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Mellemgaard C, Christensen IJ, Salkus G, Wirenfeldt Staun P, Korsgaard N, Hein Lindahl K, Skaarup Larsen M, Klausen S, Lade-Keller J. Reducing workload in malignant melanoma sentinel node examination: a national study of pathology reports from 507 melanoma patients. J Clin Pathol 2024; 77:312-317. [PMID: 36737244 DOI: 10.1136/jcp-2022-208743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/21/2023] [Indexed: 02/05/2023]
Abstract
AIMS Even though extensive melanoma sentinel node (SN) pathology protocols increase metastasis detection, there is a need for balancing high detection rates with reasonable workload. A newly tested Danish protocol recommended examining nodes at six levels 150 µm apart (six-level model) and using SOX10 and Melan-A immunohistochemistry (IHC). We explored if a protocol examining 3 levels 300 µm apart (three-level model) combined with IHC would compromise metastasis detection. The study aim was to optimise the protocol to reduce workload without compromising detection rate. METHODS 8 months after protocol implementation, we reviewed the pathology reports of SNs from 507 melanoma patients nationwide, including 117 SN-positive patients. Each report was reviewed to determine histopathological features, including detection of metastasis, exact levels with metastasis, exact levels with metastasis >1 mm in diameter and IHC results. RESULTS The six-level model detected metastases in 23% of patients, whereas the three-level model would have detected metastases in 22% of patients. The three-level model would have missed a few small metastases (n=4), measuring <0.1 mm, 0.1 mm, 0.4 mm and 0.1 mm, respectively. The six-level model detected metastases >1 mm in 7% of patients. One of these metastases (measuring 1.1 mm) would have been detected by the three-level model, but not as >1 mm. SOX10 and Melan-A had equal sensitivity. CONCLUSIONS Reducing the number of levels examined to three levels 300 µm apart combined with IHC does not have significant impact on metastasis detection rate, and we will therefore recommend that the future melanoma SN guideline takes this into consideration to reduce overall workload.
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Affiliation(s)
- Carina Mellemgaard
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
- Aarhus University, Aarhus, Denmark
| | - Ib Jarle Christensen
- Department of Pathology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - Giedrius Salkus
- Department of Pathology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Niels Korsgaard
- Department of Pathology, Hospital South West Jutland, Esbjerg, Denmark
| | | | | | - Siri Klausen
- Department of Pathology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
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Schoenfeldt T, Thompson JF, Lo S, Drzewiecki KT, Stretch J, Saw RPM, Spillane A, Shannon K, Uren RF, Chakera AH, Nieweg OE. Prognostic Significance and Management of Sentinel Nodes in the Triangular Intermuscular Space of Patients with Melanoma. Ann Surg Oncol 2023; 30:2354-2361. [PMID: 36463358 DOI: 10.1245/s10434-022-12840-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 11/03/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND The clinical significance of sentinel nodes (SNs) in the triangular intermuscular space (TIS) of patients with melanoma is poorly understood. This study aimed to determine their incidence and positivity rate, and to report their management and patient outcomes. METHODS This was a single-institution retrospective cohort study of patients with unilateral or bilateral TIS SNs on lymphoscintigraphy treated between 1992 and 2017. Recurrence-free survival was analyzed. RESULTS Lymphoscintigraphy identified TIS SNs in 266 patients. They were bilateral in 17 patients. Of the 2296 patients with a melanoma on the upper back, 259 (11%) had TIS SNs. Procurement of SNs was not attempted in 122 (43%) of the 283 cases and failed in 11 cases (7%). An SN was successfully retrieved from the TIS in 145 patients (53%) and contained metastasis in 18 of 150 TIS SNs. This was the only positive SN in 12 patients (8%), upstaging all of them. Of the 18 patients with a positive SN in the TIS, 9 (50%) underwent completion axillary lymph node dissection, but no additional involved nodes were found in any of these patients. Recurrence in the TIS was observed in six patients (5%), none of whom had their TIS SN surgically pursued previously. CONCLUSIONS Lymphoscintigraphy showed TIS SNs in 11% of patients with melanomas on their upper back. In such cases, retrieval of TIS SNs is required for accurate staging and to minimize the risk of TIS recurrence.
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Affiliation(s)
- Trine Schoenfeldt
- Melanoma Institute Australia, The University of Sydney, 40 Rocklands Road, North Sydney, NSW, 2060, Australia
- Leo Foundation Skin Immunology Research Center, University of Copenhagen, Copenhagen, Denmark
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, 40 Rocklands Road, North Sydney, NSW, 2060, Australia.
