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

Lymphatic Mapping and Sentinel Lymph Node Biopsy in the Management of Primary Cutaneous Melanoma: Report of a Single-centre Experience

Aims and Background

Lymphatic mapping and sentinel lymph node biopsy provide important prognostic data in patients with early stage melanoma and are crucial in guiding the management of the tumor. We report our experience with lymphatic mapping and sentinel lymph node biopsy in a group of patients with primary cutaneous melanoma and discuss recent concepts and controversies on its use.

Patients and Methods

A total of 111 patients with stage I-II AJCC primary cutaneous melanoma underwent lymphatic mapping and sentinel lymph node biopsy from December 1999 through December 2004 using a standardized technique of preoperative lymphoscintigraphy and biopsy guided by blue dye injection in addition to a hand-held gamma probe. After removal, sentinel lymph nodes were submitted to serial sectioning and permanent preparations for histological and immunohistochemical examination. Complete lymph node dissection was performed only in patients with tumor-positive sentinel lymph nodes.

Results

Sentinel lymph nodes were identified and removed in all patients (detection rate of 100%), and metastases were found in 17 cases (15.3%). The incidence of metastasis in sentinel lymph nodes was 2.1%, 15.9%, 35.2%, and 41.6% for melanomas < or 1.0, 1.01-2.0, 2.01-4.0, and > 4.0 mm in thickness, respectively. Complete lymph node dissection was performed in 15 of 17 patients with positive sentinel lymph nodes, and metastases in non-sentinel lymph nodes were detected in only 2 cases (11.7%). Recurrences were more frequently observed in patients with a positive than in those with negative sentinel lymph node (41.1% vs 5.3% at a median follow-up of 31.5 months, P<0.001). The false-negative rate was 2.1%.

Conclusions

Our study confirms that lymphatic mapping and sentinel lymph node biopsy allow accurate staging and yield relevant prognostic information in patients with early stage melanoma.

Melanoma: Clinical Presentations

The malignant cell in melanoma is the melanocyte. Because melanocytes are located in the basal layer of the epidermis, melanoma is most commonly seen on the skin. However, melanoma can also arise on mucosal surfaces such as the oral cavity, the upper gastrointestinal mucosa, the genital mucosa, as well as the uveal tract of the eye and leptomeninges. Melanomas tend to be pigmented but can also present as pink or red lesions. They can mimic benign or other malignant skin lesions. This chapter presents the spectrum of typical and less typical presentations of melanoma, as well as patterns of spread. It is divided into (1) cutaneous lesions; (2) patterns of regional spread, (3) non-cutaneous lesions; and (4) distant metastases.

Completion lymph node dissection after a positive sentinel node: no longer a must?

PURPOSE OF REVIEW

Sentinel node biopsy (SNB) for primary melanoma is accepted worldwide as a diagnostic procedure. When sentinel node positive, the invasive completion lymph node dissection (CLND) is usually performed. Approximately 20% of CLND patients have nonsentinel node (NSN) metastases. The therapeutic benefit is unknown. This review analyzed the necessity of CLND in sentinel node positive patients.

RECENT FINDINGS

Prognosis of sentinel node positive patients is highly heterogeneous. The Rotterdam and Dewar criteria and S-classification are important sentinel node tumor burden criteria to stratify melanoma patients for prognosis and risk of NSN metastases. Patients with less than 0.1 mm metastases seem to have similar prognosis as sentinel node negative patients, especially when located in the subcapsular area. This depends on the use of an extensive sentinel node pathology protocol identifying possibly clinically irrelevant micrometastases.

SUMMARY

Consensus on the sentinel node pathology work-up and analysis protocols are crucial for correct risk stratification and for clinical decision-making. Primary and sentinel node tumor burden parameters and patient comorbidities should be taken into consideration when offering CLND to an individual patient. In the future, prospective studies such as the MSLT-II and the EORTC 1208 (Minitub) will provide answers to whether CLND has a therapeutic benefit and to which patients might safely be spared CLND.

Surgical management of melanoma: an EORTC Melanoma Group survey

Objectives:

The objective of the article is to explore the surgical practices and views in the treatment of melanoma within members and non-members of the EORTC Melanoma Group (MG) during the years 2003–2005.

