Sentinel Node-positive Melanoma Research Articles

International Center-Level Variation in Utilization of Completion Lymph Node Dissection and Adjuvant Systemic Therapy for Sentinel Lymph Node-Positive Melanoma at Major Referral Centers.

The aim of this study was to determine overall trends and center-level variation in utilization of completion lymph node dissection (CLND) and adjuvant systemic therapy for sentinel lymph node (SLN)-positive melanoma. Based on recent clinical trials, management options for SLN-positive melanoma now include effective adjuvant systemic therapy and nodal observation instead of CLND. It is unknown how these findings have shaped practice or how these contemporaneous developments have influenced their respective utilization. We performed an international cohort study at 21 melanoma referral centers in Australia, Europe, and the United States that treated adults with SLN-positive melanoma and negative distant staging from July 2017 to June 2019. We used generalized linear and multinomial logistic regression models with random intercepts for each center to assess center-level variation in CLND and adjuvant systemic treatment, adjusting for patient and disease-specific characteristics. Among 1109 patients, performance of CLND decreased from 28% to 8% and adjuvant systemic therapy use increased from 29 to 60%. For both CLND and adjuvant systemic treatment, the most influential factors were nodal tumor size, stage, and location of treating center. There was notable variation among treating centers in management of stage IIIA patients and use of CLND with adjuvant systemic therapy versus nodal observation alone for similar risk patients. There has been an overall decline in CLND and simultaneous adoption of adjuvant systemic therapy for patients with SLN-positive melanoma though wide variation in practice remains. Accounting for differences in patient mix, location of care contributed significantly to the observed variation.

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.

Implementation of melanoma guidelines in the multidisciplinary setting: A qualitative analysis

BackgroundData suggest variation in utilization of completion lymph node dissection (CLND) and adjuvant systemic therapy (AT) for sentinel lymph node-positive melanoma. We aimed to explore how clinicians consider multidisciplinary treatment options. MethodsWe conducted semi-structured interviews of surgical oncologists, medical oncologists, and otolaryngologists to produce a thematic analysis. ResultsParticipants (n = 26) described melanoma care as inherently “multidisciplinary,” noting the importance of conversations facilitated by shared clinic days or space. Despite believing that their practice mirrored other clinicians, participants revealed diverging perspectives on CLND and AT. Multidisciplinary care presented challenges for surveillance as surgeons expressed desire to retain ownership of patients but did not feel comfortable overseeing AT needs. Participants questioned the fidelity of nodal ultrasounds, noted redundancy in their roles, and described a “surveillance burden” for patients. ConclusionOpportunities exist to improve multidisciplinary melanoma care through broader consensus of how to translate emerging data into patient care and delineating surveillance roles.

Correction: Surveillance of Sentinel Node-Positive Melanoma Patients with Reasons for Exclusion from MSLT-II: Multi-Institutional Propensity Score Matched Analysis.

Journal of the American College of Surgeons 235(4):p 692, October 2022. | DOI: 10.1097/XCS.0000000000000310

Evidence and implementation gaps in management of sentinel node–positive melanoma in the United States

BackgroundMelanoma clinical trials demonstrated that completion lymph node dissection is low value for most sentinel lymph node–positive patients. Contemporaneous trials of adjuvant systemic immunotherapy and BRAF/MEK targeted therapy showed improved recurrence-free survival in high-risk sentinel lymph node–positive patients. To better understand how oncologic evidence is incorporated into practice (implementation), we evaluated factors associated with discontinuation of completion lymph node dissection and adoption of systemic treatment at United States Commission on Cancer–accredited centers. MethodsIn a retrospective cohort study of adults with sentinel lymph node–positive melanoma treated from 2012 to 2017 using the National Cancer Database, we evaluated use of completion lymph node dissection and adjuvant systemic treatment using mixed-effects logistic regression, reporting results as odds ratios with 95% confidence intervals. ResultsAmong 10,240 sentinel lymph node–positive melanoma patients, performance of completion lymph node dissection declined from 60% to 27%. Adjuvant systemic treatment increased from 29% to 43% (37% in stage IIIA patients, 46% in IIIB–C). Completion lymph node dissection was less common with lower extremity tumors (odds ratio = 0.53, 95% confidence interval = 0.44–0.64) and more common with multiple positive sentinel lymph nodes (odds ratio = 2.36, 95% confidence interval = 2.08–2.67), treatment at a high- or moderate-volume center (odds ratiohigh = 1.49, 95% confidence interval = 1.05–2.12; odds ratiomoderate = 1.32, 95% confidence interval = 1.05–1.64), and receipt of systemic therapy (odds ratio = 1.44, 95% confidence interval = 1.27–1.63). The increased likelihood of completion lymph node dissection in patients receiving adjuvant systemic treatment persisted in the most recent study years and in patients with a single positive sentinel lymph node. ConclusionAt a population level, completion lymph node dissection declined and adjuvant systemic treatment increased, reflecting evidence-responsive care. Variation in persistent use of completion lymph node dissection and in provision of adjuvant treatment for lower risk patients highlights residual gaps in both evidence and implementation.