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
| | - Serigne Lo
- Melanoma Institute Australia, The University of Sydney, 40 Rocklands Road, North Sydney, NSW, 2060, Australia
| | - Krzysztof T Drzewiecki
- Department of Plastic Surgery, Breast Surgery and Burns, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, The University of Copenhagen, Copenhagen, Denmark
| | - Jonathan Stretch
- Melanoma Institute Australia, The University of Sydney, 40 Rocklands Road, North Sydney, NSW, 2060, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Robyn P M Saw
- Melanoma Institute Australia, The University of Sydney, 40 Rocklands Road, North Sydney, NSW, 2060, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Andrew Spillane
- Melanoma Institute Australia, The University of Sydney, 40 Rocklands Road, North Sydney, NSW, 2060, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Breast and Melanoma Surgery Unit, Royal North Shore Hospital, St Leonards, Sydney, Australia
| | - Kerwin Shannon
- Melanoma Institute Australia, The University of Sydney, 40 Rocklands Road, North Sydney, NSW, 2060, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Roger F Uren
- Melanoma Institute Australia, The University of Sydney, 40 Rocklands Road, North Sydney, NSW, 2060, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Alfred Nuclear Medicine and Ultrasound, Sydney, NSW, Australia
| | - Annette H Chakera
- Department of Plastic Surgery, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Omgo E Nieweg
- Melanoma Institute Australia, The University of Sydney, 40 Rocklands Road, North Sydney, NSW, 2060, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Ulmer A, Pfefferle V, Walter V, Granai M, Keim U, Fend F, Sulyok M, Bösmüller H. Reporting of melanoma cell densities in the sentinel node refines outcome prediction. Eur J Cancer 2022; 174:121-130. [PMID: 35994792 DOI: 10.1016/j.ejca.2022.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Sentinel node biopsy is a key procedure to predict prognosis in melanoma. In a prospective study we compare reporting on melanoma cell densities in cytospin preparations with semiquantitative histopathology for predicting outcome. PATIENTS AND METHODS Sentinel nodes from 900 melanoma patients were bisected. One half of each node was disaggregated mechanically. The melanoma cell density (number of HMB45 positive cells per million lymphocytes with at least one cell showing morphological features of a melanoma cell) was recorded after examining two cytospins. For the second half the maximum diameter of metastasis was determined after haematoxylin and eosin (H&E) and immunohistological staining of three slides. RESULTS Cytospins were positive for melanoma in 218 of 900 patients (24%). Routine pathology was positive in 111 of 900 (12%) patients. A more extensive pathological workup in cytospin-only positive patients led to a revised diagnosis (from negative to positive) in 23 of 101 patients (22.7%). We found a moderate but significant correlation between melanoma cell densities (determined in cytospins) and the maximum diameter of metastasis (determined by pathology) (rho = 0.6284, p < 0.001). At a median follow-up of 37 months (IQR 25-53 months) melanoma cell density (cytospins) (p < 0.001), thickness of melanoma (p = 0.008) and ulceration status (p = 0.026) were significant predictors for melanoma specific survival by multivariable testing and were all confirmed as key predictive factors by the random forest model. Maximum diameter of metastases, age and sex were not significant by multivariable testing (all p > 0.05). CONCLUSION Recording melanoma cell densities by examining two cytospins accurately predicts melanoma outcome and outperforms semiquantitative histopathology.
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Affiliation(s)
- Anja Ulmer
- Department of Dermatology, University of Tübingen, 72072 Tübingen, Germany.
| | - Vanessa Pfefferle
- Department of Dermatology, University of Tübingen, 72072 Tübingen, Germany.
| | - Vincent Walter
- Department of Dermatology, University of Tübingen, 72072 Tübingen, Germany.
| | - Massimo Granai
- Department of Pathology, University of Tübingen, 72072 Tübingen, Germany.
| | - Ulrike Keim
- Department of Dermatology, University of Tübingen, 72072 Tübingen, Germany.
| | - Falko Fend
- Department of Pathology, University of Tübingen, 72072 Tübingen, Germany.
| | - Mihály Sulyok
- Department of Pathology, University of Tübingen, 72072 Tübingen, Germany.
| | - Hans Bösmüller
- Department of Pathology, University of Tübingen, 72072 Tübingen, Germany.
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The Use and Technique of Sentinel Node Biopsy for Skin Cancer. Plast Reconstr Surg 2022; 149:995e-1008e. [PMID: 35472052 DOI: 10.1097/prs.0000000000009010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the indications for and prognostic value of sentinel lymph node biopsy in skin cancer. 2. Learn the advantages and disadvantages of various modalities used alone or in combination when performing sentinel lymph node biopsy. 3. Understand how to perform sentinel lymph node biopsy in skin cancer patients. SUMMARY Advances in technique used to perform sentinel lymph node biopsy to assess lymph node status have led to increased accuracy of the procedure and improved patient outcomes.