Methods:

An e-mail questionnaire (see appendix) developed within the EORTC MG was sent to all melanoma units (MUs) of the EORTC (180) and to selected international centres between 2003 and 2005. The questionnaire investigated the different practices regarding surgical management of melanoma patients at all stages.

Results:

A total of 75 questionnaires were returned from centres in Europe (70), Israel (3), Australia (1) and the United States (1). Resection margins on primary melanoma vary according to AJCC 2002 staging. Sixty three of 75 MUs perform Sentinel node biopsy. Modified radical neck dissection is performed in 82% of MUs for macrometastases and in 80% of MUs for micrometastases. Most MUs surveyed perform all three levels of Berg axillary dissection whether for macrometastases (79%) or micrometastases (62%). An ilio inguinal-obturator dissection is proposed with macrometastases (41% of MUs), whereas 33% of MUs perform a pelvic dissection only if the Cloquet node is positive. Twenty five of 75 MUs perform an isolated limb perfusion with a therapeutic indication; three also as an adjuvant. The majority of MUs perform surgery for distant metastases including superficial (53 of 75 [71%]) or solitary visceral metastases (52 of 75[69%]) or for palliation (58 of 75[77%]).

Conclusion:

The adequacy of surgery appears to be the most important milestone in the therapeutic approach of melanoma. Even if surgery is fundamental in the different stages of the disease, there is quite a variability concerning the extension of the surgical treatment related to primary and lymphnodal disease. Phase III randomised trials have shown that wide margins, elective lymph node dissections, and prophylactic isolated limb perfusions have not improved survival and cannot be considered the standard of care in the routine management of primary melanoma. The surgical subgroup of the EORTC Melanoma Group is developing a new version of the surgical survey questionnaire including new treatment modalities like isolated limb infusion and electrochemotherapy, which were not frequently in use some years ago, to obtain new data to be compared to the nearly ten-year-old data.

[Risk factors for in-transit metastasis in patients with cutaneous melanoma]

BACKGROUND

In-transit metastases have been associated with the presence of various negative prognostic factors in patients with cutaneous melanoma. It has recently been suggested that sentinel lymph node biopsy (SLNB) may lead to an increase in the incidence of this particular type of metastasis. In this study, we analyzed risk factors for the appearance of in-transit metastasis and its potential association with the use of SLNB.

MATERIAL AND METHODS

A prospective study was undertaken in a cohort of 404 patients with cutaneous melanoma seen in the melanoma unit of Hospital San Cecilio in Granada, Spain. Statistical analysis was performed with SPSS 15.0 and Epidat 3.1 using the χ(2) and Fisher exact tests.

RESULTS

Out of 93 (23%) patients with recurrence at any time, 28 (6.9%) had in-transit metastases. The occurrence of in-transit metastasis was associated with age greater than 50 years, greater Breslow depth and Clark level, the presence of ulceration, positive SLNB, and the presence of other types of recurrence (local recurrence, lymph node metastasis, or distant metastasis). There was no relationship between surgical treatment or performing SLNB and the presence of in-transit metastasis.

CONCLUSIONS

The risk factors for in-transit metastasis are the same as those for any type of recurrence and coincide with factors linked to poor prognosis. Given that in-transit metastases are much more common in patients with positive SLNB, while the technique itself is not linked to their occurrence, these findings suggest that the appearance of in-transit metastasis is linked to biological characteristics of the tumor cells rather than an influence of the surgical technique.

Sentinel lymph node biopsy and melanoma: 2010 update Part II

This article will discuss the evidence for and against the therapeutic efficacy of early removal of potentially affected lymph nodes, morbidity associated with sentinel lymph node biopsy and completion lymphadenectomy, current guidelines regarding patient selection for sentinel lymph node biopsy, and the remaining questions that ongoing clinical trials are attempting to answer. The Sunbelt Melanoma Trial and the Multicenter Selective Lymphadenectomy Trials I and II will be discussed in detail.

LEARNING OBJECTIVES

At the completion of this learning activity, participants should be able to discuss the data regarding early surgical removal of lymph nodes and its effect on the overall survival of melanoma patients, be able to discuss the potential benefits and morbidity associated with complete lymph node dissection, and to summarize the ongoing trials aimed at addressing the question of therapeutic value of early surgical treatment of regional lymph nodes that may contain micrometastases.

