Sentinel Lymph Node Biopsy Findings Research Articles

Long‐term clinical outcomes of Spitz‐type lesions in adults: A single institution retrospective cohort review

AbstractBackgroundThe lack of information on clinical outcomes of Spitz‐type lesions, means that their management remains a contentious issue, with some centres opting for a purely conservative, observational approach, while others mandate further surgery and long‐term follow‐up.ObjectivesOur aim was, therefore, to determine the long‐term clinical outcome of classic Spitz and Spitzoid naevi, atypical Spitz tumours (ASTs) and Spitzoid melanomas, with a view to finding evidence to support a unified management approach.MethodsWe conducted a retrospective cohort review of Addenbrooke's Hospital patients aged ≥18 years with a histopathologic diagnosis containing the term ‘Spitz’, from 1991 through 2020. Sentinel lymph node biopsy (SLNB) results, wide local excision (WLE) rates, metastases and fatality were assessed.ResultsOne hundred and twenty‐six patients with Spitz‐type proliferations and follow‐up information were identified (mean age: 35.9, SD: 11.6). There were 86 (68.3%) classic Spitz or Spitzoid naevi, 12 (9.5%) ASTs, 27 (21.4%) Spitzoid malignant melanomas and one (0.8%) melanoma that arose in a previously excised Spitz naevus. SLNB findings were positive in three of seven but none of the 10 individuals with ASTs and Spitzoid melanomas, respectively. Invasive non‐Spitz melanoma developed in four patients with classic Spitz or Spitzoid naevi. After a median follow‐up of 46 months (range: 1–304), only one patient with a Spitzoid melanoma, who had a different malignant melanoma (2.4 mm, level 4), developed distant metastases. No deaths were observed.ConclusionsSpitz‐type lesions are only rarely associated with mortality and distant metastasis, but CSNs may increase the risk of developing non‐Spitz‐type malignant melanoma. These findings support the suggestion that aggressive surgical management of these lesions such as SLNB and WLE may not be necessary, but surveillance should still continue to assess for subsequent development of malignant melanoma.

Melanoma Prognosis and Associated Risk Factors: A Retrospective Cohort Study Using Semantic Map Analysis.

The overall patterns of correlations among various melanoma risk factors have not yet been examined. The aim of this study was to assess the impact of different parameters on disease-free and melanoma-related overall survival. A retrospective cohort study was conducted encompassing all patients with a primary cutaneous melanoma diagnosed in a university referral centre. Associations were explored using semantic map analysis, which uses graph theory to find the strongest path of connections between variables. A total of 1,110 melanoma patients (median follow-up 10.6 years) were included. The analysis revealed a clustering of variables around 2 main hubs: Breslow thickness < 1 mm and ≥ 4 mm. Factors connected with high melanoma thickness were: older age, positive sentinel lymph node biopsy findings, presence of ulceration, nodular melanoma type, and light skin phototype. Both disease-free and melanoma-related overall survival were in this cluster and connected with positive sentinel lymph node biopsy and Breslow ≥ 4 mm. Patients with Breslow between 1 and 3.9 mm were also in this cluster and linked with negative sentinel lymph node biopsy, nodular melanoma and safety distance > 10 mm. This semantic analysis confirmed the close link between Breslow thickness, age, sentinel lymph node biopsy findings, skin type, melanoma subtype and prognosis, and provides prognostic information useful for the further stratification and management of patients with melanoma.

Merkel Cell Carcinoma: A 28-Year Experience.

