Significance of multiple nodal basin drainage in truncal melanoma patients undergoing sentinel lymph node biopsy

Prevalence of contralateral lymphatic drainage patterns during sentinel lymph node biopsy for truncal melanoma: A retrospective, observational study

BACKGROUND AND PURPOSE

This study aimed to examine the prevalence, patterns, and outcomes of contralateral lymphatic drainage during sentinel lymph node biopsy (SLNB) in patients with truncal melanoma. Understanding this phenomenon is crucial for improving surveillance and management strategies for melanoma patients.

SUBJECTS AND METHODS

This retrospective cohort study analysed 1308 consecutive patients aged 18 years and over who underwent wide local excision (WLE) for truncal melanoma followed by SLNB at The Christie Hospital, Manchester, UK, between October 2006 and November 2024. Exclusions included non-truncal melanoma and cases without lymphoscintigraphy data. SLNB evolved from intradermal injections of blue dye to include radiolabelled Technetium-99m-nano colloid. Contralateral drainage was defined as sentinel lymph nodes draining exclusively to the opposite side of the coronal midline relative to the WLE scar. Data were correlated with imaging results and patient outcomes.

MAIN FINDINGS

Contralateral drainage occurred in 14 patients (1.1%). This subgroup had melanoma thicknesses ranging from 0.80 to 6.40 mm and included 8 males and 6 females (ages 26-72 years). Notably, 10 cases involved posterior torso melanomas, with 6 located on the lower back. Three patients (21.4%) experienced melanoma recurrence during follow-up, all on the ipsilateral side. One patient treated in 2007 died following recurrence, while 2 patients treated in 2018 and 2021 remain alive following immunotherapy.

CONCLUSIONS

Contralateral sentinel lymph node drainage, though rare, highlights the need for tailored surveillance strategies for patients with truncal melanoma, particularly those with posterior torso lesions. These findings underscore the importance of incorporating this data into patient consent and individualised care plans.

Clinical significance of intra-thoracic and intra-abdominal sentinel lymph nodes detected on lymphoscintigraphy in truncal melanoma patients

BACKGROUND

Although most melanomas drain to the more common major lymph node basins (axilla, groin, neck), rarely they drain to deep SLN locations such as intra-abdominal and intra-thoracic (including intercostal and internal mammary) sites, which pose a higher surgical risk and complexity for procurement. Our study is aimed at determining the rate of positivity and likelihood of recurrence in these nodal sites to guide management decisions for patients with truncal melanomas which drain to these 'deep' SLN locations.

METHODS

Retrospective data collected between May 2008 and May 2022 including all patients with truncal melanomas who underwent lymphoscintigraphy resulting in the identification of deep SLNs in intra-abdominal and intra-thoracic sites were included. The associations between retrieval of SLNs and recurrence-free survival (RFS) and overall survival (OS) were investigated.

RESULTS

74 patients with a total of 91 SLNs located at deep sites were included. 11 (15 %) patients with a total of 12 lymph nodes had SLNB of these deep nodes, all of which were intercostal nodes. Only 1 patient had a positive SLNB. In total, 24 (32 %) patients developed recurrence. However, the remaining patients did not recur at the deep SLN sites. There were no statistically significant associations between retrieval of deep SLNs and RFS or OS. 3-year RFS in the patients who had deep SLNB performed was 62 % compared to 54 % and 50 % in those who had no SLNB or incomplete SLNB, respectively (p = 0.63).

CONCLUSION

In this study omitting procurement of these deep SLNs did not result in reduced RFS or OS.

Influencing factors associated with lymph node status in patients with cutaneous melanoma: An Asian population study

BACKGROUND

Sentinel lymph node (SLN) status is the predominant prognostic factor in patients diagnosed with clinically localized melanoma. The significance of completion lymph node dissection in patients with SLN metastasis is debatable. Not many studies have been conducted on acrallentiginous melanoma (ALM). This study aimed to characterize the prognostic factors of nodal positive ALM and confirm whether ALM patients can undergo the same treatment strategy as non-ALM patients in the Asian population.

METHODS

This is a retrospective review of patients who underwent surgery for cutaneous melanoma (CM) at Taipei Veterans General Hospital between January 1993 and December 2019. We investigated the risk factors for lymph node status. The association between clinicopathological factors and lymph node status of ALM and non-ALM patients was analyzed. Outcomes of completion lymph node dissection (CLND) performed following sentinel lymph node biopsy (SLNB) in the CM and ALM groups were compared.

RESULTS

A total of 197 patients were included in this study. ALM was the most common histological subtype, accounting for 66.5% of all the cases. Patients in the CM and ALM subgroups with metastatic SLN ( p = 0.012) or lymph nodes ( p < 0.001 and p = 0.001) exhibited higher mortality rate. Multivariate analysis showed that patients with clinical presentation of T4 category tumor ( p = 0.012) and lymphovascular invasion ( p = 0.012) had a significantly higher risk of positive lymph nodes. The overall survival of patients with lymph nodes metastasis was not associated with the performance of CLND.

CONCLUSION

Patients in the CM or ALM subgroups with metastatic SLNs or lymph nodes exhibited significantly poorer overall survival. Advanced Breslow thickness and lymphovascular invasion were independent predictive factors for CM and ALM patients with positive lymph node status. There was no significant difference in survival between CM and ALM patients following SLNB, regardless of CLND being performed.

Enhanced risk of multiple sentinel lymph node basins in truncal and head and neck melanoma

Introduction: Truncal and head and neck melanomas have a greater propensity to drain to multiple lymph node basins (MLNB) compared to extremity melanomas, which drain predominantly to a single lymph node basin (SLNB). The objective of this study was to compare the lymphatic drainage patterns and characteristics of truncal and head and neck melanoma, to assess their clinical usefulness in areas of unpredictable drainage. Methods: A retrospective review of 143 patients with head and neck or truncal melanoma from 2014–2018 treated at a tertiary referral hospital in Melbourne, Australia. Patients scheduled for a wide local excision (WLE) and SeNBx, and those whose initial biopsy results stated melanoma type, cell type and BT, were included. Patients were excluded if they underwent nodal biopsy alone. Results: We identified 95 patients with truncal and 48 with head and neck melanoma. Drainage to MLNB was significantly higher in the truncal melanoma group (36.8%) compared to the head and neck group (10.4%) (P = 0.001). Patients with drainage to MLNB had a higher positive sentinel node biopsy (SeNBx) rate compared to those with SLNB (40.0% verus. 12.6%, P <0.0001). Truncal melanomas that drained to MLNB were associated with a significantly higher Breslow thickness (2.1 versus. 1.5, P = 0.02), ulceration (40.6% vs. 20.7%, P = 0.043) and mitotic rate (3.0 versus. 2.0, P = 0.045) compared to equivalent melanomas that drained to SLNB. Conclusion: Patients with melanomas occurring in the trunk exhibit higher rates of drainage to MLNB compared to melanomas arising in the head and neck. Patients with drainage to MLNB also demonstrate a higher rate of positive SeNBx than those with SLNB drainage. This may represent more aggressive disease pathology or later diagnosis of lesions within these locations, or a lymphatic system that is more facilitatory of spread.

