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Persistent postoperative pain and sensory changes following lymph node excision in melanoma patients: a topical review. Melanoma Res 2014; 24:93-8. [PMID: 24346167 DOI: 10.1097/cmr.0000000000000041] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Studies on complications related to chronic nerve injury following sentinel lymph node biopsy (SLNB) and complete lymph node dissection (CLND) for melanoma are sparse. This review summarizes the existing literature on pain and neuropathic complications in melanoma patients undergoing SLNB with or without CLND. The Cochrane Central Register of Controlled Trials and the Embase and PubMed databases were searched. Full-text English language articles published before June 2013 were included. Prospective and retrospective studies assessing persistent (>1 month) sensory nerve injury, postoperative pain, neuropathic pain, and sensory disturbances following SLNB with or without CLND in melanoma patients were eligible. Nine studies (six prospective and three retrospective) including data for 3632 patients met our inclusion criteria. Outcome parameters were too heterogeneous to conduct a quantitative analysis, and few studies systematically evaluated pain and sensory abnormalities. Persistent postoperative pain was reported in 1-14% of patients following SLNB and in 6-34% following CLND and sensory abnormalities in 0.1-32 and 2-82%, respectively. In the one study that assessed the type of pain, neuropathic pain was suggested to explain persistent pain in 31-66% of patients with SLNB and 82-89% of patients with CLND. Sensory-nerve-related complications in melanoma patients seem to be less pronounced following SLNB compared with CLND. Prospective observational studies are necessary to identify predictors of persistent pain, to evaluate the prevalence and impact of pain and sensory abnormalities, and to develop strategies for prevention of long-term complications.
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Valsecchi ME, Silbermins D, de Rosa N, Wong SL, Lyman GH. Lymphatic mapping and sentinel lymph node biopsy in patients with melanoma: a meta-analysis. J Clin Oncol 2011; 29:1479-87. [PMID: 21383281 DOI: 10.1200/jco.2010.33.1884] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To perform a meta-analysis of all published studies of sentinel lymph node (SLN) biopsy for staging patients with melanoma. METHODS Published literature in all languages between 1990 and 2009 was critically appraised. Primary outcomes evaluated included the proportion successfully mapped (PSM) and test performance including false-negative rate (FNR), post-test probability negative (PTPN), and positive predictive value in the same nodal basin recurrence. RESULTS A total of 71 studies including 25,240 patients met full eligibility criteria. The average PSM was 98.1% (95% CI, 97.3% to 98.6%) and increased with the year of publication, female sex, ulceration, age, and the quality score of the studies. The FNR ranged from 0.0% to 34.0%, averaging 12.5% overall (95% CI, 11% to 14.2%). FNR increased with the length of follow-up (P = .002) but decreased with greater PSM (P = .001). PTPN averaged 3.4% (95% CI, 3.0% to 3.8%), which also increased in studies with longer follow-up, younger age, female sex, deeper Breslow thickness, and with tumor ulceration while decreasing with greater PSM (P < .001). Approximately 20% of the patients with a positive SLN had additional lymph nodes in the complete lymph node dissection and 7.5% of the patients with positive SLN developed recurrence in the same nodal basin which was greater in studies that also reported higher FNR (P = .01). CONCLUSION The estimated risk of nodal recurrence after a negative SLN biopsy was ≤ 5% supporting the use of this technology for staging patients with melanoma.
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Stebbins WG, Garibyan L, Sober AJ. Sentinel lymph node biopsy and melanoma: 2010 update Part II. J Am Acad Dermatol 2010; 62:737-48;quiz 749-50. [PMID: 20398811 DOI: 10.1016/j.jaad.2009.11.696] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Revised: 11/11/2009] [Accepted: 11/16/2009] [Indexed: 11/19/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- William G Stebbins
- Massachusetts General Hospital, Department of Dermatology, 55 Fruit St, Bartlett Hall 616, Boston, MA 02114, USA.