To evaluate the management and recurrence outcomes of head and neck Merkel cell carcinoma (HN-MCC) at a single institution. A retrospective review of outcomes in patients with HN-MCC. A tertiary center from May 1990 to December 2018. Electronic medical records of patients with HN-MCC were reviewed. Sixty cases were included, with 67% (40 of 60) males and a mean age of 73.3 years. Imaging had a moderate sensitivity and specificity for detection of occult disease when compared with histopathologic analysis. Forty-two percent (25 of 60) of patients underwent neck dissection, and 12% (7 of 60) had a sentinel lymph node biopsy (SLNB). There was a high rate of negative SLNB findings. The majority of patients were treated with surgery alone (29 of 60), followed by a cohort (21 of 60) treated with surgery plus adjuvant treatment, and 10 of 60 patients were treated with radiation therapy with or without chemotherapy. Recurrence-free survival was 50%, 45%, and 42% at 1, 2, and 5 years. We report higher recurrence rates and higher negative SLNB result rates than other studies. Our results affirm that imaging may not be a substitute for SLNB and that it had an intermediate ability to identify the occult disease. Traditional predictors, including SLNB and cervical node pathology, may not identify patients at risk for recurrence in HN-MCC. We report similar recurrence rates in patients who had treatment of the cervical nodes by radiation therapy or neck dissection as compared with those who did not receive neck treatment.

Sentinel lymph node biopsy in the management of conjunctival melanoma: current insights.

Purpose: To evaluate the role of sentinel lymph node biopsy (SLNB) in conjunctival melanoma (CM).Methods: This article provides a review of the literature from PUBMED.Results: Data on SLNB in the management of CM are scarce and only two relatively large cohorts have been reported. Although indication criteria for SLNB vary slightly, positive findings can be expected in 11%–13% of CM cases, including small tumors. False negative SLNB findings are rare (<10%). Failure to identify SLNB has been attributed to the surgical learning curve and recurrent tumors with scar tissue impeding spread of the tracer material. Reported 5-year survival rate following CM management including SLNB, is up to 79%, but there are no comparative cohort studies proving the assumed benefit. Adverse events reported were non-severe and transient.Conclusion: Patients can potentially benefit from SLNB and the procedure can be offered to eligible patients. However, there is not enough evidence to support SLNB as a mandatory part of CM management.

Predictive Factors for Nonsentinel Lymph Node Metastasis in Patients With Positive Sentinel Lymph Nodes After Neoadjuvant Chemotherapy: Nomogram for Predicting Nonsentinel Lymph Node Metastasis

IntroductionAxillary lymph node (ALN) status is an important prognostic factor for breast cancer patients. With increasing numbers of patients undergoing neoadjuvant chemotherapy (NAC), issues concerning sentinel lymph node biopsy (SLNB) after NAC have emerged. Patients and MethodsWe analyzed the clinicopathologic features and developed a nomogram to predict the possibility of nonsentinel lymph node (NSLN) metastases in patients with positive SLNs after NAC. A retrospective medical record review was performed of 140 patients who had had clinically positive ALNs at presentation, had a positive SLN after NAC on subsequent SLNB, and undergone axillary lymph node dissection (ALND) from 2008 to 2014. ResultsOn multivariate stepwise logistic regression analysis, pathologic T stage, lymphovascular invasion, SLN metastasis size, and number of positive SLN metastases were independent predictors for NSLN metastases (P < .05). The NAC nomogram was based on these 4 variables. A receiver operating characteristic curve was plotted, and the area under the curve (AUC) was 0.791 for the NAC nomogram. In the internal validation of performance, the AUCs for the training and test sets were 0.801 and 0.760, respectively. The nomogram was validated in an external patient cohort, with an AUC of 0.705. ConclusionThe Samsung Medical Center NAC nomogram was developed to predict the likelihood of additional positive NSLNs. The Samsung Medical Center NAC nomogram could provide information to surgeons regarding whether to perform additional ALND when the permanent biopsy revealed positive findings, although the intraoperative SLNB findings were negative.

Sentinel lymph node biopsy for ocular adnexal melanoma.

