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Gündüz N, Duran M, Akbulut İ, Şibar S, Ayhan MS. A Comparative Analysis of Sentinel Lymph Node Sampling Utilizing Sentinel Lymphoscintigraphy Alone Versus the Combined Application of Sentinel Lymphoscintigraphy and Fluorescence Lymphangiography. Ann Plast Surg 2025:00000637-990000000-00762. [PMID: 40209885 DOI: 10.1097/sap.0000000000004348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2025]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) plays a crucial role in the clinical staging of cutaneous melanoma, influencing both treatment decisions and survival prognosis. This study aims to evaluate the benefits of combining indocyanine green (ICG) angiography with sentinel lymphoscintigraphy compared to the use of isolated sentinel lymphoscintigraphy. MATERIALS AND METHODS A retrospective analysis was conducted comparing patients who underwent SLNB with isolated sentinel lymphoscintigraphy (isolated group) to those who received SLNB with a combined approach involving both sentinel lymphoscintigraphy and ICG lymphangiography (combined group). The success rates of SLNB, the incidence of false negatives, and the feasibility of using ICG alone were assessed. RESULTS The success rate for detecting at least 1 lymph node was 92.6% in the isolated group and 100% in the combined group. Among the 16 patients in the isolated group with negative SLNB results, 3 (18.7%) experienced lymph node recurrence. In contrast, none of the 16 patients in the combined group exhibited recurrence (P > 0.05). The combined method resulted in a 26.7% increase in the average number of excised lymph nodes compared to the isolated method. CONCLUSIONS The integration of ICG lymphangiography with sentinel lymphoscintigraphy enhances lymph node sampling and detection sensitivity, thereby reducing the false-negative rate. However, there is insufficient evidence to support the adequacy of using ICG alone for SLNB.
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Affiliation(s)
- Nurullah Gündüz
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
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Song JY, Ryu YJ, Lee HK, Lee DH, Choi YD, Shim HJ, Yun SJ. Risk factors for sentinel lymph node metastasis in Korean acral and non-acral melanoma patients. Pigment Cell Melanoma Res 2024; 37:332-342. [PMID: 38013393 DOI: 10.1111/pcmr.13153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/27/2023] [Accepted: 11/12/2023] [Indexed: 11/29/2023]
Abstract
Breslow thickness, ulceration, and mitotic rate are well-known prognostic factors for sentinel lymph node (SLN) metastasis in cutaneous melanoma. We investigated risk factors, including especially the degree of pigmentation, for SLN metastasis in Korean melanoma patients. We enrolled 158, composed of Korean 107 acral and 51 non-acral melanoma patients who underwent SLN biopsy. Clinicopathologic features such as Breslow thickness, ulceration, mitotic rate, and the degree of pigmentation were evaluated. The recurrence-free survival (RFS) rate and date of recurrence were determined. Fifty-four patients (34.2%) had a positive SLN biopsy result. In a multivariate analysis, Breslow thickness (odds ratio [OR] 1.93; 95% confidence interval [CI], 1.12-3.47; p = .022) and heavy pigmentation (OR 13.14; 95% CI, 2.96-95.20, p = .002) were associated with SLN metastasis. Positive SLN patients had a higher rate of loco-regional and/or distant recurrence (hazard ratio 6.32; 95% CI, 3.39-11.79; p < .001). Heavy pigmentation was associated with poor RFS. Heavy pigmentation is an independent predictor of SLN metastasis in both acral and non-acral melanoma. Our results suggest the need for in-depth SLN evaluation of cutaneous melanoma patients with heavy pigmentation and provide clinicians with important information for determining patient prognosis.
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Affiliation(s)
- Jee Yong Song
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| | - Young Jae Ryu
- Department of General Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Ho Kyun Lee
- Department of General Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Dong Hoon Lee
- Department of Otolaryngology, Chonnam National University Medical School, Gwangju, Korea
| | - Yoo Duk Choi
- Department of Pathology, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun Jeong Shim
- Department of Hemato-Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Sook Jung Yun
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
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Phillipos J, Khan A, Jayasuriya N. Differentiation of benign nevoid rests and metastatic melanoma in sentinel lymph node biopsy. J Surg Case Rep 2023; 2023:rjad036. [PMID: 36789375 PMCID: PMC9910784 DOI: 10.1093/jscr/rjad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/17/2023] [Indexed: 02/11/2023] Open
Abstract
Patients with cutaneous melanoma routinely undergo sentinel lymph node (SLN) biopsy. If this first lymph node is clear, the entire lymph node basin is very likely to be free from the metastatic disease. Lymph node analysis is therefore of great importance with respect to prognostication and further management. Various cell types, including benign nevoid rests, can mimic metastatic melanomatous cells in the SLN. There is no standardized method to differentiate naevoid rests from metastatic melanoma. Diagnosis is based on cell location, morphology and multiple immunohistochemical techniques, with no single test being completely diagnostic. We present a patient with Lentigo Maligna melanoma, who was found to have benign nevoid rests on SLN biopsy, and discuss the diagnostic tests and considerations in differentiating benign nevoid rests from metastatic melanoma.
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Affiliation(s)
- Joseph Phillipos
- Correspondence address. 22 Leonie Avenue Mount Waverley 3149 Melbourne, Victoria, Australia. Tel: +61-483-849-815; E-mail:
| | - Afaq Khan
- Anatomical Pathology, Dorovitch Pathology, Heidelberg, Australia
| | - Neil Jayasuriya
- General Surgery, La Trobe Regional Hospital, Traralgon, Australia
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Abstract
BACKGROUND Variability in guideline compliance for melanoma lymph node surgery is partially attributable to controversy about patient selection. Prior data has indicated suboptimal practice of sentinel lymph node biopsy and undertreatment of clinically node-positive disease, predating Multicenter Selective Lymphadenectomy Trial II publication. To minimize bias, we studied compliance with lymph node surgery guidelines in T2/T3 (intermediate-thickness) melanoma patients, where the greatest agreement exists. METHODS T2/T3 and metastasis 0 melanoma cases were identified from 2004 to 2018 Surveillance, Epidemiology, and End Results data. Analysis used Cochran-Armitage test for trends, multivariable logistic regression, and Kaplan-Meier survival estimates. RESULTS Of 66,319 eligible T2/T3 patients, 57,211 were clinically node negative; 2,191 were clinically node positive; 6,197 were clinical node unreported; and 19,044/66,319 (28.8%) had no lymph node surgery. Among clinically node-negative patients, 36,433 (63.7%) underwent sentinel lymph node biopsy and 31,026 (85.2%) were pathologically node negative; 1,499 clinically node-positive patients (68.4%) had a lymph node dissection. Lymph node dissection rates declined from 2004 to 2018, 79.8% to 32.0% for clinically node-negative/pathologically node-positive patients and 80.4% to 61.2% for clinically node-positive/pathologically node-positive patients (both P < .0001). For clinically node-negative patients, lymph node surgery compliance improved from 63.7% (2004) to 70.4% (2018) (P < .0001). Compliance correlated with younger age, male sex, tumor mitotic rate, and site (extremity > trunk/head/neck) in multivariable analysis and improved 5-year cancer-specific survival (90.0% vs 83.4%) (all P < .0001). CONCLUSIONS Despite clear guidelines, one-third of intermediate-thickness melanoma patients in a recent cohort did not have recommended lymph node surgery. Lymph node status is a key determinant of the relative benefit of adjuvant systemic therapy and the need for active surveillance of pathologically node-positive/clinically node-negative patients. These data highlighted a clinical care gap. Efforts to improve guideline compliance are a logical strategy to improve cancer outcomes for intermediate-thickness melanoma patients.
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Thuaire A, Nicot R, Boileau M, Raoul G, Descarpentries C, Mouawad F, Germain N, Mortier L, Schlund M. Oral mucosal melanoma - A systematic review. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e425-e432. [PMID: 35134590 DOI: 10.1016/j.jormas.2022.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 12/12/2022]
Abstract
Oral mucosal melanoma (OMM) is the subject of few studies, resulting in a lack of understanding. The aim of this study is to review the current literature on OMM. The term searched was "oral mucosal melanoma" between 01/01/2000 and 03/15/2021 in the PubMed Database (MEDLINE). Patients presenting with OMM and treated in our center between January 2009 and January 2020 were included in a case series. Demographics, location, risk factors, genetic mutations, treatment performed, and overall survival (OS) rates were evaluated. The PubMed database search yielded a total of 513 results, thirty-eight articles were finally included, which amounted to 2230 cases of OMM. 13 patients were included in the case series. A male-to-female ratio of 1.28:1.00 was found with a mean age at first diagnosis of 58.2 years old. Hard palate (1060 cases) and then gingiva (794 cases) were the two main locations. No risk factors could be identified. OMM were staged III or IV at diagnosis. Mutations were described as such: KIT in 14.6% of cases, BRAF in 7%, and NRAS in 5.6%. Treatment protocols varied but radical surgery was the cornerstone treatment associated with adjuvant therapies. Immunotherapy has not been evaluated for OMM. OS rates were 43.4% at 3 years, 33.1% at 5 year and 15.4% at 10 years. OMM show distinct features from cutaneous melanoma (CM): typical locations, no identified risk factors, different mutations profile, worse prognosis with advanced stage at diagnosis. Targeted therapies are still underused compared to CM.
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Affiliation(s)
- Antoine Thuaire
- University Lille, CHU Lille, Service de Chirurgie Maxillo-Faciale et Stomatologie, Hôpital Roger Salengro, Rue Emile Laine, Lille F-59000, France.
| | - Romain Nicot
- University Lille, CHU Lille, INSERM, Service de Chirurgie Maxillo-Faciale et Stomatologie, U1008 - Controlled Drug Delivery Systems and Biomaterial, Lille F-59000, France
| | - Marie Boileau
- University Lille, CHU Lille, Service de Dermatologie, Lille F-59000, France
| | - Gwénaël Raoul
- University Lille, CHU Lille, INSERM, Service de Chirurgie Maxillo-Faciale et Stomatologie, U1008 - Controlled Drug Delivery Systems and Biomaterial, Lille F-59000, France
| | - Clothilde Descarpentries
- Oncology and Molecular Genetics Laboratory, Division of Biochemistry and Molecular Biology, University Lille, CHU Lille, Lille F-59000, France
| | - François Mouawad
- ENT and Head and Neck Department, Lille 59037 Cedex, France; University Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille F-59000, France
| | - Nicolas Germain
- University Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer, Heterogeneity Plasticity and Resistance to Therapies, Lille F-59000, France; Banque de Tissus, CHU Lille, Lille F-59000, France
| | - Laurent Mortier
- University Lille, CHU Lille, INSERM, Service de Dermatologie, ONCO-THAI U1189, Lille F-59000, France
| | - Matthias Schlund
- University Lille, CHU Lille, INSERM, Service de Chirurgie Maxillo-Faciale et Stomatologie, U1008 - Controlled Drug Delivery Systems and Biomaterial, Lille F-59000, France
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Abstract
PURPOSE OF REVIEW The complex and varied drainage patterns in the head and neck present a challenge in the regional control of cutaneous neoplasms. Lymph node involvement significantly diminishes survival, often warranting more aggressive treatment. Here, we review the risk factors associated with lymphatic metastasis, in the context of the evolving role of sentinel lymph node biopsy. RECENT FINDINGS In cutaneous head and neck melanomas, tumor thickness, age, size, mitosis, ulceration, and specific histology have been associated with lymph node metastasis (LNM). In head and neck cutaneous squamous cell carcinomas, tumor thickness, size, perineural invasion, and immunosuppression are all risk factors for nodal metastasis. The risk factors for lymph node involvement in Merkel cell carcinoma are not yet fully defined, but emerging evidence indicates that tumor thickness and size may be associated with regional metastasis. The specific factors that predict a greater risk of LNM for cutaneous head and neck cancers generally include depth of invasion, tumor size, mitotic rate, ulceration, immunosuppression, and other histopathological factors.
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Affiliation(s)
- Albert Y Han
- Department of Head and Neck Surgery, University of California Los Angeles (UCLA), Los Angeles, CA, USA
- UCLA Head and Neck Cancer Program, UCLA Medical Center, 10833 Le Conte Ave, 62-132 CHS, Los Angeles, CA, 90095, USA
- Jonsson Comprehensive Cancer Center, UCLA Medical Center, Los Angeles, CA, USA
| | - Maie A St John
- Department of Head and Neck Surgery, University of California Los Angeles (UCLA), Los Angeles, CA, USA.