A survey of surgical management of the sentinel node positive melanoma patient in the post‐MSLT2 era

The evidence-based management of melanoma patients with a positive sentinel lymph node biopsy (SLNB) has undergone a dramatic shift following publication of practice-changing surgical trials demonstrating no melanoma-specific survival advantage for completion lymph node dissection (CLND) in this scenario. We aimed to survey how surgeons' clinical practice had shifted in response to new evidence from these trials, and at a time when there was starting to become available systemic adjuvant treatments for AJCC Stage III melanoma patients. A web-based survey consisting of practice-based questions and hypothetical clinical scenarios about current melanoma practice with regard to positive sentinel node biopsy was developed and sent to the surgical members of a Melanoma and Skin Cancer (MASC) Trials group in December 2018. Responses were analysed using descriptive statistics. There were 212 invitations sent and 65 respondents (31%). Respondents were from 17 countries, 94% of whom practice in specialist melanoma centres or at referral centres. Of these 97% were familiar with the MSLT2 and DeCOG-SLT clinical trials. At survey, 5% of respondents reported routinely recommending CLNDand 55% recommend CLND in selected cases. Respondents were most likely to recommend CLND when multiple SLNs were positive. Important factors for surgical decision-making mentioned included size of SLN deposit, number of positive SLNsand likely compliance with the recommended surveillance regimen. In line with rapid adoption of published evidence, surgical management of Stage III melanoma has altered significantly, with few surgeons within the cohort now performing routine CLNDs after positive SLNB.

Observation policy for sentinel node metastasis of melanoma: Comparative study with completion lymph node dissection in Japanese patients.

Based on the results of international multicenter randomized trials, completion lymph node dissection for patients with sentinel lymph node-positive melanoma is no longer routinely recommended. However, clinicians should take into consideration racial and medical resource differences when applying this evidence to clinical practice in Japan. To evaluate the clinical validity of the observation policy of omitting completion lymph node dissection, we retrospectively surveyed patients with sentinel lymph node-positive melanoma between 2002 and 2020 at Niigata Cancer Center Hospital. A total of 59 patients were categorized into the observation group (n=19) and completion lymph node dissection group (n=40). Newly developed anticancer agents, including targeted therapy and immunotherapy, were more commonly used in the observation group than in the completion lymph node dissection group as either adjuvant therapy (31.6% vs. 5.0%) or post-recurrence therapy (100% vs. 34.8%). The median overall survival in the observation group (not reached) was significantly longer than that in the completion lymph node dissection group (95.0months; p=0.02), which was mainly attributed to the difference in post-recurrence overall survival. There was no significant difference in recurrence-free survival between the two groups (p=0.63). Although the use of new anticancer agents leads to bias, this study demonstrates that observation without prompt completion lymph node dissection provides a favorable overall survival without increasing the risk of recurrence compared with completion lymph node dissection. The observation policy for patients with sentinel lymph node-positive melanoma patients is considered to be clinically valid in real-world medical practice.

Nodal Recurrence is a Primary Driver of Early Relapse for Patients with Sentinel Lymph Node-Positive Melanoma in the Modern Therapeutic Era.