Analysis of the Different Lymphatic Drainage Patterns during Sentinel Lymph Node Biopsy for Skin Melanoma

In the last two decades, studies of lymphoscintigraphy imaging in lymphatic mapping reported an extreme heterogeneity of skin lymphatic drainage of some skin area, in contrast with the previous scientific literature. The aim of this study was to investigate the presence of any correlations between the topographical location of cutaneous melanoma and the topographical location of sentinel lymph nodes. Data from 165 patients undergoing sentinel lymph node biopsy between January 2013 and May 2021 were analyzed, demonstrating that melanomas in the Lumbar region presented a significant more heterogeneous drainage by site than those in the Scapular region (p < 0.01) and that melanomas in the Subscapular region were significantly more heterogeneous by laterality (unilateral vs. bilateral) than those in the Scapular region (p < 0.05). Results of this study supported the evidence of multiple lymphatic drainage as regards the sentinel node biopsy performed in skin melanoma located on the dorsal subscapular region and lumbar region. For this reason, the association of preoperative lymphoscintigraphy with another imaging evaluation is needed in these critical cutaneous areas. Recent technical developments enabling fluorescence lymphography together with indocyanine green have significantly improved the visualization of lymphatic drainage patterns at a microscopic level. In the preoperative phase, any doubt can be resolved by associating the SPET-CT scan to lymphoscintigraphy, while during the intraoperative phase, an additional evaluation with indocyanine green can be performed in doubtful cases. The aim of the duplex lymphatic mapping (pre and/or intraoperative) is an accurate search of sentinel nodes, in order to reduce the rate of false negatives.

Does the pattern of lymphatic drainage influence the risk of nodal recurrence in trunk melanoma patients with negative sentinel lymph node biopsy?

Background

There are conflicting data regarding the prognostic value of the lymphatic basin drainage pattern in melanoma patients and the evidence is scant in the setting of negative sentinel lymph node biopsy.

Objective

To investigate whether the pattern of lymphatic basin drainage influences the risk of nodal disease in patients with melanoma of the trunk and negative sentinel lymph node biopsy.

Methods

A case series of patients with trunk melanoma and negative sentinel lymph node biopsy was retrospectively evaluated. Clinicopathological features, the pattern of lymphatic drainage and nodal, metastatic, and overall recurrence-free survival were reviewed.

Results

Of the 135 patients included, multiple lymphatic basin drainage was identified in 61 (45.2%). Ten of the 74 (13.5%) patients with single drainage developed nodal recurrence, compared with 2 of the 61 (3.6%) patients with multiple drainages (p = 0.04). Nodal recurrence-free survival was significantly longer in the group with multiple drainages than in the group with single drainage (175.6 vs. 138.7 months; p = 0.04). In multivariate analysis, single drainage was associated with a higher risk of nodal recurrence (HR = 4.54; p = 0.05). No significant differences in metastatic and overall recurrence-free survival were found between groups.

Study limitations

Retrospective analysis, single-center study, small sample, detailed histopathologic information not always present.

Conclusions

In patients with trunk melanoma and negative sentinel lymph node biopsy, multiple lymphatic basin drainage may be an independent risk factor for nodal disease recurrence. This factor may help to identify patients with negative sentinel lymph node biopsy with a higher risk of nodal recurrence.

Impact of multiple lymphatic basin drainage in truncal melanoma patients

INTRODUCTION

In many patients with cutaneous melanoma that affects the trunk area, there is lymphatic drainage to multiple basins (MLBD). This study aimed to examine whether MLBD is associated with disease outcomes.

METHODS

Lymphatic mapping and sentinel lymph node (SLN) biopsy were performed in 161 patients with truncal melanoma. The number and location of draining nodal basins were established during the preoperative lymphoscintigraphy using technetium-99 m rhenium sulphide nanocolloid.

RESULTS

MLBD was present in 59 (37%) patients, and single lymphatic basin drainage (SLBD) in 102 (63%) patients. Patients with MLBD showed no increased risk for SLN metastasis compared to patients with SLBD (27% versus 29%, respectively). There was no significant difference in disease-free survival (DFS) between patients with MLBD and those with SLBD. Five-year DFS was 64% for patients with MLBD and SLBD. Multivariate analysis showed that the presence of ulceration (p = 0.01) was an independent predictor of SLN metastasis, while melanoma thickness (p = 0.01) and SLN metastasis (p = 0.01) were independent predictors of DFS. In patients with a negative SLN, five-year DFS was 74% for patients with MLBD and 73% for those with SLBD. Multivariate analysis showed that melanoma thickness (p = 0.00) was an independent predictor of DFS.

CONCLUSION

MLBD does not negatively impact the disease outcome in patients with truncal melanoma.

Survival prediction in patients with cutaneous melanoma by tumour lymphangiogenesis

Objectives: Melanoma induces lymphangiogenesis by secreting lymphangiogenic growth factors. The aim of this study was to examine the role of tumour lymphangiogenesis in survival of patients with cutaneous melanoma. Methods: Immunostaining of one hundred melanoma specimens was done with lymphatic-specific antibody D2-40. The quantification of tumour lymphangiogenesis - lymphatic vessel density (LVD) and lymphatic vessel area (LVA) - was calculated by computer-assisted morphometric analysis. Results: High intratumoural LVD, high peritumoural LVD, male gender, greater tumour thickness and Clark level IV/V were significantly associated with shorter disease-free survival (p= 0.001, p= 0.004, p= 0.004, p= 0.000 and p= 0.008, respectively) and melanoma-specific survival (p= 0.002, p= 0.002, p= 0.001, p= 0.000 and p= 0.017, respectively), while the trunk melanoma site was significantly associated only with shorter disease-free survival (p= 0.033). No significant association of LVA with survival was found. At multivariate analysis, peritumoural LVD [hazard ratio (HR) = 2.143, 95% confidence interval (CI) 1.097-4.189, p= 0.026)] and melanoma thickness (HR = 1.276, 95%CI 1.106-1.473, p= 0.001) were independent predictors of disease-free survival, while intratumoural LVD (HR = 3.446, 95%CI 1.465-8.109, p= 0.005), peritumoural LVD (HR = 2.742, 95%CI 1.313-5.725, p= 0.007) and gender (HR = 2.880, 95%CI 1.304-6.362, p= 0.009) were independent predictors of melanoma-specific survival. Conclusion: Тhis study shows that LVD enables better prediction of survival than melanoma thickness and other clinical-pathological parameters. Intratumoural LVD is the most significant predictor of melanoma-specific survival, while only peritumoural LVD has a significant impact on both, a disease-free survival and a melanoma-specific survival.

Nonvisualization of Sentinel Lymph Nodes by Lymphoscintigraphy in Primary Cutaneous Melanoma: Incidence, Risk Factors, and a Review of Management Options

BACKGROUND

Lymphoscintigraphy is often performed before sentinel lymph node biopsy, especially in areas likely to have multiple or aberrant drainage patterns. This study aims to determine the incidence and characteristics of melanoma patients with negative lymphoscintigraphic findings and to review the management options and surgical recommendations.

METHODS

This is a retrospective study of patients with primary cutaneous melanoma who underwent sentinel lymph node biopsy between 2005 and 2016. Patients with nonvisualized lymph nodes on preoperative lymphoscintigraphy were compared in a 1:4 ratio with a randomly selected unmatched cohort drawn from all melanoma patients who underwent preoperative lymphoscintigraphy within the period of the study. Demographic, clinical, and outcome data were compared between these groups.