Cutting a sentinel lymph node into slices is the optimal first step for examination of sentinel lymph nodes in melanoma patients

The optimal processing for the pathology of sentinel lymph nodes of patients with melanoma is still a matter of debate. We compared two protocols of sentinel lymph node processing, which were consecutively applied. For the first protocol, the sentinel lymph nodes were cut into 1-2 mm thick slices. From each slice, 12 microtome sections were stained (multiple slices protocol). For the second protocol, which is a modification of the recent European Organisation for Research and Treatment of Cancer protocol, the sentinel lymph nodes were bivalved. Five consecutive series of microtome sections, with gaps of 50 microm between them, were prepared from each cut surface (bivalving protocol). H&E and immunohistochemical staining were integral elements of both protocols. A total of 584 sentinel lymph nodes (1.8+/-0.9 per patient) were examined. The percentages of micrometastases (29 versus 27%) and of capsular naevi (13 versus 15%) detected were very similar for both protocols. As shown by multivariate logistic regression, Breslow thickness (P=0.003) and younger age (P=0.01) correlated with nodal metastasis. The type of histological preparation, ulceration and sex were not significant. The multiple slices protocol produced, on average, 4 paraffin blocks and 46 microtome sections per node. The bivalving protocol constantly produced 2 paraffin blocks and 42 microtome sections. For technical processing, the multiple slices protocol required, on average, 38 min per sentinel lymph node, whereas the bivalving protocol required 55 min. Both protocols yielded excellent detection rates with a similar amount of work being required on the part of the pathologist. Compared with the bivalving protocol, the multiple slices protocol was less labor intensive for the technical staff.

Expert opinion in melanoma: the sentinel node; EORTC Melanoma Group recommendations on practical methodology of the measurement of the microanatomic location of metastases and metastatic tumour burden

The sentinel node (SN) status has been recognised to be the most important prognostic factor in melanoma. Many studies have investigated additional factors to further predict survival/lymph node involvement. The EORTC Melanoma Group (MG) has formulated the following question: How should we report the microanatomic location and SN tumour burden? The EORTC MG recommends the following: the EORTC MG SN pathology protocol or a similarly extensive protocol, which has also been proven to be accurate, should be used. Only measure what you can see not what you presume. Cumulative measurements decrease the accuracy and reproducibility of measuring. The most reproducible measure is a single measurement of the maximum diameter of the largest lesion in any direction (1-D). If there is any infiltration into the parenchyma, this lesion can no longer be considered solely subcapsular. Reporting of the microanatomic location of metastases should be an assessment of the entire sentinel node, not only of the largest lesion. Multifocality reflects a scattered metastatic pattern, not to be confused with multiple cohesive foci, which fall under the regular location system. A subcapsular metastasis should have a smooth usually curved outline, not ragged or irregular. We recommend all pathologists to report the following items per positive SN for melanoma patients: the microanatomic location of the metastases according to Dewar et al. for the entire node, the SN Tumour Burden according to the Rotterdam Criteria for the maximum diameter of the largest metastasis expressed as an absolute number, and the SN Tumour Burden stratified per category; <0.1mm or 0.1-1.0mm or >1.0mm.

Multidisciplinary treatment of primary melanoma

This article covers the multidisciplinary treatment of primary melanoma. Excision margins and the need for sentinel lymphadenectomy are mainly dictated by the Breslow thickness although exceptions to this dictum do exist. Interferon is the only FDA approved adjuvant therapy for high risk melanoma although its overall survival benefit is minimal. Trials examining different doses or duration of interferon therapy have not demonstrated any promising survival data so far. There have been several randomized vaccine trials for melanoma but none have shown an overall survival benefit. Research into T-cell regulation continues and will hopefully bring promise for the future of melanoma treatment.

Sentinel node tumor burden according to the Rotterdam criteria is the most important prognostic factor for survival in melanoma patients: a multicenter study in 388 patients with positive sentinel nodes

SUMMARY BACKGROUND DATA

The more intensive sentinel node (SN) pathologic workup, the higher the SN-positivity rate. This is characterized by an increased detection of cases with minimal tumor burden (SUB-micrometastasis <0.1 mm), which represents different biology.

