Pattern and incidence of first site recurrences following sentinel node procedure in melanoma patients

Polo-Like Kinase 4 Correlates with Aggressive Tumor Characteristics, Shortened Disease-Free Survival and Overall Survival in Patients with Cutaneous Melanoma who Undergo Surgical Resection

Polo-like kinase 4 (PLK4) involves in tumor progression via regulating centriole duplication. This study aimed to investigate correlations of PLK4 with tumor characteristics and survival in cutaneous melanoma patients undergoing surgical resection. Tumor specimens of 43 patients were retrieved for PLK4 determination by immunohistochemistry (IHC). The IHC score was a multiplication of staining intensity and percentage of staining-positive cells. This study found the median and mean tumor PLK4 IHC score was 0.0 (interquartile range: 0.0-6.0) and 3.5 ± 3.2 (mean ± SD), respectively. Elevated tumor PLK4 IHC score correlated with lymph node metastasis (P = 0.028), higher tumor node metastasis (TNM) stage (P = 0.004), and adjuvant therapy (P =0.029). Tumor PLK4 IHC score > 0 did not relate to disease-free survival (DFS) or overall survival (OS) (both P > 0.050). Tumor PLK4 IHC score > 3 associated with decreased DFS (P = 0.027), but not OS (P = 0.098). Five-year DFS rate of patients with tumor PLK4 IHC score = 0 and > 0 was 75.0% and 53.9%, correspondingly; while the rate of patients with the score ≤ 3 and > 3 was 81.0% and 37.5%, respectively. Five-year OS rate of patients with the score = 0 and > 0 was 100.0% and 66.3%, accordingly; whereas the rate of patients with the score ≤ 3 and > 3 was 85.7% and 61.5%, correspondingly. According to forward-step multivariate analysis, neither the score > 0 nor > 3 independently related to worse DFS and OS (all P > 0.050). Further validation via THE HUMAN PROTEIN ATLAS database showed high PLK4 RNA expression associated with shortened OS in melanoma patients (P = 0.001). PLK4 correlates with lymph node metastasis, increased TNM stage, and poor DFS in cutaneous melanoma patients undergoing surgical resection.

Preservation of the deep muscular fascia and locoregional control in melanoma

BACKGROUND

Locoregional recurrence occurs in approximately 20% of patients with melanoma and is associated with a significantly worse prognosis. Standards are well established for peripheral margins; however, there is insufficient evidence regarding depth of resection.

METHODS

Retrospective review of 964 patients undergoing excision of trunk or extremity melanoma ≥1 mm thick during a 29-year period at a tertiary academic center. Multivariate analysis and hazard ratios were used to determine the effect of excision of the deep muscular fascia on locoregional recurrence.

RESULTS

A total of 278 (29%) patients underwent resection of the muscular fascia. Of these patients, 18 (6%) developed local, 33 (12%) developed in-transit, and 68 (24%) developed nodal recurrence within 5 years. A total of 686 (71%) patients underwent excision of their primary melanoma with preservation of the muscular fascia. Of these patients, 40 (6%) developed local, 30 (4%) developed in-transit, and 84 (12%) developed nodal recurrence at 5 years. In multivariate analysis excision of the deep muscular fascia was an independent predictor of locoregional recurrence in patients treated with sentinel lymph node biopsy. Specifically, fascia resection was associated with a 2.5-fold increased risk of nodal recurrence but not associated with local recurrence or overall survival.

CONCLUSION

On the basis of no demonstrated advantage for resection of the deep muscular fascia, but potential for increased risk of intralymphatic recurrences, we recommend preservation of the deep muscular fascia during resection of primary cutaneous melanoma.

When will selective lymphadenectomy become standard of care in melanoma?

In 2006 Meiron Thomas, writing in the British Journal of Surgery, made the following statement about the value of sentinel lymph node biopsy (SLNB) as a staging procedure in cutaneous malignant melanoma (1): "Perhaps a more important concern for those hoping to gain reassurance from accurate nodal staging relates to positive SN(S) that are prognostically inaccurate, information that can be devastating for the patient, leading to unnecessary lymphadenectomy and possibly unnecessary adjuvant therapy". In September 2011 Meyrick Ross and Gershenwald, writing in the Journal of Surgical Oncology, made the following statement about the management of patients with cutaneous malignant melanoma (2): "Sentinel node biopsy has become an important component of the initial management of many of these patients for accurate staging of regional lymph nodes, as well as enhanced regional disease control and improved survival in the patients with microscopically involved nodes." These two extremes have polarized the debate about the proper management of patients with malignant melanoma and have lead to widespread confusion and dismay amongst practicing clinicians, GP's and patient groups. In fact both statements are inaccurate, misleading and result from a false reading of the literature and in the case of Ross and Gershenwald a false interpretation of their own data (3). The following article explains why.