RESULTS

A negative lymphoscintigraphic scan was seen in 2.3 percent of all cases (25 of 1073). In both univariate and multivariate analyses, predictive patient- and tumor-specific factors for negative lymphoscintigraphy included older age and head and neck location. Patients with a nonvisualized sentinel lymph node had significantly worse overall survival compared with patients who had a visualized sentinel lymph node, but there was no difference in melanoma-specific survival. In 16 of the 25 cases (64 percent), at least one sentinel lymph node was found intraoperatively despite the negative lymphoscintigraphic findings.

CONCLUSIONS

Older patients with head and neck melanomas are more likely to experience nodal nonvisualization on lymphoscintigraphy. In patients who have nodal nonvisualization, the surgeon should attempt sentinel lymph node biopsy at the time of excision of the primary lesion because a sentinel lymph node can still be found in a majority of cases, and it offers prognostic information.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Time to Procedure, Nuclear Imaging and Clinicopathological Characteristics as Predictive Factors for Sentinel Lymph Node Metastasis in Cutaneous Melanoma: A Single-Center Analysis

OBJECTIVE

Sentinel lymph node (SLN) biopsy is a widely accepted staging procedure for cutaneous melanoma patients who are at risk of clinically occult nodal metastases. Numerous predictive factors for regional lymph node metastases have been identified; however, few have been found to be reproducibly significant. Also, the role of blue dye in identification was questioned in recent trials. Time to procedure was also found to be predictive of SLN positivity, but this was not confirmed in other studies. In our study, predictive factors for metastatic involvement of SLN were analyzed, together with the role of addition blue dye in imaging on detection rate and false-negative SLN rate. An impact of time interval to procedure on the rate of SLN positivity was also explored.

METHODS

Data analysis was done in 362 cutaneous melanoma patients who underwent lymphoscintigraphy and SLN biopsy at our institution from 2010 to 2016, with a median follow-up of 29 months (1-98 months). To delineate the relation of each variable (demographical, time to procedure, and clinical and pathological variables, as well as the presence of in-transit nodes, the number of draining basins, and SLN localization on scintigraphy) with positive SLN status, we used univariate logistic regression with odds ratios representing effect size.

RESULTS

Metastatic involvement SLN was found in 67 (18.8%) of 356 patients. Detection rate was similar with or without further intraoperative SLN identification with blue dye (98.8% vs 98.17%, P > 0.05). Time to procedure was not associated with higher SLN positivity rate (P > 0.05). In univariate analysis, Breslow thickness (P < 0.001), primary ulceration lesion (P = 0.001), and lymphovascular invasion (P = 0.006) were strongly correlated with SLN positivity, as well as the site of primary tumor (P = 0.024), tumor-infiltrating lymphocytes (TILs) (P = 0.021), and sex (P = 0.026). In multivariate analysis, Breslow thickness and TILs were found to be significant independent predictors of SLN status (P < 0.05).

CONCLUSIONS

Addition of blue dye did not improve SLN detection rate; time to procedure was not found to be associated with higher SLN biopsy positivity rates. Breslow thickness and TILs, as a marker of immune response to tumor, were consistently found to be significant independent predictors of SLN status.

Prognostic Value of Multiple Draining Lymph Node Basins in Melanoma: A Matched-Pair Analysis Based on the John Wayne Cancer Institute Experience

BACKGROUND

The prognostic significance of multiple draining basins is controversial in melanoma because analyses have not adequately controlled for standard prognostic variables. We hypothesized that an analysis based on prognostically matched pairs of patients with multiple versus single drainage basins would clarify any independent role of basin number.

STUDY DESIGN

We identified patients in our 40-year prospective database, who underwent preoperative lymphoscintigraphy, intraoperative sentinel node biopsy and wide local excision for cutaneous melanoma. Overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were compared in patients with multiple versus single drainage basins after matching by age, sex, Breslow depth, primary site, and stage at diagnosis.

RESULTS

We identified 274 patients with multibasin drainage and 1,413 patients with single draining lymph node basins. Matching yielded 259 pairs (226 trunk, 27 head/neck, 6 extremity). Among matched pairs, multibasin drainage did not affect rates of lymph node metastasis (p = 0.84), OS (p = 0.23), DSS (p = 0.53), overall recurrence (p = 0.65), locoregional recurrence (p = 0.58), or distant recurrence (p = 1.0). Multivariable analysis linked higher T stage, ulceration, older age, and lymph node positivity to decreased DSS (p < 0.01) and DFS (p < 0.001). Number of drainage basins was not significant on univariable or multivariable analysis.

CONCLUSION

This analysis, the first to match for standard prognostic factors, suggests that multiplebasin drainage as identified by lymphoscintigraphy has no independent biological or prognostic significance in primary cutaneous melanoma.

Expression of Ki-67 and Estrogen Receptor Beta in Primary Cutaneous Melanoma as a Potential Indicator of Regional Lymph Node Positivity

In the early stages of cutaneous malignant melanoma (MM), it is extremely difficult to predict adequately the risk from hematogenic and lymphatic metastasis. We investigate whether the immunohistochemical expression of Ki-67 and estrogen receptor beta (ERβ) in cells of MM could predict the status of regional lymph nodes. A total of 55 tissue samples of primary cutaneous melanomas with known status of regional lymph nodes were retrospectively evaluated for Ki-67 and ERβ expression by quantitative immunohistochemistry and then correlated with the status of regional lymph nodes and relevant clinicopathologic parameters. The ERβ-positive expression was detected in 38 of 55 tumors (69.09%). The Clark level showed a strong correlation with ERβ expression, as well as pT stage. All cases of MM showed Ki-67-positive expression and an elevated Ki-67 expression was strongly associated with increased Breslow thickness, Clark level, ulceration, lymphovascular invasion, number of mitosis, and pT stage. Logistic regression analysis showed that when ERβ levels increase by 1%, the risk of positive lymph nodes decreases by 7% (odds ratio=0.930; 95% confidence interval, 0.87-0.99; P=0.036), and, when the Ki-67 expression increases by 1%, the risk of lymph nodes' positivity increases by 10% (odds ratio=1.108; 95% confidence interval, 1.02-1.19; P=0.009). Correlation between expression of Ki-67 and ERβ and the status of lymph nodes has better prognostic significance than the relationship between melanoma thickness and the status of lymph nodes. Our study showed a significant prognostic value of Ki-67 expression in predicting the behavior of MM and the potential prognostic significance of ERβ.

Outcome of Melanoma Patients Who Did Not Proceed to Sentinel Node Biopsy After Preoperative Lymphoscintigraphy

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.

Prognostic Role of Multiple Lymphatic Basin Drainage in Sentinel Lymph Node-Negative Trunk Melanoma Patients: A Multicenter Study from the Italian Melanoma Intergroup

BACKGROUND

Multiple lymphatic basin drainage (MLBD) is frequently observed in patients with trunk melanoma undergoing sentinel lymph node (SLN) biopsy. Conflicting data regarding the prognostic association of MLBD in SLN-negative patients have been reported. This study aimed to investigate the prognostic role of MLBD in patients with negative SLN biopsy.

METHODS

Retrospective data from 656 melanoma patients who underwent a SLN biopsy (1991-2012) at six Italian centers were gathered in a multicenter database. MLBD was defined as lymphoscintigraphic and intraoperative identification of an SLN in more than one nodal basin. Clinical and pathologic variables were recorded and analyzed for their impact on survival.