We sought to update our prior report of findings on sentinel lymph node biopsy (SLNB) and predictors of a positive SLN in patients with conjunctival or eyelid melanoma. We reviewed the records of all patients with ocular adnexal melanoma who underwent SLNB at one institution during 2000-2015. We determined rates of positive and false-negative findings on SLNB, primary tumour features correlated with positive findings and rate of nodal recurrence (false-negative event) after negative findings. The study included 51 patients, 31 with conjunctival and 20 with eyelid melanoma. These patients include 30 patients who underwent SLNB during 2000-2008, described in our previous report, and 21 additional patients who underwent SLNB during 2008-2015. There were 30 women and 21 men with median age at SLNB of 62years (range, 24-83). The nodal basins most commonly sampled were intraparotid (27 patients) and level II (14 patients). Ten patients had positive SLNB findings. Compared to tumours with negativefindings, tumours with positive findings had greater median thickness (3.5mmversus2.2mm, p=0.04), greater median number of mitotic figures (6 versus 2, p=0.03) and greater incidence of ulceration (80% versus 26%, p=0.003). Perineural and vascular invasion were not significantly associated with positive findings. There were three false-negative events. Three patients (6%) had temporary marginal mandibular weakness which resolved spontaneously. SLNB in patients with ocular adnexal melanoma is safe and identifies nodal micrometastasis in approximately 20% of cases. Histologic features associated with a positive SLN included greater tumour thickness, greater number of mitotic figures and ulceration.

Staging for Cutaneous Squamous Cell Carcinoma as a Predictor of Sentinel Lymph Node Biopsy Results

The appropriate clinical setting for the application of sentinel lymph node biopsy (SLNB) in the management of cutaneous squamous cell carcinoma (cSCC) is not well characterized. Numerous case reports and case series examine SLNB findings in patients who were considered to have high-risk cSCC, but no randomized clinical trials have been performed. To analyze which stages in the American Joint Committee on Cancer (AJCC) criteria and a recently proposed alternative staging system are most closely associated with positive SLNB findings in nonanogenital cSCC. Medical literature review and case data extraction from private and institutional practices to identify patients with nonanogenital cSCC who underwent SLNB. Patients were eligible if sufficient tumor characteristics were available to classify tumors according to AJCC staging criteria and a proposed alternative staging system. One hundred thirty patients had sufficient data for AJCC staging, whereas 117 had sufficient data for the alternative system. Nonanogenital cSCC and SLNB. Positive SLNB findings by cSCC stage, quantified as the number and percentage of positive nodes. A positive SLN was identified in 12.3% of all patients. All cSCCs with positive SLNs were greater than 2 cm in diameter. The AJCC criteria identifed positive SLNB findings in 0 of 9 T1 lesions (0%), 13 of 116 T2 lesions (11.2%), and 3 of 5 T4 lesions (60.0%). No T3 lesions were identified. The alternative staging system identified positive SNLB findings in 0 of 9 T1 lesions (0%), 6 of 85 T2a lesions (7.1%), 5 of 17 T2b lesions (29.4%), and 3 of 6 T3 lesions (50.0%). Rates of positive SLNB findings in patients with T2b lesions were statistically higher than those with T2a lesions (P = .02, Fisher exact test) in the alternative staging system. Our findings suggest that most cSCCs associated with positive SLNB findings occur in T2 lesions (in both staging systems) that are greater than 2 cm in diameter. The alternative staging system appears to more precisely delineate high-risk lesions in the T2b category that may warrant consideration of SLNB. Future prospective studies are necessary to validate the relationship between tumor stage and positive SLNB findings and to identify the optimal staging system.

A Positive Sentinel Lymph Node in Periocular Invasive Squamous Cell Carcinoma

The aim of this article was to describe positive sentinel lymph node biopsy (SLNB) findings in patients with periocular invasive squamous cell carcinoma (SCC). This was a retrospective chart review of 5 patients with invasive SCC of the periocular region who underwent SLNB and were found to have regional metastasis. All patients had large (2.0-4.3 cm) primary tumors with poor differentiation on pathology. In all 5 patients, SLNB was positive in the absence of other signs or evidence of regional or systemic metastasis. While tumor cells may drain to the preauricular or the submandibular basin, the preauricular lymph node was identified as the sentinel lymph node on lymphoscintigraphy in all 5 patients. With a positive sentinel lymph node, the results of SLNB changed the clinical staging and influenced subsequent treatment recommendations for each patient. We identified no complications related to SLNB including facial nerve damage, lymphedema, or allergic reaction to radioactive tracing material. In this series of patients with periocular invasive SCC, SLNB was well tolerated and uncovered regional metastasis in patients with no clinical signs of metastasis otherwise. The SLNB findings influenced subsequent oncologic management recommendations. The usefulness of SLNB for poorly differentiated SCC remains uncertain. Further research is necessary to establish the role of SLNB in periocular SCC.