Predictive role of preoperative lymphoscintigraphy on the status of the sentinel lymph node in clinically node-negative patients with cutaneous melanoma

We reviewed our experience to assess the predictive role of preoperative lymphoscintigraphy with regard to the pathological status of sentinel lymph node (sN) in patients with cutaneous melanoma, to optimize the surgical treatment planning with regard to the use of intraoperative frozen section examination of sN. Eighty-eight patients with clinically node-negative cutaneous melanoma pT1b-T4 stage underwent preoperative lymphoscintigraphy for the lymphatic mapping of sN. A lymphoscintigraphic 'score' (from L1 to L5) was developed based on the ratio of radiotracer concentration within sN nodes as compared with the injection site. Our score allowed us to foresee that sN of patients with thick melanomas (T3 and T4) and a low preoperative score (L1-L2-L3) had a 90% expected likelihood (P<0.001) of harboring metastasis, whereas sN in patients with thin melanomas (T1b-T2) and high preoperative score (from L4 to L5) showed a 100% likelihood of being metastasis free. In conclusion, the sN is a reliable predictor of regional lymph node status in patients with cutaneous malignant melanoma. Moreover, we suggest that a low score (L1-L2-L3) associated with a thick melanoma is a good predictive factor of the positive sN involvement. This information could be useful in scheduling the intraoperative frozen-section examination with an expected benefit of a positive test in almost 90% of patients. Such patients might be selected for a 'one-stage' procedure with a more effective cost/benefit ratio and decreased hospitalization costs.

Follow-up schedules after treatment for malignant melanoma

BACKGROUND

Existing follow-up guidelines after treatment for melanoma are based largely on dated literature and historical precedent. This study aimed to calculate recurrence rates and establish prognostic factors for recurrence to help redesign a follow-up schedule.

METHODS

Data were retrieved from the Sydney Melanoma Unit database for all patients with a single primary melanoma and American Joint Committee on Cancer (AJCC) stage I-II disease, who had received their first treatment between 1959 and 2002. Recurrence rates, timing and survival were recorded by substage, and predictive factors were analysed.

RESULTS

Recurrence occurred in 18.9 per cent (895 of 4748) of patients overall, 5.2 per cent (95 of 1822) of those with stage IA disease, 18.4 per cent (264 of 1436) with IB, 28.7 per cent (215 of 750) with IIA, 40.6 per cent (213 of 524) with IIB and 44.3 per cent (86 of 194) with IIC disease. Overall, the median disease-free survival time was 2.6 years, but there were marked differences between AJCC subgroups. Primary tumour thickness, ulceration and tumour mitotic rate were important predictors of recurrence.

CONCLUSION

A new follow-up schedule was proposed: stage I annually, stage IIA 6-monthly for 2 years and then annually, stage IIB-IIC 4-monthly for 2 years, 6-monthly in the third year and annually thereafter.

Patterns of First-Recurrence and Post-recurrence Survival in Patients with Primary Cutaneous Melanoma After Sentinel Lymph Node Biopsy

BACKGROUND

Sentinel lymph node biopsy (SLNB) has become well accepted in management of patients with primary cutaneous melanoma. An understanding of the pattern of recurrence after SLNB is helpful in coordinating a rational plan of follow-up in these patients. We sought to determine the site and timing of initial recurrence and post-recurrence survival after SLNB.

METHODS

Stage I/II melanoma patients who underwent SLNB during 1991-2004 were identified from a prospective single-institution database. Site and date of first recurrence after SLNB were recorded. Patterns of recurrence after SLNB and post-recurrence survival were analyzed.

RESULTS

One thousand and forty-six patients underwent SLNB. The sentinel lymph node (SLN) was positive in 164 patients (16%). Median follow-up was 36 months for survivors. Median and 3-year relapse-free survival for SLN-positive patients were 41 months and 56%, and for SLN-negative patients were not reached and 87%, respectively (P < .0001). Of the SLN-positive patients, 47% experienced recurrence, compared with 14% SLN-negative patients. The pattern of recurrence stratified by SLN status was similar between the two groups (P = NS). After recurrence, the site of recurrence was the only significant prognostic factor influencing survival (P < .0001).