METHODS

The slides of positive SN from 3 major centers within the European Organization of Research and Treatment of Cancer (EORTC) Melanoma Group were reviewed and classified according to the Rotterdam Classification of SN Tumor Burden (<0.1 mm; 0.1-1 mm; >1 mm) maximum diameter of the largest metastasis. The predictive value for additional nodal metastases in the completion lymph node dissection (CLND) and disease outcome as disease-free survival (DFS) and overall survival (OS) was calculated.

RESULTS

In 388 SN positive patients, with primary melanoma, median Breslow thickness was 4.00 mm; ulceration was present in 56%. Forty patients (10%) had metastases <0.1 mm. Additional nodal positivity was found in only 1 of 40 patients (3%). At a mean follow-up of 41 months, estimated OS at 5 years was 91% for metastasis <0.1 mm, 61% for 0.1 to 1.0 mm, and 51% for >1.0 mm (P < 0.001). SN tumor burden increased significantly with tumor thickness. When the cut-off value for SUB-micrometastases was taken at <0.2 mm (such as in breast cancer), the survival was 89%, and 10% had additional non-SN nodal positivity.

CONCLUSION

This large multicenter dataset establishes that patients with SUB-micrometastases <0.1 mm have the same prognosis as SN negative patients and can be spared a CLND. A <0.2 mm cut-off for SUB-micrometastases does not seem correct for melanoma, as 10% additional nodal positivity is found.

Randomized adjuvant therapy trials in melanoma: surgical and systemic

The utility of adjuvant surgical procedures in the management of primary melanomas has been evaluated in a large number of phase III randomized trials. These trials have shown that wide margins, elective lymph node dissection, sentinel lymph node (SLN) biopsy, and prophylactic isolated limb perfusion (ILP) do not improve survival but may improve locoregional control. Based on the claim of providing a survival benefit, these surgical procedures cannot be considered standard of care in the routine management of primary melanoma. Regarding the role of SLN biopsy it must be stated that this procedure provides the best information on prognosis and provides us with an important tool to stratify for and study more homogeneous patient populations to evaluate adjuvant systemic therapies in randomized phase III trials. The utility of systemic adjuvant therapy remains marginal as a result of the fact that a lack of effective drugs in stage IV disease is reflected by a lack of effective adjuvant therapies in stage II-III melanoma. Thus far, chemotherapeutic drugs, immunostimulants, and various vaccines have all failed. Interferon (IFN) has an effect on relapse-free survival but not on overall survival. Thus its impact is judged by many to be too small to be considered standard of care. The population of patients that can benefit from IFN needs to be better defined by identifying new biomarkers by genomic and proteomic studies, which are ongoing.

Role of lymphadenectomy in surgical treatment of solid tumors: an update on the clinical data

BACKGROUND

The role of lymphadenectomy as an adjunct of standard excision for treatment of cancer is highly debated and controversial. Standard practice for treatment of solid tumors is resection with regional lymphadenectomy. This surgical concept assumes that cancers grow and spread in an orderly manner, from primary cancer to regional lymph nodes and finally to vital organs. We reviewed randomized trials, published a description of lymphatic anatomy and physiology, and presented data that disputed the role of lymphadenectomy as standard practice. The present review updates the literature and reiterates the concept that lymphadenectomy does not increase survival in the surgical treatment of solid tumors.

METHODS

We reviewed the English-language literature (Medline) for prospective randomized trials and nonrandomized reports, as well as retrospective studies addressing the role of lymphadenectomy in cancers of the esophagus, lung, stomach, pancreas, breast, and skin (melanoma) reported between 2000 and 2006.

RESULTS

This extensive review demonstrates that there are few prospective randomized trials assessing patient survival with solid tumors that contrast resection with or without lymphadenectomy. However, there was at least one, and for some cancers more than one, prospective randomized trial for each organ site studied, and the data demonstrate no statistically significant difference in overall survival of patients treated with or without lymphadenectomy. Most nonrandomized and retrospective studies, with a few exceptions, support the conclusions of randomized trials; lymphadenectomy does not improve overall survival in solid tumors. Overall survival is primarily a function of the biological nature of the primary tumor, as evidenced by lymphovascular invasion, lymph node involvement, and other prognostic features.

CONCLUSIONS

This extensive literature review of recent reports indicates that lymphadenectomy does not improve overall survival. Lymph node resection should be conceived in terms of staging, prognosis, and regional control only.

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.

