Underwent Completion Lymph Node Dissection Research Articles

Survival benefit of sentinel lymph node biopsy in Asian melanoma patients.

Sentinel lymph node biopsy (SLNB) provides important prognostic information for early-stage melanomas. However, statistics regarding the survival comparison between SLNB and nodal observation in Asia, where acral lentiginous melanoma (ALM) predominates, are limited. This study aimed to identify if SLNB offered survival benefits over nodal observation in early-stage melanomas in Taiwan. The retrospective study included 227 patients who met the SLNB criteria according to the National Comprehensive Cancer Network guidelines and were treated at National Taiwan University Hospital from June 1997 to June 2021. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression models. Of the study population, ALM accounted for 73.1%; 161 patients (70.9%) underwent SLNB and 66 patients (29.1%) were under nodal observation. Multivariate analysis showed significantly improved melanoma-specific survival (hazard ratio [HR], 0.6; p = .02) in the SLNB group. Among those who underwent completion lymph node dissection (CLND), the non-sentinel node positivity rate was 44.4%. Immediate CLND resulted in significantly longer melanoma-specific survival and distant-metastasis-free survival (DMFS) compared to nodal observation. (HR, 0.2; p = .01 for melanoma-specific survival. HR, 0.3; p = .046 for DMFS). In conclusion, SLNB may provide survival benefits of cutaneous melanoma over nodal observation in the Taiwanese population.

Correlation of Tumor Burden in Sentinel Lymph Nodes with Tumor Burden in Nonsentinel Lymph Nodes and Survival in Cutaneous Melanoma.

In patients with cutaneous melanoma, metastasis in a nonsentinel lymph node (non-SLN) is a strong independent adverse prognostic factor. However, patients with a tumor-involved SLN no longer routinely undergo completion lymph node dissection (CLND). We hypothesized that SLN tumor burden may predict non-SLN tumor burden. We compared tumor burden parameters between SLN and non-SLN in patients with cutaneous melanoma who underwent SLN biopsy with a positive SLN during 2003 to 2008 at The University of Texas MD Anderson Cancer Center. We identified 336 eligible patients with a positive SLN. Of these, 308 (92%) underwent CLND, and 35 (10%) had non-SLN metastasis. The median follow-up time was 6.0 years. For patients with maximum diameter of tumor in the SLN ≤2.0 mm, >2.0-5.0 mm, and >5.0 mm, non-SLN metastasis was detected in 5 of 200 patients (3%), 10 of 63 patients (16%), and 20 of 57 patients (35%), and the mean maximum diameters of the non-SLN tumor deposits were 0.09, 1.56, and 2.71 mm, respectively (P < 0.0001). The percentage of patients with both subcapsular and intraparenchymal non-SLN tumor was higher for patients with SLN tumor in both locations than for patients with SLN tumor in only one location (P < 0.0001). Extranodal extension in a non-SLN was more common in patients with extranodal extension in an SLN (P = 0.003). In patients with cutaneous melanoma who undergo CLND, SLN tumor burden predicts non-SLN tumor burden. SLN tumor burden parameters provide accurate prognostic stratification independent of non-SLN status and should be considered for incorporation into future staging systems and integrated risk models.

A model for predicting low probability of nonsentinel lymph node positivity in melanoma patients with a single positive sentinel lymph node.

Identifying factors associated with nonsentinel lymph node (NSN) metastases in melanoma patients with a single positive sentinel lymph node (SLN) could aid decision making regarding adjuvant therapy. We describe a model for identifying patients with a single positive SLN at low risk for NSN metastasis. Factors associated with NSN metastasis in patients with a primary cutaneous melanoma and a single positive SLN who underwent completion lymph node dissection (CLND) were identified. These factors were used to construct a model for predicting the NSN status. The model was validated using a separate data set from another tertiary referral cancer center. In the training data set, 111 patients had a single positive SLN. Of these, 27 had positive NSN. SLN tumor deposit diameter ≥0.75 mm (OR, 3.43; P = 0.047), age ≥40 (OR, 12.14; P = 0.024), and multifocal SLN tumor deposit location (OR, 4.16; P = 0.0096) were independently associated with NSN positivity. Patients with 0 to 1 of these risk factors had a low risk of NSN metastasis in both the training (7.5%) and validation (4.6%) data sets. A combination of patient and SLN tumor burden characteristics can help to identify patients with a single positive SLN who are at a low risk of NSN metastasis.