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Ling A, Dawkins R, Bailey M, Leung M, Cleland H, Serpell J, Kelly J. Short-term morbidity associated with sentinel lymph node biopsy in cutaneous malignant melanoma. Australas J Dermatol 2010; 51:13-7. [DOI: 10.1111/j.1440-0960.2009.00575.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Postoperative morbidity of lymph node excision for cutaneous melanoma-sentinel lymphonodectomy versus complete regional lymph node dissection. Melanoma Res 2008; 18:16-21. [PMID: 18227703 DOI: 10.1097/cmr.0b013e3282f2017d] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
For patients with melanoma metastasis to a sentinel lymph node, subsequent complete regional lymph node dissection (CLND) is currently regarded to be the surgical standard. This approach, however, has not been confirmed by controlled studies, so that surgical morbidity is of primary importance. Using clinical examination and a questionnaire, we determined morbidity in 315 patients with axillary or inguinal lymph node excision on whom 275 sentinel lymphonodectomies (SLNEs) and 90 CLNDs were performed. The overall incidence of at least one complication following SLNE was 13.8%. The short-term complication rate was 11.3% (allergic reaction to blue dye 0%, wound breakdown 0%, haematoma 2.5%, wound infection 3.6%, seroma 6.9%). The incidence of long-term complications was 4.1% (persistent tattoo 0.4%, functional deficit 0.4%, nerve dysfunction/pain 0.7% or swelling 2.5%). All complications were mild. Significantly, the complication rate was not higher for patients aged 70 years or older. After CLND, the overall complication rate was significantly higher (65.5%, P<0.000001). The incidence of short-term complications was 50% (haematoma 0%, wound breakdown 6.7%, wound infection 24.7% or seroma 34.8%). The incidence of long-term complications was also 50% (nerve dysfunction/pain 8.9%, functional deficit 16.8%, swelling 37.1%). Overall, inguinal lymph node excision was burdened by a higher complication rate (P=0.015). Age and sex did not influence postoperative morbidity. No deaths linked to either procedure were noted. Complication rates after SLNE are low and most complications are minor and short-lasting. In contrast, CLND has been demonstrated to be a major and potentially morbid surgical procedure. This highlights the importance of testing the therapeutic value that CLND adds to the sentinel lymph node procedure.
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Karakousis GC, Gimotty PA, Czerniecki BJ, Elder DE, Elenitsas R, Ming ME, Fraker DL, Guerry D, Spitz FR. Regional Nodal Metastatic Disease Is the Strongest Predictor of Survival in Patients with Thin Vertical Growth Phase Melanomas: A Case for SLN Staging Biopsy in These Patients. Ann Surg Oncol 2007; 14:1596-603. [PMID: 17285396 DOI: 10.1245/s10434-006-9319-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Accepted: 11/15/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND The benefit of sentinel lymph node (SLN) biopsy for patients with thin (< or =1.0 mm) melanomas, even for prognostic value, is controversial. This may partly result from the relatively small number and short follow-up of SLN-positive patients in this group. Previously, we have shown that clinical regional nodal metastatic disease (RNMD) serves as a good surrogate for SLN positivity. Here, we use RNMD as a validated surrogate for SLN positivity and examine its prognostic value in a large pre-SLN group of patients with thin vertical growth phase (VGP) lesions who would today commonly be offered SLN biopsy in our practice. METHODS Between 1972 and 1991, 472 patients with thin VGP melanomas with at least 10 years' follow-up were eligible for the study. Kaplan-Meier survival curves were computed for patients with and without RNMD. A multivariate Cox model and classification tree analysis were used to evaluate clinical and histopathologic predictors of survival. RESULTS Sixty-seven patients (14.2%) developed recurrence, 53.7% of whom developed RNMD. Forty-five patients (9.5%) experienced melanoma-related deaths (MRD). The most statistically significant predictor of MRD was RNMD (hazard ratio [HR] 13.5, P < .0001). Thickness (HR 10.5, P = .004), axial location (HR 4.6, P = .001), and age >60 years (HR 2.7, P = .005) additionally were independently associated with an increased risk of MRD. RNMD patients demonstrated a 44.4% 10-year disease-specific mortality. CONCLUSIONS RNMD was the most statistically significant factor associated with MRD in patients with thin VGP lesions. This supports the prognostic use of SLN biopsy in this group, recognizing that additional factors, including thickness, axial location, and older age were independently associated with a worse survival outcome.