The treatment of melanoma with an emphasis on immunotherapeutic strategies

Melanoma continues to be one of the most difficult to treat of all solid tumors. Many new advances have been made in the surgical management of melanoma, including new guidelines for margins of excision, as well as sentinel node biopsy for the diagnosis of lymph node micrometastases. The search continues for an effective adjuvant melanoma treatment that can prevent local and distant recurrences. Melanoma is one of the most immunogenic of all tumors, and several clinical trials testing the immunotherapy of melanoma have been conducted, including trials in interferon, interleukin-2, and melanoma vaccines. Here we discuss many of the recent clinical trials in the surgical management of melanoma, in addition to the advances that have been made in the field of immunotherapy. A new second-generation melanoma vaccine, DC-MelVac (patent # 11221/5), has recently been granted FDA approval for Phase I clinical trials and will be introduced in this review.

Value of sentinel node status as a prognostic factor in melanoma: prospective observational study

OBJECTIVE

To establish the prognostic value of knowledge of sentinel node status in melanoma.

DESIGN

Single centre prospective observational study, with sentinel nodes identified by lymphoscintigraphy, gamma probe, and intraoperative blue dye and examined by both conventional histopathology and immunopathology.

SETTING

Specialist surgical service in west of Scotland.

PARTICIPANTS

482 patients with melanoma who consented to sentinel node biopsy in 1996-2003.

MAIN OUTCOME MEASURE

Time to recurrence of or death from melanoma.

RESULTS

Of 472 patients who consented to sentinel node biopsy and in whom at least one sentinel node was identified, 367 (78%) had no tumour in the sentinel node. At mean follow-up of 42 months, 299 (82%) of this group were alive and free from disease, 24 were alive with melanoma recurrence, and 31 had died of melanoma. Of 105 patients with a positive sentinel node biopsy, 44 (42%) were alive and disease free, 12 were alive with recurrence, and 46 had died of melanoma. The survival difference between patients who were negative and those who were positive for tumour in the sentinel node was highly significant at all thickness levels over 1.0 mm (P < 0.001). Multivariate analysis showed that sentinel node status was independent of tumour thickness and ulceration. 71/105 (68%) patients with a positive sentinel node had a negative completion lymphadenectomy, and 44/71 (62%) were alive and disease free at follow-up; 34 patients with a positive sentinel node had further nodes involved, and only 4 (12%) were disease free (P < 0.001). 16 patients (13 sentinel node biopsy positive; 3 negative) died of other causes.

CONCLUSION

Sentinel node status is a highly significant predictor of prognosis in melanoma and should be considered in adjuvant studies. However, it should not be regarded as a standard of care until mature data from ongoing randomised trials are available.

The role of preoperative lymphoscintigraphy in surgery planning for sentinel lymph node biopsy in malignant melanoma

AIM

To evaluate four years of preoperative lymphoscintigraphy experience and the accuracy of sentinel lymph node biopsy in our institution in melanoma patients with various tumor thicknesses. An additional aim was to evaluate the recurrence rate related to pathohistological findings.

METHODS AND PATIENTS

During the period from February 2002 to November 2005, 201 patients underwent sentinel node biopsy. Lymphoscintigraphy for identification of sentinel nodes was performed four to six hours prior to operation of the patient. Sentinel lymph node biopsy using an intraoperative hand-held gamma probe was performed in all patients, together with wide local excision of biopsy wound or primary lesion (N=56). Immediate complete basin dissection was performed in patients with sentinel node metastases. In four patients delayed complete lymph node dissection was performed after definitive histopathologic examination of sentinel nodes. The accuracy of sentinel node biopsy was determined by comparing the intraoperative rates of sentinel node identification and the subsequent development of nodal metastases in regional nodal basins in patients with tumor-negative sentinel nodes and in those with tumorpositive sentinel nodes.

RESULTS

Using preoperative lymphoscintigraphy, we identified sentinel nodes in all but one of the 201 patients (99.0%), and in 248 nodal basins (1.2/patient) we observed 372 sentinel nodes (1.52 sentinels/basin; 1.8 sentinels/patient). The highest number of sentinel nodes was noticed in the groin of patients with melanoma on the lower extremities (1.5/patient), followed by the axilla (1.3/patient). Anomalous lymphatic drainage patterns were observed in 15.0% of all patients. The identification rate of sentinel nodes was 99.0% overall: 100% for the groin basins, and 98.0% for the axilla and head and neck basin. Forty-two patients (20.8%) had tumor-positive sentinel nodes. Ten patients (5.0%) had local or distant recurrences during a median follow-up of 23.1 months (range 2-46). The rate of false-negative lymphatic mapping and sentinel node biopsy as measured by nodal recurrence in patients with tumor-negative sentinel nodes was 1.3%. During the follow-up period, three of 201 patients died from other diseases and three patients died as the result of melanoma metastases, with a median follow-up of 13.5 months (range 12-22).