Management of patients with sentinel lymph node (SLN)-positive melanoma has changed dramatically over the last few years such that completion lymph node dissection (CLND) has become uncommon, and many patients receive adjuvant immunotherapy or targeted therapy. This study seeks to characterize patterns and predictors of early recurrence in this setting. All patients with primary cutaneous melanoma undergoing sentinel lymph node biopsy (SLNB) between 3/2016 and 12/2019 were identified. The subset with a positive SLN who did not undergo CLND were examined for further analysis of outcomes and predictors of recurrence. Overall, 215 patients with SLN-positive melanoma who did not have CLND were identified. Adjuvant systemic therapy was administered to 102 (47%), with 93% of this subset receiving immunotherapy (n = 95). Median follow-up from SLNB was 20months (IQR 12-28.5months), and 57 patients (27%) recurred during this time. The SLN basin was the most common site of recurrence (n = 38, 67% of recurrence), with isolated nodal recurrence being the most common first site of recurrent disease (n = 22, 39% of recurrence). On multivariable analysis, lymphovascular invasion (LVI) of the primary tumor, two or more involved nodes, and > 1mm nodal deposit were independently associated with higher rates of nodal relapse. Nodal recurrence is a primary driver of early disease relapse for patients with SLN-positive melanoma who do not undergo CLND in the era of effective adjuvant systemic therapy. LVI, ≥ 2 nodes, or > 1mm nodal disease identifies patients at particularly high risk of nodal relapse.

Fallen dogmas – recent advances in locoregionally advanced melanoma

Last decade brought new achievements in the melanoma research, which resulted in an important changes in the clinical management of stage III melanoma. The article summarizes recent updates with particular focus on practical aspects. Results from surgical studies, Multicenter Selective Lymphadenectomy Trial II (MSLT-II) and German Dermatologic Cooperative Oncology Group (DeCOG-SLT) proved that surgical dogmatic approach that all sentinel node melanoma metastasis warrants completion lymphadenectomy is no longer valid; omission of completion lymphadenectomy in large proportion of sentinel node positive melanoma patients has no negative impact on survival rates. Moreover oncological trials (COMBI-AD, EORTC 1325/KEYNOTE-054 and CheckMate 238) showed that in stage III melanoma patients' chances of recurrence-free survival can be improved by 10-20% by modern immunotherapy and/or molecular targeted therapy. These findings led to fall of another dogma in oncology: lack of effective adjuvant therapy for stage III melanoma at acceptable toxicity. At the end of the day in 2021 modern multidisciplinary approach incorporating newest findings offer stage III melanoma patients less surgical complications of better tailored surgery and longer survival in result of efficient adjuvant therapy.

Active surveillance of patients who have sentinel node positive melanoma: An international, multi‐institution evaluation of adoption and early outcomes after the Multicenter Selective Lymphadenectomy Trial II (MSLT‐2)