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Affiliation(s)
- Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, 4th Floor Silverstein Building, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Kretschmer L, Bertsch HP, Meller J. [Sentinel lymph node biopsy in malignant melanoma--an update]. J Dtsch Dermatol Ges 2005; 1:777-84. [PMID: 16281813 DOI: 10.1046/j.1439-0353.2003.03048.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Lutz Kretschmer
- Abteilung Dermatologie und Venerologie, Georg-August-Universität Göttingen, Germany.
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Johnson TM, Sondak VK, Bichakjian CK, Sabel MS. The role of sentinel lymph node biopsy for melanoma: evidence assessment. J Am Acad Dermatol 2005; 54:19-27. [PMID: 16384752 DOI: 10.1016/j.jaad.2005.09.029] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Revised: 08/23/2005] [Accepted: 09/13/2005] [Indexed: 02/06/2023]
Affiliation(s)
- Timothy M Johnson
- Department of Dermatology, University of Michigan Medical School, Ann Arbor, Michigan, USA.
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Références. Ann Dermatol Venereol 2005. [DOI: 10.1016/s0151-9638(05)79608-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Affiliation(s)
- Thomas A Aloia
- University of Texas M. D. Anderson Cancer Center Houston, Texas, USA
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Trost O, Danino AM, Kadlub N, Dalac S, Hervé C, Malka G. Ganglion sentinelle dans le mélanome malin de bas stade : état des lieux en France en 2003. ANN CHIR PLAST ESTH 2005; 50:99-103. [PMID: 15820594 DOI: 10.1016/j.anplas.2004.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2004] [Accepted: 11/04/2004] [Indexed: 11/26/2022]
Abstract
AIM The aim of this study was to establish the status of sentinel lymph node (SLN) biopsy procedure in cutaneous melanoma in France in 2002. MATERIAL AND METHODS This study was based upon the statistics of the main French melanoma centers. A short questionnary was sent to Head Physician by email. The authors asked for the global attitude as far as SLN was concerned, number of cutaneous melanoma diagnosed during year 2002 and of SLN procedures performed, critters of inclusion and postoperative management in each case. Abstension could be argued in a free item. Answers were sent back by email. RESULTS The authors collected 22 answers coming from overall territory; 64% performed SLN procedure (14 centers), 36% applied "wait and watch" policy. Staffs performing SLN diagnosed a mean of 101 (8-400) melanoma and biopsied a mean of 21 (0-53) sentinel nodes. The others diagnosed a mean of 151 (15-250) melanoma. Patients were enrolled for Breslow thickness upper to 1.5 mm in 71%, to 1 mm in 29%. Ulceration was a critter of inclusion in 93% (21 staffs), 100% enrolled patients whose tumor presented signs of regression. SLN was performed for primary sites located overall body in 71%, only in limbs and trunk in 29%. Positive node lead to regional lymph node clearance, then observation or interferon protocol. Negative node lead to "wait and watch policy" in 14%, different interferon protocols according to Breslow thickness in 86%. CONCLUSION SLN procedure is not homogenous in France. France is divided as far as SLN is concerned. If 64% are performing SLN, more than 50% of the new melanoma are not included in the trial.