CONCLUSION

Preoperative lymphoscintigraphy is a sensitive, inexpensive and essential method for the identification of drainage basins, determination of the number and position of sentinel nodes and their location outside the usual nodal basins. Scintigraphic findings may lead to changes in surgical management due to the unpredictability of lymphatic drainage. The low incidence of regional disease recurrence in patients with tumor-negative sentinel nodes supports the use of preoperative lymphoscintigraphy and sentinel node biopsy as a safe and accurate procedure for staging the regional nodal basin in patients with malignant melanoma.

Randomized Trials in Melanoma: An Update

No effective therapy for metastatic melanoma exists. Polychemotherapy or chemoimmunotherapy have not shown survival benefits. Vaccines have shown little activity in stage IV disease. To advance the identification of effective agents, new drugs can and should be offered as first-line treatment. Efforts must be made to improve understanding of the biology of malignant melanoma. Too many phase III trials have been conducted with a poor understanding of the mechanism of action of the involved drugs.

Is there increased risk of local and in-transit recurrence following sentinel lymph node biopsy?

Recent publications have suggested that sentinel lymph node biopsy (SLNB) and completion lymphadenectomy (CLND) increase the rate of local and in-transit disease up to 23% in sentinel node positive group of patients with cutaneous melanoma. This retrospective study combined the data from two national centres on local and in-transit disease in 972 melanoma patients who underwent SLNB procedure over 6.5 years period. In total, 77 patients (7.9%) developed loco-regional recurrence: 41 (4.2%) local recurrence only and 36 patients (3.7%) in-transit metastases during a mean follow-up of 42 months. Patients with positive sentinel lymph node were three times more likely to develop loco-regional metastases than those with no nodal disease (17 vs. 5.6%). Over one third of all recurrences developed following excision of thick (Breslow thickness over 4mm) primary tumours. In both centres age and Breslow thickness were found to be significantly higher in the recurrence group (p<0.001 for both). This study revealed a strong association between increased risk of loco-regional metastases and aggressive tumour biology and adverse patients factors. No conclusive evidence was found to support an increased incidence in patients undergoing SLNB and CLND compared to that published for patients undergoing wide local excision alone.

High positive sentinel node identification rate by EORTC melanoma group protocol. Prognostic indicators of metastatic patterns after sentinel node biopsy in melanoma

Methods to work-up sentinel nodes (SN) vary considerably between institutes. This single institution study evaluated the positive SN-identification rate of the EORTC Melanoma Group (MG) protocol and investigated the prognostic value of the SN status regarding disease-free survival (DFS) and overall survival (OS) and evaluated the locoregional control after the SN procedure. Multivariate and univariate analyses using Cox's proportional hazard regression model was employed to assess the prognostic value of covariates regarding DFS and OS. The positive SN-identification rate was 29% at a median Breslow thickness of 2.00 mm and the false-negative rate was 9.4%. Breslow thickness and ulceration of the primary correlated with SN status. SN status, ulceration and site of the primary tumour correlated with DFS. SN status and ulceration of the primary correlated with OS. The in-transit metastasis rate correlated with SN-positivity, Breslow thickness and ulceration. Projected 3-year OS was 95% in SN-negative and 74% in SN-positive patients. Transhilar bivalving of the SN with step sections from the central planes is simple and had a high SN-positive detection rate of about 30%. The SN status is the most important predictive value for DFS and OS. In-transit metastasis rates correlated with SN-positivity, Breslow thickness and ulceration of the primary.

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.

Sentinel node biopsy in melanoma delays recurrence but does not change melanoma-related survival: a retrospective analysis of 673 patients

BACKGROUND

The status of the sentinel lymph node (SLN) is an important parameter to predict the prognosis of melanoma patients but it is a matter of debate if removal of micrometastases by SLN biopsy (SLNB) influences the prognosis of melanoma patients.