Long-term Outcome of Spitz-Type Melanocytic Tumors

Despite recent advances in our molecular understanding of Spitz-type tumors, the clinical behavior of these lesions remains unclear. We thus set out to define the clinical outcome of classic Spitz nevi, atypical Spitz tumors (ASTs), and spitzoid melanomas. From 1987 through 2002, data on all lesions containing the term "Spitz" or "Spitz" [AND] "melanoma" were retrieved from the pathology database at Massachusetts General Hospital, and the cases were followed up for their outcome. The study was performed at a university-affiliated tertiary health care center in Boston, Massachusetts. A total of 157 patients with Spitz-type melanocytic lesions and follow-up information were identified. Sentinel lymph node biopsy results, metastases, or fatality were assessed. There were 68 classic Spitz nevi, 76 ASTs, 10 spitzoid melanomas, and 3 melanomas that arose in Spitz nevi. Spitz nevi were diagnosed at a younger age than ASTs (mean age, 26.4 years vs 33.7 years) (P = .01), though both occurred earlier than melanomas (mean age, 50.4 years, P < .001). Sentinel lymph node biopsy findings were positive in 1 of 6 and 4 of 8 patients with ASTs and spitzoid melanomas, respectively. After a median follow-up of 9.1 years, only 1 patient with an AST, who had a separate intermediate-thickness melanoma, developed distant metastasis. There were 6 documented invasive melanomas among 144 patients with classic Spitz nevi or ASTs (observed/expected ratio, 8.03) (P = .01). Atypical Spitz tumors are associated with minimal lethal potential, an increased melanoma risk, and a moderate risk of metastasis to regional nodes. It makes clinical sense to minimize aggressive treatment but to offer careful surveillance for rare relapses and subsequent melanomas.

Prediction of Non-SN Involvement in Patients with SN Isolated Tumor Cells or Micrometastases

Sentinel lymph node biopsy has allowed improved staging of the axilla with reduced morbidity in breast cancer patients. However, as with any new technology there are questions as to how to best implement the technique into clinical practice. Changes in the staging system for breast cancer have incorporated sentinel lymph node biopsy findings, resulting in questions as to how to manage the remainder of the axilla when there is low volume disease in the sentinel lymph nodes. The use of the sentinel lymph node to predict additional positive nodes and to direct surgical management of the axilla and adjuvant systemic and radiation therapy is reviewed.

Sentinel Lymph Node Biopsy for Ocular Adnexal Melanoma: Experience in 30 Patients

To report the findings on sentinel lymph node biopsy (SLNB) in 30 patients with ocular adnexal (conjunctival or eyelid) melanomas. Prospective nonrandomized clinical trial. Thirty patients with diagnosis of eyelid or conjunctival melanoma. All patients with ocular adnexal melanoma who underwent SLNB at The University of Texas MD Anderson Cancer Center between December 2000 and July 2008 are the subject of this report. Sentinel lymph node biopsy was performed as previously described by our group, and patients were prospectively followed up. Findings on preoperative lymphoscintigraphy, SLNB, histopathologic examination of the primary tumor and sentinel lymph nodes (SNL), and nodal recurrence after SLNB. Tumor sites were as follows: bulbar conjunctiva only, 14 patients; palpebral conjunctiva only, 8 patients; both bulbar and palpebral conjunctiva, 4 patients; and eyelid skin only, 4 patients. At least 1 SLN was identified in all patients. The median number of SLNs removed was 2 (range, 1-5). The most common basin sampled was the intraparotid (16 patients), followed by submandibular (level I) (11 patients), preauricular (9 patients), and superior cervical (level II) (6 patients). Five patients had SLN metastasis. Among the 25 patients with negative SLNB findings, there were 2 false-negative events. There were no false-negative events among patients treated during the last 4.5 years of the study. The mean Breslow thickness was 2.57 mm (range, 0.62-12 mm) among patients with negative SLNB and 4.86 mm (range, 2.0-7.2 mm) among patients with positive SLNB findings (P = 0.055). Ulceration was present in 11 patients (39%): 4 (80%) of 5 patients with positive SLNB and 7 (28%) of 25 with negative SLNB, including both patients with false-negative results. The median time from SLNB to last contact was 2 years (range, 10 months to 6 years). Sentinel lymph node biopsy is effective for identifying nodal micrometastasis in patients with ocular adnexal melanoma and provides important prognostic information. The false-negative event rate in our series improved in the last 4 years, most likely because of a better technique and better patient selection for SLNB. We recommend consideration of SLNB for patients with intermediate-thickness ocular adnexal melanoma and those with ulceration.