RESULTS

SLN-negative patients with MLBD were at lower risk of melanoma recurrence [hazard ratio (HR) 0.73, P = 0.05) and melanoma-related death (HR 0.68, P = 0.001) independent of common staging features. Multivariable Cox analyses of disease-free interval (DFI) and disease-specific survival (DSS) showed that MLBD maintained a favorable role and ulceration an unfavorable role. Histologic regression was independently associated only with DFI. When survival was stratified according to presence of MLBD, histologic regression and Breslow thickness <2 mm were associated with improved DFI (5-year DFI: 96.9 vs. 66,1 %, respectively; HR 0.48, P < 0.001) and DSS (5-year DSS: 96.7 vs. 71.8 %, respectively; HR 0.52, P = 0.005) compared to patients without these three favorable parameters.

CONCLUSIONS

Patients with negative SLN biopsy results have better prognosis when two or more lymphatic basins are identified and analyzed. Further research is required to investigate the mechanisms behind this evidence.

Systemic Targeting of Lymph Node Metastasis through the Blood Vascular System by Using Size-Controlled Nanocarriers

Occult nodal metastases increase the risk of cancer recurrence, demoting prognosis and quality of life of patients. While targeted drug delivery by using systemically administered nanocarriers can potentially control metastatic disease, lymph node metastases have been mainly dealt by locally injecting nanocarriers, which may not always be applicable. Herein, we demonstrated that sub-50 nm polymeric micelles incorporating platinum anticancer drugs could target lymph node metastases in a syngeneic melanoma model after systemic injection, even after removing the primary tumors, limiting the growth of the metastases. By comparing these micelles with clinically used doxorubicin-loaded liposomes (Doxil) having 80 nm, as well as a 70 nm version of the micelles, we found that the targeting efficiency of the nanocarriers against lymph node metastases was associated with their size-regulated abilities to extravasate from the blood vasculature in metastases and to penetrate within the metastatic mass. These findings indicate the potential of sub-50 nm polymeric micelles for developing effective conservative treatments against lymph node metastasis capable of reducing relapse and improving survival.

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

BACKGROUND

Melanoma patients with palpable nodal disease in more than one basin have a worse prognosis than those with single-basin disease. Little is known about the outcome of patients with microscopically positive nodal disease in more than one basin, or how they are currently managed at tertiary referral centers.

METHODS

We identified 97 patients with positive sentinel lymph nodes (SLNs) in more than one lymph node basin from 1994 to 2010 from three tertiary care centers. Clinical and pathologic outcome variables were analyzed.

RESULTS

Ninety-seven patients (72 men, 25 women) were identified with at least one positive SLN in at least two node basins. Most primary tumors were truncal (68, 70 %) followed by extremity (16, 17 %) and head/neck (13, 13 %). The median Breslow depth was 3.2 mm (range 0.8-12 mm), and 49 (51 %) were ulcerated. The most frequently involved nodal basins were the axilla (112, 57 %), neck (40, 20 %), and groin (24, 12 %). Seventy-seven percent (153 of 198) of all positive SLN basins underwent completion lymph node dissection (CLND). Most patients (54, 56 %) developed recurrent disease, with a median time to recurrence of 20 months. The majority of first recurrences were distant (42, 43 %), followed by regional nonnodal metastases (17, 18 %) and regional nodal metastases (16, 16 %). There was no significant difference in median overall survival between CLND versus no-CLND groups (45 vs. 30 months, respectively).

CONCLUSIONS

Most melanoma patients with more than one SLN-positive basin are currently managed with CLND. Outcomes after CLND and no CLND are similarly poor; therefore, consideration of close nodal observation may be more appropriate.

Surgical management of sentinel lymph node biopsy outside major nodal basin in patients with cutaneous melanoma

PURPOSE

To assess the incidence of nonmajor lymphatic basin sentinel nodes in patients with cutaneous melanoma in order to propose a correct nomenclature and inform appropriate surgical management.

METHODS

This was a retrospective review of 1,045 consecutive patients with cutaneous melanoma who underwent sentinel lymph node biopsy and dynamic lymphoscintigraphy to identify sentinel node site. Nonmajor drainage sites were classified as uncommon (located in a minor lymphatic basin along the lymphatic drainage to a major classical nodal basin) or interval (located anywhere along the lymphatics between the primary tumor site and the nearest lymphatic basin) sentinel nodes.

RESULTS

Nonclassical sentinel nodes were identified in 32 patients (3.0 %). Uncommon sentinel nodes were identified in 3.2 % (n = 17) of trunk melanoma primary disease and in 1.5 % (n = 7) of upper and lower extremity sites. Interval sentinel nodes were identified in 1.3 % (n = 7) of trunk primary lesions, with none from upper and lower extremities melanomas. The incidence of tumor-positive sentinel nodes was 24.1 % (245 of 1,013) in classical sites and 12.5 % (4 of 32) in uncommon/interval sites.

CONCLUSIONS

The definition of uncommon and interval sentinel nodes allows the identification of different lymphatic pathways and inform appropriate surgical treatment. Wider experience with uncommon/interval sentinel nodes will better clarify the clinical implications and surgical management to be adopted in the management of uncommon and interval sentinel node sites.

Molecular mechanisms and imaging of lymphatic metastasis

In many types of cancer, tumors metastasize through the lymphatic system to draining lymph nodes. These sentinel lymph nodes have gained increased attention as a prognostic indicator for the severity of the disease, leading to the sentinel lymph node mapping and biopsy procedure to be accepted as standard-of-care for breast cancer and melanoma. However, many limitations exist with this procedure resulting in high false negative rates. In this review we highlight the new advances in the understanding of the molecular mechanisms of lymphangiogenesis and tumor metastasis that may lead to improved strategies in the detection of the sentinel lymph nodes and therapeutic interventions to prevent further tumor spread. In addition, advances in imaging technology are allowing new approaches for anatomical mapping of lymphatic drainage patterns and molecular imaging strategies that may improve detection of metastatic tumor cells within sentinel lymph nodes.

Prognostic significance of drainage to pelvic nodes at sentinel lymph node mapping in patients with extremity melanoma

Patients undergoing sentinel lymph node (SLN) mapping for lower extremity melanoma may have drainage to pelvic nodes (DPN) in addition to superficial inguinal nodes. These nodes are not sampled routinely at SLN biopsy. Factors predicting DPN and its prognostic significance were assessed in a large cohort of patients undergoing an SLN biopsy. Three hundred and twenty five patients with single primary melanomas of the lower extremity or buttocks who underwent SLN mapping were identified from our prospective melanoma database (December 1995-October 2008). Associations of clinical and pathologic factors with DPN and time to melanoma recurrence (TTR) were analyzed by logistic and Cox regression, respectively. DPN was common, occurring in 23% of cases. Increased Breslow's thickness (P=0.007) and age (P=0.01) were associated with DPN by multivariate analysis. Patients with DPN were not more likely to have a positive SLN; however, SLN- patients with DPN showed a shorter TTR (P=0.02) in a multivariable model including thickness and ulceration. With age included in the model, DPN remained marginally associated with TTR in this group (P=0.08). The pelvic recurrence rates observed were similar in recurrent patients with DPN compared with those without DPN (39% in both groups). In conclusion, DPN occurs in almost one-quarter of patients with lower extremity melanoma and is marginally associated with a shorter TTR in SLN- patients.

