clusters with functional roles in melanoma metastasis were discovered by next-generation sequencing and validated by quantitative polymerase chain reaction using a discovery set of 73 benign nevi, 76 primary cutaneous melanoma, and 11 in-transit melanoma metastases. We then used polymerase chain reaction to quantify gene expression in a model development cohort of 360 consecutive thin and intermediate-thickness melanomas and a validation cohort of 146 melanomas. Outcome of interest was SLN biopsy metastasis within 90 days of melanoma diagnosis. Logic and logistic regression analyses were used to develop a model for the likelihood of SLN metastasis from molecular, clinical, and histologic variables. RESULTS ITGB3, LAMB1, PLAT, and TP53 expression were associated with SLN metastasis. The predictive ability of a model that included these molecular variables in combination with clinicopathologic variables (patient age, Breslow depth, and tumor ulceration) was significantly greater than a model that only considered clinicopathologic variables and also performed well in the validation cohort (area under the curve, 0.93; 95% CI, 0.87 to 0.97; false-positive and false-negative rates of 22% and 0%, respectively, using a 10% cutoff for predicted SLN metastasis risk). CONCLUSION The addition of cell adhesion-linked gene expression variables to clinicopathologic variables improves the identification of patients with SLN metastases within 90 days of melanoma diagnosis.
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Affiliation(s)
- Alexander Meves
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Ekaterina Nikolova
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Joel B Heim
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Edwin J Squirewell
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mark A Cappel
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mark R Pittelkow
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Clark C Otley
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nille Behrendt
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ditte M Saunte
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jorgen Lock-Andersen
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Louis A Schenck
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Amy L Weaver
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Vera J Suman
- Alexander Meves, Ekaterina Nikolova, Joel B. Heim, Edwin J. Squirewell, Clark C. Otley, Louis A. Schenck, Amy L. Weaver, and Vera J. Suman, Mayo Clinic, Rochester, MN; Mark A. Cappel, Mayo Clinic, Jacksonville, FL; Mark R. Pittelkow, Mayo Clinic, Scottsdale, AZ; and Nille Behrendt, Ditte M. Saunte, and Jorgen Lock-Andersen, Hospital Roskilde, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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