Complete Node Dissection Research Articles

Does Stage Migration Occur as a Consequence of Omitting Completion Lymph Node Dissection for Melanoma?

Completion lymph node dissection (CLND) is no longer recommended routinely in the treatment of melanoma. CLND omission may understage patients for whom the distinction between stage IIIA and IIIB-C could alter adjuvant therapy recommendations. The aim of this study is to determine if stage migration has occurred with the declining use of CLND. Patients with clinically node-negative ≥T1b cutaneous melanoma were identified from the National Cancer Database (NCDB) from 2012 to 2018. CLND utilization and changes in AJCC staging were analyzed. Patients undergoing sentinel lymph node biopsy (SLNB) alone were compared with those undergoing SLNB + CLND. Overall, 68,933 patients met inclusion criteria and 60,536 underwent SLNB, of which 9031 (14.9%) were tumor positive. CLND was performed in 3776 (41.8%). Patients undergoing CLND were younger (58 versus 62 years, p < 0.0001) and more likely male (61.5% versus 57.9%, p = 0.0005). Patients were more likely to have an N classification >N1a if they received SLNB + CLND (36.8%) versus SLNB alone (19.3%), p < 0.0001. This translated to a small difference in stage IIIA patients between groups (SLNB alone 34.0%, SLNB + CLND 31.8%, p < 0.0001). Of the patients with T1b/T2a tumors who would be upstaged from IIIA to IIIC with identification of additional positive nodes, IIIC incidence was only slightly higher after SLNB + CLND compared with SLNB alone (4.4% versus 1.1%, p < 0.0001). CLND utilization dramatically decreased from 59% in 2012 to 12.6% in 2018, p < 0.0001. However, the incidence of stage IIIA disease for all patients remained stable over the 7-year study period. While the utilization of CLND after positive SLNB has declined dramatically in the last 7 years, stage migration that may affect adjuvant therapy decisions has not occurred to a clinically meaningful degree.

Surgical treatment of patients with a combined forms of pulmonary tuberculosis and lung cancer

Objective — to improve surgical treatment of patients with combined forms of pulmonary tuberculosis and non small cell lung cancer due to minimally invasive diagnostics and with the use of sterno-mediastinal surgical dissection of tissue and complete systematic bilateral lymph node dissection (CSBLND). Materials and methods. Our studies involved retrospective analysis of 101 cases of treatment of patients with stage I—II—IIIА non-small cell lung cancer (NSCLC) and pulmonary tuberculosis. A review of diagnostics and operations over the past decade were conducted. All patients underwent surgical treatment. The main group included 48 patients who underwent 16 lobectomy and 32 pneumonectomy from the sternomediastinal access. A comparative analysis of the effectiveness of the CSBLND was carried out. The comparison group included 53 patients who underwent 17 lobectomy and 36 pneumonectomy, a surgical operation for lateral thoracotomy and selective dissection of the mediastinal lymph nodes was performed. Results and discussion. The analysis of the morphological features of combined forms of pulmonary tuberculosis and NSCLC has been made in comparison groups, that were explored retrospectively. There was a trend improved survival patients combined forms of pulmonary tuberculosis and NSCLC stage I—II—IIIA, who underwent of CSBLND (p = 0.05). A statistically significant of survival of patients who underwent pneumonectomy in the mail group (n = 32) with CSBLND (p = 0.01). In a comparative analysis of the frequency and nature of complications during surgery, we found out that in general in the main group they met in 2.1 times less often than in the comparison group (p &lt; 0.05). Complications during operation in patients of the main group occurred in (11.4 ± 2.6) %, while in the comparison group — in (22.6 ± 4.2) % of cases. The analysis of data showed that patients with adenocarcinoma of lung cancer have been improvements in the performance of sterno-mediastinal surgical techniques (CSBLND) (p = 0.12). Therefore, patients with combined forms of pulmonary tuberculosis and NSCLC for suspected «jumping metastases» we recommended to carry out operations with sternotomy surgical access with full system bilateral lymph nodes dissection and radical rezection of pathologically altered lung. All this requires further development of high-tech surgical techniques in our country. Conclusions. The leading effect of pulmonary tuberculosis on the surgical treatment of patients with combined forms of tuberculosis and lung cancer has been shown in groups of comparison. The increase of 3 years survival in patients of basic groups is set, demonstrating the advantage of active diagnostical surgical tactics of stage I—II—IIIА NSCLC with used sterno-mediastinal access and the appliance of more radical CSBLND. Thus, the clinical effect of operative patients of the main groups in the immediate postoperative period was reached 95.7 % patients, in the groups comparison clinical effect be noted in 80.5 %.