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El Sharouni MA, Laeijendecker AE, Suijkerbuijk KP, Witkamp AJ, Sigurdsson V, van Diest PJ, van Gils CH, Blokx WA. High discordance rate in assessing sentinel node positivity in cutaneous melanoma: Expert review may reduce unjustified adjuvant treatment. Eur J Cancer 2021; 149:105-113. [PMID: 33848712 DOI: 10.1016/j.ejca.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/01/2021] [Accepted: 03/05/2021] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Identification of sentinel node (SN) metastases can set the adjuvant systemic therapy indication for patients with stage III melanoma. Studies re-evaluating the diagnosis of initially positive SN biopsies are scarce. MATERIALS AND METHODS Dutch patients with melanoma who underwent SN biopsy between 2003 and 2014 were selected from PALGA, the Dutch Pathology Registry. Histopathological slides of SN-positive patients were retrieved for review. A random sample was reassessed by an expert melanoma pathologist. Recurrence-free survival (RFS) of patients who were misclassified (false-positive) was compared with those with a true positive SN status. For comparison, a group of SN-negative patients was included. Multivariable logistic analysis was performed to assess clinicopathological characteristics associated with misclassification of SN status. RESULTS Diagnosis was downgraded from melanoma metastasis to nodal nevus in 38 of the 322 reviewed patients (11.8%). Considering the inclusion criteria of phase III adjuvant trials, at least 4.3% of patients would have falsely qualified for adjuvant therapy. In multivariable analysis, patients with a low SN tumour burden and subcapsular SN tumour location had a significantly higher chance of being misclassified. The five-year RFS of the 38 downgraded patients was 86.7% (95% confidence interval [CI] = 72.6-96.6), similar to the 85.9% (95% CI = 84.9-86.8, p = 0.18) for 6413 SN-negative patients and better than the 53.2% (95% CI = 47.2-59.9, p = 0.009) of 284 patients who were truly SN positive upon review. CONCLUSION More than 10% of originally positive SN biopsies of patients with melanoma concern misclassified nodal nevi. We advocate that when adjuvant treatment is considered in patients with stage III melanoma, SN biopsies should be reassessed by an expert melanoma pathologist.
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Affiliation(s)
- Mary-Ann El Sharouni
- Department of Dermatology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands.
| | - Annelien E Laeijendecker
- Department of Dermatology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Karijn Pm Suijkerbuijk
- Department of Medical Oncology, University Medical Center Cancer Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Arjen J Witkamp
- Department of Surgery, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Vigfús Sigurdsson
- Department of Dermatology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Paul J van Diest
- Department of Pathology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Carla H van Gils
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Willeke Am Blokx
- Department of Pathology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
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Nijhuis AAG, Spillane AJ, Stretch JR, Saw RPM, Menzies AM, Uren RF, Thompson JF, Nieweg OE. Current management of patients with melanoma who are found to be sentinel node-positive. ANZ J Surg 2019; 90:491-496. [PMID: 31667924 PMCID: PMC7216885 DOI: 10.1111/ans.15491] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 12/29/2022]
Abstract
Background The results of the DeCOG‐SLT and MSLT‐II studies, published in 2016 and mid‐2017, indicated no survival benefit from completion lymph node dissection (CLND) in melanoma patients with positive sentinel nodes (SNs). Subsequently, several studies have been published reporting a benefit of adjuvant systemic therapy in patients with stage III melanoma. The current study assessed how these findings influenced management of SN‐positive patients in a dedicated melanoma treatment centre. Methods SN‐positive patients treated at Melanoma Institute Australia between July 2017 and December 2018 were prospectively identified. Surgeons completed a questionnaire documenting the management of each patient. Information on patients, primary tumours, SNs, further treatment and follow‐up was collected from patient files, the institutional research database and pathology reports. Results During the 18‐month study period, 483 patients underwent SN biopsy. A positive SN was found in 61 (13%). Two patients (3%) requested CLND because of anxiety about observation in view of unfavourable primary tumour and SN characteristics. The other 59 patients (97%) were followed with a four‐monthly ultrasound examination of the relevant lymph node field(s). Two of them (3%) developed an isolated nodal recurrence after 4 and 11 months of follow‐up. Fifty‐seven patients (93%) were seen following the publication of the first two adjuvant systemic therapy studies in November 2017; 46 (81%) were referred to a medical oncologist to discuss adjuvant systemic therapy, which 32 (70%) chose to receive. Conclusion At Melanoma Institute Australia most patients with an involved SN are now managed without CLND. The majority are referred to a medical oncologist and receive adjuvant systemic therapy.