CONCLUSIONS

Although SLN-positive patients experience recurrence far earlier and more frequently than SLN-negative patients, the pattern of recurrence is similar. After recurrence, its site is the primary determinant of survival.

Natural history of melanoma in 773 patients with tumor-negative sentinel lymph nodes

BACKGROUND

A tumor-negative sentinel lymph node (SLN) does not preclude recurrence of melanoma. We hypothesized that certain patient-related and tumor factors are predictive of a worse outcome in these patients.

METHODS

Disease-free survival (DFS), overall survival (OS), and recurrence patterns were retrospectively analyzed in 773 patients who underwent lymphatic mapping and SLN biopsy for primary cutaneous melanoma at our institution between 1995 and 2002, and who had tumor-negative SLNs by standard pathological analysis. Patient sex, age, tumor site and thickness, ulceration status, Clark level, and histology were evaluated for their influence on outcome by univariate and multivariate Cox regression analysis and classification and regression tree analysis.

RESULTS

DFS and OS at 5 years were 88% and 93%, respectively. Sixty-nine (8.9%) of 773 patients developed recurrence. Three-year OS was lower in patients with distant recurrence (17.1%) than in those with local/regional recurrence (55.5%). By multivariate analysis, primary tumor thickness (P < .0001), site on head/neck versus trunk (P = .0093) versus extremity (P = .0042), and ulceration status (P = .0024) were independently significant for DFS; primary tumor thickness (P = .0106) and ulceration status (P = .0001) also were independently significant for OS. Classification and regression tree analysis demonstrated DFS was shortest in patients who had ulcerated tumors >2 mm.

CONCLUSIONS

Melanoma will recur in approximately 9% of patients with tumor-negative SLNs. Patients with thick, ulcerated melanomas on the head or neck have the highest risk for recurrence. This group should be followed closely for recurrence and considered for adjuvant therapy.

Survival analysis and clinicopathological factors associated with false-negative sentinel lymph node biopsy findings in patients with cutaneous melanoma

BACKGROUND

We analyzed the outcomes and factors associated with false-negative (FN) results of sentinel lymph node (SLN) biopsy findings in patients with cutaneous melanoma. SLN biopsy failure rate was defined as nodal recurrence in the biopsied regional basin without previous local or in-transit recurrence.

METHODS

Between April 1997 and December 2004, a total of 1207 patients with cutaneous melanoma with a median Breslow thickness of 2.4 mm underwent SLN biopsy by preoperative and intraoperative lymphoscintigraphy combined with dye injection. In 228 cases, we found positive SLNs; of these, 220 underwent completion lymph node dissection (CLND). Median follow-up was 3 years.

RESULTS

The SLN biopsy failure rate was 5.8% (57 of 979 SLN negative). Median time to occurrence of FN relapse after SLN biopsy was 16 months (range, 3-74 months). The FN SLN biopsy results correlated with primary tumor thickness >4 mm (P = .0012), primary tumor ulceration (P = .0002), primary tumor level of invasion Clark stage IV/V (P = .0005), and nodular melanoma histological type (P = .0375). Five-year overall survival, calculated from the date of primary tumor excision, in the FN group was 53.7%, which was not statistically significantly worse than the CLND group (56.8%; P = .9). The FN group was characterized by a higher ratio of two or more metastatic nodes and extracapsular involvement of lymph nodes after LND compared with the CLND group (P < .0001 and P < .0001, respectively). Additional detailed pathological review of FN SLN revealed metastatic disease in 14 patients, which decreased the SLN biopsy failure rate to 4.4% (43 of 979).

CONCLUSIONS

Survival of patients with FN results of SLN biopsy does not differ statistically significantly from that of patients undergoing CLND, although it is slightly lower. The SLN biopsy failure rate is approximately 5.0% in long-term follow-up and is associated mainly with the same factors that indicate a poor prognosis in primary melanoma.

Factors Predicting the Risk of In-Transit Recurrence After Sentinel Lymphonodectomy in Patients With Cutaneous Malignant Melanoma

BACKGROUND

In-transit metastasis is an important morbidity factor after sentinel lymphonodectomy (SLNE). So far, factors posing an increased risk after SLNE have not been adequately analyzed.

METHODS

Using Kaplan-Meier estimations and the Cox proportional hazards model, we analyzed the risk of developing in-transit metastases after SLNE for 328 consecutive patients (median tumor thickness, 2.0 mm; median follow-up period, 40 months).