- UCLA Head and Neck Cancer Program, UCLA Medical Center, 10833 Le Conte Ave, 62-132 CHS, Los Angeles, CA, 90095, USA.
- Jonsson Comprehensive Cancer Center, UCLA Medical Center, Los Angeles, CA, USA.
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Diagnosis and Prognosis of Canine Melanocytic Neoplasms. Vet Sci 2022; 9:vetsci9040175. [PMID: 35448673 PMCID: PMC9030435 DOI: 10.3390/vetsci9040175] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 02/04/2023] Open
Abstract
Canine melanocytic neoplasms have a highly variable biological behavior ranging from benign cutaneous melanocytomas to malignant oral melanomas that readily metastasize to lymph nodes and internal organs. This review focuses on the diagnosis and prognosis of canine melanocytic neoplasms. While pigmented melanocytic neoplasms can be diagnosed with fine-needle aspirates, an accurate prognosis requires surgical biopsy. However, differentiating amelanotic spindloid melanomas from soft tissue sarcomas is challenging and often requires immunohistochemical labeling with a diagnostic cocktail that contains antibodies against Melan-A, PNL-2, TRP-1, and TRP-2 as the current gold standard. For questionable cases, RNA expression analysis for TYR, CD34, and CALD can further differentiate these two entities. The diagnosis of amelanotic melanomas will be aided by submitting overlying and/or lateral flanking epithelium to identify junctional activity. Wide excision of lateral flanking epithelium is essential, as lentiginous spread is common for malignant mucosal melanomas. Combining histologic features (nuclear atypia, mitotic count, degree of pigmentation, level of infiltration, vascular invasion; tumor thickness and ulceration) with the Ki67 index provides the most detailed prognostic assessment. Sentinel lymph nodes should be evaluated in cases of suspected malignant melanomas using serial sectioning of the node combined with immunohistochemical labeling for Melan-A and PNL-2.
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Saleem A, Narala S, Raghavan SS. Immunohistochemistry in melanocytic lesions: Updates with a practical review for pathologists. Semin Diagn Pathol 2022; 39:239-247. [PMID: 35016807 DOI: 10.1053/j.semdp.2021.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 01/10/2023]
Abstract
This review provides a summary of the immunohistochemical markers pertinent to the diagnosis of melanocytic lesions. There is considerable morphologic overlap between benign and malignant melanocytic lesions, and given the significant differences in clinical management, the diagnostic workup becomes crucial. Immunohistochemistry aids in the distinction between various melanocytic proliferations and recent contributions to the literature have furthered our optimization of panels in the diagnostic workup. In recent years, SOX10 has been considered as the optimal marker for melanocytic lesions given the similar sensitivity but higher specificity than S100. HMB-45 is less sensitive than S100 but demonstrates utility in confirmation of deceptively banal small cell and nevoid melanoma variants where deep nests of melanocytes are highlighted. Melan-A (MART-1) and MiTF show similar sensitivity to S100 however there is a lack of expression in spindle cell and desmoplastic melanomas.
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Affiliation(s)
- Atif Saleem
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Saisindhu Narala
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Shyam S Raghavan
- Department of Pathology, University of Virginia, 200 Jeanette Lancaster Way, Charlottesville, VA 22903, USA.
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Newcomer K, Robbins KJ, Perone J, Hinojosa FL, Chen D, Jones S, Kaufman CK, Weiser R, Fields RC, Tyler DS. Malignant melanoma: evolving practice management in an era of increasingly effective systemic therapies. Curr Probl Surg 2022; 59:101030. [PMID: 35033317 PMCID: PMC9798450 DOI: 10.1016/j.cpsurg.2021.101030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/12/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Ken Newcomer
- Department of Surgery, Barnes-Jewish Hospital, Washington University, St. Louis, MO
| | | | - Jennifer Perone
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - David Chen
- e. Department of Medicine, Washington University, St. Louis, MO
| | - Susan Jones
- f. Department of Pediatrics, Washington University, St. Louis, MO
| | | | - Roi Weiser
- University of Texas Medical Branch, Galveston, TX
| | - Ryan C Fields
- Department of Surgery, Washington University, St. Louis, MO
| | - Douglas S Tyler
- Department of Surgery, University of Texas Medical Branch, Galveston, TX.
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Hui JYC, Burke E, Broman KK, Marmor S, Jensen E, Tuttle TM, Zager JS. Surgeon decision-making for management of positive sentinel lymph nodes in the post-Multicenter Selective Lymphadenectomy Trial II era: A survey study. J Surg Oncol 2021; 123:646-653. [PMID: 33289125 PMCID: PMC7902320 DOI: 10.1002/jso.26302] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/01/2020] [Accepted: 11/04/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Completion lymph node dissection (CLND) did not improve melanoma-specific survival for patients with sentinel lymph node (SLN)-positive melanoma in the second Multicenter Selective Lymphadenectomy Trial (MSLT-II). We assessed surgeons' awareness of MSLT-II and its impact on CLND recommendations. METHODS An anonymous online cross-sectional survey of the Society of Surgical Oncology membership evaluated surgeon thresholds in offering CLND using patient scenarios and clinicopathologic characteristics ranking. RESULTS Of the 2881 e-mails delivered, 146 surgeons (5.1%) completed all seven scenarios. Most (129 of 131, 98%) were aware of MSLT-II and 125 (95%) found it practice-changing. Specifically, 52% (65 of 125) always, 40% usually, 6% rarely, and 3% never offered CLND before MSLT-II. Meanwhile, 4% always, 9% usually, 78% rarely, and 8% never offer CLND now, after MSLT-II (p < .0001). The most important clinicopathologic factors in determining CLND recommendations were extracapsular extension, number of positive SLN, and SLN tumor deposit size, while primary tumor mitotic index and nodal basin location were the least important. Surgical oncology fellowship training, melanoma patient volume, and academic center practice also influenced CLND recommendations. CONCLUSIONS Most surgeon respondents are aware of MSLT-II, but its application in practice varies according to several clinicopathologic and surgeon factors.
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Affiliation(s)
| | - Erin Burke
- Department of Surgery, University of Kentucky, Lexington KY
| | - Kristy K. Broman
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center, Tampa FL
- Department of Oncological Sciences, University of South Florida, Morsani College of Medicine, Tampa FL
- Department of Surgery, University of Alabama at Birmingham, Birmingham AL
| | - Schelomo Marmor
- Department of Surgery, University of Minnesota, Minneapolis MN
| | - Eric Jensen
- Department of Surgery, University of Minnesota, Minneapolis MN
| | - Todd M. Tuttle
- Department of Surgery, University of Minnesota, Minneapolis MN
| | - Jonathan S. Zager
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center, Tampa FL
- Department of Oncological Sciences, University of South Florida, Morsani College of Medicine, Tampa FL
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Ravichandran S, Nath N, Jones DC, Li G, Suresh V, Brys AK, Hanks BA, Beasley GM, Salama AKS, Howard BA, Mosca PJ. The utility of initial staging PET-CT as a baseline scan for surveillance imaging in stage II and III melanoma. Surg Oncol 2020; 35:533-539. [PMID: 33161362 DOI: 10.1016/j.suronc.2020.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/11/2020] [Accepted: 10/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND This study evaluates the utility of whole-body PET-CT for the initial staging and subsequent surveillance imaging of patients with completely resected stage II and stage III melanoma. METHODS A single-center, retrospective review of patients who received perioperative whole-body PET-CT from January 1, 2005 to December 1, 2019 within three months of initial melanoma diagnosis was performed. RESULTS Of 258 total patients with completely resected melanoma who had a PET-CT within 3 months after their melanoma diagnosis, 113 had stage II and 145 had stage III melanoma. PET-CT detected distant metastasis in 3 (2.7%) of 113 stage II patients and 7 (4.8%) of 145 stage III patients. 179 of 258 patients had adequate follow-up time to determine whether they received surveillance cross-sectional imaging and whether they had a melanoma recurrence. 143 (79.9%) received subsequent surveillance imaging, 74 of whom developed a recurrence. In 64 (86.5%) of 74 cases, recurrence was detected by routine surveillance. 26 (34.2%) of 76 stage II and 65 (63.1%) of 103 stage III patients developed a recurrence. The median time to recurrence among the 179 patients for stage II and III was 16.3 and 13.0 months, respectively. CONCLUSIONS These findings indicate that baseline staging with whole-body PET-CT rarely provides information that changes initial management. Rather, the value of the initial PET-CT is as a baseline for subsequent surveillance scans. Therefore, it may be premature to discourage cross-sectional imaging for patients with stage II and III melanoma without supportive evidence or a reliable biomarker of recurrent disease.
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Affiliation(s)
- Surya Ravichandran
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Neel Nath
- Department of Dermatology, Duke University Medical Center, Durham, NC, USA
| | - David C Jones
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Gabriel Li
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Visakha Suresh
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Adam K Brys
- Department of Dermatology, Duke University Medical Center, Durham, NC, USA
| | - Brent A Hanks
- Department of Medicine, Division of Medical Oncology and Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, USA
| | - Georgia M Beasley
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - April K S Salama
- Department of Medicine, Division of Medical Oncology and Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, USA
| | - Brandon A Howard
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Paul J Mosca
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
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Shakeel O, Ullah F, Khalid N, Ali SI, Batool S, Amjad A, Anwer AW, Ali H, Zafar H, Syed AA. Malignant Melanoma of the Female Genital Tract: Experience of an Oncology Center in Pakistan. Cureus 2020; 12:e8484. [PMID: 32642388 PMCID: PMC7336621 DOI: 10.7759/cureus.8484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction Malignant melanoma, which arises from melanocytes or pigment cells, is one of the most common forms of epithelial cancer. Cutaneous and noncutaneous melanomas differ clinically and genetically. Mucosal melanomas are rare. In the female genital tract, the most frequent location of melanoma is the vulva, whereas the vagina is seldom affected. The occult nature of their anatomical location contributes to the late presentation and late diagnosis of vaginal melanoma, resulting in an exceedingly poor patient prognosis. The present study describes the incidence, symptoms, management, and prognosis of women in Pakistan with malignant melanoma of the vulva, vagina, and cervix. Materials and methods The Hospital Information System of Shaukat Khanam Memorial Cancer Hospital and Research Center was searched electronically to identify patients diagnosed with malignant melanoma from January 1995 to December 2017. Patients with cutaneous malignant melanoma, multiple primary tumors, and metastases to the female genital tract from primary tumors located elsewhere were excluded. All included patients had been diagnosed with primary malignant melanoma of the female genital tract. Results The search of medical records identified 271 patients with malignant melanoma, of whom 13 had primary malignant melanomas of the female genital tract. Of these 13 patients, nine, three, and one had primary vaginal, vulvar, and cervical melanomas, respectively. Median age at presentation was 60 years (range, 30-70 years), with 10 patients being post-menopausal. The most common presentations were per-vaginal bleeding and per-vaginal discharge (five patients each). The mean duration of symptoms was 7.46 months. Seven patients underwent wide local excision. Six patients had nodular type malignant melanoma, two had superficial spreading type, and five were unclassified. Nine patients had pathological T4 disease, and two had pathological T3. Mean Breslow depth was 5.4 millimeters (mm), with 10 patients having tumor depth >4 mm. Eight patients were positive for the microscopic involvement of margins. The mean time to recurrence was 11.8 months (range, 1-24 months), and the mean time to metastasis was 17.6 months (range, 2-44 months). The median survival after surgery was 25 months (range, 2-75 months). Conclusion This study is the first to report the incidence, symptoms, management, and prognosis of patients in Pakistan with malignant melanoma of the female genital tract. Meta-analyses and prospective multicenter studies are needed.