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Affiliation(s)
- Amanda A G Nijhuis
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia.,Surgery department, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andrew J Spillane
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia.,Breast and Melanoma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney School of Medicine, Sydney, New South Wales, Australia
| | - Jonathan R Stretch
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney School of Medicine, Sydney, New South Wales, Australia.,Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Robyn P M Saw
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney School of Medicine, Sydney, New South Wales, Australia.,Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Alexander M Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney School of Medicine, Sydney, New South Wales, Australia.,Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, New South Wales, Australia
| | - Roger F Uren
- Faculty of Medicine and Health, The University of Sydney School of Medicine, Sydney, New South Wales, Australia.,Alfred Nuclear Medicine and Ultrasound, Sydney, New South Wales, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney School of Medicine, Sydney, New South Wales, Australia.,Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Omgo E Nieweg
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney School of Medicine, Sydney, New South Wales, Australia.,Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Nijhuis AAG, Santos Filho IDDAO, Holtkamp LHJ, Uren RF, Thompson JF, Nieweg OE. Sentinel Node Biopsy for Melanoma Patients with a Local Recurrence or In-Transit Metastasis. Ann Surg Oncol 2019; 27:561-568. [DOI: 10.1245/s10434-019-07699-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Indexed: 12/24/2022]
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Adler NR, Wolfe R, McArthur GA, Kelly JW, Haydon A, McLean CA, Mar VJ. Tumour mutation status and melanoma recurrence following a negative sentinel lymph node biopsy. Br J Cancer 2018; 118:1289-1295. [PMID: 29755118 PMCID: PMC5959932 DOI: 10.1038/s41416-018-0088-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/12/2018] [Accepted: 03/27/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND A proportion of patients develop recurrence following a tumour-negative sentinel lymph node biopsy (SLNB). This study aimed to explore whether melanoma patients with BRAF or NRAS mutant tumours have an increased risk of developing disease recurrence following a negative SLNB compared to patients with wild-type tumours. METHODS Prospective cohort study of melanoma patients at three tertiary referral centres in Melbourne, who underwent SLNB. Clinical, pathological and molecular characteristics and recurrence data were prospectively recorded. Multivariate Cox proportional hazards regression models estimated the adjusted hazard ratio (aHR) and corresponding 95% confidence interval (CI) for the association between mutation status and development of recurrence following a negative-SLNB. RESULTS Overall, 344/477 (72.1%) patients had a negative SLNB. Of these, 54 (15.7%) developed subsequent recurrence. The risk of disease recurrence following a negative SLNB was increased for patients with either a BRAF or NRAS mutant tumour compared to wild-type tumours (aHR 1.92, 95% CI: 1.02-3.60, p = 0.04). CONCLUSION Melanoma patients with BRAF or NRAS mutant tumours had an increased risk compared to patients with BRAF/NRAS wild-type tumours of developing disease recurrence following a tumour-negative SLNB. The findings also confirm the importance of continued surveillance to monitor for disease recurrence among SLNB-negative patients.
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Affiliation(s)
- Nikki R Adler
- Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC, 3004, Australia.
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia.
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
| | - Grant A McArthur
- Divisions of Research and Cancer Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, 3000, Australia
| | - John W Kelly
- Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - Andrew Haydon
- Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC, 3004, Australia
- Department of Medical Oncology, Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - Catriona A McLean
- Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC, 3004, Australia
- Department of Anatomical Pathology, Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - Victoria J Mar
- Victorian Melanoma Service, Alfred Hospital, Melbourne, VIC, 3004, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
- Skin and Cancer Foundation, Carlton, VIC, 3053, Australia
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Abstract
The metastasis of neoplastic cells from their site of origin to distant anatomic locations continues to be the principal cause of death from malignant tumors, and that fact has been recognized by physicians for over a century. After the work done by Halsted in the treatment of breast cancer in the 1880s, accepted surgical canon held that metastasis occurred in a linear fashion, with centrifugal "growth in continuity" from the primary neoplasm that first involved regional lymph nodes. Those structures were considered to then be the sources of more distant, visceral metastases. With that premise in mind, radical and "ultra-radical" surgical procedures were devised to remove as many lymph nodes as possible in the treatment of carcinomas and melanomas. However, such interventions were ineffective in altering tumor-related mortality. This review considers the details of the historical material just mentioned. It also reviews currently-held concepts on biological mechanisms of metastasis, the "sentinel" lymph node biopsy technique, and the important topic of metastatic tumor "dormancy" as the cause of surgical treatment failure. Finally, predictive models of tumor behavior are discussed, which are based on gene signatures. These will likely be the key to identifying malignant lesions of low surgical stage that ultimately prove fatal through later manifestation of metastasis.
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Affiliation(s)
- Mark R Wick
- Division of Surgical Pathology & Cytopathology, Department of Pathology, University of Virginia Medical Center, Room 3020, 1215 Lee Street, Charlottesville, VA 22908-0214, United States.