For patients with sentinel lymph node (SLN)-positive cutaneous melanoma, the Second Multicenter Selective Lymphadenectomy trial demonstrated equivalent disease-specific survival (DSS) with active surveillance using nodal ultrasound versus completion lymph node dissection (CLND). Adoption and outcomes of active surveillance in clinical practice and in adjuvant therapy recipients are unknown. In a retrospective cohort of SLN-positive adults treated at 21 institutions in Australia, Europe, and the United States from June 2017 to November 2019, the authors evaluated the impact of active surveillance and adjuvant therapy on all-site recurrence-free survival (RFS), isolated nodal RFS, distant metastasis-free survival (DMFS), and DSS using Kaplan-Meier curves and Cox proportional hazard models. Among 6347 SLN biopsies, 1154 (18%) were positive and had initial negative distant staging. In total, 965 patients (84%) received active surveillance, 189 (16%) underwent CLND. Four hundred thirty-nine patients received adjuvant therapy (surveillance, 38%; CLND, 39%), with the majority (83%) receiving anti-PD-1 immunotherapy. After a median follow-up of 11 months, 220 patients developed recurrent disease (surveillance, 19%; CLND, 22%), and 24 died of melanoma (surveillance, 2%; CLND, 4%). Sixty-eight patients had an isolated nodal recurrence (surveillance, 6%; CLND, 4%). In patients who received adjuvant treatment without undergoing prior CLND, all isolated nodal recurrences were resectable. On risk-adjusted multivariable analyses, CLND was associated with improved isolated nodal RFS (hazard ratio [HR], 0.36; 95% CI, 0.15-0.88), but not all-site RFS (HR, 0.68; 95% CI, 0.45-1.02). Adjuvant therapy improved all-site RFS (HR, 0.52; 95% CI, 0.47-0.57). DSS and DMFS did not differ by nodal management or adjuvant treatment. Active surveillance has been adopted for most SLN-positive patients. At initial assessment, real-world outcomes align with randomized trial findings, including in adjuvant therapy recipients. For patients with melanoma of the skin and microscopic spread to lymph nodes, monitoring with ultrasound is an alternative to surgically removing the remaining lymph nodes. The authors studied adoption and real-world outcomes of ultrasound monitoring in over 1000 patients treated at 21 centers worldwide, finding that most patients now have ultrasounds instead of surgery. Although slightly more patients have cancer return in the lymph nodes with this strategy, typically, it can be removed with delayed surgery. Compared with up-front surgery, ultrasound monitoring results in the same overall risk of melanoma coming back at any location or of dying from melanoma.

Post-operative follow-up of 150 patients with sentinel lymph node biopsy under tumescence local anesthesia.

Sentinel lymph node biopsy (SLNB) is useful for staging of patients with melanoma. Although SLNB is mostly performed under general anesthesia (GA), tumescence local anesthesia (TLA) can also be used. However, less data are available regarding feasibility of SLNB under TLA. Here we present a post-operative follow-up of 150 patients. We prospectively analyzed data from 150 patients with primary cutaneous malignant melanoma. We assessed pain, post-operative complications and patients' satisfaction after SLNB under TLA. 32% of the patients reported post-operative pain within the first 48h after SLNB. Seroma was the most frequent complication, as 29 seromas after SLNB were observed. Wound infection was observed in 3.3% of the patients. 98.7% of the patients were satisfied with SLNB under TLA. SLNB under TLA is a safe and feasible option and should be considered for patients with melanoma. Especially with multimorbid or elderly patients, the risks of GA can be avoided.

Surveillance of Sentinel Node-Positive Melanoma Patients with Reasons for Exclusion from MSLT-II: Multi-Institutional Propensity Score Matched Analysis

In sentinel lymph node (SLN)-positive melanoma, two randomized trials demonstrated equivalent melanoma-specific survival with nodal surveillance vs completion lymph node dissection (CLND). Patients with microsatellites, extranodal extension (ENE) in the SLN, or >3 positive SLNs constitute a high-risk group largely excluded from the randomized trials, for whom appropriate management remains unknown. SLN-positive patients with any of the three high-risk features were identified from an international cohort. CLND patients were matched 1:1 with surveillance patients using propensity scores. Risk of any-site recurrence, SLN-basin-only recurrence, and melanoma-specific mortality were compared. Among 1,154 SLN-positive patients, 166 had ENE, microsatellites, and/or >3 positive SLN. At 18.5 months median follow-up, 49% had recurrence (vs 26% in patients without high-risk features, p < 0.01). Among high-risk patients, 52 (31%) underwent CLND and 114 (69%) received surveillance. Fifty-one CLND patients were matched to 51 surveillance patients. The matched cohort was balanced on tumor, nodal, and adjuvant treatment factors. There were no significant differences in any-site recurrence (CLND 49%, surveillance 45%, p= 0.99), SLN-basin-only recurrence (CLND 6%, surveillance 14%, p= 0.20), or melanoma-specific mortality (CLND 14%, surveillance 12%, p= 0.86). SLN-positive patients with microsatellites, ENE, or >3 positive SLN constitute a high-risk group with a 2-fold greater recurrence risk. For those managed with nodal surveillance, SLN-basin recurrences were more frequent, but all-site recurrence and melanoma-specific mortality were comparable to patients treated with CLND. Most recurrences were outside the SLN-basin, supporting use of nodal surveillance for SLN-positive patients with microsatellites, ENE, and/or >3 positive SLN.