Histological immune response patterns in sentinel lymph nodes involved by metastatic melanoma and prognostic significance.

To further characterize the micromorphometric immunological pattern to metastatic melanoma in sentinel lymph node (SLN) biopsies and completion lymph node (CLN) dissections and their relation to 5-year overall survival (OS). Retrospective cohort of 49 patients from 1996 to 2005 with a positive SLN who underwent CLN dissection (CLD) was studied. Micromorphometric characteristics included follicular center count (FCC)/profile, sinus histiocytosis, metastatic size, tumor infiltrating lymphocytes (intranodal), paracortical dendritic cells, germinal center reaction and morphology. Comparison of Kaplan-Meier survival curves used the exact log-rank statistic. In the high-FCC (n = 5-51) vs the low-FCC (n < 5) lymph nodes, a delayed separation occurred at 3 years, with 5-year OS rates being 73% vs 54% in the high- and low-FCC groups, respectively. Improved survival up to 3 years was also noted in CLDs that showed a higher FCC when compared to the prior SLN. Patients with metastatic deposits >2 mm had significantly lower 5-year survival (both <.001). Nodal micromorphometric features (ie, FCC) are probably related to host immune response to metastasis. Quantitative evaluation of lymphoid follicular centers could provide valuable prognostic information to help to stratify patients.

Does the number of sentinel lymph nodes removed affect the false negative rate for head and neck melanoma?

Head and neck (HN) cutaneous melanoma is associated with worse disease-free survival compared to non-HN cutaneous melanoma, possibly due to inadequate staging. We aim to determine if a higher yield of sentinel lymph nodes (SLNs) affected rates of sentinel lymph node biopsy (SLNB) positivity. Two Cancer Registries were used to identify patients who underwent SLNB for HN melanoma. A false negative (FN) was defined by nodal recurrence after negative SLNB. Out of 333 patients who underwent SLNB, 20% (n = 69) had a positive SLN with a FN rate of 6.3%. Those with three or more SLNs had a higher rate of SLN positivity (23.8% [17.5-29.9% CI] vs 16.4% [10.7-23.6% CI]), a lower FN rate (16.7% [10.2-21.2% CI] vs 35.3% [27.1-42.9% CI]), and higher sensitivity (83.3% [82.59-84.09% CI] vs 65.7% [64.87-66.53% CI]) compared to those with one or two SLNs. Of patients in Group 1 (one or two SLNs) with a positive SLN who underwent completion lymph node dissection (20/23), 47% (33-61% CI) had one or more positive non-sentinel nodes compared to 29% (16-51%) of patients in Group 2 (three or more SLNs) (42/46). In HN melanoma cases in which multiple nodes are identified, removal of all SLNs will more adequately stage patients.

The Role of Sentinel Lymph Node Biopsy in Thin Melanoma (Breslow Thickness ≤ 0.75 mm and 0.76 mm - 1.0 mm Respectively): Our Results and Review of the Literature

Introduction: The Sentinel Lymph Node Biopsy (SLNB) in melanoma is an important tool of staging. The impact on overall survival still remains unclear. The guidelines in regard to depth, taking in mind where SLNB staging benefits do not outweigh the risks of the procedure, are constantly reviewed and modified. Patients and Methods: From 2010 to 2015, 104 patients with thin melanoma Stage IA with presence of adverse or high risk features and from IB only TIb, N0, M0 (American Joint Committee on Cancer, AJCC Melanoma Staging and Classification 7th Edition 2009) were included and divided into 2 groups: Group A: 68 patients with Breslow ≤ 0.75 mm and Group B: 36 patients with Breslow 0.76 - 1.0 mm. Initially all patients underwent excision of the primary site and subsequently wide local excision and SLNB. We analyzed the histopathology reports of SLNB procedures in both groups. Results: There was no positive SLN in group A (0%). 4 patients from group B had positive SLN (11.1%) and underwent Completion Lymph Node Dissection (CLND). The total percentage of positive SLNs from both groups was 3.8%. Conclusions: Our findings justify the SLNB procedure in thin melanomas of 0.76 - 1.0 mm. In melanomas ≤ 0.75 mm, SLNB should be considered on an individual basis when “high-risk features” are present. More comparable studies should be evaluated in order to accurately define the threshold value of Breslow thickness where SLNB is safely deemed unnecessary.