RESULTS

The 5-year probability of developing in-transit metastases as a first recurrence was 11.2%. After negative and positive SLNE, the probabilities were 6.3% and 24%, respectively. Patients in whom satellite metastases were excised concurrently with the primary tumor had a probability of recurrence with in-transit metastases of 41%. In sentinel lymph node (SLN)-negative patients with primary tumors having a thickness of more than 4 mm, the probability was 22.1%. Among the group of SLN-positive patients, significantly increased in-transit probabilities were observed in those with primary tumors that were thicker than 4 mm (41.8%), with tumors located on the distal extremities (42.1%), and with penetration of the nodal metastasis of >1 mm into the SLN (36%) and in patients with capsular breakthrough (63.3%). By using multifactorial analysis, the SLN status (P = .005), Breslow thickness (P = .0009), and extremity location of the primary melanoma (P = .005) significantly predicted the risk of in-transit recurrence. Satellite metastasis (P < .089), Clark level, and ulceration did not reach significance.

CONCLUSIONS

Subgroups of patients can be identified who seem to have an increased risk of developing in-transit metastases as a first recurrence after SLNE. Individualized therapeutic strategies should be developed for these patients.

Novel Imaging Techniques in Melanoma

Cutaneous melanoma is one of the most deadly malignancies. Although it accounts for approximately 4% of all cancer cases, it ac-counts for approximately 79% of skin cancer-related deaths. In the past few years, the nuclear medicine platform used in the management of melanoma has extended to biochemical and structural imaging. In clinical practice, integrated positron emission tomography/CT devices allow anatomic and metabolic characterization of meta-static disease in a single study. Similarly, more accurate localization of sentinel nodes in a 3-D space now is feasible with hybrid single photon emission CT/CT system. In translational research, [18F]fluorodeoxyglucose probes have been designed to optimize the detection of melanoma tumor sites in vivo.

Does sentinel lymph node biopsy in cutaneous head and neck melanoma alter disease outcome?

BACKGROUND AND OBJECTIVES

In the head and neck region, value, reliability, and safety of sentinel lymph node biopsy (SLNB) have not yet been determined conclusively. The aim of study was to assess impact of SLNB on disease outcome in cutaneous head and neck melanoma.

METHODS

Thirty-six patients with a clinically node-negative head and neck melanoma, > or =1.0 mm Breslow thickness, participated in a prospective study from 1995 to 2005. Sentinel lymph node (SLN) tumor-positive patients underwent completion lymphadenectomy. SLN tumor-negative patients underwent clinical monitoring. Median follow-up was 54 (range 10-114) months. Recurrence-free and overall survival curves were constructed by Kaplan-Meier.

RESULTS

SLNs could be identified in 33 patients (92%). In 7 patients (21%) the SLN was tumor-positive. In 1 patient (13%) the SLNB was false-negative. In 17 patients (47%) SLNs could be identified in the parotid region (success rate parotid region 100%). This study showed no significant difference in recurrence-free and overall survival between patients with tumor-positive and tumor-negative SLN.

CONCLUSIONS

The safety and accuracy of SLNB in the neck and parotid nodal basins were similar to those in non-head and neck sites. However, the technique is technically demanding in this region. In this small series SLNB did not alter disease outcome.

In transit/local recurrences in melanoma patients after sentinel node biopsy and therapeutic lymph node dissection

This study has analyzed the incidence of in transit/local recurrences (IT/LR) in melanoma patients after sentinel node (SLN) biopsy; completion lymph node dissection (CLND) that was performed due to positive node; and therapeutic LND (TLND) due to clinically detected node metastases and factors influencing IT/LR. Between May 1995 and May 2004, 1187 consecutive patients underwent SLN biopsy (median Breslow thickness 2.5 mm) and 224 of them had subsequent CLND. During the same time period, 306 patients had TLND (median Breslow 3.9 mm). The excision margin of primaries was > or =1cm. At median follow-up time of 37.5 months, we analyzed the incidence of IT/LR as the first site of relapse and clinicopathological parameters affecting these recurrences. In SLN-negative cases, IT/LR as the site of the first recurrence were rare (46/963; 4.8%) and; in SLN+/-CLND IT/LR were detected in 45/224 cases (20.1%). IT/LR in SLNB group correlated with presence of SLN metastases (P<0.0001), higher Breslow thickness (P<0.001) and lower extremity localization (P=0.03). In TLND group, IT/LR were observed in 52/306 patients (17%), which is similar to all CLND patients (P=0.3), but less common when analyzing only patients who relapsed (TLND: 52/209 (24.9%) vs. CLND: 45/121 (37.2%); P=0.02). Estimated 3-year overall survival (from the date of relapse) in IT/LR only patients was better than in other types of relapses after LND (29% vs. 8%; P<0.0001). IT/LR incidence in the entire group of SLN+/-CLND patients was similar to that observed in TLND patients and it was affected by presence of nodal metastases, Breslow thickness and lower extremity location.