Nail Apparatus Melanoma: Current Management and Future Perspectives.

Nail apparatus melanoma (NAM) is a rare type of cutaneous melanoma that belongs to the acral melanoma subtype. NAM is managed principally in accordance with the general treatment for cutaneous melanoma, but there is scarce evidence in support of this in the literature. Acral melanoma is genetically different from non-acral cutaneous melanoma, while recently accumulated data suggest that NAM also has a different genetic background from acral melanoma. In this review, we focus on recent advances in the management of NAM. Localized NAM should be surgically removed; amputation of the digit and digit-preserving surgery have been reported. Sentinel lymph node biopsy can be considered for invasive NAM for the purpose of accurate staging. However, it is yet to be clarified whether patients with metastatic sentinel lymph nodes can be safely spared completion lymph node dissection. Similar to cutaneous melanoma, immune checkpoint inhibitors and BRAF/MEK inhibitors are used as the first-line treatment for metastatic NAM, but data on the efficacy of these therapies remain scarce. The therapeutic effects of immune checkpoint inhibitors could be lower for NAM than for cutaneous melanoma. This review highlights the urgent need to accumulate data to better define the optimal management of this rare melanoma.

The Evolution of the Sentinel Node Biopsy in Melanoma.

The growing repertoire of approved immune-checkpoint inhibitors and targeted therapy has revolutionized the adjuvant treatment of melanoma. While the treatment of primary cutaneous melanoma remains wide local excision (WLE), the management of regional lymph nodes continues to evolve in light of practice-changing clinical trials and dramatically improved adjuvant therapy. With large multicenter studies reporting no benefit in overall survival for completion lymph node dissection (CLND) after a positive sentinel node biopsy (SLNB), controversy remains regarding patient selection and clinical decision-making. This review explores the evolution of the SLNB in cutaneous melanoma in the context of a rapidly changing adjuvant treatment landscape, summarizing the key clinical trials which shaped current practice guidelines.

Therapeutic response analysis for patients with adenosquamous carcinoma of the gallbladder: data analysis based on the Surveillance, Epidemiology, and End Results (SEER) database.

Adenosquamous carcinoma of the gallbladder (GBASC) is a rare histological variant without defined appropriate clinical measures. Using the Surveillance, Epidemiology, and End Results (SEER) database, data on a cohort of patients with GBASC were collected from 21 cancer registries between 1975 and 2018. We used Kaplan-Meier analysis to evaluate the effectiveness of different treatment regimens on patients with GBASC. Then we used Cox proportional hazards regression method to determine the prognostic factors for cancer-specific survival (CSS) of GBASC patients. A total of 388 patients with GBASC were identified: 80 patients diagnosed as early stage and 308 patients diagnosed as advanced stage. For early-stage GBASC, radical lymph node dissection improved the CSS significantly; for advanced-stage GBASC, radical surgery, nonradical surgery, lymph node dissection, chemotherapy, and radiotherapy improved the CSS significantly. Surgery, lymph node dissection, radiation, chemotherapy, age, race, and the American Joint Committee on Cancer (AJCC) stage were the independent risk factors for the CSS of GBASC patients. Radical intraoperative lymph node dissection provided a survival benefit for patients with early-stage GBASC, whereas chemotherapy and radiotherapy provided no significant benefit; surgical treatment, more complete lymph node dissection, radiotherapy, and chemotherapy provided survival benefits for patients with advanced GBASC. The prognosis for GBASC patients is affected by the factors of surgery, lymph node dissection, radiation, chemotherapy, age, race, and the AJCC stage.