The prognostic role of further positive non sentinel nodes in melanoma patients.

e20058 Background: The aim of the study was to investigate whether the non-sentinel node (NSN) status after nodal dissection affected prognosis in melanoma patients with positive SN. Methods: We retrospectively evaluated the clinicopathological data of 1,096 consecutive patients treated from 2000 to 2014 at a single institution, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy, who underwent completion lymph-node dissection (CLND) after a positivity of SN. The most frequently involved nodal basins were axilla, groin and neck; 507 positive SNs were detected in axillar basin, 477 in the inguinal-iliac one and 112 in the neck basin. Results: In the axillar nodal basin 18,7% of cases showed one or more positive further LN after the CLND. A similar rate of positive NSNs (18,5%) was found in patients who had inguinal and pelvic lymphadenectomy; of these cases, 23.2% of further positive nodes were observed in the inguinal basin while 13.8% were located in the iliac one. In the neck basin was detected...

International multi-institutional management and outcome of melanoma patients with positive sentinel lymph nodes in more than one nodal basin.

Melanoma patients with palpable nodal disease in more than one basin have a worse prognosis than those with single-basin disease. Little is known about the outcome of patients with microscopically positive nodal disease in more than one basin, or how they are currently managed at tertiary referral centers. We identified 97 patients with positive sentinel lymph nodes (SLNs) in more than one lymph node basin from 1994 to 2010 from three tertiary care centers. Clinical and pathologic outcome variables were analyzed. Ninety-seven patients (72 men, 25 women) were identified with at least one positive SLN in at least two node basins. Most primary tumors were truncal (68, 70 %) followed by extremity (16, 17 %) and head/neck (13, 13 %). The median Breslow depth was 3.2 mm (range 0.8-12 mm), and 49 (51 %) were ulcerated. The most frequently involved nodal basins were the axilla (112, 57 %), neck (40, 20 %), and groin (24, 12 %). Seventy-seven percent (153 of 198) of all positive SLN basins underwent completion lymph node dissection (CLND). Most patients (54, 56 %) developed recurrent disease, with a median time to recurrence of 20 months. The majority of first recurrences were distant (42, 43 %), followed by regional nonnodal metastases (17, 18 %) and regional nodal metastases (16, 16 %). There was no significant difference in median overall survival between CLND versus no-CLND groups (45 vs. 30 months, respectively). Most melanoma patients with more than one SLN-positive basin are currently managed with CLND. Outcomes after CLND and no CLND are similarly poor; therefore, consideration of close nodal observation may be more appropriate.

Nonsentinel Lymph Node Status in Patients With Cutaneous Melanoma: Results From a Multi-Institution Prognostic Study

We investigated whether the nonsentinel lymph node (NSLN) status in patients with melanoma improves the prognostic accuracy of common staging features; then we formulated a proposal for including the NSLN status in the current melanoma staging system. We retrospectively collected the clinicopathologic data of 1,538 patients with positive SLN status who underwent completion lymph node dissection (CLND) at nine Italian centers. Multivariable Cox regression survival analysis was used to identify independent prognostic factors. Literature meta-analysis was used to summarize the available evidence on the prognostic value of the NSLN status in patients with positive SLN. NSLN metastasis was observed in 353 patients (23%). After a median follow-up of 45 months, NSLN status was an independent prognostic factor for melanoma-specific survival (hazard ratio [HR] = 1.34; 95% CI, 1.18 to 1.52; P < .001). NSLN status efficiently stratified the prognosis of patients with two to three positive lymph nodes (n = 387; HR = 1.39; 95% CI, 1.07 to 1.81; P = .013), independently of other staging features. Searching the literature, this patient subgroup was investigated in other two studies. Pooling the results (n = 620 patients; 284 NSLN negative and 336 NSLN positive), we found that NSLN status is a highly significant prognostic factor (summary HR = 1.59; 95% CI, 1.27 to 1.98; P < .001) in patients with two to three positive lymph nodes. These findings support the independent prognostic value of the NSLN status in patients with two to three positive lymph nodes, suggesting that this information should be considered for the routine staging in patients with melanoma.