The prognostic role of the sentinel lymph node in clinically node-negative patients with cutaneous melanoma: experience of the Genoa group

AIM

To define the benefit of intraoperative frozen section examination of the sentinel lymph node (sN), and to assess its prognostic value in clinically node-negative melanoma patients.

MATERIALS AND METHODS

Between July 1993 and December 2001, 214 patients with Stage I-II cutaneous melanoma underwent sN biopsy; complete follow-up data are available in 169 of 175 patients who underwent preoperative lymphoscintigraphy, lymphatic mapping with Patent Blue-V and radio-guided surgery (RGS).

RESULTS

In an initial subset, the sN was identified in 35 out of 39 patients; in the principal group of 169 patients, the sN was detected in all patients. The benefit of frozen section examination, that is the proportion of all patients having intraoperative histologic examination who tested positive, was 17.2% (29/169); notably, in patients with pT(1-2) vs pT(3-4) melanoma the corresponding values were 2.3 and 33.3%, respectively, (P=0.000). Cox regression analysis for overall survival indicated that sN-positive patients had a two-fold increased risk of death; the most significant predictors of relapse-free survival were sN status (P=0.004), age (P=0.015), and T stage grouping (P=0.033).

CONCLUSIONS

The sN is a reliable predictor of regional lymph node status in patients with cutaneous melanoma. Frozen section examination can be useful in avoiding a 'two-stage' operative procedure in patients with tumour-positive sN, but its greatest benefit seems to be restricted to patients with pT(3)-pT(4) primary melanoma.

CD44v3 levels in primary cutaneous melanoma are predictive of prognosis: Assessment by the use of tissue microarray

Despite the use of sentinel node biopsy techniques, the search continues for other strategies to improve the accuracy of estimating prognosis in melanoma patients. Various biomarkers have previously been studied for use in this role, but none has yet achieved acceptance in routine practice. We have applied the novel technology of tissue microarray for the high throughput screening of a cohort of 120 primary cutaneous melanoma specimens for expression of the transmembrane glycoprotein CD44, splice variant 3 (v3), which has previously been implicated in tumor progression. A highly significant correlation between CD44v3 expression and Breslow thickness, Clark's level and patient age was demonstrated (Spearman correlation p < 0.001). Regarding clinical outcome, CD44v3 expression was shown to be significantly associated with better outcome (chi(2) = 7.2219, p = 0.0072). Furthermore, subgroup analysis revealed a sequentially improved survival probability associated with the intensity of CD44v3 staining (chi(2) = 12.5162, p = 0.0058). Analysis in a Cox multivariate model, however, did not show CD44v3 to be independently predictive of prognosis. The implications of these findings are considered, and the use of CD44v3 as a potential prognostic marker or a target for therapeutic manipulation are discussed.

Identification of P-cadherin in Primary Melanoma Using a Tissue Microarrayer

Sentinel lymph node biopsy is the most accurate technique for establishing melanoma patient prognosis but is associated with morbidity and is of little value in those tumors that first metastasize to sites other than the regional nodal basin. Noninvasive methods of establishing prognosis are therefore desirable. We have used the novel technology of tissue microarray to study a cohort of 120 patients with melanoma with long-term follow-up data for the expression of P-cadherin. The tissue microarray was successfully constructed and stained. Loss of P-cadherin expression was found to be significantly correlated with outcome (log rank chi2 = 10.1336, P = 0.0015). The results suggest a fundamental role for P-cadherin in melanoma progression and identify it as a potential prognostic marker and a possible target for therapeutic manipulation.