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10
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Ferrara G, Improta G. Sentinel Node Biopsy in Melanoma: Lessons Learned From Different Positivity Rates From Different Hospitals. Ann Surg 2017; 266:e81. [PMID: 29136999 DOI: 10.1097/sla.0000000000001662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Gerardo Ferrara
- Department of Oncology, Anatomic Pathology Unit, Gaetano Rummo General Hospital, Benevento, Italy Laboratory of Clinical Research and Advanced Diagnostics, IRCCS - CROB Centro di Riferimento Oncologico della Basilicata, Rionero in Vulture, Italy
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11
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Gershenwald JE, Scolyer RA, Hess KR, Sondak VK, Long GV, Ross MI, Lazar AJ, Faries MB, Kirkwood JM, McArthur GA, Haydu LE, Eggermont AMM, Flaherty KT, Balch CM, Thompson JF. Melanoma staging: Evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin 2017; 67:472-492. [PMID: 29028110 PMCID: PMC5978683 DOI: 10.3322/caac.21409] [Citation(s) in RCA: 1422] [Impact Index Per Article: 203.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/09/2017] [Accepted: 08/10/2017] [Indexed: 02/06/2023] Open
Abstract
Answer questions and earn CME/CNE To update the melanoma staging system of the American Joint Committee on Cancer (AJCC) a large database was assembled comprising >46,000 patients from 10 centers worldwide with stages I, II, and III melanoma diagnosed since 1998. Based on analyses of this new database, the existing seventh edition AJCC stage IV database, and contemporary clinical trial data, the AJCC Melanoma Expert Panel introduced several important changes to the Tumor, Nodes, Metastasis (TNM) classification and stage grouping criteria. Key changes in the eighth edition AJCC Cancer Staging Manual include: 1) tumor thickness measurements to be recorded to the nearest 0.1 mm, not 0.01 mm; 2) definitions of T1a and T1b are revised (T1a, <0.8 mm without ulceration; T1b, 0.8-1.0 mm with or without ulceration or <0.8 mm with ulceration), with mitotic rate no longer a T category criterion; 3) pathological (but not clinical) stage IA is revised to include T1b N0 M0 (formerly pathologic stage IB); 4) the N category descriptors "microscopic" and "macroscopic" for regional node metastasis are redefined as "clinically occult" and "clinically apparent"; 5) prognostic stage III groupings are based on N category criteria and T category criteria (ie, primary tumor thickness and ulceration) and increased from 3 to 4 subgroups (stages IIIA-IIID); 6) definitions of N subcategories are revised, with the presence of microsatellites, satellites, or in-transit metastases now categorized as N1c, N2c, or N3c based on the number of tumor-involved regional lymph nodes, if any; 7) descriptors are added to each M1 subcategory designation for lactate dehydrogenase (LDH) level (LDH elevation no longer upstages to M1c); and 8) a new M1d designation is added for central nervous system metastases. This evidence-based revision of the AJCC melanoma staging system will guide patient treatment, provide better prognostic estimates, and refine stratification of patients entering clinical trials. CA Cancer J Clin 2017;67:472-492. © 2017 American Cancer Society.
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Affiliation(s)
- Jeffrey E. Gershenwald
- Professor of Surgery and Cancer Biology, Department of Surgical Oncology; Medical Director, Melanoma and Skin Center, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Richard A. Scolyer
- Conjoint Medical Director, Melanoma Institute Australia; Clinical Professor, The University of Sydney, Sydney, New South Wales, Australia
- Senior Staff Pathologist, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kenneth R. Hess
- Professor, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vernon K. Sondak
- Chair, Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL
| | - Georgina V. Long
- Conjoint Medical Director and Chair of Melanoma Medical Oncology and Translational Research, Melanoma Institute Australia, The University of Sydney and Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Merrick I. Ross
- Professor of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alexander J. Lazar
- Professor of Pathology, Dermatology, and Translational Molecular Pathology; Director, Melanoma Molecular Diagnostics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mark B. Faries
- Co-Director, Melanoma Program; Head, Surgical Oncology, The Angeles Clinic and Research Institute, Los Angeles, CA
| | - John M. Kirkwood
- Professor of Medicine, Dermatology, and Translational Science, The University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Grant A. McArthur
- Executive Director, Victorian Comprehensive Cancer Center, Melbourne, Victoria, Australia
| | - Lauren E. Haydu
- Manager, Clinical Data Management Systems, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Keith T. Flaherty
- Director, Termeer Center for Targeted Therapy, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Charles M. Balch
- Professor of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John F. Thompson
- Professor of Melanoma and Surgical Oncology, Melanoma Institute Australia, The University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Histopathologic review of negative sentinel lymph node biopsies in thin melanomas: an argument for the routine use of immunohistochemistry. Melanoma Res 2017; 27:369-376. [DOI: 10.1097/cmr.0000000000000361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Kibrité A, Milot H, Douville P, Gagné ÉJ, Labonté S, Friede J, Morin F, Ouellet JF, Claveau J. Predictive factors for sentinel lymph nodes and non-sentinel lymph nodes metastatic involvement: a database study of 1,041 melanoma patients. Am J Surg 2016; 211:89-94. [DOI: 10.1016/j.amjsurg.2015.05.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 05/07/2015] [Accepted: 05/25/2015] [Indexed: 11/28/2022]