Luarea deciziilor terapeutice în carcinomul cu celule Merkel – punctul de vedere al chirurgului oncolog

Introduction. Merkel cell carcinoma (MCC) is not as well-known as other malignant skin tumors, although it has been found to have a higher mortality rate than malignant melanoma, estimated at 30%. This poor prognosis is due to its aggressiveness characterized by an increased risk of recurrence, both regional and at distance. Materials and method. We conducted a literature review over the past five years, from January 2017 to September 2022, looking for relevant publications in the PubMed database, on Merkel cell carcinoma, or cutaneous neuroendocrine cancer, or trabecular skin cancer, as it is also known in literature, since 1972, when Toker first introduced the term. A total of 799 results were identified at the initial search in the database, which is why we added another secondary selection criterion by entering the terms “treatment” and “surgical excision”. In the end, 44 articles were analyzed, relevant for the surgical stage of the treatment and for its classification in multimodal treatment, excluding those that were not written in English. In addition, articles from the bibliographic indices were selected and consulted. Results. Six retrospective studies were selected, which ana­lyze the role of adjuvant radiation therapy, complete lymph node dissection (CLND) or both procedures in patients with positive sentinel lymph node biopsy (SNLB). Conclusions. Surgery is the basic treatment, and the earlier it is applied by the first curative intention, the better the rest of the mul­ti­mo­dal treatments manage to control the tumor evo­lu­tion. Radiation therapy as a single therapy has not led to satis­factory results, even though Merkel cell carcinoma is highly radiosensitive, and will be considered only in ad­di­tion to surgery.

Alternatives and reduced need for sentinel lymph node biopsy (SLNB) staging for melanoma

Sentinel lymph node biopsy (SLNB) has been introduced in the 1990s to identify patients who might benefit from completion lymph node dissection. Neither SLNB nor CLND improved survival, but SLNB staging did provide the best staging, above Breslow thickness and ulceration. The SLN status and SLN tumour burden were used in all trials until date looking at modern adjuvant systemic therapy with immune checkpoint inhibition (ICI) or targeted therapies (TT). Adjuvant ICI and TT are shifting towards stage II melanoma. The question is whether there is still role for SLNB in melanoma, in this day and age, and if so, how does the future look for SLNB staging? The SLN status and SLN tumour burden might be useful for a consultation to discuss the number needed to treat in a risk/benefit discussion. For stage IIB/C patients, it seems likely, however, that patients will forego a nuclear scan followed by the risk of surgical intervention and morbidity associated with SLNB if they opt to receive adjuvant therapy regardless of the SLNB result. For stage I/IIA, it is still required to detect high-risk patients who might benefit from adjuvant therapy. However, biomarkers are emerging, such as gene expression profilers (GEP), immunohistological signatures and liquid biopsies with ctDNA. There still is a role for SLNB staging in melanoma today, but we expect that the availability of therapeutic option independent of SLNB status as well as emergence of validated biomarkers to predict risk will reduce the need for SLNB staging in the upcoming decade to the point it will no longer be used.

Assessment of the Diagnostic Value of Sentinel Lymph Node Mapping with Blue Dye (Blue Methylene) with Complete Lymph Node Dissection for Endometrial Cancer Staging Surgery (a Multicenter, Prospective, Cross-Sectional Study)

In gynecological cancers, sentinel lymph node (SLN) mapping has been proposed as an alternative to complete lymph node dissection. The goal of this study was to determine sentinel lymph node mapping's sensitivity, specificity, NPV, and PPV versus gold standard surgery (complete lymph node dissection) in patients with metastatic illness. A total of 26 patients were prospectively enrolled from spring 2021 to winter 2022. Sentinel lymph node mapping with complete pelvic lymph node dissection was done in all of them, and para-aortic lymphadenectomy was detected in 11 (43.33%) patients. At least one sentinel lymph node was successfully mapped in 22 (84.6%) patients. Three patients (11.5%) had positive lymph nodes, with an 85.7% sensitivity (95 percent CI) to detect node positive illness, a specificity of 74.93%, an NPV of 99.6 (99.5 CI), and a PPV of 5.9% calculated. There were no serious adverse effects due to blue dye. The accuracy rate of sentinel lymph node mapping by methylene blue was 75.1%.

Robot-assisted esophagectomy with robot-sewn intrathoracic anastomosis (Ivor Lewis): surgical technique and early results.