Clinical and biological aspects of sentinel node biopsy in malignant melanoma — an update

The diagnostic usefulness of sentinel lymph node biopsy (SLNB) has been well established, but its therapeutic value remains unproven. First introduced by Morton and colleagues, the SLNB procedure is now widely available, and markedly enhances our ability to pathologically stage the regional nodes. Although the SLN status is acknowledged as the most powerful indicator of prognosis in melanoma, there is no evidence to-date, of survival advantage for complete lymphadenectomy in SLN-positive patients. Also, there is no effective adjuvant therapy that could benefit these sentinel node-positive patients, as yet. Additionally, new data have emerged indicating a possible increase in local/in-transit recurrence following complete lymphadenectomy in sentinel node-positive patients. To understand fully and to evaluate these observations we need information from randomized controlled trials. Major changes have occurred following the latest revision of melanoma staging system (AJCC, 6th edition). Concerning N category, these include the incorporation of the number of metastatic lymph nodes, the tumour burden of nodal metastases, and the ulceration of the primary tumour. The data obtained from the new staging system will reflect differences in prognosis that were not previously emphasized and which, we hope, will serve as a guide to more accurate analysis of metastatic pathways in cutaneous melanoma as well as a rationale for new forms of treatment.

Sentinel node status in melanoma patients is not predictive for overall survival upon multivariate analysis

Sentinel lymph node biopsy (SLNB) has become a widely accepted standard procedure in the staging of patients with cutaneous melanoma and absence of clinical lymph node metastases, although there is no final proof that SLNB influences overall survival in these patients. This study investigated the accuracy of SLNB and the clinical outcome of patients after a mean follow-up of 22 months. Between 1998 and 2003, SLNB was performed in 309 consecutive patients. Patients with one or more positive sentinel lymph nodes (SLNs) were subjected to selective lymphadenectomy (SL). Survival analyses were performed using the Kaplan–Meier approach. A Cox proportional-hazard analysis was used for univariate and multivariate analysis to explore the effect of variables on survival. Sentinel lymph nodes were identified in 299 of 309 patients (success rate: 96.8%). Of these, 69 (23%) had a positive SLN. The false-negative rate was 9.2%. Recurrence of disease to the regional lymph node basin (3.0%) and to the locoregional skin (2.6%) was rare in SLN-negative patients in contrast to SLN-positive patients (7.2 and 17.4%, respectively). The 3-year overall survival was 93 and 83% for SLN-negative and SLN-positive patients, respectively. Upon multivariate analysis, SLN status (P<0.001), Breslow thickness (P<0.02) and ulceration (P<0.026) were all found to be independent prognostic factors with respect to disease-free survival, whereas Breslow thickness proved to be the only significant factor with respect to overall survival.

Sentinel lymphonodectomy does not increase the risk of loco-regional cutaneous metastases of malignant melanomas

With regard to malignant melanoma, the impact of lymph node surgery on the development of loco-regional cutaneous metastases (LCM) has not yet been adequately addressed. However, this aspect is of interest, since sentinel lymphonodectomy (SLNE) has been suspected of causing LCM by inducing entrapment of melanoma cells. We analysed 244 patients with SLNE and compared the data with 199 patients treated with delayed lymph node dissection (DLND) for clinically palpable metastases. Analysis of both groups commenced at the time of excision of the primary tumour, using the Kaplan-Meier method. LCM that appeared as a first recurrence, as well as the overall probability of developing LCM, were recorded. For sentinel-negative patients with a primary melanoma >1mm thick, the 5-year probability of developing LCM as a first recurrence was 6.9 +/- 0.02% (+/-standard error of the mean (SEM)). The probability was 17.6 +/- 0.03% in the DLND group. Comparing the two node-positive subgroups, the probability of developing LCM as a first recurrence was significantly higher in patients with positive SLNE (27.3 +/- 0.05%, P = 0.03). However, the 5-year overall probability of developing LCM did not differ significantly in the node-positive groups (33.3% in the DLND group vs. 33.7% in patients with positive sentinel lymph nodes (SLNs)). Since early excision of lymphatic metastases by SLNE avoids nodal recurrences, thereby prolonging the recurrence-free interval, the chance of LCM to manifest as a first recurrence should inevitably increase. However, the overall in-transit probability is not increased after SLNE.

Selective lymphadenectomy in sentinel node-positive patients may increase the risk of local/in-transit recurrence in malignant melanoma

AIM

To determine whether sentinel lymph node biopsy (SLNB) for cutaneous malignant melanoma, particularly when followed by selective lymphadenectomy (SL) if involved nodes are found, alters the incidence of local/in-transit recurrence.

METHODS

A literature overview of SLNB with or without SL has been performed, concentrating on the reported site(s) of first recurrence, and with specific reference to the incidence of local/in-transit recurrence. This is compared to the incidence after wide local excision (WLE) alone.