Five-year follow-up of 16 melanoma patients with a Starz I-involved sentinel node in whom completion lymph node dissection was omitted

The aim of the study was to determine the incidence of lymph node recurrence in 16 melanoma patients with a minimal metastasis (Starz level I) in a sentinel node in whom a completion lymph node dissection was omitted. A secondary aim was to examine whether other melanoma-related recurrences developed. Sixteen melanoma patients with an SI-involved sentinel node, who did not undergo completion lymph node dissection, were followed for a median of 66 months. Lymph node recurrences did not occur. One of the 16 patients developed a local recurrence and another developed satellite metastases. None of the 16 patients with an SI-positive sentinel node developed a nodal recurrence, which suggests that the risk of refraining from node dissection in such patients is small. This option could be considered and discussed with the patient in terms of the risk of nonsentinel node involvement and the unsolved problem of unknown overall survival advantage.

Clinical experience with atypical spitzoid tumors in patients younger than age 18: Does fluorescence in situ hybridization predict lymph node metastasis?

8586 Background: Determining the malignant potential of atypical spitzoid melanocytic proliferations can be diagnostically challenging, and many patients are therefore managed as if they had melanoma. However, few studies focus specifically on atypical spitzoid tumors (AST). Further, cytogenetic analysis using fluorescence in situ hybridization (FISH) has been used to determine malignant potential. We reviewed our institutional experience to determine staging and clinical outcomes, and the correlation between FISH findings and regional nodal positivity in patients with AST. Methods: With IRB approval, we retrospectively reviewed all patients aged &lt;18 years treated for AST from 1981-2011 to determine staging variables, outcome, and the results of 4-probe FISH assay. A total of 44 patients with a median age of 11.5 years were identified. All pathology was re-reviewed by a single dermatopathologist. Staging was based on 2010 AJCC criteria. Correlations were determined using either the Pearson or Spearman correlation coefficient. Results: Median lesion thickness was 2.8 mm (range: 0.55-12) and eight (18%) lesions met spitzoid melanoma criteria. Median followup was 4.1 years for all patients (5.5 years for spitzoid melanomas). Thirty-nine patients (89%) underwent sentinel lymph node biopsies (SLNB) and 15 (38%) were positive. Lymph node (LN) positivity correlated with tumor thickness (p=0.002), stage (p=0.001), and mitotic rate (p=0.05). FISH was available for 17/39 patients who had SLNB; sensitivity and specificity for LN metastases were 50% and 54%, respectively. Of 15 patients with a positive SLNB, 12 underwent completion LN dissection, three of which were positive for 1, 2, and 3 additional nodes, respectively. There were no recurrences or disease-related deaths. Conclusions: Traditional indicators of thickness and stage predicted nodal involvement in pediatric patients with AST. However, FISH results did not predict nodal status and should not be used to guide management. With 100% disease specific survival and no recurrences, AST should be considered a separate entity from melanoma and complete excision may be sufficient therapy.

Multimodality approach to the sentinel node

In a recent article by Lam et al. describing the experience of the Sydney Melanoma Unit, a novel term called 'multimodality approach' to the sentinel node (SN) was applied. However, the timing of the use of the tools available in the presented cases should be discussed. An algorithm of which time to use, which tool to detect the correct SN by preoperative ultrasound (US) in combination with an US-guided fine needle aspiration cytology (FNAC) will be proposed and demonstrated using five clinical examples. All examples prove the advantage of a combined strategy to track down the correct and involved SN. A sensitive US power mode, for the amplification of even the slightest changes in vascularization, is the most important tool in our diagnostic preoperative approach. First, reliable US criteria, as recently published must consequently be applied. Second, a FNAC should be performed early enough, even when only early signs are visible. Third, a swift overnight cytology before sentinel lymph node biopsy should be available. US is a method for the early detection of clinically nonevident metastases. Using the proposed algorithm when to perform which part of the multimodality approach, we demonstrated the enormous information out of additionally performed US. In the case of a suspicious US finding, we always perform a FNAC of the node. In the event of a negative finding, the SLND will take place as scheduled. In the case of a positive finding, the patient can directly undergo completion lymph node dissection.