Esophagectomy is the selected treatment for nonmetastatic esophageal and esophagogastric junction cancer, although high perioperative morbidity and mortality incur. Robot-assisted minimally invasive esophagectomy (RAMIE) effectively reduces cardiopulmonary complications compared to open esophagectomy and offers a technical advantage, especially for lymph node dissection and intrathoracic anastomosis. This article aims at describing our initial experience of Ivor Lewis RAMIE, focusing on the technique's main steps and robotic-sewn esophagogastrostomy. Prospectively collected data from all consecutive patients who underwent Ivor Lewis RAMIE for cancer was reviewed. Reconstruction was performed with a gastric conduit pull-up and a robotic-sewn intrathoracic anastomosis. Intraoperative and postoperative complications were recorded as prescribed by the Esophagectomy Complications Consensus Group (ECCG). Thirty patients underwent Ivor Lewis RAMIE with complete mediastinal lymph node dissection and robot-sewn anastomosis. No intraoperative complications nor conversion occurred. Pulmonary complications totaled 26.7%. Anastomotic leakage (ECCG, type III) and conduit necrosis (ECCG, type III) both occurred in one patient (3.3%). Chylothorax appeared in 2 patients (6.7%) (ECCG, Type IIA). Anastomotic stricture, successfully treated with endoscopic dilatations, occurred in 8 cases (26.7%). Median overall postoperative stay was 11days (range, 6-51days). 30day and 90day mortality was 0%. R0 resection was performed in 96.7% of patients with a median number of 47 retrieved lymph nodes. RAMIE with robot-sewn intrathoracic anastomosis appears to be feasible, safe and effective, with favorable perioperative results. Nevertheless, further high-quality studies are needed to define the best anastomotic technique for Ivor Lewis RAMIE.

Unmeasured factors are associated with the use of completion lymph node dissection (CLND) in melanoma.

Completion lymph node dissection (CLND) was the standard treatment for patients with melanoma with positive sentinel lymph nodes (SLN) until 2017when data from the DeCOG-SLT and MLST-2 randomized trials challenged the survival benefit of this procedure. We assessed the contribution of patient, tumor and facility factors on the use of CLND in patients with surgically resected Stage III melanoma. Using the National Cancer Database, patients who underwent surgical excision and were found to have a positive SLN from 2012 to 2017 were included. A multivariable mixed-effects logistic regression model with a random intercept for the facility was used to determine the effect of patient, tumor, and facility variables on the risk of CLND. Reference effect measures (REMs) were used to compare the contribution of contextual effects (unknown facility variables) versus measured variables on the variation in CLND use. From 2012 to 2017, the overall use of CLND decreased from 59.9% to 26.5% (p < 0.0001). Overall, older patients and patients with government-based insurance were less likely to undergo CLND. Tumor factors associated with a decreased rate of CLND included primary tumor location on the lower limb, decreasing depth, and mitotic rate <1. However, the contribution of contextual effects to the variation in CLND use exceeded that of the measured facility, tumor, time, and patient variables. There was a decrease in CLND use during the study period. However, there is still high variability in CLND use, mainly driven by unmeasured contextual effects.

Ganglio centinela positivo en melanoma: factores predictivos y resultados del vaciamiento ganglionar

Background: Sentinel lymph node (SLN) biopsy is the technique accepted to determine the prognosis of early cutaneous melanomas. The advantage of lymph node dissection (LND) when SLN biopsy is positive has recently been questioned. Objective: The aim of this study is to describe the percentages and factors associated with SLN and non-sentinel node (NSN) metastases in LNDs of SLN-positive patients. Material and methods: The clinical records and pathology reports of 139 patients undergoing surgery for cutaneous melanoma between January 2012 and December 2019 were retrospectively reviewed. Results: Ninety-six (69%) patients underwent SLN biopsy. Mean age was 61.7 ± 17.5 years (19-93) and 53 (55.2%) were men. The primary lesion was located in the extremities in 47 (49%) cases, in the trunk in 39 (40.6%), and in the head and neck in 10 (10.4%). Mean Breslow thickness was 5.01 mm (1.05-50 mm) and ulceration was found in 35 cases (36.4%). The SLN was identified in all the cases and was positive in 39 (40.6%). There was an association with thickness ≥ 3 mm (p = 0.000017) and ulceration (p = 0.0011). Those patients with positive SLN biopsy underwent LND of the territory involved: axillary in 23, inguinal in 10 and cervical in 6. Twenty-three (59%) presented NSLN metastases and were associated with thickness (p = 0.022) and ulceration (p = 0.019). Conclusion: There was a high percentage of positive NSLN in the population studied which was associated with thickness and ulceration. These characteristics and the difficulty to achieve strict follow-up are the reasons for completion LND in SLN-positive patients.