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Affiliation(s)
- Osama Shakeel
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Faizan Ullah
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Karachi, PAK
| | - Nazish Khalid
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Shalla I Ali
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
| | - Sadaf Batool
- Surgery, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Awais Amjad
- Surgery, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, PAK
| | - Abdul Wahid Anwer
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Hannan Ali
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Hania Zafar
- Obstetrics and Gynecology, The Indus Hospital, Lahore, PAK.,Obstetrics and Gynecology, Nishtar Medical College and Hospital, Multan, PAK
| | - Aamir Ali Syed
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
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Cong H, Wang K, Zhou Z, Yang J, Piao Y, Yu B, Shen Y, Zhou Z. Tuning the Brightness and Photostability of Organic Dots for Multivalent Targeted Cancer Imaging and Surgery. ACS NANO 2020; 14:5887-5900. [PMID: 32356972 DOI: 10.1021/acsnano.0c01034] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Specific labeling of biomarkers with bright and high photostable fluorophores is vital in fluorescent imaging applications. Here, we report a general strategy to develop single-molecule dendritic nanodots with finely tunable optical properties for in vivo fluorescent imaging. The well-defined nanodots are based on the divergent growth of biodegradable polylysine dendrimers with a fluorophore as the core. By tuning the size and surface chemistry, we obtained fluorescent nanodots with excellent brightness and photostability, favorable pharmacokinetics, and multivalent tumor-targeting capability. The nanodots provided robust, stable, long-lasting, and specific fluorescence enhancement in tumor tissue with an in situ tumor-to-normal ratio (TNR) of ∼3 and lasting over 5 days and an ex vivo TNR up to ∼17, holding considerable promise for cancer imaging and image-guided surgery. This strategy significantly improves the in vivo performance of fluorophores and can be applied to other modality imaging probes.
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Affiliation(s)
- Hailin Cong
- Institute of Biomedical Materials and Engineering, College of Materials Science and Engineering, College of Chemistry and Chemical Engineering, State Key Laboratory of Bio-Fibers and Eco-Textiles, Qingdao University, Qingdao 266071, China
- Key Laboratory of Biomass Chemical Engineering of Ministry of Education and Center for Bionanoengineering, College of Chemical and Biological Engineering, Zhejiang University, Hangzhou 310027, China
| | - Kaiqi Wang
- Institute of Biomedical Materials and Engineering, College of Materials Science and Engineering, College of Chemistry and Chemical Engineering, State Key Laboratory of Bio-Fibers and Eco-Textiles, Qingdao University, Qingdao 266071, China
- Key Laboratory of Biomass Chemical Engineering of Ministry of Education and Center for Bionanoengineering, College of Chemical and Biological Engineering, Zhejiang University, Hangzhou 310027, China
| | - Zhuha Zhou
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, East Qingchun Road 3, Hangzhou 310016, Zhejiang, China
| | - Jiajia Yang
- Key Laboratory of Biomass Chemical Engineering of Ministry of Education and Center for Bionanoengineering, College of Chemical and Biological Engineering, Zhejiang University, Hangzhou 310027, China
| | - Ying Piao
- Key Laboratory of Biomass Chemical Engineering of Ministry of Education and Center for Bionanoengineering, College of Chemical and Biological Engineering, Zhejiang University, Hangzhou 310027, China
| | - Bing Yu
- Institute of Biomedical Materials and Engineering, College of Materials Science and Engineering, College of Chemistry and Chemical Engineering, State Key Laboratory of Bio-Fibers and Eco-Textiles, Qingdao University, Qingdao 266071, China
| | - Youqing Shen
- Institute of Biomedical Materials and Engineering, College of Materials Science and Engineering, College of Chemistry and Chemical Engineering, State Key Laboratory of Bio-Fibers and Eco-Textiles, Qingdao University, Qingdao 266071, China
- Key Laboratory of Biomass Chemical Engineering of Ministry of Education and Center for Bionanoengineering, College of Chemical and Biological Engineering, Zhejiang University, Hangzhou 310027, China
| | - Zhuxian Zhou
- Key Laboratory of Biomass Chemical Engineering of Ministry of Education and Center for Bionanoengineering, College of Chemical and Biological Engineering, Zhejiang University, Hangzhou 310027, China
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Herb JN, Ollila DW, Stitzenberg KB, Meyers MO. Completion Lymph Node Dissection for Select Patients with Sentinel Node-Positive Melanoma: In Reply to Bartlett and Coit. J Am Coll Surg 2020; 230:1122-1123. [PMID: 32178941 DOI: 10.1016/j.jamcollsurg.2020.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/20/2020] [Indexed: 11/18/2022]
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Isom C, Wheless L, Hooks MA, Kauffmann RM. Early Melanoma Nodal Positivity and Biopsy Rates Before and After Implementation of the 7th Edition of the AJCC Cancer Staging Manual. JAMA Dermatol 2020; 155:572-577. [PMID: 30840034 DOI: 10.1001/jamadermatol.2018.5902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance There has been a continued increase in the incidence of newly diagnosed melanomas, most of which are T1 melanomas. The associations between changes in tumor staging, implemented with the 7th edition of the AJCC Cancer Staging Manual (AJCC 7), and sentinel lymph node biopsy rates and nodal positivity rates remain to be seen. Objective To evaluate the change that the implementation of the AJCC 7 had on staging criteria and the distribution of thin melanomas requiring nodal surgery and nodal positivity rates. Design, Setting, and Participants Retrospective cross-sectional study from 2004 through 2013 of all adults (≥18 years) diagnosed with a T1 (Breslow depth ≤1.0 mm) melanoma using The National Cancer Database that captures 70% of all newly diagnosed cancers from accredited Commission on Cancer organizations, including both academic and community settings. Data were analyzed in May 2017. Exposures Patients were grouped together based on year of diagnosis, before and after 2009. Main Outcomes and Measures To determine the sentinel lymph node biopsy rate before and after the implementation of the AJCC 7. Results A total of 141 280 patients met inclusion criteria. Of 86 846 patients diagnosed from 2004 through 2009, 53.7% (49 644) were male and had a mean (SD) age of 57.7 (16.4) years. Of 54 434 patients diagnosed from 2010 through 2013, 54.3% (31 086) were male and had a mean (SD) age of 59.5 (15.9) years. After 2010, there was a 3.8% decrease in the number of nodal surgeries performed (32 485 of 86 846 patients [37.6%] vs 18 379 of 54 434 patients [33.8%]; P < .001). The nodal positivity rate decreased 1.0% from (9.8% [3166 of 86 846] to 8.8% [1618 of 54 434]) (P < .001). An increase in the proportion of T1b melanomas being evaluated, from 48.8% to 62.2%, was seen (P < .001). Of T1b melanomas that underwent nodal evaluation from 2004 through 2009, 74.0% had Clark level IV (invasion of the reticular dermis) or Clark level V (invasion of the deep, subcutaneous tissue) and 9.5% were ulcerated. From 2010 through 2013, of the T1b melanomas undergoing nodal evaluation, 82.6% had an elevated mitotic rate only, 3.7% were ulcerated, and 13.7% had both ulceration and an elevated mitotic rate. Conclusions and Relevance It appears that after the institution of AJCC 7, there was an overall decrease in the number of T1 melanomas undergoing nodal biopsy without a clinically relevant change in sentinel lymph node positivity, with an increase in the number of T1b melanomas undergoing nodal evaluation.
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Affiliation(s)
- Chelsea Isom
- Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lee Wheless
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary A Hooks
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rondi M Kauffmann
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Use of Completion Lymph Node Dissection for Sentinel Lymph Node-Positive Melanoma. J Am Coll Surg 2020; 230:515-524. [PMID: 31954818 DOI: 10.1016/j.jamcollsurg.2019.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND 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. STUDY DESIGN 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. RESULTS 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). CONCLUSIONS 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.
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Predictive biomarkers and tumor microenvironment in female genital melanomas: a multi-institutional study of 55 cases. Mod Pathol 2020; 33:138-152. [PMID: 31383965 DOI: 10.1038/s41379-019-0345-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 07/11/2019] [Accepted: 07/11/2019] [Indexed: 02/06/2023]
Abstract
Female genital melanomas are rare. At diagnosis, most affected patients have advanced disease. Surgery remains the primary treatment, and adjuvant therapy is largely ineffective. Recently, immune checkpoints and the mitogen-activated protein kinase pathway have been explored as treatment targets. However, evaluation of these biomarkers in genital melanomas is limited. We evaluated the clinicopathological features of 20 vulvar, 32 vaginal, and three cervical melanomas and assessed programmed cell death ligand 1 (PD-L1) expression, CD8 tumor-infiltrating lymphocyte density, mismatch repair proteins, VE1 immunohistochemistry, and KIT and BRAF mutations. The median age of the patients was 66 years, and median tumor sizes were 25, 30, and 20 mm for vulvar, vaginal, and cervical tumors, respectively. Mean mitotic figures were 18, 19, and 30 per mm2. Thirty-seven patients (67%) had operable tumors. After a median follow-up of 15 months, only nine patients (16%) were alive. Eight of the nine survivors did not have lymph node metastasis. Using 5% as the threshold, PD-L1 expression was observed in 55%, 50%, and 33% of vulvar, vaginal, and cervical tumors, respectively, when the Roche SP263 antibody was used and 20%, 53%, and 0%, respectively, when the Dako 28-8 antibody was used. The median CD8 tumor-infiltrating lymphocyte density was significantly higher in vulvar/vaginal than cervical melanomas and correlated with PD-L1 expression. No cases exhibited loss of mismatch repair proteins. Five cases harbored KIT mutations, three of which were hotspots. BRAF V600E mutation was not detected. Univariable analysis showed that tumor size greater than or equal to 33 mm, mitotic figures of greater than or equal to 10 per mm2, lymph node metastasis, and low CD8+ tumor-infiltrating lymphocyte density were adverse prognostic factors. Thus, patients with genital melanomas have a poor prognosis, and evaluation of multiple biomarkers is necessary to identify patients who may benefit from immunotherapy or targeted therapy.
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Stoffels I, Jansen P, Petri M, Goerdt L, Brinker TJ, Griewank KG, Poeppel TD, Schadendorf D, Klode J. Assessment of Nonradioactive Multispectral Optoacoustic Tomographic Imaging With Conventional Lymphoscintigraphic Imaging for Sentinel Lymph Node Biopsy in Melanoma. JAMA Netw Open 2019; 2:e199020. [PMID: 31411710 PMCID: PMC6694392 DOI: 10.1001/jamanetworkopen.2019.9020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/24/2019] [Indexed: 12/16/2022] Open
Abstract
Importance The metastatic status of sentinel lymph nodes (SLNs) is the most relevant prognostic factor in breast cancer, melanoma, and other tumors. The conventional standard to label SLNs is lymphoscintigraphy with technetium Tc 99m. A worldwide shortage and known disadvantages of Tc 99m have intensified efforts to establish alternative, nonradioactive imaging techniques. Objective To assess a new nonradioactive method using multispectral optoacoustic tomographic (MSOT) imaging in comparison with conventional lymphoscintigraphic imaging for SLN biopsy (SLNB) in melanoma. Design, Setting, and Participants Analysis of a cross-sectional study was conducted at the University Hospital-Essen, Skin Cancer Center, Essen, Germany. Between June 2, 2014, and February 22, 2019, 83 patients underwent SLNB with an additional preoperative indocyanine green (ICG) application. Sentinel lymph node basins were preoperatively identified by MSOT imaging, and ICG-labeled SLNs were intraoperatively detected using a near-infrared camera. The surgeons were blinded to the lymphoscintigraphic imaging results in the beginning of the SLNB. Use of a γ probe was restricted until the SLNB procedure was attempted by the nonradioactive method. Main Outcomes and Measures Concordance of SLN basins and SLNs identified by MSOT imaging plus near-infrared camera vs lymphoscintigraphic imaging plus single-photon emission computed tomographic or computed tomographic imaging was assessed. Results Of the 83 patients (mean [SD] age, 54.61 [17.53] years), 47 (56.6%) were men. In 83 surgical procedures, 165 SLNs were excised. The concordance rate of ICG-labeled and Tc 99m-marked detected SLN basins was 94.6% (n = 106 of 112). Intraoperatively, 159 SLNs were detected using a near-infrared camera and 165 were detected by a γ probe, resulting in a concordance rate of 96.4%. Multispectral optoacoustic tomographic imaging visualized SLNs in all anatomic regions with high penetration depth (5 cm). Conclusions and Relevance The findings of this study suggest that nonradioactive SLN detection via MSOT imaging allows identification of SLNs at a frequency equivalent to that of the current radiotracer conventional standard. Multispectral optoacoustic tomographic imaging appears to be a viable nonradioactive alternative to detect SLNs in malignant tumors.