The EORTC-DeCOG nomogram adequately predicts outcomes of patients with sentinel node–positive melanoma without the need for completion lymph node dissection

PurposeBased on recent advances in the management of patients with sentinel node (SN)–positive melanoma, we aimed to develop prediction models for recurrence, distant metastasis (DM) and overall mortality (OM). MethodsThe derivation cohort consisted of 1080 patients with SN-positive melanoma from nine European Organization for Research and Treatment of Cancer (EORTC) centres. Prognostic factors for recurrence, DM and OM were studied with Cox regression analysis. Significant factors were incorporated in the models. Performance was assessed by discrimination (c-index) and calibration in cross-validation across centres. The models were externally validated using a prospective cohort consisting of 705 German patients with SN-positive: 473 trial participants of the German Dermatologic Cooperative Oncology Group study (DeCOG-SLT) and 232 screened patients. A nomogram was developed for graphical presentation. ResultsThe final model for recurrence and the calibrated models for DM and OM included ulceration, age, SN tumour burden and Breslow thickness. The models showed reasonable calibration. The c-index for the recurrence, DM and OM model was 0.68, 0.70 and 0.70, respectively, and 0.70, 0.72 and 0.74, respectively, in external validation. The EORTC-DeCOG model identified a robust low-risk group, with all identified low-risk patients (approximately 4% of the entire population) having a 5-year recurrence probability of <25% and an overall 5-year recurrence rate of 13%. A model including information on completion lymph node dissection (CLND) showed only marginal improvement in model performance. ConclusionsThe EORTC-DeCOG nomogram provides an adequate prognostic tool for patients with SN-positive melanoma, without the need for CLND. It showed consistent results across validation. The nomogram could be used for patient counselling and might aid in adjuvant therapy decision-making.

Use of Completion Lymph Node Dissection for Sentinel Lymph Node-Positive Melanoma

For patients with sentinel node-positive melanoma (SNPM), randomized trials, first reported in 2015, found no benefit for routine completion lymph node dissection (CLND) in selected patients. This study examines time trends in CLND and explores institutional and clinical factors associated with CLND. The National Cancer Database was queried for patients older than 18 years from 2012 to 2016 with SNPM. A high-volume center was defined as >80th percentile for number of sentinel node procedures. Poisson regression assessed temporal trends and identified patient, pathologic, and institutional characteristics associated with CLND. From 2012 to 2016, we identified 7,146 patients with SNPM. The proportion of patients undergoing CLND was steady in 2012 to 2014 (61% to 63%), but decreased to 57% in 2015 and 50% in 2016 (p < 0.0001). The proportion of patients with SNPM who underwent CLND decreased over time for both high- (66% to 52%; p < 0.0001) and lower-volume centers (55% to 45%; p= 0.06). Female sex (relative risk [RR] 0.97; p < 0.001) and increasing age (RR 0.98; p < 0.0001) were associated with lower likelihood of CLND. Increased Breslow depth (RR 1.015; p= 0.006), ulceration (RR 1.067; p= 0.02), and high-volume centers (RR 1.180; p < 0.0001) were associated with higher likelihood of CLND. Regional differences in likelihood of CLND were also present (p < 0.0001). Completion lymph node dissection in SNPM decreased over time, with the greatest change in 2016. Several patient, pathologic, and institutional characteristics were associated with likelihood of CLND. As evidence supports close observation for selected patients, efforts should be undertaken to improve and standardize patient selection for CLND across institutions caring for patients with melanoma.

Cutaneous melanoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†.

Cutaneous melanoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†.

Risk stratification of sentinel node positive melanoma patients defines surgical management and adjuvant therapy treatment considerations

Background: In light of the evolving landscape of adjuvant therapy in melanoma and the recently confirmed absent survival benefit of completion lymph node dissection (CLND), it becomes important to explore possible consequences of omitting CLND, and whether it is possible to adequately stratify positive sentinel node (SN) patients solely based on information retrieved from the melanoma up to the sentinel lymph node biopsy (SLNB).