OBJECTIVES

We sought to investigate the impact of SLNB in melanoma patients with regard to recurrence-free survival, overall survival and metastatic pathways.

PATIENTS AND METHODS

We studied, retrospectively, 673 melanoma patients with a primary melanoma (tumour thickness > or = 1 mm) and without clinical evidence of metastases at the time of melanoma diagnosis. In 377 patients the melanoma was removed without SLNB between January 1995 and March 2000 (pre-SLNB group). In 296 patients the melanoma was removed with SLNB between April 2000 and March 2003 (SLNB group). Otherwise, both groups received identical surgical treatment of the primary melanoma and initial staging procedures performed by the same team of physicians. Follow-up recommendations were also identical in both groups.

RESULTS

Both groups showed no significant differences with regard to characteristics of the primary melanoma, sex and age. By Kaplan-Meier analyses, melanoma-related overall survival was comparable in both groups. However, recurrence-free survival was increased in pre-SLNB patients due to significantly fewer regional lymph node metastases, whereas frequencies of locoregional cutaneous and distant metastases were comparable in both groups.

CONCLUSIONS

SLNB advances the detection of regional lymph node metastases and therefore avoids nodal recurrences but does not influence metastatic behaviour of melanoma cells and does not protect patients from melanoma-related death caused by distant metastases. Thus, our retrospective data favour the marker hypothesis for melanoma metastasation. To elucidate further if subgroups of patients benefit from SLNB, prospective randomized studies with long-term follow-up are needed.

Should sentinel lymph-node biopsy be used routinely for staging melanoma and breast cancers?

The sentinel lymph node (SLN) is the lymph node that represents the 'gate-keeper' of the lymphatic basin; it is the first node to receive lymphatic drainage from the site of the primary tumor. SLN biopsy is a staging procedure and should be considered as such; it is not meant to be a therapeutic operation. The SLN can be mapped and biopsied using tracer agents (e.g. radiolabelled colloid and/or vital blue dye), which are injected around the primary tumor site. Pathologic analysis of the SLN using a combination of serial sectioning of the node, standard hematoxylin and eosin staining, and immunohistochemistry decreases the false-negative rate compared with traditional nodal processing. SLN biopsy is associated with lower morbidity than full lymphadenectomy. The SLN technique accurately reflects the metastatic status of the regional lymph-node basin; recurrent nodal disease in the mapped basin is rare following a tumor-free SLN biopsy result. The objectives of this review are to provide a current and concise overview of the current literature on SLN biopsy and describe its role in clinical oncology.

Intraoperative Detektion von Sentinel-Lymphknoten beim malignen Melanom der Haut-Vitalfarbung allein versus Vitalfarbung plus Gammasonde. Intraoperative detection of sentinel lymph nodes in cutaneous malignant melanoma - blue dye alone versus blue dye plus gamma-detection

BACKGROUND

Compared with intraoperative sentinel lymph node identification using blue dye only, the introduction of a hand-held gamma probe has improved the identification rates. In this retrospective study, further aspects related to the introduction of gamma-guided preparation are analysed in detail.

PATIENTS AND METHODS

81 patients who underwent sentinel biopsy using the blue dye technique were compared to 247 patients whose operations were guided by blue dye and gamma probe.

RESULTS

After the introduction of radio-guided surgery, the sentinel node identification rate increased from 87.7 % to 99.2 % (P < 0.00001). The number of harvested sentinel lymph nodes increased from 1.4 +/- 0.9 to 1.8 +/- 0.09 (P < 0.00001). The "clinical false-negative rate" decreased from 15.8 % to 9.6 %. The percentage of positive completion lymphadenectomy decreased from 50 % to 24.6 %. The risk of postoperative seroma decreased as a consequence of gamma guided preparation (5.1 % versus 15 %, P = 0.01). Regarding overall survival and recurrence-free survival, there were no significant differences between both groups. The 5-year-probability of nodal basin failure was 7.9 % after negative sentinel biopsy and 25.3 % after positive sentinel lymphonodectomy plus consecutive completion lymphadenectomy.

CONCLUSIONS

Combined application of blue dye and gamma-probe improved sensitivity and decreased the risk of postoperative seroma. The probability of recurrence and survival was not influenced by the technique of intraoperative sentinel node identification.