Cost evaluation of the Merlin assay for predicting melanoma sentinel lymph node biopsy metastasis.

The Merlin assay for melanoma-risk assessment has become commercially available to reduce the rate of unnecessary sentinel lymph node biopsies (SLNB) in SLNB-eligible patients with cutaneous melanoma. Merlin low-risk patients are recommended to undergo wide local excision (WLE) of the primary tumor, whereas Merlin high-risk patients are recommended to undergo both SLNB and WLE. Here, we compared the cost of a Merlin testing strategy to that of a no-testing strategy (usual care) before prescribing SLNB. We identified T1 and T2 patients who underwent WLE and SLNB but not completion lymph node dissection between 2007 and 2018. Controls were T1 patients who only underwent WLE. Costs for WLE and SLNB were calculated by converting institutional cost data to standardized Medicare reimbursement rates. We then developed a decision tree to compare the cost of Merlin testing to that of a no-testing strategy (usual care). The average standardized cost of WLE was $2066, whereas the cost of WLE and SLNB was $11,976 based on Medicare rates. At a cost below $7350 for T1b melanoma and $4600 for T1b to T2 melanoma, Merlin testing was cost-saving compared to a no-testing strategy (usual care), assuming Medicare reimbursement rates. Merlin testing for T1b and T2 melanoma is potentially cost saving depending on the cost of the molecular assay and SLNB reimbursement rates. In addition to being cost saving, Merlin is expected to improve health-related quality of life.

Population-Level Impact of Omitting Axillary Lymph Node Dissection in Early Breast Cancer Women: Evidence from an Economic Evaluation in Germany.

The American College of Surgeons Oncology Group Z0011 trial showed that complete axillary lymph node dissection (cALND) did not improve survival benefits in patients with one or two tumour-involved sentinel lymph nodes and undergoing breast conservation. Still, a considerable number of the Z0011-eligible patients continue to be treated with cALND in various countries. Given the potential economic gain from implementation of the Z0011 recommendations, we quantified population-level impacts of omitting cALND among Z0011-eligible patients in clinical practice. This 2-year economic analysis adopted both the perspective of patients under statutory insurance and the societal perspective, using data collected prospectively from 179 German breast cancer units between 2008 and 2015. The estimation of cost savings and health gain relied on a single decision tree, which considered three scenarios: clinical practice at the baseline; actual implementation in routine care; and hypothetical full implementation in all eligible patients. Data for 188,909 patients with primary breast cancer were available, 13,741 (7.3%) of whom met the Z0011 inclusion criteria. The use of cALND decreased from 94.3% in 2010 to 46.9% in 2015, resulting in a gain of 335 quality-adjusted life-years and a saving of EUR50,334,756 for the society. Had cALND been omitted in all eligible patients, the total gain would have been more than double. The implementation of the Z0011 recommendations resulted in substantial savings and health gain in Germany. Our findings suggest that it is beneficial to introduce additional policy measures to promote further uptake of the Z0011 recommendations in clinical practice.

Continuous vagal intraoperative neuromonitoring during video-assisted thoracoscopic surgery for left lung cancer: its efficacy in preventing permanent vocal cord paralysis.

We investigated the safety and efficacy of continuous intraoperative neuromonitoring (CIONM) during video-assisted thoracoscopic lobectomy for left lung cancer in preventing recurrent laryngeal nerve injury. From August 2015 to March 2020, 22 patients with left lung cancer without CIONM (unmonitored) and 20 patients with left lung cancer with CIONM underwent thoracoscopic lobectomy with complete mediastinal lymph node dissection including 4L dissection. Clinical outcomes from these 2 groups were compared. The incidence of 4L metastasis was 7.14% (3 patients). There was no significant difference in the total number of dissected 4L lymph nodes between the 2 groups (3.23 ± 2.2 in the unmonitored group, 3.95 ± 2.0 in the CIONM group). CIONM was successful in all of the cases. There was no significant difference in the incidence of postoperative vocal cord palsy (22.7% in the unmonitored group, 20% in the CIONM group, P = 1.000). All of the 5 patients (100%) had permanent vocal cord palsy in the unmonitored group. Although statistically insignificant, 75% (3 patients) had total recovery of the vocal cord function, with only 1 patient remaining in permanent vocal cord palsy in the CIONM group. CIONM was safe and efficient. CIONM might be helpful to avoid permanent vocal cord palsy by immediately warning the surgeon about impending nerve injury, so the surgeon can stop delivering further injury to the recurrent laryngeal nerve.