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Affiliation(s)
- Ingo Stoffels
- Department of Dermatology, Venerology and Allergology, University Hospital-Essen, University of Duisburg-Essen, Essen, Germany
- West German Cancer Center, University Duisburg-Essen, Essen, Germany
- German Consortium for Translational Cancer Research, Partner Site, University Hospital-Essen, Essen, Germany
| | - Philipp Jansen
- Department of Dermatology, Venerology and Allergology, University Hospital-Essen, University of Duisburg-Essen, Essen, Germany
- West German Cancer Center, University Duisburg-Essen, Essen, Germany
- German Consortium for Translational Cancer Research, Partner Site, University Hospital-Essen, Essen, Germany
| | - Maximilian Petri
- Department of Dermatology, Venerology and Allergology, University Hospital-Essen, University of Duisburg-Essen, Essen, Germany
- West German Cancer Center, University Duisburg-Essen, Essen, Germany
- German Consortium for Translational Cancer Research, Partner Site, University Hospital-Essen, Essen, Germany
| | - Lukas Goerdt
- Department of Dermatology, Venerology and Allergology, University Hospital-Essen, University of Duisburg-Essen, Essen, Germany
- West German Cancer Center, University Duisburg-Essen, Essen, Germany
- German Consortium for Translational Cancer Research, Partner Site, University Hospital-Essen, Essen, Germany
| | - Titus J. Brinker
- Department of Dermatology, Venerology and Allergology, University Hospital-Essen, University of Duisburg-Essen, Essen, Germany
- West German Cancer Center, University Duisburg-Essen, Essen, Germany
- German Consortium for Translational Cancer Research, Partner Site, University Hospital-Essen, Essen, Germany
| | - Klaus G. Griewank
- Department of Dermatology, Venerology and Allergology, University Hospital-Essen, University of Duisburg-Essen, Essen, Germany
- West German Cancer Center, University Duisburg-Essen, Essen, Germany
- German Consortium for Translational Cancer Research, Partner Site, University Hospital-Essen, Essen, Germany
| | - Thorsten D. Poeppel
- Department of Nuclear Medicine, University Essen-Duisburg, University of Duisburg, Essen, Germany
| | - Dirk Schadendorf
- Department of Dermatology, Venerology and Allergology, University Hospital-Essen, University of Duisburg-Essen, Essen, Germany
- West German Cancer Center, University Duisburg-Essen, Essen, Germany
- German Consortium for Translational Cancer Research, Partner Site, University Hospital-Essen, Essen, Germany
| | - Joachim Klode
- Department of Dermatology, Venerology and Allergology, University Hospital-Essen, University of Duisburg-Essen, Essen, Germany
- West German Cancer Center, University Duisburg-Essen, Essen, Germany
- German Consortium for Translational Cancer Research, Partner Site, University Hospital-Essen, Essen, Germany
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Pavri SN, Han G, Khan S, Han D. Does sentinel lymph node status have prognostic significance in patients with acral lentiginous melanoma? J Surg Oncol 2019; 119:1060-1069. [PMID: 30883783 DOI: 10.1002/jso.25445] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/20/2019] [Accepted: 02/26/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prognostic benefit of sentinel lymph node biopsy (SLNB) and factors predictive of survival specifically in patients with acral lentiginous melanoma (ALM) are unknown. METHODS The SEER database was queried for ALM cases that underwent SLNB from 1998 to 2013. Clinicopathological factors were correlated with SLN status, overall survival (OS), and melanoma-specific survival (MSS). RESULTS Median age for the 753 ALM study patients was 65 years, and 48.2% were male. Median thickness was 2 mm with 38.1% of cases having ulceration. SLN metastases were detected in 194 of 753 cases (25.7%). Multivariable analysis showed that thickness, Clark level IV-V, and ulceration significantly predicted for SLN metastasis (P < 0.05). For patients with positive SLN, 5-year OS and MSS were significantly worse at 48.1% and 58.9%, respectively, compared with 78.7% and 88.5%, respectively, for patients with negative SLN (P < 0.0001). On multivariable analyses, older age, male gender, increasing thickness, ulceration, and a positive SLN significantly predicted for worse OS and MSS (all P < 0.05). CONCLUSION This study confirms the important role of SLNB in ALM. SLN metastases are seen in 25.7% of ALM cases, providing significant prognostic information. In addition, thickness, ulceration status, and SLNB status significantly predict survival in patients with ALM.
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Affiliation(s)
- Sabrina N Pavri
- Aesthetic and Reconstructive Surgery Institute, UF Health Cancer Center-Orlando Health, Orlando, Florida
| | - Gang Han
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, Texas
| | - Sajid Khan
- Section of Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Dale Han
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, Portland, Oregon
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Thomas DC, Han G, Leong SP, Kashani-Sabet M, Vetto J, Pockaj B, White RL, Faries MB, Schneebaum S, Mozzillo N, Charney KJ, Sondak VK, Messina JL, Zager JS, Han D. Recurrence of Melanoma After a Negative Sentinel Node Biopsy: Predictors and Impact of Recurrence Site on Survival. Ann Surg Oncol 2019; 26:2254-2262. [DOI: 10.1245/s10434-019-07369-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Indexed: 01/03/2023]
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Jang BS, Eom KY, Cho HS, Song C, Kim IA, Kim JS. Observational approach on regional lymph node in cutaneous melanomas of extremities. Radiat Oncol J 2019; 37:51-59. [PMID: 30947481 PMCID: PMC6453812 DOI: 10.3857/roj.2018.00507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/11/2019] [Indexed: 11/03/2022] Open
Abstract
PURPOSE We evaluated failure pattern and treatment outcomes of observational approach on regional lymph node (LN) in cutaneous melanoma of extremities and sought to find clinico-pathologic factors related to LN metastases. Material and Methods We retrospectively reviewed 73 patients with cutaneous melanoma of extremities between 2005 and 2016. If preoperative 18-F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT) findings were non-specific for regional LNs, surgical resection of primary tumors with adequate margins was performed without sentinel lymph node biopsy (SLNB) and/or complete lymph node dissection (CLND), irrespective of tumor thickness or size. In patients with suspicious or positive findings on PET/CT or CT, SLNB followed by CLND or CLND was performed at the discretion of the surgeon. We defined LN dissection (LND) as SLNB and/or CLND. RESULTS With a median follow-up of 38 months (range, 6 to 138 months), the dominant pattern of failure was regional failure (17 of total 23 events, 74%) in the observation group (n = 56). Pathologic LN metastases were significant factor for poor regional failure-free survival (hazard ration [HR] = 3.21; 95% confidence interval [CI], 1.03-10.33; p = 0.044) and overall survival (HR = 3.62; 95% CI, 1.02-12.94; p = 0.047) in multivariate analysis. In subgroup analysis for cN0 patients according to the preoperative PET/CT findings, LND group showed the better trend of LRFFS (log rank test, p = 0.192) and RFFS (p = 0.310), although which is not statistically significant. CONCLUSION Observational approach on regional LNs on the basis of the PET/CT in patients with cutaneous melanoma of extremities showed the dominant regional failure pattern compared to upfront LND approach. To reveal regional lymph node status, SLND for cN0 patients may of importance in managing cutaneous melanoma patients.
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Affiliation(s)
- Bum-Sup Jang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
| | - Keun-Yong Eom
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hwan Seong Cho
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Changhoon Song
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In Ah Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae-Sung Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
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dos Santos FDM, da Silva FC, Pedron J, Furian RD, Fortes C, Bonamigo RR. Association between tumor-infiltrating lymphocytes and sentinel lymph node positivity in thin melanoma. An Bras Dermatol 2019; 94:47-51. [PMID: 30726463 PMCID: PMC6360962 DOI: 10.1590/abd1806-4841.20197414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/13/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Sentinel lymph node biopsy in thin invasive primary cutaneous melanoma (up to 1mm thick) is a controversial subject. The presence of tumor-infiltrating lymphocytes could be a factor to be considered in the decision to perform this procedure. OBJECTIVE To evaluate the association between the presence of tumor-infiltrating lymphocytes and lymph node metastases caused by thin primary cutaneous melanoma. METHODS Cross-sectional study with 137 records of thin invasive primary cutaneous melanoma submitted to sentinel lymph node biopsy from 2003 to 2015. The clinical variables considered were age, sex and topography of the lesion. The histopathological variables assessed were: tumor-infiltrating lymphocytes, melanoma subtype, Breslow thickness, Clark levels, number of mitoses per mm2, ulceration, regression and satellitosis. Univariate analyzes and logistic regression tests were performed as well the odds ratio and statistical relevance was considered when p <0.05. RESULTS Among the 137 cases of thin primary cutaneous melanoma submitted to sentinel lymph node biopsy, 10 (7.3%) had metastatic involvement. Ulceration on histopathology was positively associated with the presence of metastatic lymph node, with odds ratio =12.8 (2.77-59.4 95% CI, p=0.001). The presence of moderate/marked tumor-infiltrating lymphocytes was shown to be a protective factor for the presence of metastatic lymph node, with OR=0.20 (0.05-0.72 95% CI, p=0.014). The other variables - clinical and histopathological - were not associated with the outcome. STUDY LIMITATIONS The relatively small number of positive sentinel lymph node biopsy may explain such an expressive association of ulceration with metastatization. CONCLUSIONS In patients with thin invasive primary cutaneous melanoma, few or absent tumor-infiltrating lymphocytes, as well as ulceration, represent independent risk factors for lymph node metastasis.
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Affiliation(s)
| | - Felipe Correa da Silva
- Discipline of Pathology, Faculdade de Medicina da Universidade
Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS),
Brazil
| | - Julia Pedron
- Discipline of Pathology, Faculdade de Medicina da Universidade
Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS),
Brazil
| | | | - Cristina Fortes
- Department of Epidemiology, Istituto Dermopatico dell’Immacolata,
Rome, Italy
| | - Renan Rangel Bonamigo
- Service of Dermatology, Hospital de Clínicas de Porto
Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre (RS), Brazil
- Pathology Post-Graduate Program, Universidade Federal de
Ciências da Saúde de Porto Alegre, Porto Alegre (RS), Brazil
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Bertolli E, Franke V, Calsavara VF, de Macedo MP, Pinto CAL, van Houdt WJ, Wouters MWJM, Duprat Neto JP, van Akkooi ACJ. Validation of a Nomogram for Non-sentinel Node Positivity in Melanoma Patients, and Its Clinical Implications: A Brazilian–Dutch Study. Ann Surg Oncol 2018; 26:395-405. [DOI: 10.1245/s10434-018-7038-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Indexed: 12/14/2022]
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Cheraghlou S, Agogo GO, Girardi M. Treatment of primary nonmetastatic melanoma at high-volume academic facilities is associated with improved long-term patient survival. J Am Acad Dermatol 2018; 80:979-989. [PMID: 30365997 DOI: 10.1016/j.jaad.2018.10.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/04/2018] [Accepted: 10/11/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Previous studies of cancer care have demonstrated improved long-term patient outcomes for those treated at high-volume centers. The influence of treatment center characteristics on outcomes for primary nonmetastatic melanoma is not currently established. OBJECTIVE We aimed to investigate the association of cancer treatment center case volume and academic affiliation with long-term patient survival for cases of primary nonmetastatic melanoma. METHODS Cases of melanoma diagnosed in US adults from 2004 to 2014 and included in the National Cancer Database were identified. Hospitals were grouped by yearly case-volume quartile: bottom quartile, 2 middle quartiles, and top quartile. RESULTS Facility case volume was significantly associated with long-term patient survival (P < .0001). The 5-year survival rates were 76.8%, 81.9%, and 86.4% for patients treated at institutions in the bottom, middle, and top quartiles of case volume, respectively. On multivariate analysis, treatment at centers in both middle quartiles (hazard ratio, 0.834; 95% confidence interval, 0.778-0.895) and in the top quartile (hazard ratio, 0.691; 95% confidence interval, 0.644-0.741) of case volume was associated with improved survival relative to that of patients treated at hospitals in the bottom quartile of case volume. Academic affiliation was associated with improved outcomes for top-quartile- but not middle-quartile-volume facilities. LIMITATIONS Disease-specific survival was not available. CONCLUSIONS Treatment at a high-volume facility is associated with improved long-term patient survival for melanoma. High-volume academic centers have improved patient outcomes compared with other high-volume centers.
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Affiliation(s)
- Shayan Cheraghlou
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - George O Agogo
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael Girardi
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.