Sentinel node studies in truncal melanoma: does an increased number of draining basins correlate with an increased risk of lymph metastasis?

OBJECTIVES

To assess whether an association exists between drainage to multiple basins and lymphatic metastasis in patients with truncal melanoma.

METHODS

We retrospectively reviewed 227 patients with primary malignant melanoma between January 2006 and December 2009. All patients received an intradermal injection of (99m)Tc-nanocolloid and lymphoscintigraphy followed by sentinel node biopsy. Pre-staging histology with Breslow thickness from excision biopsy was also obtained.

RESULTS

82/227 (36%) patients with primary truncal melanoma were identified. Nodal histology was positive for metastatic disease in 27/82 (32.9%) patients. Of these 27, 15 had 1 basin of drainage, 7 had 2 basins of drainage and 5 had 3 basins of drainage. Of the 55 node-negative patients, 35 had 1 basin, 18 had 2 basins and 2 had 3 basins of drainage. We found no significant correlation with sentinel node positivity and those that had ≥2 drainage basins. Breslow thickness was available in 65/82(79.2%) patients. Sentinel node biopsy was positive in 6/28 patients who had <1.5 mm thickness, 8/14 who had a 1.5-3.9 mm thickness and 9/23 who had ≥4 mm thickness. There was a significant correlation between Breslow thickness of ≥4 mm and nodal positivity (P = 0.03).

CONCLUSION

This study demonstrates no association between multiple drainage basins and sentinel node histology. Sentinel lymph node status did correlate with Breslow thickness.

Modifying effect of gender on the prognostic value of clinicopathological factors and Ki67 expression in melanoma: a population-based cohort study

Background

Malignant melanoma is the most deadly form of skin cancer. Female sex is known to have a protective effect on incidence, tumour characteristics, and mortality from melanoma. However, the potentially modifying effect of sex on the prognostic significance of clinicopathological and investigative factors is generally not taken into consideration in biomarker studies. In this study, we compared the sex-specific distribution and prognostic value of established tumour characteristics and Ki67 expression in 255 cases of incident primary melanoma in a prospective, population-based cohort study.

Methods

The study included 255 incident cases of melanoma, 132 females and 123 males, in the Malmö Diet and Cancer Study. Tumours from 226 (88.6%) cases had been assembled in tissue microarrays. Clinicopathological factors and immunohistochemical Ki67 expression were assessed and correlated with disease-free survival (DFS) and overall survival (OS) using Kaplan-Meier analysis, log rank test and univariable and multivariable Cox regression analyses, stratified for gender. Effect of gender on melanoma-specific survival (MSS) after first recurrence was also analysed.

Results

Women were significantly younger at diagnosis than men (p = 0.012). The most common tumour sites were the legs in women (37.5%) and the dorsal trunk in men (37.8%). Kaplan-Meier analysis revealed that tumour location had no prognostic impact in women, but in men, location to the frontal trunk was significantly associated with a reduced DFS compared with all other locations combined and location to the dorsal trunk was significantly associated with a prolonged OS. High Ki67 expression was significantly associated with a reduced DFS and OS in men but not in women, also when adjusted for other factors. In men, but not in women, ulceration was an independent prognostic factor for both DFS and OS. MSS after first local, regional or distant recurrence was significantly shorter for men than for women.

Conclusions

The results from this study demonstrate that the prognostic value of tumour location, Ki67 expression and ulceration in melanoma differs according to gender. These findings need to be validated in future studies, as they may help improve prognostication in patients with melanoma. Moreover, our findings demonstrate that sex-stratified analyses add valuable information to biomarker studies.

Clinicopathologic and Survival Differences between Upper and Lower Extremity Melanomas

This analysis was performed to compare differences in clinicopathologic factors, sentinel lymph node (SLN) status, and survival between upper extremity (UE) and lower extremity (LE) melanoma patients. Post hoc analysis of a prospective clinical trial was performed of all patients with extremity melanomas with complete data. Survival was evaluated with Kaplan-Meier analysis. Univariate and multivariate analyses were performed. A total of 1115 patients aged 18 to 70 years with extremity melanomas ≥ 1.0 mm Breslow thickness were analyzed; all underwent SLN biopsy with completion lymphadenectomy for a tumor-positive SLN. Compared with UE patients, LE melanoma patients were younger, predominantly female, and had a higher rate of SLN metastasis. Kaplan-Meier analysis revealed worse 5-year disease-free survival (DFS) and worse local and in-transit recurrence-free survival in LE versus UE melanoma patients, but no difference in overall survival (OS). Subgroup analysis revealed that older patients (age > 51 years) with LE melanomas had worse DFS, local and in-transit recurrence-free-survival, and OS. LE tumor location was not an independent risk factor for OS or DFS. Compared with UE melanoma patients, those with LE melanomas have a greater risk of tumor-positive SLN and local/in-transit recurrence.

Prognostic implications of anatomic location of primary cutaneous melanoma of 1 mm or thicker

BACKGROUND

Breslow thickness, ulceration, and sentinel lymph node (SLN) status are well established as the most important prognostic factors for patients with cutaneous melanoma. Anatomic location of the primary tumor is generally considered to play a minor role in determining prognosis compared with these other factors. This analysis was performed to better define the influence of anatomic location of the primary melanoma on prognosis.

METHODS

In this post hoc analysis of a prospective randomized trial that included patients ages 18 to 70 years with melanomas 1 mm or greater in Breslow thickness, all patients underwent SLN biopsy and completion lymphadenectomy if tumor-positive SLN were found. Kaplan-Meier survival analysis and univariate and multivariate analyses were performed to evaluate factors predictive of disease-free survival (DFS), local and in-transit recurrence-free survival (LITRFS), and overall survival (OS).

RESULTS

A total of 2,500 patients were included in this analysis with a median follow-up period of 68 months. Anatomic locations included head, neck, trunk, upper extremity, and lower extremity. Age, Breslow thickness, and percentage of patients with a positive SLN were significantly different by anatomic location on univariate analysis, as were positive SLN status, presence of regression, sex, and histologic subtype (P < .0001). On multivariate analysis, anatomic location was an independent predictor of SLN status (P < .0001), DFS (P = .045), LITRFS (P = .023), and OS (P < .0001). By Kaplan-Meier analysis, anatomic location was associated significantly with DFS, LITRFS, and OS.

CONCLUSIONS

Anatomic location of the primary melanoma is an important independent predictor of SLN status and prognosis. Patients with primary melanomas of the head/neck and trunk have a worse prognosis than primary melanomas of other anatomic locations.

Lymphoscintigraphy defines new lymphatic pathways from cutaneous melanoma site: clinical implications and surgical management

Sentinel lymph node biopsy is commonly applied as staging procedure of regional lymph nodes in patients with cutaneous melanoma. Dynamic lymphoscintigraphy defines the lymphatic pathways from a primary melanoma site and allows to identify the node receiving lymphatic drainage from the primary tumor, which is the sentinel lymph node. In rare cases, lymphoscintigraphy shows sites of lymphatic drainage in nonclassical basins never described in the past when lymphatic drainage was considered only according to the anatomical proximity of the tumor primary site. These peculiar sentinel nodes, so-called "uncommon/interval" nodes, must be surgically removed because they may contain micrometastatic disease and may be the only site of nodal involvement.