No non‐sentinel node involvement in melanoma patients with limited Breslow thickness and low sentinel node tumour load

Most melanoma patients with a positive sentinel node (SN) undergo completion lymph node dissection and frequently experience associated morbidity. However, only 10-30% of SN-positive patients have further lymph node metastases. The aim of the present study was to predict the absence of non-SN metastases in a multicentre study of patients with a positive SN based on primary melanoma features and SN tumour load. Of 70 SN positive patients, 18 had non-SN metastases. Penetrative depth of metastatic cells into the SN and SN tumour load was assessed by morphometry. None of the 14 patients (20%) with a Breslow thickness <2.0 mm and an SN tumour load <0.2 mm2 had non-SN metastases. Similarly, none of the 15 patients (21%) with a Breslow thickness <2.0 mm and SN penetrative depth <600 μm had non-SN metastases. Lastly, none of the 14 patients (20%) with a Breslow thickness <2.0 mm and a diameter of the largest SN deposit <500 μm had non-SN metastases. A combination of limited Breslow thickness and low SN tumour load predicts absence of non-SN metastases in melanoma patients with a positive SN with high accuracy. We propose that this subgroup may be spared completion lymph node dissection.

Prognosis in Patients With Sentinel Node–Positive Melanoma Is Accurately Defined by the Combined Rotterdam Tumor Load and Dewar Topography Criteria

Prognosis in patients with sentinel node (SN)-positive melanoma correlates with several characteristics of the metastases in the SN such as size and site. These factors reflect biologic behavior and may separate out patients who may or may not need additional locoregional and/or systemic therapy. Between 1993 and 2008, 1,080 patients (509 women and 571 men) were diagnosed with tumor burden in the SN in nine European Organisation for Research and Treatment of Cancer (EORTC) melanoma group centers. In total, 1,009 patients (93%) underwent completion lymph node dissection (CLND). Median Breslow thickness was 3.00 mm. The median follow-up time was 37 months. Tumor load and tumor site were reclassified in all nodes by the Rotterdam criteria for size and in 88% by the Dewar criteria for topography. Patients with submicrometastases (< 0.1 mm in diameter) were shown to have an estimated 5-year overall survival rate of 91% and a low nonsentinel node (NSN) positivity rate of 9%. This is comparable to the rate in SN-negative patients. The strongest predictive parameter for NSN positivity and prognostic parameter for survival was the Rotterdam-Dewar Combined (RDC) criteria. Patients with submicrometastases that were present in the subcapsular area only, had an NSN positivity rate of 2% and an estimated 5- and 10-year melanoma-specific survival (MSS) of 95%. Patients with metastases < 0.1 mm, especially when present in the subcapsular area only, may be overtreated by a routine CLND and have an MSS that is indistinguishable from that of SN-negative patients. Thus the RDC criteria provide a rational basis for decision making in the absence of conclusions provided by randomized controlled trials.

Why Does No One Want to Perform Lymph Node Dissection Anymore?