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Lee DY, Huynh KT, Teng A, Lau BJ, Vitug S, Lee JH, Stern SL, Foshag LJ, Faries MB. Predictors and Survival Impact of False-Negative Sentinel Nodes in Melanoma. Ann Surg Oncol 2015; 23:1012-8. [PMID: 26586498 DOI: 10.1245/s10434-015-4912-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND The status of the sentinel lymph node in melanoma is an important prognostic factor. The clinical predictors and implications of false-negative (FN) biopsy remain debatable. METHODS We compared patients with positive sentinel lymph node biopsy (SNB) [true positive (TP)] and negative SNB with and without regional recurrence [FN, true negative (TN)] from our prospective institutional database. RESULTS Among 2986 patients (84 FN, 494 TP, and 2408 TN; median follow-up 93 months), the incidence of FN-SNB was 2.8%. While calculated FN rate was 14.5% [84 FN/(494 TP + 84 FN) × 100], when we accounted for local/in-transit recurrence (LITR) this rate was 8.5% [46 FN/(494 TP + 46 FN) × 100 %]. On multivariate analysis, male gender (OR 2.0, 95% CI 1.1-3.6, p = 0.018), head/neck primaries (OR 2.5, 95% CI 1.3-4.8, p < 0.006), and LITR (OR 3.5, 95% CI 2.1-5.8, p < 0.001) were associated with FN-SNB. Melanoma-specific survival (MSS) for the FN group was similar to the TP group at 5 years (68 vs. 73%, p = 0.539). However, MSS declined more for the FN group with a longer follow up and was significantly worse at 10 years (44 vs. 64%, p < 0.001). On multivariate analysis, FN-SNB was a significant predictor of worse MSS in melanomas <4 mm in Breslow thickness (HR 1.6; 95% CI 1.1-2.5, p = 0.021). CONCLUSIONS Male gender, LITR, and head and neck tumors were associated with FN-SNB. FN-SNB was an independent predictor of worse MSS in melanomas <4 mm in thickness, but this survival difference did not become apparent until after 5 years of follow-up.
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Affiliation(s)
- David Y Lee
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, CA, USA
| | - Kelly T Huynh
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, CA, USA
| | - Annabelle Teng
- Department of Surgery, Mount Sinai, St-Luke's-Roosevelt Hospital Center, New York, NY, USA
| | - Briana J Lau
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, CA, USA
| | - Sarah Vitug
- Ochsner Clinical School, University of Queensland School of Medicine, Saint Lucia, QLD, Australia
| | - Ji-Hey Lee
- Department of Biostatistics, The John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, CA, USA
| | - Stacey L Stern
- Department of Biostatistics, The John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, CA, USA
| | - Leland J Foshag
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, CA, USA
| | - Mark B Faries
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, CA, USA.
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Vollmer RT. Probabilistic issues with sentinel lymph nodes in malignant melanoma. Am J Clin Pathol 2015; 144:464-72. [PMID: 26276777 DOI: 10.1309/ajcp50dkltiuazte] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES To address issues of probability for sentinel lymph node results in melanoma and provide details about the probabilistic nature of the numbers of sentinel nodes as well as to address how these issues relate to tumor thickness and patient outcomes. METHODS Analysis of the probability of observing sentinel node metastases uses the discrete exponential probability distribution to address the number of observed positive sentinel nodes. In addition, mathematical functions derived from survival analysis are used. Data are then chosen from the literature to illustrate the approach and to derive results. RESULTS Observations about the numbers of positive and negative sentinel nodes closely follow discrete exponential probability distributions, and the relationship between the probability of a positive sentinel node and tumor thickness follows closely a function derived from survival analysis. Sentinel node results relate to tumor thickness as well as to the total number of nodes harvested but fall short of identifying all those who eventually develop metastatic melanoma. CONCLUSIONS Probability analyses provide useful insight into the success and failure of the sentinel node biopsy procedure in patients with melanoma.
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McCormack CJ, Conyers RK, Scolyer RA, Kirkwood J, Speakman D, Wong N, Kelly JW, Henderson MA. Atypical Spitzoid neoplasms: a review of potential markers of biological behavior including sentinel node biopsy. Melanoma Res 2014; 24:437-47. [PMID: 24892957 DOI: 10.1097/cmr.0000000000000084] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Atypical cutaneous melanocytic lesions, including those with Spitzoid features, can be difficult to categorize as benign or malignant. This can lead to suboptimal management, with potential adverse patient outcomes. Recent studies have enhanced knowledge of the molecular and genetic biology of these lesions and, combined with clinicopathological findings, is further defining their biological spectrum, classification, and behavior. Sentinel node biopsy provides important prognostic information in patients with cutaneous melanoma, but its role in the management of melanocytic lesions of uncertain malignant potential (MELTUMP) is controversial. This paper examines the role of molecular testing and sentinel node biopsy in MELTUMPs, particularly atypical Spitzoid tumors.