TRANS-Peritoneal PARA-Aortic Node Dissection Two Different Technique

<h3>Study Objective</h3> Trans-peritoneal para-aortic node dissection two different approach. <h3>Design</h3> Prospective analysis. <h3>Setting</h3> Patient underwent 3D laparoscopy, all procedure done by experienced and qualified team. <h3>Patients or Participants</h3> CA Endometrium (> 50% invasion), CA cervix patients. <h3>Interventions</h3> Laparoscopic transperitoneal para-aortic lymph node dissection. <h3>Measurements and Main Results</h3> all patient reviewed at monthly interval followed by 3 monthly interval with USG (A+P). PET scan done at 6 months did not reveal any recurrence. median follow up 18 months. all patients are diseased free. <h3>Conclusion</h3> Two different approaches for transperitoneal para-aortic dissection possible laparoscopically. since para-aortic dissection is part of pelvic dissection in radical hysterectomy so without changing position of patient and surgeon (surgeon standing on right side of patient) we can achieve complete nodal dissection.

Surgery, Limb Edema and Health-related Quality of Life: A Prospective Follow-up Study on Patients With Cutaneous Malignant Melanoma.

The latest developments in oncological therapies for malignant melanoma, and the discovery that complete lymph node dissection offers no survival benefit, are changing the landscape of melanoma surgery. There is a need for more information on health-related quality of life (HRQoL) consequences of melanoma surgery. This longitudinal cohort study was carried out from 2004 to 2009 in the Helsinki and Uusimaa Hospital District and patients were followed-up at 6, 12 and 24 months. The patients were asked to fill in the generic 15D questionnaire and the cancer-specific European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-30). In addition, they were asked selected questions from the EORTC Item Library regarding upper and lower limb edema. A total of 169 (64.5%) patients with local or locally advanced melanoma referred for surgical treatment responded, of whom 161 were included in the final analysis. For the whole patient group, distress, depression and emotional function improved over time. Worse HRQoL in some of the dimensions were associated with female sex, skin transplant versus direct wound closure and complications 30 days or more after surgery, but none was associated with worse overall HRQoL. Postoperative complications, type of wound closure or lymph node surgery had no effect on overall HRQoL. Patient-reported limb edema was associated with worse overall HRQoL at baseline and during follow-up by both instruments. Patients reporting limb edema reported worse mobility and more pain throughout the study. Patient-reported limb edema, regardless of the cause, seems to be an important predictor of worse HRQoL among patients with melanoma.

Mathematical models for intraoperative prediction of metastasis to regional lymph nodes in patients with clinical stage I non-small cell lung cancer.

It remains challenging to determine the regions of metastasis to lymph nodes during operation for clinical stage I non-small cell lung cancer (NSCLC). This study aimed to establish intraoperative mathematical models with nomograms for predicting the hilar-intrapulmonary node metastasis (HNM) and the mediastinal node metastasis (MNM) in patients with clinical stage I NSCLC. The clinicopathological variables of 585 patients in a derivation cohort who underwent thoracoscopic lobectomy with complete lymph node dissection were retrospectively analyzed for their association with the HNM or the MNM. After analyzing the variables, we developed multivariable logistic models with nomograms to estimate the risk of lymph node metastasis in different regions. The predictive efficacy was then validated in a validation cohort of 418 patients. It was confirmed that carcinoembryonic antigen (>5.75 ng/mL), CYFRA211 (>2.85 ng/mL), the maximum diameter of tumor (>2.75 cm), tumor differentiation (grade III), bronchial mucosa and cartilage invasion, and vascular invasion were predictors of HNM, and carcinoembryonic antigen (>8.25 ng/mL), CYFRA211 (>2.95 ng/mL), the maximum diameter of tumor (>2.75 cm), tumor differentiation (grade III), bronchial mucosa and cartilage invasion, vascular invasion, and visceral pleural invasion were predictors of MNM. The validation of the prediction models based on the above results demonstrated good discriminatory power. Our predictive models are helpful in the decision-making process of specific therapeutic strategies for the regional lymph node metastasis in patients with clinical stage I NSCLC.