Survival Analysis and Clinicopathological Factors Associated With False-Negative Sentinel Lymph Node Biopsy Findings in Patients with Cutaneous Melanoma

Survival Analysis and Clinicopathological Factors Associated With False-Negative Sentinel Lymph Node Biopsy Findings in Patients with Cutaneous Melanoma

Survival Analysis and Clinicopathological Factors Associated With False-Negative Sentinel Lymph Node Biopsy Findings in Patients with Cutaneous Melanoma

We analyzed the outcomes and factors associated with false-negative (FN) results of sentinel lymph node (SLN) biopsy findings in patients with cutaneous melanoma. SLN biopsy failure rate was defined as nodal recurrence in the biopsied regional basin without previous local or in-transit recurrence. Between April 1997 and December 2004, a total of 1207 patients with cutaneous melanoma with a median Breslow thickness of 2.4 mm underwent SLN biopsy by preoperative and intraoperative lymphoscintigraphy combined with dye injection. In 228 cases, we found positive SLNs; of these, 220 underwent completion lymph node dissection (CLND). Median follow-up was 3 years. The SLN biopsy failure rate was 5.8% (57 of 979 SLN negative). Median time to occurrence of FN relapse after SLN biopsy was 16 months (range, 3-74 months). The FN SLN biopsy results correlated with primary tumor thickness >4 mm (P = .0012), primary tumor ulceration (P = .0002), primary tumor level of invasion Clark stage IV/V (P = .0005), and nodular melanoma histological type (P = .0375). Five-year overall survival, calculated from the date of primary tumor excision, in the FN group was 53.7%, which was not statistically significantly worse than the CLND group (56.8%; P = .9). The FN group was characterized by a higher ratio of two or more metastatic nodes and extracapsular involvement of lymph nodes after LND compared with the CLND group (P < .0001 and P < .0001, respectively). Additional detailed pathological review of FN SLN revealed metastatic disease in 14 patients, which decreased the SLN biopsy failure rate to 4.4% (43 of 979). Survival of patients with FN results of SLN biopsy does not differ statistically significantly from that of patients undergoing CLND, although it is slightly lower. The SLN biopsy failure rate is approximately 5.0% in long-term follow-up and is associated mainly with the same factors that indicate a poor prognosis in primary melanoma.

Sentinel Lymph Node Biopsy for Evaluation and Treatment of Patients With Merkel Cell Carcinoma

To determine the diagnostic accuracy and usefulness of sentinel lymph node biopsy (SLNB) and computed tomographic scans in the initial evaluation and treatment of patients with Merkel cell carcinoma (MCC). Single-institution case series and literature-based case-level meta-analysis. Academic cutaneous oncology clinic.Patients Sixty-one adults with biopsy-proven MCC (30 who had undergone SLNB) plus 92 cases from the literature of patients who had undergone SLNB. Relapse-free survival. In 122 patients with no nodal disease found by physical examination, SLNB findings revealed nodal involvement in 39 cases (32%). At 3 years, the recurrence rate for those with a positive SLNB was 3 times (60%) higher than for those with a negative SLNB (20%; P = .03). Patients with a positive SLNB who received adjuvant nodal therapy had a relapse-free survival rate of 51% at 3 years (n = 26) compared with 0% for patients who did not receive nodal therapy (n = 3; P < .01). In contrast, among patients with a negative SLNB there was no significant difference in 3-year relapse-free survival rates for those who did (90%; n = 24) or did not (70%; n = 19; P = .26) receive adjuvant nodal therapy. Using SLNB plus clinical follow-up as a gold standard, computed tomographic scans had low sensitivity (20%) for detecting MCC that had spread to the lymph node basin and low specificity for distant disease (only 4 of 21 "positive" scans were confirmed during 6 months of follow-up). Sentinel lymph node biopsy detects MCC spread in one third of patients whose tumors would have otherwise been clinically and radiologically understaged and who may not have received treatment to the involved node bed. There was a significant benefit of adjuvant nodal therapy, but only when the SLNB was positive. Thus, SLNB is important for both prognosis and therapy and should be performed routinely for patients with MCC. In contrast, computed tomographic scans have poor sensitivity in detecting nodal disease as well as poor specificity in detecting distant disease.