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Affiliation(s)
- Christopher J McCormack
- aPeter Macallum Cancer Institute, East Melbourne bVictorian Melanoma Service, Alfred Hospital, Prahran cDepartment of Paediatrics, Murdoch Children's Research Institute, Royal Children's Hospital, The University of Melbourne, Parkville dThe Royal Children's Hospital, Flemington Road, Parkville, Victoria eMelanoma Institute Australia , Royal Prince Alfred Hospital, The University of Sydney, Sydney, New South Wales, Australia fDepartment of Medicine, Melanoma and Skin Cancer Program, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania, USA
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Histopathologic evaluation of the sentinel lymph node for malignant melanoma: the unstandardized process. Am J Dermatopathol 2014; 36:80-7. [PMID: 23860116 DOI: 10.1097/dad.0b013e31829432c7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Metastasis from malignant melanoma (MM) usually first presents in the draining lymph node basin and thus sentinel lymph node (SLN) biopsy is a staging tool used to predict risk of metastases and death in higher risk tumors and has become the standard of care. Differences in the processing and methods used in the histopathological examination of SLNs can affect the positivity rate for metastatic MM because isolated MM deposits may be small and variably distributed in the SLN. The examination of SLNs is not standardized. The authors surveyed institutions across the United States who process SLNs for MM to better characterize the current methods used and to suggest a standardized approach to improve the reliability of the SLN biopsy. A survey of 142 academic institutions in the United States regarding the methods used in the evaluation of the SLN biopsy for MM was conducted. Thirty-two institutions responded. Eighty-one percent of the institutions (26 of 32) had a protocol that they used for SLN examination. In regards to gross dissection, 28% of the responders (9 of 32) initially bivalve (cut the SLN in half), whereas 59% (19 of 32) use a bread loaf technique, cutting the SLN at even intervals without specifically commenting about orientation to the hilum. The number of levels initially cut from the SLN block varied from 1 to 8 levels per block. Thirty-nine percent of the respondents (12 of 31) routinely order immunohistochemistry before evaluation of the initial hematoxylin- and eosin-stained sections. Eighty percent of the respondents (24 of 30) report the maximum dimension of the metastatic tumor deposit. The response rate was low (22%), and most respondents did not indicate how many SLN accessions were performed at their institution each year. Histologic protocols for processing SLNs for MM vary among institutions. Different methods of handling SLNs result in varying sensitivities for detection of metastases. Data derived from these varied approaches to develop and determine prognostic and staging categories may be inconsistent. A standardized yet practical approach is needed to provide reliable information on which prognosis can be determined and therapeutic guidelines can be based. The hope is for dermatologists and those treating patients with MM to understand the intricacies and inconsistencies involved in performance and interpretation of this key staging tool.
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Hruby G, Scolyer RA, Thompson JF. The important role of radiation treatment in the management of Merkel cell carcinoma. Br J Dermatol 2014; 169:975-82. [PMID: 23898924 DOI: 10.1111/bjd.12481] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2013] [Indexed: 11/27/2022]
Abstract
Merkel cell carcinoma is an aggressive, radiosensitive cutaneous neuroendocrine tumour. In this review, the roles of radiation therapy and chemoradiation in the management of Merkel cell carcinoma are described and discussed, and guidelines for patient management are presented. Radiation treatment may be indicated for definitive (> 55 Gy) or adjuvant (> 50 Gy) treatment of the primary tumour site and for prophylactic (> 50 Gy), adjuvant (> 50 Gy) or definitive (> 55 Gy) treatment of the regional lymph node field. If a patient presents with positive margins after initial biopsy or resection, definitive radiation therapy or chemoradiation may be an alternative to further surgery and, importantly, results in less delay than re-resection followed by adjuvant radiation treatment. Given the rarity of this tumour, patients should be enrolled on prospective databases and clinical trials, and managed in a multidisciplinary clinical setting wherever possible.
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Affiliation(s)
- G Hruby
- Department of Radiation Oncology, Royal Prince Alfred Hospital, Camperdown, Sydney, NSW, Australia; Discipline of Medicine, The University of Sydney, Sydney, NSW, Australia
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Dandekar M, Lowe L, Fullen DR, Johnson TM, Sabel MS, Wong SL, Patel RM. Discordance in Histopathologic Evaluation of Melanoma Sentinel Lymph Node Biopsy with Clinical Follow-Up: Results from a Prospectively Collected Database. Ann Surg Oncol 2014; 21:3406-11. [DOI: 10.1245/s10434-014-3773-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Indexed: 11/18/2022]
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Beylergil V, Carrasquillo JA. Molecular imaging and therapy of merkel cell carcinoma. Cancers (Basel) 2014; 6:1020-30. [PMID: 24784954 PMCID: PMC4074814 DOI: 10.3390/cancers6021020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/08/2014] [Accepted: 04/14/2014] [Indexed: 11/16/2022] Open
Abstract
Several molecular imaging modalities have been evaluated in the management of Merkel cell carcinoma (MCC), a rare and aggressive tumor with a high tendency to metastasize. Continuous progress in the field of molecular imaging might improve management in these patients. The authors review the current modalities and their impact on MCC in this brief review article.