In this issue of Annals of Surgical Oncology, Kingham et al. from Memorial Sloan-Kettering Cancer Center present their single-institution retrospective experience of melanoma patients who did not undergo completion lymph node dissection (CLND) for a tumor-positive sentinel lymph node (SLN). Of 313 patients who had a tumorpositive SLN, 271 underwent CLND and 42 did not. Of the 42 patients who did not undergo CLND, 5 did not do so because they were found to have stage IV disease on further workup, leaving 37 patients who should reasonably have considered CLND. The nodal recurrence rates were no different in the no-CLND group (7%) versus the CLND group (6%). Because the disease-free and disease-specific survival rates were similar between the groups, the authors question the value of CLND. We must recognize the limitations of this study. It is a small, retrospective review from a single institution. The groups are not well balanced in terms of clinicopathologic factors. Patients in the no-CLND group versus the CLND group were older (median age, 70 vs. 56 years, P .01), more often had lower-extremity melanomas (40% vs. 13%, P .01), and had a trend toward thicker (3.5 vs. 2.8 mm, P .06), more often ulcerated (62 vs. 44%, P = .09) melanomas. Why did the patients not undergo CLND in this study? In 33% of cases, it seems that the surgeon essentially talked the patient out of having a CLND. Although patient refusal was cited as the most common reason for failure to perform CLND (45%), it is likely that the surgeon’s opinion strongly influenced the patients’ decisions in these cases as well. The patients who chose to forego CLND did not do so for random reasons; selection bias is a major drawback of this study. In my experience, most patients choose CLND if recommended by their surgeon. So what does this study really tell us? I believe it tells us that the experienced melanoma surgeons at Memorial Sloan-Kettering Cancer Center were very good at selecting patients who were unlikely to have nodal recurrence and/or were very likely to develop distant metastatic disease, and thus were unlikely to benefit from CLND. It does not tell us that CLND is of no value. The authors cite population studies that indicate that only 50–69% of melanoma patients in the United States who have a tumor-positive SLN undergo CLND. So why are surgeons so reluctant to perform CLND these days? To address this question, we must consider the reasons for performing CLND. There are two goals: regional disease control and cure. The patients who undergo CLND for a tumor-positive SLN fall into three camps: (1) those who do not need CLND because they do not have, and never will have, additional nodal disease; (2) those who will not benefit from CLND because they are going to die of distant metastatic disease or because their disease will recur in the regional nodes, despite the best possible lymph node dissection; and (3) those who have nonsentinel node metastases for whom CLND will prevent regional nodal recurrence and, in some cases, result in cure. The third camp undoubtedly represents the smallest group. The article by Kingham et al. implies that the third camp does Society of Surgical Oncology 2009

Reevaluation of the Locoregional Recurrence Rate in Melanoma Patients With a Positive Sentinel Node Compared to Patients With Palpable Nodal Involvement

The main aims of this study were to evaluate the occurrence of the various forms of locoregional recurrence in sentinel node-positive melanoma patients, to determine whether the different definitions that are being used to describe in-transit metastases influence this rate, and to identify factors associated with locoregional recurrence. A comparison was made with the rate of locoregional recurrence in patients who underwent lymph node dissection for palpable metastases. Between December 1993 and December 2008, a total of 141 patients underwent completion lymph node dissection because of a tumor-positive sentinel node. In the same period, 178 patients underwent a regional lymph node dissection for palpable nodal metastases. In the sentinel node-positive patients, the local recurrence rate was 5%, the rate of satellite metastasis was 2%, and for in-transit metastasis, it was 15%. In patients with palpable nodal involvement, these values were 3%, 2%, and 14%, respectively. There was no statistically significant difference in locoregional recurrence-free rates between these two groups of node-positive patients (P = .172). Breslow thickness was the only predictive factor for locoregional recurrence (P = .015). The rate of locoregional metastases in patients with a tumor-positive sentinel node and patients with palpable nodal involvement is similar. The present study refutes the suggestion that a positive sentinel node indicates a predisposition for developing in-transit metastases.

Absence of second echelon involvement in melanoma patients with limited Breslow thickness and low sentinel node tumor load

9060 Background: The sentinel node (SN) procedure has become a widely used staging procedure for stage I/II melanoma. Most melanoma patients with a positive SN undergo completion lymph node dissection and, as a consequence, frequently experience associated morbidity. However, only approximately 20% of these patients have second echelon metastases. The aim of the present study therefore was to predict the absence of second echelon metastases in patients with a positive SN based on primary melanoma features, depth of SN invasion and SN tumor load. Methods: Of 70 SN positive patients, 18 had second echelon metastases. Penetrative depth of metastatic cells into the SN and SN tumor load (largest diameter and total tumour area) were assessed with morphometry. Primary tumour features concerned Breslow thickness, Clark level and ulceration. Results: None of the patients with a Breslow thickness <2.5 mm and a SN tumor load <0.3 mm2 had second echelon metastases. Similarly, none of the patients with a Breslow thickness <2.5 mm and SN depth of invasion <200 μm had second echelon metastases. Lastly, none of the patients with a Breslow thickness <2.5 mm and a diameter of the largest SN deposit <40 μm had second echelon metastases. Conclusions: A combination of limited Breslow thickness and low SN tumour load predicts absence of second echelon metastases in melanoma with a positive SN. We therefore propose that this subgroup may be spared completion lymph node dissection. No significant financial relationships to disclose.