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Isaksson K, Nielsen K, Mikiver R, Nieweg OE, Scolyer RA, Thompson JF, Ingvar C. Sentinel lymph node biopsy in patients with thin melanomas: Frequency and predictors of metastasis based on analysis of two large international cohorts. J Surg Oncol 2018; 118:599-605. [DOI: 10.1002/jso.25208] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/26/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Karolin Isaksson
- Department of Clinical Sciences Lund, Surgery; Lund University, Skåne University Hospital; Lund Sweden
| | - Kari Nielsen
- Department of Clinical Sciences Lund, Dermatology; Lund University, Helsingborg Hospital; Helsingborg Sweden
| | - Rasmus Mikiver
- Department of Clinical and Experimental Medicine; Regional Cancer Center South East Sweden, Linköping University; Linköping Sweden
| | - Omgo E. Nieweg
- Melanoma Institute Australia, The University of Sydney; Sydney New South Wales Australia
- Sydney Medical School, The University of Sydney; Sydney New South Wales Australia
- Departments of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital; Camperdown New South Wales Australia
| | - Richard A. Scolyer
- Melanoma Institute Australia, The University of Sydney; Sydney New South Wales Australia
- Sydney Medical School, The University of Sydney; Sydney New South Wales Australia
- Departments of Tissue Pathology and Diagnostic Oncolocy, Royal Prince Alfred Hospital; Camperdown New South Wales Australia
| | - John F. Thompson
- Melanoma Institute Australia, The University of Sydney; Sydney New South Wales Australia
- Sydney Medical School, The University of Sydney; Sydney New South Wales Australia
- Departments of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital; Camperdown New South Wales Australia
| | - Christian Ingvar
- Department of Clinical Sciences Lund, Surgery; Lund University, Skåne University Hospital; Lund Sweden
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Balch CM. Detection of melanoma metastases with the sentinel node biopsy: the legacy of Donald L. Morton, MD (1934-2014). Clin Exp Metastasis 2018; 35:425-429. [PMID: 29855858 DOI: 10.1007/s10585-018-9908-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 05/29/2018] [Indexed: 01/07/2023]
Abstract
Dr. Donald L. Morton was clearly the pioneer of the sentinel node biopsy, which was a major advance in oncology that has improved the management of cancer patients worldwide. He conducted a series of practice-changing clinical trials to validate the important staging role of the sentinel lymph node biopsy for melanoma, and also spawned other studies that demonstrated its staging value in multiple other cancer types, most notably in breast cancer, gastric cancer, and colorectal cancer. His many contributions in this field have provided a unique opportunity to study host/tumor relationships, since the sentinel lymph node is the first location were the host immune defenses are confronted with metastasis arising from the primary cancer.
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Affiliation(s)
- Charles M Balch
- University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Sullivan RJ, Atkins MB, Kirkwood JM, Agarwala SS, Clark JI, Ernstoff MS, Fecher L, Gajewski TF, Gastman B, Lawson DH, Lutzky J, McDermott DF, Margolin KA, Mehnert JM, Pavlick AC, Richards JM, Rubin KM, Sharfman W, Silverstein S, Slingluff CL, Sondak VK, Tarhini AA, Thompson JA, Urba WJ, White RL, Whitman ED, Hodi FS, Kaufman HL. An update on the Society for Immunotherapy of Cancer consensus statement on tumor immunotherapy for the treatment of cutaneous melanoma: version 2.0. J Immunother Cancer 2018; 6:44. [PMID: 29848375 PMCID: PMC5977556 DOI: 10.1186/s40425-018-0362-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/17/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cancer immunotherapy has been firmly established as a standard of care for patients with advanced and metastatic melanoma. Therapeutic outcomes in clinical trials have resulted in the approval of 11 new drugs and/or combination regimens for patients with melanoma. However, prospective data to support evidence-based clinical decisions with respect to the optimal schedule and sequencing of immunotherapy and targeted agents, how best to manage emerging toxicities and when to stop treatment are not yet available. METHODS To address this knowledge gap, the Society for Immunotherapy of Cancer (SITC) Melanoma Task Force developed a process for consensus recommendations for physicians treating patients with melanoma integrating evidence-based data, where available, with best expert consensus opinion. The initial consensus statement was published in 2013, and version 2.0 of this report is an update based on a recent meeting of the Task Force and extensive subsequent discussions on new agents, contemporary peer-reviewed literature and emerging clinical data. The Academy of Medicine (formerly Institute of Medicine) clinical practice guidelines were used as a basis for consensus development with an updated literature search for important studies published between 1992 and 2017 and supplemented, as appropriate, by recommendations from Task Force participants. RESULTS The Task Force considered patients with stage II-IV melanoma and here provide consensus recommendations for how they would incorporate the many immunotherapy options into clinical pathways for patients with cutaneous melanoma. CONCLUSION These clinical guidleines provide physicians and healthcare providers with consensus recommendations for managing melanoma patients electing treatment with tumor immunotherapy.
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Affiliation(s)
- Ryan J. Sullivan
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
| | | | | | - Sanjiv S. Agarwala
- St. Luke’s Cancer Center and Temple University, Center Valley, PA 18034 USA
| | | | | | | | | | | | | | - Jose Lutzky
- Mt. Sinai Medical Center, Miami Beach, FL 33140 USA
| | | | | | | | - Anna C. Pavlick
- New York University Cancer Institute, New York, NY 10016 USA
| | | | - Krista M. Rubin
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
| | - William Sharfman
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD 21231 USA
| | | | | | - Vernon K. Sondak
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612 USA
| | | | | | - Walter J. Urba
- Earle A. Chiles Research Institute, Providence Cancer Center, Portland, OR 97213 USA
| | | | | | | | - Howard L. Kaufman
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
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28
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Wong SL, Kennedy EB, Lyman GH. Sentinel Lymph Node Biopsy and Management of Regional Lymph Nodes in Melanoma: American Society of Clinical Oncology and Society of Surgical Oncology Clinical Practice Guideline Update Summary. J Oncol Pract 2018; 14:242-245. [DOI: 10.1200/jop.2017.028241] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Sandra L. Wong
- Dartmouth-Hitchcock Medical Center, Lebanon, NH; American Society for Clinical Oncology, Alexandria, VA; and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Erin B. Kennedy
- Dartmouth-Hitchcock Medical Center, Lebanon, NH; American Society for Clinical Oncology, Alexandria, VA; and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Gary H. Lyman
- Dartmouth-Hitchcock Medical Center, Lebanon, NH; American Society for Clinical Oncology, Alexandria, VA; and Fred Hutchinson Cancer Research Center, Seattle, WA
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29
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Schmalbach CE, Bradford CR. Completion lymphadenectomy for sentinel node positive cutaneous head & neck melanoma. Laryngoscope Investig Otolaryngol 2018; 3:43-48. [PMID: 29492467 PMCID: PMC5824115 DOI: 10.1002/lio2.136] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/22/2017] [Accepted: 12/24/2017] [Indexed: 12/13/2022] Open
Abstract
The application and utility of melanoma sentinel lymph node biopsy (SLNB) has evolved significantly since its inception over two decades ago. The current focus has shifted from a staging modality to potentially a therapeutic intervention. Recent research to include large multi-institutional randomized trials have attempted to answer the question: is a completion lymph node dissection (CLND) required following a positive SLNB? This review provides an evidence-based, contemporary review of the utility of CLND for SLNB positive head and neck cutaneous melanoma patients. Level of Evidence NA.
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Affiliation(s)
- Cecelia E Schmalbach
- Department of Otolaryngology-Head & Neck Surgery Indiana University School of Medicine, Roudebush VA Medical Center Indianapolis Indiana U.S.A
| | - Carol R Bradford
- School of Medicine University of Michigan Ann Arbor Michigan U.S.A
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30
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Wong SL, Faries MB, Kennedy EB, Agarwala SS, Akhurst TJ, Ariyan C, Balch CM, Berman BS, Cochran A, Delman KA, Gorman M, Kirkwood JM, Moncrieff MD, Zager JS, Lyman GH. Sentinel Lymph Node Biopsy and Management of Regional Lymph Nodes in Melanoma: American Society of Clinical Oncology and Society of Surgical Oncology Clinical Practice Guideline Update. Ann Surg Oncol 2017; 25:356-377. [PMID: 29236202 DOI: 10.1245/s10434-017-6267-7] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Indexed: 01/01/2023]
Abstract
PURPOSE To update the American Society of Clinical Oncology (ASCO)-Society of Surgical Oncology (SSO) guideline for sentinel lymph node (SLN) biopsy in melanoma. METHODS An ASCO-SSO panel was formed, and a systematic review of the literature was conducted regarding SLN biopsy and completion lymph node dissection (CLND) after a positive sentinel node in patients with melanoma. RESULTS Nine new observational studies, two systematic reviews and an updated randomized controlled trial (RCT) of SLN biopsy, as well as two randomized controlled trials of CLND after positive SLN biopsy, were included. RECOMMENDATIONS Routine SLN biopsy is not recommended for patients with thin melanomas that are T1a (non-ulcerated lesions < 0.8 mm in Breslow thickness). SLN biopsy may be considered for thin melanomas that are T1b (0.8 to 1.0 mm Breslow thickness or <0.8 mm Breslow thickness with ulceration) after a thorough discussion with the patient of the potential benefits and risk of harms associated with the procedure. SLN biopsy is recommended for patients with intermediate-thickness melanomas (T2 or T3; Breslow thickness of >1.0 to 4.0 mm). SLN biopsy may be recommended for patients with thick melanomas (T4; > 4.0 mm in Breslow thickness), after a discussion of the potential benefits and risks of harm. In the case of a positive SLN biopsy, CLND or careful observation are options for patients with low-risk micrometastatic disease, with due consideration of clinicopathological factors. For higher risk patients, careful observation may be considered only after a thorough discussion with patients about the potential risks and benefits of foregoing CLND. Important qualifying statements outlining relevant clinicopathological factors, and details of the reference patient populations are included within the guideline.
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Affiliation(s)
- Sandra L Wong
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Mark B Faries
- The Angeles Clinic and Research Institute, Santa Monica, CA, USA
| | - Erin B Kennedy
- American Society of Clinical Oncology, Alexandria, VA, USA.
| | | | | | | | | | | | - Alistair Cochran
- Los Angeles Center for Health Services, University of California, Los Angeles, CA, USA
| | | | | | - John M Kirkwood
- University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | | | - Jonathan S Zager
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Gary H Lyman
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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31
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Wong SL, Faries MB, Kennedy EB, Agarwala SS, Akhurst TJ, Ariyan C, Balch CM, Berman BS, Cochran A, Delman KA, Gorman M, Kirkwood JM, Moncrieff MD, Zager JS, Lyman GH. Sentinel Lymph Node Biopsy and Management of Regional Lymph Nodes in Melanoma: American Society of Clinical Oncology and Society of Surgical Oncology Clinical Practice Guideline Update. J Clin Oncol 2017; 36:399-413. [PMID: 29232171 DOI: 10.1200/jco.2017.75.7724] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Purpose To update the American Society of Clinical Oncology (ASCO)-Society of Surgical Oncology (SSO) guideline for sentinel lymph node (SLN) biopsy in melanoma. Methods An ASCO-SSO panel was formed, and a systematic review of the literature was conducted regarding SLN biopsy and completion lymph node dissection (CLND) after a positive sentinel node in patients with melanoma. Results Nine new observational studies, two systematic reviews, and an updated randomized controlled trial of SLN biopsy, as well as two randomized controlled trials of CLND after positive SLN biopsy, were included. Recommendations Routine SLN biopsy is not recommended for patients with thin melanomas that are T1a (nonulcerated lesions < 0.8 mm in Breslow thickness). SLN biopsy may be considered for thin melanomas that are T1b (0.8 to 1.0 mm Breslow thickness or < 0.8 mm Breslow thickness with ulceration) after a thorough discussion with the patient of the potential benefits and risk of harms associated with the procedure. SLN biopsy is recommended for patients with intermediate-thickness melanomas (T2 or T3; Breslow thickness of > 1.0 to 4.0 mm). SLN biopsy may be recommended for patients with thick melanomas (T4; > 4.0 mm in Breslow thickness), after a discussion of the potential benefits and risks of harm. In the case of a positive SLN biopsy, CLND or careful observation are options for patients with low-risk micrometastatic disease, with due consideration of clinicopathological factors. For higher-risk patients, careful observation may be considered only after a thorough discussion with patients about the potential risks and benefits of foregoing CLND. Important qualifying statements outlining relevant clinicopathological factors and details of the reference patient populations are included within the guideline. Additional information is available at www.asco.org/melanoma-guidelines and www.asco.org/guidelineswiki .