Lymph Node Dissection in Patients With Melanoma and Sentinel Lymph Node Metastasis: An Updated, Evidence-Based Decision Algorithm

Recent publication of the results of clinical trials in which lymph node dissection was not associated with any survival benefit in patients with sentinel node metastasis makes it necessary to reconsider the treatment of patients with melanoma. This article provides an update on the available evidence on the diverse factors (routes of metastatic spread, predictors, adjuvant therapy, etc.) that must be considered when treating patients with sentinel node-positive melanoma. The authors propose a decision-making algorithm for use in this clinical setting. The current evidence no longer supports lymph node dissection in patients with low-risk sentinel node metastasis (sentinel node tumor load ≤1mm).

Risk stratification of sentinel node–positive melanoma patients defines surgical management and adjuvant therapy treatment considerations

BackgroundIn light of the evolving landscape of adjuvant therapy in melanoma and the recently confirmed absent survival benefit of completion lymph node dissection (CLND), it becomes important to explore possible consequences of omitting CLND, and whether it is possible to adequately stratify positive sentinel node (SN) patients solely based on information retrieved from the melanoma up to the sentinel lymph node biopsy (SLNB). MethodsA retrospective cohort from nine European Organization for Research and Treatment of Cancer Melanoma Group centres was used. Patients were staged based on SLNB and CLND result according to the American Joint Committee on Cancer (AJCC) criteria and stratified by ulceration and SN tumour burden. These were incorporated in Cox regression models. Predictive ability was assessed using Harrell's concordance index (c-index) and the Akaike information criterion (AIC). ResultsIn total, 1015 patients were eligible. CLND led to upstaging in N-category in 19% and in AJCC stage in 5–6%. The model incorporating only ulceration and SN tumour burden performed equally well as the model incorporating substages after CLND. The model incorporating substages based on SLNB had the lowest predictive ability. Stratifying by ulceration and SN tumour burden resulted in four positive SN groups from which low-, intermediate- and high-risk prognostic classes could be derived. ConclusionsAdequate stratification of positive SN patients was possible based on ulceration and SN tumour burden category. The identification of low-, intermediate- and high-risk patients could guide adjuvant therapy in clinical practice. Omitting CLND seems to have little consequences.

Disección ganglionar en el paciente con melanoma y metástasis en el ganglio centinela: propuesta de decisión basada en la evidencia actual

Recent publication of the results of clinical trials in which lymph node dissection was not associated with any survival benefit in patients with sentinel node metastasis makes it necessary to reconsider the treatment of patients with melanoma. This article provides an update on the available evidence on the diverse factors (routes of metastatic spread, predictors, adjuvant therapy, etc.) that must be considered when treating patients with sentinel node-positive melanoma. The authors propose a decision-making algorithm for use in this clinical setting. The current evidence no longer supports lymph node dissection in patients with low-risk sentinel node metastasis (sentinel node tumor load ≤1mm).

Patients with sentinel lymph node positive melanoma: Who needs completion lymph node dissection?

IntroductionCompletion lymph node dissection (CLND) for melanoma after positive sentinel lymph node biopsy (SLNB) was recently shown to improve regional but not overall survival, likely due to the majority of patients harboring no further nodal disease. We sought to determine predictors of non-sentinel node (NSN) positivity. MethodsRetrospective review of prospectively collected data on melanoma patients undergoing SLNB. Results116 patients underwent 119 CLNDs. The incidence of NSN positivity was 17.6%; the average number of positive NSNs in those cases was 1.5. Cervical and inguinofemoral location were most likely to yield positive NSN(s) (40% each). Conversely, the axilla was least likely at 18% (p < 0.001). The average number of nodes harvested was 13 for NSN negative cases and 20 for NSN positive cases (p = 0.005). Tumor thickness increased the probability of positive NSN(s) (OR 1.2, p = 0.02). ConclusionsTumor thickness and nodal basin were predictors of NSN metastasis, factors that could help determine which patients may benefit from CLND. Further, CLNDs with fewer nodes may inadequately clear residual nodal disease.