Factors predictive of the status of sentinel lymph nodes in melanoma patients from a large multicenter database

BACKGROUND

Numerous predictive factors for cutaneous melanoma metastases to sentinel lymph nodes have been identified; however, few have been found to be reproducibly significant. This study investigated the significance of factors for predicting regional nodal disease in cutaneous melanoma using a large multicenter database.

METHODS

Seventeen institutions submitted retrospective and prospective data on 3463 patients undergoing sentinel lymph node (SLN) biopsy for primary melanoma. Multiple demographic and tumor factors were analyzed for correlation with a positive SLN. Univariate and multivariate statistical analyses were performed.

RESULTS

Of 3445 analyzable patients, 561 (16.3%) had a positive SLN biopsy. In multivariate analysis of 1526 patients with complete records for 10 variables, increasing Breslow thickness, lymphovascular invasion, ulceration, younger age, the absence of regression, and tumor location on the trunk were statistically significant predictors of a positive SLN.

CONCLUSIONS

These results confirm the predictive significance of the well-established variables of Breslow thickness, ulceration, age, and location, as well as consistently reported but less well-established variables such as lymphovascular invasion. In addition, the presence of regression was associated with a lower likelihood of a positive SLN. Consideration of multiple tumor parameters should influence the decision for SLN biopsy and the estimation of nodal metastatic disease risk.

What does ulceration of a melanoma mean for prognosis?

Ulceration of a primary cutaneous melanoma is clearly associated with worse prognosis, although the underlying mechanisms are not well understood. Recent studies have shown that the presence of ulceration may predict response to adjuvant IFN in high-risk patients. As molecular pathways continue to be elucidated, it is possible that continued study of ulceration will provide insight into potential therapeutic strategies, or will predict response to novel targeted therapies. Future investigation into melanoma ulceration is warranted.

Melanoma sentinel node biopsy and prediction models for relapse and overall survival

BACKGROUND

To optimise predictive models for sentinal node biopsy (SNB) positivity, relapse and survival, using clinico-pathological characteristics and osteopontin gene expression in primary melanomas.

METHODS

A comparison of the clinico-pathological characteristics of SNB positive and negative cases was carried out in 561 melanoma patients. In 199 patients, gene expression in formalin-fixed primary tumours was studied using Illumina's DASL assay. A cross validation approach was used to test prognostic predictive models and receiver operating characteristic curves were produced.

RESULTS

Independent predictors of SNB positivity were Breslow thickness, mitotic count and tumour site. Osteopontin expression best predicted SNB positivity (P=2.4 × 10⁻⁷), remaining significant in multivariable analysis. Osteopontin expression, combined with thickness, mitotic count and site, gave the best area under the curve (AUC) to predict SNB positivity (72.6%). Independent predictors of relapse-free survival were SNB status, thickness, site, ulceration and vessel invasion, whereas only SNB status and thickness predicted overall survival. Using clinico-pathological features (thickness, mitotic count, ulceration, vessel invasion, site, age and sex) gave a better AUC to predict relapse (71.0%) and survival (70.0%) than SNB status alone (57.0, 55.0%). In patients with gene expression data, the SNB status combined with the clinico-pathological features produced the best prediction of relapse (72.7%) and survival (69.0%), which was not increased further with osteopontin expression (72.7, 68.0%).

CONCLUSION

Use of these models should be tested in other data sets in order to improve predictive and prognostic data for patients.

Sentinel node biopsy in malignant melanoma: Swedish experiences 1997-2005

The sentinel node biopsy (SNB) procedure is a multidisciplinary technique, invented to gain prognostic information in different malignant tumors. The aim of the present study was to study the cohort of patients with malignant melanoma, operated with SNB, from the introduction of the technique in Sweden, concerning the prognostic information retrieved and the outcome of the procedures. In Sweden all patients with malignant melanoma are registered at regional Oncological Centers. From these databases ten centers were identified, treating malignant melanoma and performing sentinel node biopsy. Consecutive data concerning tumor characteristics, outcome of the procedure and disease related events during the follow-up time were collected from these ten centers. All cases from the very first in each centre were included. The SNB procedure was performed in 422 patients with a sentinel node (SN) detection rate of 97%, the mean Breslow thickness of the primary tumors was 3.2 mm (median 2.4 mm) and the proportion of ulcerated melanomas 38%. Metastasis in the SN was found in 19% of the patients but there was a wide range in the proportion of SN metastases between the different centers (5-52%). After a follow-up of median 12 months of 361 patients, SN negative patients had better disease-free survival than SN positive (p<0.0001). A false negative rate of 14% was found during the follow-up time. In this study the surgical technique seemed acceptable, but the non-centralized pathology work-up sub-optimal. However, SNB was still found to be a significant prognostic indicator, concerning disease free survival.

A comprehensive overview of radioguided surgery using gamma detection probe technology

The concept of radioguided surgery, which was first developed some 60 years ago, involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. The use of gamma detection probe technology in radioguided surgery has tremendously expanded and has evolved into what is now considered an established discipline within the practice of surgery, revolutionizing the surgical management of many malignancies, including breast cancer, melanoma, and colorectal cancer, as well as the surgical management of parathyroid disease. The impact of radioguided surgery on the surgical management of cancer patients includes providing vital and real-time information to the surgeon regarding the location and extent of disease, as well as regarding the assessment of surgical resection margins. Additionally, it has allowed the surgeon to minimize the surgical invasiveness of many diagnostic and therapeutic procedures, while still maintaining maximum benefit to the cancer patient. In the current review, we have attempted to comprehensively evaluate the history, technical aspects, and clinical applications of radioguided surgery using gamma detection probe technology.

In-transit sentinel nodes must be found: implication from a 10-year follow-up study in melanoma

The aim was to study the occurrence of in-transit nodes at a preoperative lymphoscintigraphy for patients with primary melanoma, and to reveal their potential role in prognosis. From 1984 to 1996, 911 patients, hospitalized for wide excision of a clinically localized primary cutaneous head-neck or truncal melanoma, had a static lymphoscintigraphy on the day before surgery as part of a prospective protocol. Lymph nodes were in no case removed at the time of scintigraphy. Recurrence and survival patterns were compared for patients with in-transit nodes with the remaining patients with only regional nodes. Follow-up time was a minimum of 10 years. In-transit nodes were visualized by lymphoscintigraphy in 6% of the patients, 18% of whom had a later recurrence in this region. The melanomas in the in-transit node group were slightly thicker, and ulceration was slightly more frequent (neither significant). The in-transit node group had significantly more lymph node basins visualized at scintigraphy compared with the remaining group of patients with only regional nodes. The risk of recurrence and/or death from melanoma was significantly worse (P<0.05) in the in-transit node group compared with the remaining patients. The clinical significance of the in-transit nodes, occasionally seen in melanoma patients (also in stage Ia), may suggest a slightly poorer prognosis and a substantial risk of a later recurrence in the in transit region. We therefore recommend that in-transit nodes must be found and examined exactly as is done with locoregional sentinel nodes.