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Affiliation(s)
- Sandra L Wong
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Mark B Faries
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Erin B Kennedy
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Sanjiv S Agarwala
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Timothy J Akhurst
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Charlotte Ariyan
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Charles M Balch
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Barry S Berman
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Alistair Cochran
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Keith A Delman
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Mark Gorman
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - John M Kirkwood
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Marc D Moncrieff
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jonathan S Zager
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Gary H Lyman
- Sandra L. Wong, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Mark B. Faries, The Angeles Clinic and Research Institute, Santa Monica; Alistair Cochran, University of California, Los Angeles Center for Health Services, Los Angeles, CA; Erin B. Kennedy, American Society of Clinical Oncology, Alexandria, VA; Sanjiv S. Agarwala, St Luke's Cancer Center, Easton; John M. Kirkwood, University of Pittsburgh Cancer Institute, Pittsburgh, PA; Timothy J. Akhurst, Peter MacCallum Cancer Centre, Victoria, Australia; Charlotte Ariyan, Memorial Sloan Kettering Cancer Center, New York, NY; Charles M. Balch, MD Anderson Cancer Center, Houston, TX; Barry S. Berman, Broward Health, Fort Lauderdale; Jonathan S. Zager, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Keith A. Delman, Emory University, Atlanta, GA; Mark Gorman, Silver Spring, MD; Marc D. Moncrieff, Norfolk and Norwich University Hospital, Norwich, United Kingdom; and Gary H. Lyman, Fred Hutchinson Cancer Research Center, Seattle, WA
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Alessi C, Scapulatempo Neto C, Viana CR, Vazquez VDL. PD-1/PD-L1 and VEGF-A/VEGF-C expression in lymph node microenvironment and association with melanoma metastasis and survival. Melanoma Res 2017; 27:565-572. [PMID: 28984690 DOI: 10.1097/cmr.0000000000000396] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Regional lymph nodes are affected frequently by melanoma metastasis. Its microenvironment may be associated with tumor progression. We investigated sentinel nodes with and without tumor and negative nodes surrounding positive nodes, looking for patterns related to tumor immune interaction and lymphovascular progression. We quantified programmed cell death protein 1 (PD-1)/programmed cell death-ligand 1, vascular endothelial growth factor (VEGF)-A/VEGF-C expressions in lymph nodes of 103 patients who underwent sentinel lymph node biopsy. Two groups were studied: negative sentinel lymph nodes and positive ones. Negative lymph nodes of sequential lymphadenectomy from positive cases were also studied. Markers were assessed by immunohistochemistry. Results were related to clinical/histological outcomes. VEGF-A/VEGF-C analysis showed higher positivity in metastatic nodes and higher positivity in the surrounding negative nodes from positive cases in comparison with nonmetastatic patients. Programmed cell death-ligand 1, studied only in metastasis, presented high positivity, not associated with prognosis. PD-1 expressions were similar in the groups with a 1% cutoff and higher in the metastasis with a 5% cutoff. Higher VEGF-A expression was related to higher pathological stages. PD-1 expression in the lymph node was associated with higher survival. Other clinical and histopatological variables were not associated with marker expression patterns. VEGF-A and VEGF-C expressions in lymph nodes were associated with the presence of lymph node metastasis. PD-1 expression in the lymph node was related to higher survival rates and this should be explored in the context of adjuvant immunotherapy.
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Affiliation(s)
- Cristina Alessi
- aDepartment of Dermatology in Medical Clinic 'Alessi e Rocha' and Medical Specialists Ambulatories of Barretos bIEP/CEPOM - Research Institute and Molecular Oncology Research Center cDepartment of Surgery - Melanoma and Sarcoma, Barretos Cancer Hospital, Barretos dDepartment of Pathology of Laboratório Bacchi, Botucatu, São Paulo ePathology Service, Américas Centro Oncológico Integrado, Rio de Janeiro, Brazil
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A prediction tool incorporating the biomarker S-100B for patient selection for completion lymph node dissection in stage III melanoma. Eur J Surg Oncol 2017; 43:1753-1759. [DOI: 10.1016/j.ejso.2017.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 06/23/2017] [Accepted: 07/13/2017] [Indexed: 11/20/2022] Open
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Chu BS, Koffi W, Hoehn RS, Ertel A, Shah SA, Ahmad SA, Sussman JJ, Neuman HB, Abbott DE. Improvement and persistent disparities in completion lymph node dissection: Lessons from the National Cancer Database. J Surg Oncol 2017; 116:1176-1184. [PMID: 28743173 DOI: 10.1002/jso.24766] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 06/21/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Completion lymph node dissection (CLND) is recommended for melanoma patients with positive sentinel lymph node biopsies (SLNB); however, 50% do not undergo CLND. We sought to determine CLND trends over time, and factors contributing to variability. METHODS The NCDB was queried for patients undergoing wide local excision (WLE), with or without SLNB and CLND. Cohorts were created based on demographic/socioeconomic variables and era of treatment (Era 1: 2003-07, Era 2: 2008-12). Univariate and multivariate analyses identified factors associated with performance of or trends in CLND. RESULTS 122 849 underwent WLE with SLNB. Of 24 267 (19.8%) with +SLNB, 13 594 (56.0%) continued to CLND. In multivariate analyses, Medicaid (OR 0.78; P = 0.04) or Medicare (OR 0.79; P < 0.01) in Era 1 and patients without insurance in Era 2 (OR 0.78; P = 0.01) underwent less CLND. In both eras, Blacks (OR 0.45; P < 0.01, OR 0.59; P < 0.01), head/neck lesions (OR 0.72; P < 0.01, OR 0.66; P < 0.01) and lower extremity lesions (OR 0.75; P < 0.01, OR 0.72; P < 0.01) underwent less CLND. However, Blacks experienced greatest increase in CLND usage (+9.2%). CONCLUSIONS CLND usage continues to be low and racial/socioeconomic disparities persist. Until the results of MSLT-2 become available, continued focus on understanding poor adherence to, and improving rates of CLND is necessary.
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Affiliation(s)
- Brian S Chu
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Wima Koffi
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Richard S Hoehn
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Audrey Ertel
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Heather B Neuman
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Durham AB, Schwartz JL, Lowe L, Zhao L, Johnson AG, Harms KL, Bichakjian CK, Orsini AP, McLean SA, Bradford CR, Cohen MS, Johnson TM, Sabel MS, Wong SL. The natural history of thin melanoma and the utility of sentinel lymph node biopsy. J Surg Oncol 2017; 116:1185-1192. [PMID: 28715140 DOI: 10.1002/jso.24765] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/21/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Current literature may overestimate the risk of nodal metastasis from thin melanoma due to reporting of data only from lesions treated with SLNB. Our objective was to define the natural history of thin melanoma, assessing the likelihood of nodal disease, in order to guide selection for SLNB. METHODS Retrospective review. The primary outcome was the rate of nodal disease. Clinicopathologic factors were evaluated to find associations with nodal disease. RESULTS Five hundred and twelve lesions, follow up available for 488 (median: 48 months). Lesions treated with WLE/SLNB compared to WLE alone were more likely to have high-risk features. The rate of nodal disease was higher in the WLE/SLNB group (24 positive SLNB, five false-negative SLNB with nodal recurrence: 10.2%) compared to WLE alone (four nodal recurrences: 2.0%). Univariate analysis showed age ≤45, Breslow depth ≥0.85 mm, mitotic rate >1 mm2 , and ulceration were associated with nodal disease. Multivariate analysis confirmed the association of age ≤45 and ulceration. CONCLUSIONS SLNB for melanoma 0.75-0.99 mm should be considered in patients age ≤45, Breslow depth ≥0.85 mm, mitotic rate >1 mm2 , and/or with ulceration. Thin melanoma <0.85 mm without high-risk features may be treated with WLE alone.
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Affiliation(s)
- Alison B Durham
- Department of Dermatology, University of Michigan Health System, Ann Arbor, Michigan
| | - Jennifer L Schwartz
- Department of Dermatology, University of Michigan Health System, Ann Arbor, Michigan
| | - Lori Lowe
- Department of Pathology, University of Michigan Health System, Ann Arbor, Michigan
| | - Lili Zhao
- Department of Biostatistics, University of Michigan Health System, Ann Arbor, Michigan
| | | | - Kelly L Harms
- Department of Dermatology, University of Michigan Health System, Ann Arbor, Michigan
| | | | - Amy P Orsini
- Department of Dermatology, University of Michigan Health System, Ann Arbor, Michigan
| | - Scott A McLean
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Carol R Bradford
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Mark S Cohen
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Timothy M Johnson
- Department of Dermatology, University of Michigan Health System, Ann Arbor, Michigan.,Department of Otolaryngology - Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan.,Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Michael S Sabel
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Sandra L Wong
- Department of Surgery, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Onega T, Reisch LM, Frederick PD, Geller BM, Nelson HD, Lott JP, Radick AC, Elder DE, Barnhill RL, Piepkorn MW, Elmore JG. Use of Digital Whole Slide Imaging in Dermatopathology. J Digit Imaging 2017; 29:243-53. [PMID: 26546178 DOI: 10.1007/s10278-015-9836-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Digital whole slide imaging (WSI) is an emerging technology for pathology interpretation, with specific challenges for dermatopathology, yet little is known about pathologists' practice patterns or perceptions regarding WSI for interpretation of melanocytic lesions. A national sample of pathologists (N = 207) was recruited from 864 invited pathologists from ten US states (CA, CT, HI, IA, KY, LA, NJ, NM, UT, and WA). Pathologists who had interpreted melanocytic lesions in the past year were surveyed in this cross-sectional study. The survey included questions on pathologists' experience, WSI practice patterns and perceptions using a 6-point Likert scale. Agreement was summarized with descriptive statistics to characterize pathologists' use and perceptions of WSI. The majority of participating pathologists were between 40 and 59 years of age (62%) and not affiliated with an academic medical center (71%). Use of WSI was seen more often among dermatopathologists and participants affiliated with an academic medical center. Experience with WSI was reported by 41%, with the most common type of use being for education and testing (CME, board exams, and teaching in general, 71%), and clinical use at tumor boards and conferences (44%). Most respondents (77%) agreed that accurate diagnoses can be made with this technology, and 59% agreed that benefits of WSI outweigh concerns. However, 78% of pathologists reported that digital slides are too slow for routine clinical interpretation. The respondents were equally split as to whether they would like to adopt WSI (49%) or not (51%). The majority of pathologists who interpret melanocytic lesions do not use WSI, but among pathologists who do, use is largely for CME, licensure/board exams, and teaching. Positive perceptions regarding WSI slightly outweigh negative perceptions. Understanding practice patterns with WSI as dissemination advances may facilitate concordance of perceptions with adoption of the technology.
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Affiliation(s)
- Tracy Onega
- Department of Biomedical Data Science, Department of Epidemiology, Norris Cotton Cancer Center, Lebanon, NH, USA.