Implementation of Melanoma Guidelines in the Multidisciplinary Setting: A Qualitative Analysis

INTRODUCTION: Treatment of advanced melanoma has evolved dramatically recently. Randomized trials now support omitting completion lymph node dissection (CLND) and offering adjuvant systemic therapy for many patients with sentinel lymph node–positive melanoma. Recent data from an international melanoma consortium suggest wide variation in CLND and adjuvant therapy utilization. We aimed to explore how providers consider multidisciplinary treatment options in this setting. METHODS: We conducted semi-structured interviews among surgical oncologists, medical oncologists, and otolaryngologists. Two researchers performed analysis through independent data abstraction of transcripts. Findings were discussed to reach consensus. RESULTS: All participants (n = 17) practiced at a cancer center in an academic setting. Melanoma comprised an estimated 30% to 80% of their practice (only 2% to 15% for otolaryngologists). Participants described melanoma care as inherently “multidisciplinary.” Many noted the importance of real-time conversations among providers, particularly those facilitated by shared clinic days or space, for everyday decision-making compared with formal tumor boards. Despite stating a belief that their practice mirrored other providers within and outside their institutions, participants revealed differing perspectives on CLND and adjuvant therapy (Table). Multidisciplinary care presented challenges for melanoma surveillance because surgical oncologists expressed desire to retain ownership of patients undergoing active surveillance but did not feel comfortable overseeing needs related to adjuvant therapy. Both surgical and medical oncologists noted potential redundancy in roles and burden to patients in the form of uncoordinated visits and scans. Table. - Differences in Perspectives on Completion Lymph Node Dissection (CLND) and Adjuvant Systemic Therapy Treatment option Representative example (surgical oncology) Representative example (medical oncology) Representative example (otolaryngology) Completion lymph node dissection At our institution almost never do patients get a [CLND]. Soon after the trials, there was some ambiguity about should some patients that may not have been as well represented in those trials be considered for completion, and there’s probably less issue there. Probably the main factor that pushes for dissection now would be ability to comply with routine surveillance. (Participant 7) I have seen somewhat of a push for surgery just because all of our adjuvant trials were done in patients who did have a nodal basin dissected. So it’s a little bit of a different population that we’re actually treating than was studied in [MSLT-II] because we may have patients who have residual disease. So to be more purely like the trial, there are sometimes people who push for a lymph node dissection. (Participant 1) Some of this really just relates to your philosophy of approaching cancer and surgical aggressiveness in general. I generally err on the side of being a more conservative surgeon, which applies not just to melanoma. So I am a bit more reticent to recommend a completion than some of my colleagues, but that’s not to say they’re wrong and I’m right. (Participant 14) Adjuvant systemic therapy So it’s really hard to give adjuvant therapy when there’s no survival benefit, and you see that the toxicity is so bad. From my standpoint, it’s very hard for me to think about let’s take a patient, let’s remove all of their disease, and then give them immunotherapy. Let’s boost the immune system. Oh—but I already took it all out. So the adjuvant therapy idea is hard for me. (Participant 2) We know with the Keynote 716 trial, pembrolizumab can be [used] in patients who have high risk stage II disease. Based on that trial, we are now recommending adjuvant immune therapy. So it’s kind of a continuum. Now we can justify [stage] IIIA patients that were excluded from the stage III trials. (Participant 15) A lot of these patients are going to get adjuvant therapy, no matter what, so both for immunotherapy and for like a dabrafenib or trametinib treatment. The question is not whether or not we do adjuvant therapy, the question is whether they get the [adjuvant] therapy with or without a completion lymphadenectomy. (Participant 10) CONCLUSION: Opportunities exist to improve multidisciplinary melanoma care through broader consensus of how to translate emerging data into patient care and delineating surveillance roles.