Sentinel lymph node biopsy for melanoma: aspects of pathologic assessment

Sentinel lymph node (SLN) biopsy affords an accurate, minimally invasive means of staging and determining prognosis in patients with melanoma and for identifying those patients who may benefit from complete regional lymph node dissection. Careful and accurate histopathologic assessment of SLNs is critical to achieving optimal reliability of the technique. Micromorphometric parameters of melanoma deposits in SLNs have been shown to be predictive of regional non-SLN involvement and of clinical outcomes. Several non-histopathologic methods of SLN evaluation have been investigated, and while some of them show promise for the future, excision and histopathologic examination currently remains the gold standard for the evaluation of SLNs.

The complex relationships between sentinel node positivity, patient age, and primary tumor desmoplasia: analysis of 2303 melanoma patients treated at a single center

BACKGROUND

Recent studies have shown that younger age is associated with a greater likelihood of positive sentinel node (SN) status in patients with localized melanoma. This is a paradoxical situation because it is well known that younger patients have a far more favorable overall survival rate than older patients. In addition, desmoplastic melanomas are associated with a lower frequency of SN positivity, although this is less well documented.

METHODS

The outcome for 2303 cutaneous melanoma patients undergoing sentinel lymph node biopsy (SLNB) at the Sydney Melanoma Unit between 1993 and 2006 was examined to clarify the role of patient age and desmoplastic histogenetic type on SN positivity.

RESULTS

By univariate analysis, patients aged <40 years had a higher SN positivity rate (22.6%) than patients aged > or =40 years (15.4%; P < .004). Features associated with SN positivity were tumor thickness, mitotic rate, ulcerative state, and nondesmoplastic histogenetic type (all P < .001). Patient sex and primary melanoma site were not statistically significantly associated. Multivariate analyses revealed that only tumor thickness, patient age, nondesmoplastic type (all P < .001), and ulceration (P < .026) were independently associated with SN positivity. Key prognostic determinants such as total number of disease-positive nodes (both SNs and non-SNs) and site of first relapse did not vary according to age.

CONCLUSIONS

Tumor thickness, patient age, desmoplastic histogenetic type, and primary melanoma ulceration were all independently associated with SN status. The factors underlying the paradox of a poorer survival rate in older patients despite a lower incidence of positive SNs remain unclear.

Predicting sentinel node status in AJCC stage I/II primary cutaneous melanoma

BACKGROUND

Sentinel lymph node (SLN) status is an important prognostic factor for survival for patients with primary cutaneous melanoma. To address the issue of selecting patients at high and low risk for a positive SLN, prognostic factors were sought that predict SLN involvement by examining characteristics of both the primary tumor and the patient within the context of a biological model of melanoma progression.

METHODS

The study included 682 patients with primary vertical growth phase (VGP) melanoma and no clinical evidence of metastatic disease who underwent SLN biopsy (1995-2003). Logistic regression and classification tree analyses were used to investigate the association between SLN positivity and Breslow thickness, Clark level, tumor infiltrating lymphocytes (TIL), ulceration, mitotic rate (MR), lesion site, gender, and age. RESULTS.: In all, 88 of the 682 patients had > or =1 positive SLN (12.9%). In the multivariate analysis, MR, TIL, and thickness were found to be independent prognostic factors for SLN positivity. In the classification tree, four different risk groups were defined, ranging from minimal risk (2.1%) to high risk (40.4%). In lesions < r =2.0 mm, MR was important in risk-stratifying patients, and in lesions >2.0 mm TIL was important.

CONCLUSIONS

By incorporating biologically based variables such as VGP, TIL, and MR along with thickness into a prognostic model, both patients at high risk and minimal risk for SLN positivity can be identified. If validated, this model can be used in patient management and trial design to select patients to undergo or be spared SLN biopsy.

The role of sentinel lymph node biopsy in the management of melanoma

During the last 2 decades, the development and wide acceptance of SLN biopsy have affected the management of melanoma profoundly. This technique represents a considerable improvement in the ability to evaluate the tumor status of the regional lymph node basin, which is the most important predictor of survival in patients who have melanoma. Histopathologic and molecular assessment of the SLN has enhanced the detection of clinically occult nodal metastases, thereby distinguishing patients who might benefit from immediate lymphadenectomy from those for whom this procedure is unlikely to be helpful. This technique also identifies patients who would be candidates for clinical trials of adjuvant therapy. Centers can offer SLN biopsy without routine CLND once they reach a level of proficiency that usually corresponds to a learning phase of 55 cases. The role of molecular technology in the identification and analysis of the SLN remains to be established. Although molecular evidence of SLN metastasis has been identified in patients who have early-stage melanoma, its clinical relevance cannot be determined until marker selection is improved. The markers presently under study lack sensitivity and specificity. The role of molecular biomarkers can be validated only through large, multicenter, randomized. controlled trials such as the MSLT-II, a trial that will determine the benefit of multimarker RT-PCR assay in SLN specimens. SLN offers a promising future in staging lymph nodes and will improve the management of patients who have melanoma. Although SLN biopsy has become widely accepted as a minimally invasive technique of staging regional lymph nodes, its use in patients who have melanoma continues to be challenged. The future of SLN biopsy holds promise if prospective multicenter trials confirm a survival benefit for SLN biopsy as compared with watch-and-wait observation.

Accuracy of lymphatic mapping and sentinel lymph node biopsy after previous wide local excision in patients with primary melanoma

BACKGROUND

Sentinel lymph node (SLN) status is the most important prognostic factor with respect to the survival of patients with primary cutaneous melanoma. However, lymphatic mapping and SLN biopsies (LM/SLNBs) performed in patients who have had a wide local excision (WLE) may not accurately reflect the pathologic status of the draining lymph node basins. The purpose of this study was to assess the feasibility and accuracy of LM/SLNB in patients who have had a previous WLE.

METHODS

A single-institution database was examined to identify patients who had a WLE before LM/SLNB and patients who had a concomitant LM/SLNB. Primary clinicopathologic features (age, tumor thickness, and ulceration), SLN identification rate, SLN pathologic status, and the incidence and sites of recurrences were compared between patients with and without prior WLE.

RESULTS

Of the 1395 patients identified, 104 had WLE before LM/SLNB. The mean preoperative WLE radial margin was 1.4 cm (median, 1.0 cm). LM/SLNB was successful in 103 of 104 (99%) patients. Age, tumor thickness, incidence of ulceration, and incidence of SLN positivity in the group with prior WLE were similar to those of the cohort of patients who had concomitant LM/SLNB and WLE (n = 1291). In 97 (93%) of the 104 prior-WLE patients, the surgical defects were closed by either primary closure or skin graft; 7 patients (7%) had rotational flaps. The median follow-up of these 104 patients was 51 months. Among the prior-WLE group, 19 patients (18%) had a positive SLNB; of these 19 patients, 4 (21%) had recurrences (3 distant failures and 1 local and distant failure). There were no lymph node recurrences-in a mapped or unmapped basin-in these 104 patients with a negative or positive SLNB.

CONCLUSIONS

SLNs can be successfully identified and accurately reflect the status of the regional lymph node basin in carefully selected melanoma patients with a previous WLE. Prior WLE does not appear to adversely impact the ability to detect lymphatic metastases, although the utility of LM/SLNB in patients who have undergone extensive reconstruction of the primary excision site remains to be defined. Because more extensive surgery may be required to accomplish accurate lymph node staging in patients who have undergone prior WLE-including the possible removal of SLNs from additional lymph node basins and an additional surgical procedure-to minimize morbidity and cost, concomitant WLE and LM/SLNB is strongly preferred whenever possible.