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
| | | | | | - Berta M Geller
- Department of Family Medicine, University of Vermont Burlington, Burlington, VT, USA
| | | | | | | | - David E Elder
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Raymond L Barnhill
- Department of Pathology, Institut Curie, Paris, France
- University of California, Los Angeles, CA, USA
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Dermatopathology Northwest, Bellevue, WA, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington, Seattle, WA, USA
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Santos-Juanes J, Fernández-Vega I, Galache Osuna C, Coto-Segura P, Martínez-Camblor P. Sentinel lymph node biopsy plus wide local excision vs. wide location excision alone for primary cutaneous melanoma: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2017; 31:241-246. [PMID: 27592851 DOI: 10.1111/jdv.13824] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 05/18/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy and wide local excision of the primary melanoma (SLNB) is now a standard staging procedure for patients with melanomas 1 mm or more in thickness, but its therapeutic benefit is not clear. OBJECTIVE To determine whether there is an association between performance of SLNB and patient prognosis. METHODS Studies assessing the association between performance of SLNB and patient prognosis were pooled from MEDLINE, EMBASE, PubMed, Cochrane Database of Systematic Reviews and Google Scholar. From each study, first author's last name, publication year, origin country, type of study design, characteristics of participants and the Hazard risk (HR) for melanoma specific survival (MSS) with the corresponding 95% confidence interval (95% CI) were collected. Methodological assessment of the studies was evaluated using the Newcastle-Ottawa scale (NOS) and the 'Risk of bias' tool detailed in the Cochrane Handbook for Systematic Reviews of Interventions. Meta-analyses for the global HR were performed. In addition, in order to explore the sources of heterogeneity among the studies, sensitivity analyses are also provided. RESULTS A total of six studies with 8764 patients who had undergone SLNB and 11054 patients who had undergone wide location excision alone (WLEA) were identified for the analysis. The indicators suggest that the heterogeneity is low: τ2 = 0; H = 1 [1; 1.74]; I2 = 0% [0%; 66.5%]. Evidence for publication bias was not found (Egger's test P = 0.4654). The pooled MSS HR from fixed effects analysis was determined to be 0.88 (95% CI = 0.80-0.96). CONCLUSIONS Although no significant survival difference was observed in four of the six series, the pooling summary data from all the studies that deal with this issue suggested that SLNB is associated with a significantly better outcome compared with WLEA for localized melanoma.
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Affiliation(s)
- J Santos-Juanes
- Dermatology II Department of Hospital Universitario Central de Asturias, Oviedo, Spain
| | - I Fernández-Vega
- Pathology Department of Hospital Universitario Araba, Álava, Spain
| | - C Galache Osuna
- Departamento de Radiodiagnóstico, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - P Coto-Segura
- Dermatology II Department of Hospital Universitario Central de Asturias, Oviedo, Spain
| | - P Martínez-Camblor
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Universidad Autónoma de Chile, Santiago, Chile
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Dunne JA, Wormald JCR, Steele J, Woods E, Odili J, Powell BWEM. Is sentinel lymph node biopsy warranted for desmoplastic melanoma? A systematic review. J Plast Reconstr Aesthet Surg 2017; 70:274-280. [PMID: 28017261 DOI: 10.1016/j.bjps.2016.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 10/31/2016] [Accepted: 11/08/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Desmoplastic melanoma (DM) is an uncommon malignancy associated with a high local recurrence rate. The aim of this systematic review was to determine the positivity rate of sentinel lymph node biopsy (SLNB) in patients with DM. The secondary outcome was to establish if SLNB is warranted for both pure DM (PDM) and mixed DM (MDM). METHODS A full systematic literature review of SLNB in DM was performed by two authors in January 2016. Ovid MEDLINE, Ovid EMBASE and the Cochrane Central Register of Controlled Trials were searched. RESULTS Sixteen studies involving 1519 patients having SLNB in DM were included, of which 99 patients had positive SLNB (6.5%). Two articles reported a significantly reduced disease-free survival (DFS) with positive SLNB and three published a reduced melanoma-specific survival (MSS). Six studies compared SLNB in MDM and PDM. Of the 275 patients, 38 (13.8%) had a positive SLNB in MDM compared to 17 of 313 patients (5.4%) with positive SLNB in PDM. CONCLUSIONS Rates of positive SLNB in DM are reduced compared to other variants of melanoma; however, nodal status may still predict DFS and MSS. MDM is associated with a higher rate of micro-metastases to regional lymph nodes than PDM, and DFS and MSS may be lesser in MDM than in PDM. We would recommend the consideration of SLNB in MDM. However, with such low rates of positive SLNB in PDM, and in the absence of high-risk features to stratify patients, we would not recommend SLNB in PDM.
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Affiliation(s)
- Jonathan A Dunne
- Department of Plastic and Reconstructive Surgery, St George's Hospital, Blackshaw Rd, Tooting, London, SW17 0QT, United Kingdom.
| | - Justin C R Wormald
- Department of Plastic and Reconstructive Surgery, St George's Hospital, Blackshaw Rd, Tooting, London, SW17 0QT, United Kingdom
| | - Jessica Steele
- Department of Plastic and Reconstructive Surgery, St George's Hospital, Blackshaw Rd, Tooting, London, SW17 0QT, United Kingdom
| | - Elizabeth Woods
- Department of Plastic and Reconstructive Surgery, St George's Hospital, Blackshaw Rd, Tooting, London, SW17 0QT, United Kingdom
| | - Joy Odili
- Department of Plastic and Reconstructive Surgery, St George's Hospital, Blackshaw Rd, Tooting, London, SW17 0QT, United Kingdom
| | - Barry W E M Powell
- Department of Plastic and Reconstructive Surgery, St George's Hospital, Blackshaw Rd, Tooting, London, SW17 0QT, United Kingdom
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Mihai MM, Holban AM, Călugăreanu A, Orzan OA. Recent advances in diagnosis and therapy of skin cancers through nanotechnological approaches. NANOSTRUCTURES FOR CANCER THERAPY 2017:285-306. [DOI: 10.1016/b978-0-323-46144-3.00011-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Rutkowski P. Introduction to the special issue of European Journal of Surgical Oncology: New roads in melanoma management. Eur J Surg Oncol 2016; 43:513-516. [PMID: 28034500 DOI: 10.1016/j.ejso.2016.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 12/06/2016] [Indexed: 12/27/2022] Open
Affiliation(s)
- P Rutkowski
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Department of Soft Tissue/Bone Sarcoma and Melanoma, Roentgena Str. 5, 02-781 Warsaw, Poland.
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Tardelli E, Mazzarri S, Rubello D, Gennaro M, Fantechi L, Duce V, Romanini A, Chondrogiannis S, Volterrani D, Colletti PM, Manca G. Sentinel Lymph Node Biopsy in Cutaneous Melanoma: Standard and New Technical Procedures and Clinical Advances. A Systematic Review of the Literature. Clin Nucl Med 2016; 41:e498-e507. [PMID: 27749418 DOI: 10.1097/rlu.0000000000001370] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Melanoma is an important public health problem, and its incidence is increasing worldwide. The disease status of regional lymph nodes is the most important prognostic factor in early-stage melanoma patients. Sentinel lymph node biopsy (SLNB) was introduced in the early 1990s as a less invasive procedure than complete lymph node dissection to allow histopathologic evaluation of the "sentinel lymph node" (SLN), which is the first node along the lymphatic pathway from a primary tumor. Sentinel lymph node biopsy has minimal complication risks compared with standard complete lymph node dissection. Currently, SLNB is the accepted method for staging patients with clinically node-negative cutaneous melanoma and provides the most powerful prognostic information by evaluating the nodal basin status. The current practice of SLNB consists of the injection of Tc-labeled radiopharmaceutical, preoperative lymphoscintigraphy with the possibility of using the SPECT/CT hybrid imaging, and intraoperative SLN localization using a handheld gamma probe with or without the use of blue dye. Recently, the SLN localization and detection have been enhanced with the use of new tracers and new intraoperative devices, which have demonstrated to be particularly useful in melanomas of the head and neck region and in area of complex anatomy. Despite these important advances in the technology and the increasing experience in SLN mapping, major research centers have reported a false-negative rate higher than 15%. This relatively high false-negative rate, greater than those reported in the initial validation studies, points out the importance for the nuclear medicine community to continuously improve their knowledge on the biological behavior of melanoma and to improve the technical aspects that may allow more precise staging. For the SLNB procedure to be accurate, it is of critical importance that all "true" SLNs are identified and removed for examination. The aim of this article is to provide general information about the SLNB procedure in clinical practice highlighting the importance of standardization and accuracy of SLN identification in the light of the most recent technical innovations.
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Affiliation(s)
- Elisa Tardelli
- From the *Regional Center of Nuclear Medicine, University Hospital of Pisa, Pisa; †Department of Nuclear Medicine, Santa Maria della Misericordia Rovigo Hospital, Rovigo; ‡Nuclear Medicine Department, Sant'Andrea Hospital, La Spezia; §Department of Oncology, University Hospital of Pisa, Pisa, Italy; and ∥Department of Nuclear Medicine, University of Southern California, Los Angeles, CA
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Rubinstein JC, Han G, Jackson L, Bulloch K, Ariyan S, Narayan D, Rothberg BG, Han D. Regression in thin melanoma is associated with nodal recurrence after a negative sentinel node biopsy. Cancer Med 2016; 5:2832-2840. [PMID: 27671840 PMCID: PMC5083736 DOI: 10.1002/cam4.922] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/21/2016] [Accepted: 08/23/2016] [Indexed: 02/06/2023] Open
Abstract
Prognostic markers for nodal metastasis in thin melanoma patients are debated. We present a single institution study looking at factors predictive of nodal disease in thin melanoma patients. Retrospective review from 1997 to 2012 identified 252 patients with thin melanoma (≤1 mm) who underwent a sentinel lymph node biopsy (SLNB). Node‐positive patients included positive SLNB patients and negative SLNB patients who developed a nodal recurrence (false‐negative SLNB). Clinicopathologic characteristics were correlated with nodal status and outcome. Median follow‐up was 45.5 months. Twelve of 252 patients (4.8%) were node‐positive including six positive SLNB (2.4%) and six false‐negative SLNB (2.4%) patients. No clinicopathologic factors were significantly correlated with nodal disease. For the six false‐negative SLNB patients, median time to nodal recurrence was 37.5 months. Regression was seen in only 16% of cases, but the rate increased to 60% for false‐negative SLNB cases. Both age (odds ratio [OR]: 1.09, 95% CI: 1.01–1.17; P = 0.02) and regression (OR: 8.33, 95% CI: 1.34–52.63; P = 0.02) were significantly associated with nodal recurrence after a negative SLNB on univariable analysis. Nodal disease in thin melanoma patients was seen in 4.8% of cases. Although regression was not correlated with nodal metastasis, it was correlated with a false‐negative SLNB. Patients with thin melanoma and regression may need more intensive surveillance after a negative SLNB. Further study is needed to determine if the same immune mechanisms that result in regression in primary tumors also lead to regression in lymph nodes, which may decrease detection of melanoma nodal metastases.
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Affiliation(s)
- Jill C Rubinstein
- Section of Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, 06520
| | - Gang Han
- Department of Epidemiology & Biostatistics, Texas A&M, College Station, Texas, 77843
| | - Laura Jackson
- Medical Oncology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, 06520
| | - Kaleigh Bulloch
- Medical Oncology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, 06520
| | - Stephan Ariyan
- Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, 06520
| | - Deepak Narayan
- Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, 06520
| | - Bonnie G Rothberg
- Medical Oncology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, 06520
| | - Dale Han
- Section of Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, 06520.