RESULTS

The incidence of local/in-transit recurrence after WLE alone is 2.5-6.3% over a given range of tumour thickness, and is 9.0% after SLNB (with or without SL). In the latter group, the local/in-transit recurrence rate is 5.7% following SLNB alone in SN-negative patients, and is 20.9% after SLNB plus SL in SN-positive patients.

CONCLUSIONS

The incidence of local/in-transit recurrence following selective lymphadenectomy in sentinel node-positive patients may be greater than four times the incidence expected. This possible iatrogenic risk should be confirmed or refuted by randomised controlled trial. Until then the SLNB procedure should be regarded as experimental and not performed outside validation trials.

Sentinel lymph node detection in primary melanoma with preoperative dynamic lymphoscintigraphy and intraoperative γ probe guidance

Background

This study assessed the value of the radioisotopic method used alone, and factors influencing relapse rates, for sentinel lymph node (SLN) mapping in primary melanoma.

Methods

One hundred and thirty-three patients with a diagnosis of melanoma (thickness greater than 0·75 mm) underwent γ probe-directed lymphatic mapping in a prospective single-centre study.

Results

Mean Breslow thickness was 3 mm. At least one SLN was identified in 132 patients (mean 1·8 nodes per patient); the success rate was 99·2 per cent. Twenty-two patients (16·7 per cent) had a metastasis within the SLN. The mean tumour thickness in patients with a metastatic SLN was 4·4 mm compared with 2·7 mm for patients with a negative SLN (P &lt; 0·001). The median time to recurrence was 20·4 months in SLN-negative patients compared with 8·5 months in those with SLN metastasis (P &lt; 0·001). Ten (9·1 per cent) of the 110 SLN-negative patients developed recurrence. Three patients relapsed in the previously mapped lymphatic basin after a median follow-up of 27·1 months.

Conclusion

This study confirmed the reliability and accuracy of SLN mapping using a radioisotope technique, and also the importance of the SLN as a predictive factor for survival. There was a low risk of locoregional recurrence when the SLN was not involved.

Excision margins in high-risk malignant melanoma

BACKGROUND

Controversy exists concerning the necessary margin of excision for cutaneous melanoma 2 mm or greater in thickness.

METHODS

We conducted a randomized clinical trial comparing 1-cm and 3-cm margins.

RESULTS

Of the 900 patients who were enrolled, 453 were randomly assigned to undergo surgery with a 1-cm margin of excision and 447 with a 3-cm margin of excision; the median follow-up was 60 months. A 1-cm margin of excision was associated with a significantly increased risk of locoregional recurrence. There were 168 locoregional recurrences (as first events) in the group with 1-cm margins of excision, as compared with 142 in the group with 3-cm margins (hazard ratio, 1.26; 95 percent confidence interval, 1.00 to 1.59; P=0.05). There were 128 deaths attributable to melanoma in the group with 1-cm margins, as compared with 105 in the group with 3-cm margins (hazard ratio, 1.24; 95 percent confidence interval, 0.96 to 1.61; P=0.1); overall survival was similar in the two groups (hazard ratio for death, 1.07; 95 percent confidence interval, 0.85 to 1.36; P=0.6).

CONCLUSIONS

A 1-cm margin of excision for melanoma with a poor prognosis (as defined by a tumor thickness of at least 2 mm) is associated with a significantly greater risk of regional recurrence than is a 3-cm margin, but with a similar overall survival rate.

Review and evaluation of sentinel node procedures in 250 melanoma patients with a median follow-up of 6 years

BACKGROUND

The aim of this study was to evaluate the results of sentinel node biopsy in cutaneous melanoma at our institute.

METHODS

A total of 250 patients with cutaneous melanoma were studied prospectively. Preoperative lymphoscintigraphy was performed after injection of (99m)Tc-nanocolloid intradermally around the primary tumor or biopsy site (.32 mL, 65.5 MBq [1.8 mCi]). The sentinel node was surgically identified with the aid of patent blue dye and a gamma ray detection probe. The median follow-up was 72 months.

RESULTS

Lymphoscintigraphic visualization was 100%, and surgical identification was 99.6%. In 60 patients (24%), 1 or more sentinel nodes were tumor positive at initial pathology evaluation. Late complications after sentinel node biopsy of the remaining 190 patients were seen in 35 patients (18%). The false-negative rate was 9%. In-transit metastases were seen in 7% of sentinel node-negative and 23% of sentinel node-positive patients. The estimated 5-year overall survival rates were 89% and 64%, respectively (P <.001).