Lymphovascular invasion and local recurrence

Axillary lymph node (ALN) status is an important prognostic factor for breast cancer patients. With increasing numbers of patients undergoing neoadjuvant chemotherapy (NAC), issues concerning sentinel lymph node biopsy (SLNB) after NAC have emerged.We analyzed the clinicopathologic features and developed a nomogram to predict the possibility of nonsentinel lymph node (NSLN) metastases in patients with positive SLNs after NAC. A retrospective medical record review was performed of 140 patients who had had clinically positive ALNs at presentation, had a positive SLN after NAC on subsequent SLNB, and undergone axillary lymph node dissection (ALND) from 2008 to 2014.On multivariate stepwise logistic regression analysis, pathologic T stage, lymphovascular invasion, SLN metastasis size, and number of positive SLN metastases were independent predictors for NSLN metastases (P < .05). The NAC nomogram was based on these 4 variables. A receiver operating characteristic curve was plotted, and the area under the curve (AUC) was 0.791 for the NAC nomogram. In the internal validation of performance, the AUCs for the training and test sets were 0.801 and 0.760, respectively. The nomogram was validated in an external patient cohort, with an AUC of 0.705.The Samsung Medical Center NAC nomogram was developed to predict the likelihood of additional positive NSLNs. The Samsung Medical Center NAC nomogram could provide information to surgeons regarding whether to perform additional ALND when the permanent biopsy revealed positive findings, although the intraoperative SLNB findings were negative.

Intraoperative evaluation of sentinel lymph nodes for metastatic melanoma by imprint cytology.

Sentinel lymph node (SLN) biopsy has revolutionized lymph node staging in patients with malignant melanoma. Intraoperative evaluation is a new addition to the SLN procedure that allows for a one-step regional lymph node dissection to be performed when the SLN biopsy findings are positive. To date, several studies have evaluated the use of intraoperative frozen sectioning to evaluate the SLN in patients with melanoma. The literature pertaining to the use of intraoperative imprint cytology (IIC) to evaluate the SLN in melanoma patients is scant and to the authors' knowledge studies published to date are relatively small. The purpose of the current study was to evaluate the utility of IIC in patients undergoing SLN for melanoma. A total of 235 SLN biopsies from 93 patients with malignant melanoma and 3 patients with atypical Spitz nevi were examined by IIC after SLN biopsy using a double indicator technique. The SLNs were bisected and a pair of imprints were made from each half. One imprint from each half was stained with hematoxylin and eosin (H & E) whereas its counterpart was stained with Diff-Quik. Paraffin-embedded permanent sections were examined using multiple H & E stained sections from the SLNs in conjunction with immunohistochemical staining for S-100 and HMB-45 proteins. A total of 235 SLNs were excised from 93 patients (2.5 SLNs per patient). On a per patient basis, metastases were identified in 21 patients (23%) on permanent section evaluation. Of these 21 patients, 8 were detected by IIC (sensitivity of 38%). The negative predictive value was 85%. No false-positive results were identified (specificity of 100%). The positive predictive value was 100%. The overall accuracy of the intraoperative evaluation was 86%. Patients found to have positive SLNs by IIC went on to undergo lymphadenectomy under the same anesthetic. The sensitivity and specificity of IIC are similar to those of intraoperative frozen-section evaluation. Therefore, IIC appears to be a viable alternative to frozen sectioning when intraoperative evaluation is required. IIC evaluation of SLN makes a single surgical procedure possible for patients with malignant melanoma who are undergoing SLN.