QS113-A. Extent of Lymph Node Dissection Impacts Disease Specific Survival in Melanoma Patients

Background: Extent of lymph node (LN) dissection has been defined as a potential indicator of surgical quality for patients with various solid tumors. The objective of the current analysis was to determine: (1) the most relevant measure of extent of LN dissection, (2) identify the threshold value of the most relevant measure, and (3) examine its impact on disease specific survival (DSS) in melanoma patients undergoing therapeutic LN dissection. Methods: Patients with pathologically confirmed, node positive, cutaneous melanoma who underwent completion LN dissection were identified from the SEER database (1988-2004).

Sentinel Lymph Node Biopsy in Cutaneous Melanoma: A Case-Control Study

Sentinel lymph node biopsy (SLNB) is the most precise method for staging invasive cutaneous melanoma, but its therapeutic effect has been difficult to assess, and SLNB is not routinely used in all melanoma treatment centers. This case-control study of 305 prospective SLNB patients compared them with 616 retrospective patients who had not undergone invasive nodal staging at diagnosis. Thin melanomas were included in both study groups. A total of 50 SLNB patients were sentinel positive (16.4%) and 255 were sentinel negative (83.6%). A total of 49 of the 50 sentinel-positive patients underwent completion lymph node dissection, and 9 of them (18%) had additional metastases in the nonsentinel nodes. The false-negative rate was 1.6% (five same-basin nodal recurrences during follow-up). There was a significant difference in melanoma-related overall survival (OS) between sentinel-positive and sentinel-negative patients (P < .001). The tumor burden of the sentinel nodes was a significant prognostic factor for melanoma-related OS (P < .001). There was no significant difference in melanoma-related OS or disease-free survival between the study groups, but the nodal disease-free survival was significantly longer among the SLNB patients (P = .004). SLNB is recommended for routine use in the treatment of cutaneous melanoma because the sentinel node status carries unique prognostic information on the survival of melanoma patient. Improved regional disease control is an obvious therapeutic advantage of SLNB and immediate completion lymph node dissection.

Assessment of value of the sentinel lymph node biopsy in melanoma in children and adolescents and applicability of subcutaneous infusion anesthesia

Background/Purpose The management of pediatric melanoma is controversial but equates that of adults. Lymphatic mapping with sentinel lymph node (SLN) biopsy is proposed as standard of care for patients with primary melanoma. The operation can be done with general or local anesthesia in adults. The goal of this study was to determine the applicability of subcutaneous infusion anesthesia (SIA) for SLN biopsy in children and adolescents, as well as to assess complications of this procedure and to document outcome of patients with melanoma in this particular age group after SLN biopsy. Methods Charts of patients with melanomas on the trunk and extremities who underwent lymphatic mapping and SLN biopsy in SIA between November 2000 and January 2006 revealed 13 patients with age 21 years or less. Tumescent solutions with lidocaine (0.2%) were used for SLN biopsy. Patient demographics, tumor thickness, Clark level, location of primary melanoma, ulceration, number of SLNs, number of positive nodes, and follow-up of patients were included. Results In 13 patients (age range, 12-21), SLN biopsy was performed. Mean tumor thickness was 1.8 mm (range, 1.0-7.0), none of these melanomas showed ulceration. The operation was tolerated in SIA by all patients; none had any associated complications. Of 13 patients, 5 (38.5%) had positive sentinel nodes. Three patients underwent completion lymph node dissection, and no further positive nodes were found. After a mean follow-up of 29.2 months (range, 13-68), all patients were found disease-free. Conclusions Sentinel lymph node biopsy in SIA can safely be performed in children and adolescents with primary melanomas. Further studies are necessary to determine the prognostic information and therapeutic implications of SLN biopsy in this patient group.