CONCLUSIONS

This study confirms that the status of the sentinel node is a strong independent prognostic factor. The false-negative rate and the incidence of in-transit metastases in sentinel node-positive patients are high and have to be weighed against the possible survival benefit of early removal of nodal metastases.

Biomarkers in melanoma: staging, prognosis and detection of early metastases

Currently, melanoma remains a surgical disease since early detection and excision of thin melanomas offers the best chance of a cure. Despite intensive clinical investigation, no effective systemic therapies exist for metastatic melanoma. Sentinel lymph node biopsy has greatly aided the staging and prognostic evaluation of primary cutaneous melanoma, however, approximately a third of patients diagnosed with metastatic melanomas present without prior regional lymph node involvement. Additional prognostic biomarkers exist which help determine the risk of advanced melanoma but the accuracy for each current marker is less than 100%. A greater understanding of the biology of melanomas and the development of new methods to identify patients with early (subclinical) metastatic disease may allow for selective and more effective therapy for patients at-risk for advanced disease. In this paper, current and novel potentially more accurate biomarkers for the staging and prognostic evaluation of melanoma patients, and for the detection of subclinical metastases are reviewed.

How morphometric analysis of metastatic load predicts the (un)usefulness of PET scanning: the case of lymph node staging in melanoma

BACKGROUND

In primary cutaneous melanoma, the sentinel node (SN) biopsy is an accurate method for the staging of the lymph nodes. Positron emission tomography (PET) has been suggested as a useful alternative. However, the sensitivity of PET may be too low to detect SN metastases, which are often small.

AIM

To predict the value of PET for initial lymph node staging in melanoma based on morphometric analysis of SN metastatic load, without exposing patients to PET.

MATERIALS AND METHODS

In 59 SN positive patients with melanoma, the sizes of tumour deposits in the SNs and subsequent dissection specimens were measured by morphometry and correlated with the detection limits of current and future PET scanners.

RESULTS

The median tumour volume within the basin was 0.15 mm(3) (range, 0.0001-118.86). Seventy per cent of these deposits were smaller than 1 mm(3). State of the art PET scanners that have a resolution of about 5 mm would detect only 15-49% of positive basins. Logistic regression analysis revealed no pretest indicators identifying patients expected to have a positive PET. However, the SN tumour load was a significant and single predictor of the presence of PET detectable residual tumour.

CONCLUSION

Morphometric analysis of metastatic load predicts that PET scanning is unable to detect most metastatic deposits in sentinel lymph nodes of patients with melanoma because the metastases are often small. Therefore, the SN biopsy remains the preferred method for initial regional staging.

Clinical outcome of stage I/II melanoma patients after selective sentinel lymph node dissection: long-term follow-up results

PURPOSE

Although sentinel lymph node (SLN) status is part of the new American Joint Committee on Cancer staging system, there is no final proof that the SLN procedure in melanoma patients influences outcome of disease. This study investigated the accuracy of the SLN procedure and clinical outcome in melanoma patients after at least 60 months of follow-up.

PATIENTS AND METHODS

Between 1993 and 1996, 209 patients with stage I/II cutaneous melanoma underwent selective SLN dissection by the triple technique. If the SLN contained metastatic disease, a completion lymphadenectomy was performed. Survival analyses were performed using the Kaplan-Meier approach. Factors associated with survival were analyzed using the Cox proportional hazards regression model.

RESULTS

The success rate was 99.5%. Median follow-up was 72 months. Forty patients (19%) had a positive SLN. The false-negative rate was 9%. Five-year overall survival was 87% for the entire group and 92% and 67% for SLN-negative and SLN-positive patients (P <.0001), respectively. All patients with a positive SLN and a Breslow thickness < or = 1.00 mm survived, and SLN-positive patients with a Breslow thickness less than 2.00 mm tend to have a better prognosis compared with SLN-negative patients with a Breslow thickness greater than 2.00 mm. SLN status (P =.002), Breslow thickness (P =.002), and lymphatic invasion (P =.0009) were all found to be independent prognostic factors for overall survival.

CONCLUSION

With a success rate of 99.5% and a false-negative rate of 9% after long-term follow-up, the triple-technique SLN procedure is a reliable and accurate method. Survival data seem promising, although a therapeutic effect is still questionable. As shown in this study, not all SLN-positive patients have a poor prognosis.