Clinical Outcomes of 160 Patients with Clinically Node-Negative Merkel Cell Carcinoma after Wide Excision and Sentinel Lymph Node Biopsy

INTRODUCTION: Merkel cell carcinoma (MCC) is a rare, aggressive skin cancer with high nodal metastasis rates. Studies regarding the prognostic significance of sentinel lymph node (SLN) status differ. We evaluated the outcomes of MCC patients after wide excision + sentinel lymph node biopsy (WE+SLNB). METHODS: A retrospective review of 160 MCC patients who underwent WE+SLNB at our institution (April 2005 through July 2021) was performed. Clinicopathologic variables and outcomes were assessed. RESULTS: Sixty-four patients (40%) were SLNB(+), 92 (58%) were SLNB(–); 4 did not map. SLNB(+) patients were more likely to be female (42% vs 27%, p = 0.05), have larger primary tumors (13.0 vs 7.4 mm, p < 0.001), higher rates of lymphovascular invasion (61% vs 36%, p = 0.006), and infiltrative growth patterns (72% vs 62%, p = 0.048). Most SLNB(+) patients received further nodal therapy: completion lymph node dissection (CLND, n = 9), CLND with radiotherapy (n = 6), or radiotherapy (n = 26). Patients who underwent CLND (n = 15, 23%) were more likely to have SLNs with extracapsular extension (40% vs 14%, p = 0.02) and receive systemic therapy (80% vs 51%, p = 0.07), and less likely to receive nodal basin radiotherapy (40% vs 71%, p = 0.04) than those who did not undergo CLND. At a median follow-up of 32 months, 40% of SLNB(–) patients recurred vs 48% of SLNB(+) patients (with CLND, 67%; without CLND, 43%; Table). Recurrence-free survival for SLNB(–), SLNB(+) without CLND, and SLNB(+) with CLND patients was 61.6, 35.6, and 26.8 months, respectively. Table. - Outcomes of MCC Patients Who Underwent WE+SLNB Outcomes Total cohort (n = 160) (+) SLNB (n = 64) (–) SLNB (n = 92) With CLND (n=15) Without CLND (n=49) Overall survival, mo, median (range) 89 (1–199) 35 (0–40) 69 (0–69) 105 (0–199) Recurrence-free survival, mo, median (range) 39 (25–69) 27 (13–39) 36 (20–69) 62 (19–X) Any recurrence, N (%) 69 (43) 10 (67) 21 (43) 37 (40) Status at last follow-up, N (%) Alive, no evidence of disease 94 (58.9) 5 (33.3) 28 (57.1) 56 (63.0) Alive with disease 16 (10.0) 3 (20.0) 5 (10.2) 8 (8.7) Deceased 50 (31.3) 7 (46.7) 16 (32.7) 26 (28.3) CONCLUSION: SLNB(–) patients had better outcomes than SLNB(+) patients. Among the SLNB(+) patients, CLND was associated with worse outcomes. Work to evaluate trends in the multimodal treatment of SLNB(+) MCC patients and the impact on outcomes is underway.

Radar reflector guided axillary surgery in node positive breast cancer patients

ABSTRACT Introduction In patients with non-palpable breast cancer, the availability of wireless localization techniques facilitates removal of the target lesion. One such technique uses a radar reflector for localization (RRL). This study evaluates the feasibility and effectiveness of RRL to guide excision of axillary lymph nodes in patients with node-positive breast cancer. Methods Our Breast Cancer Database was queried for patients diagnosed with breast cancer, between 5/2017 and 10/2021, who underwent preoperative placement of a radar reflector into a biopsy proven axillary lymph node. Clinicopathologic data were reported using descriptive statistics. Results Twenty patients underwent preoperative placement of a radar reflector into the axilla. Intraoperatively, the clip and radar reflector were successfully removed in all patients. Among the 10 patients treated with NAC, 5 patients achieved an axillary pathologic complete response (pCR) and were spared a complete axillary lymph node dissection (cALND). Among the entire cohort, RRL resulted in a 53% reduction in the number of lymph nodes removed. Conclusions Wireless localization of axillary lymph nodes is safe and feasible. The technique ensures excision of biopsy proven positive axillary lymph nodes and enables a targeted approach to assessing the axilla, both in the setting of NAC and upfront surgery.