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Affiliation(s)
- O Trost
- Service de chirurgie plastique et maxillofaciale, CHU de Dijon, 3, rue du Faubourg-Raines, 21033 Dijon, France
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Danino AM, Mouaffak M, Trost O, Dutronc Y, Dalac S, Lambert D, Malka G. Is the staging of melanoma the principal objective of its treatment? Plast Reconstr Surg 2004; 113:2239-40. [PMID: 15253242 DOI: 10.1097/01.prs.0000123632.80614.c1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Timothy M Pawlik
- Department of Surgical Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX 77030, USA
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Bonnen MD, Ballo MT, Myers JN, Garden AS, Diaz EM, Gershenwald JE, Morrison WH, Lee JE, Oswald MJ, Ross MI, Ang KK. Elective radiotherapy provides regional control for patients with cutaneous melanoma of the head and neck. Cancer 2004; 100:383-9. [PMID: 14716775 DOI: 10.1002/cncr.11921] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In the current study, the authors assessed the efficacy of elective radiotherapy in providing regional (lymph node) control in patients with cutaneous melanoma of the head and neck who were at high risk for lymph node involvement. Toxicity was also assessed. METHODS From 1983 to 1998, 157 patients with Stage I or II cutaneous melanoma of the head and neck received elective regional radiotherapy after wide local excision of the primary lesion. None of the patients had received sentinel lymph node biopsy or dissection of the lymph nodes. Their medical records were reviewed retrospectively and analyzed for outcome. RESULTS The median follow-up for the current review was 68 months (range, 7-185 months). The disease recurred locally in 9 patients, in the neck lymph nodes in 15 patients, and distantly in 57 patients. The actuarial regional control rate was 89% at both 5 years and 10 years. The actuarial disease-specific survival and distant metastasis-free survival rates were 68% and 63%, respectively, at 5 years and 58% and 49%, respectively, at 10 years. Breslow thickness was a significant determinant of disease-specific survival and distant metastasis-free survival rates. At 10 years, 6% of patients had developed a symptomatic treatment-related complication. There were no treatment-related deaths. CONCLUSIONS The results of the current study confirmed the efficacy and safety of elective regional radiotherapy for patients with cutaneous head and neck melanoma predicted to have a high rate of lymph node involvement. Elective irradiation was a viable alternative to elective lymph node dissection. It may also serve as an alternative to sentinel lymph node biopsy, particularly for patients for whom dissection and systemic therapy are not therapeutic options.
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Affiliation(s)
- Mark D Bonnen
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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Trost O, Danino AM, Dutronc Y, Dalac S, Lambert D, Malka G. Is sentinel node biopsy beneficial in melanoma patients? A report on 200 patients with cutaneous melanoma (EJSO 2002; 28: 673--678). Eur J Surg Oncol 2003; 29:699. [PMID: 14511622 DOI: 10.1016/s0748-7983(03)00145-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Guller U, Blumenstein BA. Trends in clinical trials in surgical oncology: implications for outcomes research. Clin Ther 2003; 25:684-98. [PMID: 12749522 DOI: 10.1016/s0149-2918(03)80105-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Outcomes analysis is emerging as a crucial tool in understanding and improving health care. To this end, outcomes research is focused on methodologies for assessing the impact and quality of clinical services and the penetration of new findings. Clinical trials are an important mechanism for generating data to support outcomes research activities. In clinical trials in surgical oncology, there has been a general broadening of the spectrum of end points that are more focused on the needs of providing data to outcomes researchers. For example, in addition to traditional "mechanical" end points reflecting the physical dimensions of disability, awareness of the importance of end points related to quality of life has increased. Moreover, a variety of innovative study designs and methodologies have found more widespread use, including noninferiority trials, preresection staging designed to direct therapy more precisely, planned early reports of conditional results, prognostic studies, assessment of an event status at a point in time, and large simple trials. The goal of this article is to summarize and assess some of the trends in clinical trials in surgical oncology. Examples of ongoing studies or of trials in development from the American College of Surgeons Oncology Group are discussed.
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Affiliation(s)
- Ulrich Guller
- American College of Surgeons Oncology Group and the Duke University Medical Center, Durham, North Carolina 27710, USA.
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