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Dinh KH, Harris AF, LaFemina J, Whalen GF, Sullivan M, Licho R, Hill T, Lambert LA. Advantages of day-before lymphoscintigraphy and undiluted methylene blue dye injections for sentinel lymph node biopsies for melanoma. J Surg Oncol 2016; 114:947-950. [PMID: 27634654 DOI: 10.1002/jso.24432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 08/22/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Lymphatic mapping (LM) and blue dye injections are essential to identification of sentinel lymph nodes (SLN) for melanoma. LM is performed the day before (DB) or the same day (SD) of surgery, but the optimal timing is unknown. Similarly, methylene blue (MB), used during SLN biopsy (SLNB), is administered diluted (dMB) or undiluted (uMB), but the relative efficacies are unknown. METHODS Patients who underwent SLNB for melanoma from 2009 to 2013 at our institution were evaluated. Outcomes included operative correlation with LM, SLN identification, and postoperative complications. RESULTS One hundred seventy-one patients underwent SLNB. Sixty-seven (39%) had DB LM. Sixty-seven (39%) received uMB. Operative findings correlated with both LM groups, though the DB patients had lower background count (P = 0.018) and lower highest SLN radioactive signal count (P = 0.046). More uMB patients had blue SLNs (90% vs. 68%, P = 0.001). There was no difference in the total number of SLNs or complication rates in the LM and MB groups. CONCLUSIONS This is the first study to compare the use of DB LM with SD LM and the efficacy of uMB versus dMB. DB LM and uMB offer advantageous alternatives for patients and their surgeons without loss of accuracy or increased morbidity. J. Surg. Oncol. 2016;114:947-950. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Kate H Dinh
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Ariana F Harris
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jennifer LaFemina
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Giles F Whalen
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Mary Sullivan
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Robert Licho
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Thomas Hill
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Laura A Lambert
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
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Wollina U, Langner D, Schönlebe J, Tanner C, Fuchs M, Nowak A. Sentinel lymph node biopsy in early melanoma-comparison of two techniques for sentinel removal. Wien Med Wochenschr 2016; 167:100-103. [PMID: 27577250 DOI: 10.1007/s10354-016-0499-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 07/13/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy is an established technique for melanoma staging. OBJECTIVE There are no studies available comparing different techniques for the removal of sentinel lymph nodes related to safety and postsurgical complication rate. METHODS This is a retrospective single-center trial. We analyzed the postsurgical complications in 201 consecutive melanoma patients with ligature of lymphatic vessels by sutures (group A) and in 91 consecutive patients with occlusion of lymphatic vessels by bipolar tweezers (group B). We paid particular attention to complications related to disturbed lymphatic function, such as lymph edema, lymphatic fistula, and seroma. RESULTS The complication rate was 5.5 % (group A) and 9.6 % (group B) which is in the range of other published trials (p = 0.89). There was no increase of complications related to lymphatic vessels in group B, although the rate of patients with more than two sentinel lymph nodes removed was 5‑times higher than in group A. CONCLUSIONS Removal of sentinel lymph nodes with the use of bipolar tweezers does not increase the risk of postsurgical complications, and in particular it is not associated with a higher rate of complications related to lymphatic vessel dysfunction.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology and Allergology, Hospital Dresden-Friedrichstadt, Academic Teaching Hospital of the Technical University of Dresden, Friedrichstrasse 41, 01067, Dresden, Germany.
| | - Dana Langner
- Department of Dermatology and Allergology, Hospital Dresden-Friedrichstadt, Academic Teaching Hospital of the Technical University of Dresden, Friedrichstrasse 41, 01067, Dresden, Germany
| | - Jacqueline Schönlebe
- Institute of Pathology "Georg Schmorl", Hospital Dresden-Friedrichstadt, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany
| | - Carmen Tanner
- Clinic for Nuclear Medicine Fuchs & Tanner, Dresden, Germany
| | - Martin Fuchs
- Clinic for Nuclear Medicine Fuchs & Tanner, Dresden, Germany
| | - Andreas Nowak
- Department of Anaesthesiology & Intensive Medicine, Emergency Medicine & Pain Management, Hospital Dresden-Friedrichstadt, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany
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Ge L, Vilain RE, Lo S, Aivazian K, Scolyer RA, Thompson JF. Breslow Thickness Measurements of Melanomas Around American Joint Committee on Cancer Staging Cut-Off Points: Imprecision and Terminal Digit Bias Have Important Implications for Staging and Patient Management. Ann Surg Oncol 2016; 23:2658-63. [PMID: 27075324 DOI: 10.1245/s10434-016-5196-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Breslow thickness is the most important prognostic factor in patients with clinically localized primary cutaneous melanomas, and its accuracy has important implications for staging and management. A review of the Melanoma Institute Australia database and population-based data for the state of New South Wales, Australia, found an unexpectedly large number of melanomas reported as being exactly 1.0 mm thick. We sought to determine possible causes for this biologically implausible finding. METHODS The tumor thickness of 125 invasive cutaneous melanomas with a recorded Breslow thickness of 0.9-1.1 mm was remeasured and recorded by two pathologists. RESULTS Concordance of measurements between the two pathologists was high (intraclass correlation coefficient 0.816, 95 % CI 0.733-0.873). The original measurements showed clustering at 0.9, 1.0, and 1.1 mm, whereas the review measurements did not. The original measurements staged 84 cases (72 %) as T1 and 33 (28 %) as T2, while the reviewed measurements staged 58 cases (50 %) as T1 and 59 (50 %) as T2 (p < 0.001). CONCLUSIONS Our study demonstrated imprecision in Breslow thickness measurements and its significant impact on staging. Two potential sources of imprecision are failure to follow standardized thickness measurement guidelines and the phenomenon of terminal digit bias, not previously identified as a problem in this field. Educating pathologists about this phenomenon and the importance of utilizing ocular micrometers may improve the precision of melanoma thickness measurements around critical staging cut-off points. Clinicians must also be educated to appreciate that there is an inevitable margin of error with Breslow thickness measurements that should be considered when making management decisions.
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Affiliation(s)
- Ludi Ge
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Ricardo E Vilain
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Serigne Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Karina Aivazian
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
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Ipenburg NA, Nieweg OE, Uren RF, Thompson JF. Outcome of Melanoma Patients Who Did Not Proceed to Sentinel Node Biopsy After Preoperative Lymphoscintigraphy. Ann Surg Oncol 2016; 24:117-126. [PMID: 27480356 DOI: 10.1245/s10434-016-5458-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND At our institution, a planned sentinel node biopsy (SNB) procedure is occasionally canceled after preoperative lymphoscintigraphy. This study reports the frequency of this, the reasons, and the management and outcomes of these patients. METHODS All patients with clinically localized cutaneous melanoma treated at Melanoma Institute Australia between 2000 and 2009 whose planned SNB procedure was not undertaken after lymphoscintigraphy were included in this retrospective study. RESULTS Of the 3148 patients in whom the procedure had been planned, 203 patients (6.4 %) did not have a SNB. The main reason for not proceeding with SNB (in 84 % of cases) was the lymphoscintigraphic demonstration of multiple drainage fields and/or multiple sentinel nodes (SNs). Patients who did not proceed to SNB were significantly older than those who did, more often had melanomas of the head or neck, and had more SNs and more nodal drainage fields. Of the 203 patients, 181 (89 %) were followed with high-resolution ultrasound of their SNs, which identified 33 % of the nodal recurrences before they were clinically apparent. Patients whose SNB was canceled had significantly worse recurrence-free survival and regional node disease-free survival, but melanoma-specific survival was similar. Compared to SN-positive patients, node-positive patients without SNB had significantly more involved nodes when a delayed lymphadenectomy was performed, but melanoma-specific survival was not significantly different after a median follow-up of 42 months. CONCLUSIONS Lymphoscintigraphy with ultrasound follow-up of previously identified SNs is an acceptable management strategy for patients in whom a SNB procedure is likely to be challenging.
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Affiliation(s)
| | - Omgo E Nieweg
- Melanoma Institute Australia, North Sydney, NSW, Australia. .,Central Medical School, The University of Sydney, Sydney, NSW, Australia. .,The Mater Hospital, North Sydney and Royal Prince Alfred Hospital, Camperdown, Australia.
| | - Roger F Uren
- Central Medical School, The University of Sydney, Sydney, NSW, Australia.,Alfred Nuclear Medicine and Ultrasound, RPAH Medical Centre, Newtown, NSW, Australia
| | - John F Thompson
- Melanoma Institute Australia, North Sydney, NSW, Australia.,Central Medical School, The University of Sydney, Sydney, NSW, Australia.,The Mater Hospital, North Sydney and Royal Prince Alfred Hospital, Camperdown, Australia
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Measuring the quality of melanoma surgery - Highlighting issues with standardization and quality assurance of care in surgical oncology. Eur J Surg Oncol 2016; 43:561-571. [PMID: 27422583 DOI: 10.1016/j.ejso.2016.06.397] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/09/2016] [Accepted: 06/18/2016] [Indexed: 01/21/2023] Open
Abstract
In an attempt to ensure high standards of cancer care, there is increasing interest in determining and monitoring the quality of interventions in surgical oncology. In recent years, this has been particularly the case for melanoma surgery. The vast majority of patients with melanoma undergo surgery. Usually, this is with combinations of wide excision, sentinel lymph node biopsy and lymphadenectomy. The indications for these procedures evolved during a time when no effective systemic adjuvant therapy was available, and whilst the rationale has been sound, the justification for differences in extent and thoroughness has generally been supported by inadequate or low-level evidence. This has led to a substantial variation among melanoma centres or even among surgeons within a centre in how these procedures are done. With recent rapid progress in the efficacy of systemic treatments that are impacting on overall survival, the prospect of long-term survival in these previously high risk patients means that more than ever long-term locoregional control of melanoma is imperative. Furthermore, the understanding of effects of systemic therapy on locoregional disease will only be interpretable if surgeons use standardized, high quality techniques. This article focuses on standardization and evolution of quality indicators for melanoma surgery and how these might have a positive impact on patient care.
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48
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Murphy BL, Boughey JC, Degnim AC, Hieken TJ, Harmsen WS, Keeney GL, Jakub JW. A Picture is Worth a Thousand Words: Intraoperative Photography as a Quality Metric for Axillary Dissection. Ann Surg Oncol 2016; 23:3494-3500. [PMID: 27198512 DOI: 10.1245/s10434-016-5271-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The adequacy of an axillary lymph node dissection (ALND) is frequently assessed by the number of LNs pathologically identified. We hypothesized that intraoperative photographs facilitate objective measurement of the surgical quality of an ALND. METHODS Intraoperative photographs of the axilla were obtained prospectively following ALND by four surgeons. An objective scoring system was created based on the visibility of anatomic landmarks, with a maximum score of 7. Photographs of each case were scored independently by the other three surgeons. Factors thought to influence LN count were evaluated for correlation. Interrater variability was calculated. RESULTS A total of 115 cases were evaluated: 98 breast and 17 melanoma. Mean LN count was 25.1 (SD 10.5): 23.2 (SD 7.9) for breast and 36.5 (SD 15.8) for melanoma. Ninety percent of cases had a LN count ≥15. Factors associated with a higher number of LNs were melanoma (p < 0.001), visualization of the axillary vein (p = 0.03), and long thoracic nerve (p = 0.04). There was no association with age, body mass index, number of positive LNs, neoadjuvant chemotherapy, or matted LNs. Mean ALND photograph score was 4.8 (SD 1.3). A 1-point change in total score increased the mean LN count by 2.4 (p = 0.002). Correlations for interrater reliability varied from 0.27 to 0.62. CONCLUSIONS Photographic visualization of axillary anatomic structures correlates with the number of LNs identified on pathology. These findings support initiating a larger study with more surgeons to define the optimal photo metrics of an adequate ALND.
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Affiliation(s)
| | - Judy C Boughey
- Department of General Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amy C Degnim
- Department of General Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tina J Hieken
- Department of General Surgery, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Gary L Keeney
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | - James W Jakub
- Department of General Surgery, Mayo Clinic, Rochester, MN, USA.
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Han D, Thomas DC, Zager JS, Pockaj B, White RL, Leong SPL. Clinical utilities and biological characteristics of melanoma sentinel lymph nodes. World J Clin Oncol 2016; 7:174-188. [PMID: 27081640 PMCID: PMC4826963 DOI: 10.5306/wjco.v7.i2.174] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/05/2015] [Accepted: 02/16/2016] [Indexed: 02/06/2023] Open
Abstract
An estimated 73870 people will be diagnosed with melanoma in the United States in 2015, resulting in 9940 deaths. The majority of patients with cutaneous melanomas are cured with wide local excision. However, current evidence supports the use of sentinel lymph node biopsy (SLNB) given the 15%-20% of patients who harbor regional node metastasis. More importantly, the presence or absence of nodal micrometastases has been found to be the most important prognostic factor in early-stage melanoma, particularly in intermediate thickness melanoma. This review examines the development of SLNB for melanoma as a means to determine a patient’s nodal status, the efficacy of SLNB in patients with melanoma, and the biology of melanoma metastatic to sentinel lymph nodes. Prospective randomized trials have guided the development of practice guidelines for use of SLNB for melanoma and have shown the prognostic value of SLNB. Given the rapidly advancing molecular and surgical technologies, the technical aspects of diagnosis, identification, and management of regional lymph nodes in melanoma continues to evolve and to improve. Additionally, there is ongoing research examining both the role of SLNB for specific clinical scenarios and the ways to identify patients who may benefit from completion lymphadenectomy for a positive SLN. Until further data provides sufficient evidence to alter national consensus-based guidelines, SLNB with completion lymphadenectomy remains the standard of care for clinically node-negative patients found to have a positive SLN.
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50
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Damude S, Hoekstra H, Bastiaannet E, Muller Kobold A, Kruijff S, Wevers K. The predictive power of serum S-100B for non-sentinel node positivity in melanoma patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2016; 42:545-51. [DOI: 10.1016/j.ejso.2015.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 12/01/2015] [Accepted: 12/16/2015] [Indexed: 10/22/2022]
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