Significance of multiple lymphatic basin drainage in truncal melanoma patients undergoing sentinel lymph node biopsy

BACKGROUND

Truncal melanoma involving metastases to multiple lymph node basins has a much worse prognosis than tumor involvement of a single lymph node basin. Recent results also suggest that, independently of the status of lymph node involvement, patients with multiple lymphatic basin drainage (MLBD) on lymphoscintigraphy have an increased risk of lymph node metastasis and a worse prognosis than those with a single lymphatic drainage basin. Because published reports have conflicting results, the authors compared their experience at the University of Michigan Comprehensive Cancer Center with recently published findings.

METHODS

The authors searched a prospectively maintained melanoma database at the University of Michigan for patients with primary truncal melanoma who underwent lymphoscintigraphy and sentinel lymph node biopsy between 1997 and 2004. The association of MLBD with the clinical and pathologic characteristics collected and the presence of regional metastases was tested by using contingency tables and the chi(2) test statistic and by using the Fisher's exact test statistic when cell frequencies were small. The product-limit method of Kaplan and Meier was used to estimate disease-free and overall survival probabilities.

RESULTS

Of 423 patients with primary truncal melanoma who underwent sentinel lymph node biopsy, 123 (29%) had a positive result, and 98 patients (23.2%) had MLBD. Patients with tumors located in the middle of the trunk and tumor ulceration were more likely to have MLBD (P < .0001 and P = .045, respectively). Patients with a single lymphatic drainage basin and MLBD had a similar risk of lymph node metastasis and similar disease-free and overall survival.

CONCLUSIONS

Patients with truncal melanomas tend to have MLBD when the tumor is located in the middle of the trunk or when ulceration is present. In our experience, drainage to multiple lymphatic basins was not an independent risk factor for sentinel lymph node metastasis and has no independent prognostic significance.

Ultrasound Mapping of Lymph Node and Subcutaneous Metastases in Patients with Cutaneous Melanoma: Results of a Prospective Multicenter Study

BACKGROUND

Ultrasound (sonography, B-mode sonography, ultrasonography) examination improves the sensitivity in more than 25% compared to the clinical palpation, especially after surgery on the regional lymph node area.

OBJECTIVE

To evaluate the distribution of metastases during follow-up in the draining lymph node areas from the scar of primary to regional lymph nodes (head and neck, supraclavicular, axilla, infraclavicular, groin) in patients with cutaneous melanoma with or without sentinel lymph node biopsy (SLNB) or former elective or consecutive complete lymph node dissection in case of positive sentinel lymph node (CLND). cv: Prospective multicenter study of the Departments of Dermatology of the Universities of Homburg/Saar, Tubingen and Munich (Germany) in which the distribution of lymph node and subcutaneous metastases were mapped from the scar of primary to the lymphatic drainage region in 53 melanoma patients (23 women, 30 men; median age: 64 years; median tumor thickness: 1.99 mm) with known primary, visible lymph nodes or subcutaneous metastases proven by ultrasound and histopathology during the follow-up.

RESULTS

Especially in the axilla, infraclavicular region and groin the metastases were not limited to the anatomic lymph node regions. In 5 patients (9.4%) (4 of them were in stage IV) lymph node metastases were not located in the corresponding lymph node area. 32 patients without former SLNB had a time range between melanoma excision and lymph node metastases of 31 months (median), 21 patients with SLNB had 18 months (p < 0.005). In 11 patients with positive SLNB the time range was 17 months, in 10 patients with negative SLNB 21 months (p < 0.005); in 32 patients with CLND the time range was 31 months and in 21 patients without CLND 18 months (p<0.005). In thinner melanomas lymph node metastases occurred later (p<0.05).

CONCLUSIONS

After surgery of cutaneous melanoma, SLNB and CLND the lymphatic drainage can show significant changes which should be considered in clinical and ultrasound follow-up examinations. Especially for high-risk melanoma patients follow-up examinations should be performed at intervals of 3 months in the first years. Patients at stage IV should be examined in all regional lynph node areas clinically and by ultrasound.

[Sentinel lymph node biopsy in malignant melanoma--an update]

Ten years after the introduction of the sentinel lymph node biopsy technique in the management of malignant melanoma, it is time to take stock. The complex method has proved itself sufficiently sensitive, although a certain percentage of false-negative histological results have to be taken into account. Presently, it is still a point at issue whether sentinel lymph node biopsy should be regarded as the standard of care in high-risk patients. Three prospective multicentre trials have failed to demonstrate a survival benefit resulting from elective lymph node dissection. In contrast, a retrospective multicentre study has recently shown that patients with node metastases diagnosed by the sentinel procedure benefit from early excision of their nodal disease in terms of overall survival, as compared to patients with delayed dissection of palpable nodes. Studies worldwide have established the pathologic status of the sentinel lymph node biopsy as the most important prognostic factor for recurrence and survival after the excision of primary melanoma. As with any invasive staging procedure, sentinel lymph node biopsy should have demonstrated therapeutic consequences. Unfortunately, an unequivocally acknowledged adjuvant therapy is lacking. Moreover, the impact of complete lymph node dissection after positive sentinel biopsy on survival or local disease control has not yet been clarified.

[Value of sentinel node biopsy considering melanoma management as an example]

Sentinel lymph node biopsy has replaced elective lymph node dissection in the management of melanoma. It provides an exact staging method of the regional lymph basin and is associated with low morbidity. Patients who are found to have a positive sentinel lymph node can selectively undergo regional lymph node dissection. Sentinel lymph node biopsy also provides the means to stratify patients into homogeneous groups for adjuvant therapies. Sentinel lymph node involvement is regarded as an independent prognostic factor. The therapeutic value of subsequent surgical and medical therapies in patients with positive sentinel nodes is currently being investigated in clinical trials.

A nomogram that predicts the presence of sentinel node metastasis in melanoma with better discrimination than the American Joint Committee on Cancer staging system

BACKGROUND

The threshold and indications for sentinel lymph node (SLN) biopsy in patients with melanoma remain somewhat arbitrary. Many variables associated with SLN positivity have previously been identified, including a significant association between the American Joint Committee on Cancer (AJCC) staging system and SLN status. We developed a user-friendly nomogram that takes several characteristics into account simultaneously to more accurately predict the presence of SLN metastasis for an individual patient.

METHODS

A total of 979 patients who underwent successful SLN biopsy for cutaneous melanoma at a single institution between February 1991 and November 2003 were included in the analysis. Predictors were used to develop a nomogram, based on logistic regression analysis, to predict the probability of SLN positivity. A large multi-institutional trial with 3108 patients was used to validate the predictive accuracy of the nomogram compared with the AJCC staging system.

RESULTS

The nomogram was developed and found to be accurate and discriminating. The concordance index of the nomogram, a measure of predictive ability, was .694 when evaluated with the validation dataset. In contrast, the concordance index of the AJCC staging system was lower (.663; P < .001).

CONCLUSIONS

Using commonly available clinicopathologic information, we developed a nomogram to accurately predict the probability of a positive SLN in patients with melanoma. This tool takes several characteristics into account simultaneously. This model should enable improved patient counseling and treatment selection.