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Affiliation(s)
- Volkan Beylergil
- Molecular and Imaging Therapy Service, Department of Radiology Box 77, Memorial Sloan-Kettering Cancer Center 1275 York Ave, New York, NY 10065, USA; E-mail:
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-212-639-5313; Fax: +1-212-639-8045
| | - Jorge A. Carrasquillo
- Molecular and Imaging Therapy Service, Department of Radiology Box 77, Memorial Sloan-Kettering Cancer Center 1275 York Ave, New York, NY 10065, USA; E-mail:
- Department of Radiology, Weill Cornell Medical Center, New York, NY 10065, USA
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Riber-Hansen R, Hamilton-Dutoit SJ, Steiniche T. Nodal distribution, stage migration due to diameter measurement and the prognostic significance of metastasis volume in melanoma sentinel lymph nodes: a validation study. APMIS 2014; 122:968-75. [DOI: 10.1111/apm.12240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 12/02/2013] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Torben Steiniche
- Institute of Pathology; Aarhus University Hospital; Aarhus Denmark
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Dekker J, Duncan LM. Lack of standards for the detection of melanoma in sentinel lymph nodes: a survey and recommendations. Arch Pathol Lab Med 2013; 137:1603-9. [PMID: 24168497 DOI: 10.5858/arpa.2012-0550-oa] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Detection of microscopic melanoma metastases in sentinel lymph nodes drives clinical care; patients without metastases are observed, and patients with metastases are offered completion lymphadenectomy and adjuvant therapy. OBJECTIVE We sought to determine common elements in currently used analytic platforms for sentinel lymph nodes in melanoma patients. DESIGN An electronic survey was distributed to 83 cancer centers in North America. RESULTS Seventeen responses (20%) were received. The number of sentinel lymph node mapping procedures for melanoma ranged from less than 11 to more than 100 patients per year, with 72% of institutions mapping more than 50 melanoma patients a year. Uniform practices included (1) processing all of the lymph node tissue rather than submitting representative sections and (2) use of immunohistochemical stains if no tumor was identified on the hematoxylin-eosin-stained sections. Significant variability existed regarding the method of sectioning lymph nodes at grossing and in the histology laboratory; most bisected nodes longitudinally (94%) and performed deeper levels into the block (67%), but these were not uniform practices. S-100 was the most commonly used immunohistochemical stain (78%), followed by Melan-A (56%), MART-1 (50%), HMB-45 (44%), tyrosinase (33%), MiTF (11%), and pan-melanoma (6%). CONCLUSIONS There is a need for a standardized platform for detecting melanoma in sentinel lymph nodes. Current practices by a majority of laboratories and findings in the reported literature support the following: histologic evaluation of all lymph node tissue, use of immunohistochemical stains, bisecting lymph nodes longitudinally, and performing deeper levels into the tissue block.
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Affiliation(s)
- John Dekker
- From the Department of Pathology, Massachusetts General Hospital, Boston
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Scolyer RA, Judge MJ, Evans A, Frishberg DP, Prieto VG, Thompson JF, Trotter MJ, Walsh MY, Walsh NMG, Ellis DW. Data set for pathology reporting of cutaneous invasive melanoma: recommendations from the international collaboration on cancer reporting (ICCR). Am J Surg Pathol 2013; 37:1797-814. [PMID: 24061524 PMCID: PMC3864181 DOI: 10.1097/pas.0b013e31829d7f35] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
An accurate and complete pathology report is critical for the optimal management of cutaneous melanoma patients. Protocols for the pathologic reporting of melanoma have been independently developed by the Royal College of Pathologists of Australasia (RCPA), Royal College of Pathologists (United Kingdom) (RCPath), and College of American Pathologists (CAP). In this study, data sets, checklists, and structured reporting protocols for pathologic examination and reporting of cutaneous melanoma were analyzed by an international panel of melanoma pathologists and clinicians with the aim of developing a common, internationally agreed upon, evidence-based data set. The International Collaboration on Cancer Reporting cutaneous melanoma expert review panel analyzed the existing RCPA, RCPath, and CAP data sets to develop a protocol containing "required" (mandatory/core) and "recommended" (nonmandatory/noncore) elements. Required elements were defined as those that had agreed evidentiary support at National Health and Medical Research Council level III-2 level of evidence or above and that were unanimously agreed upon by the review panel to be essential for the clinical management, staging, or assessment of the prognosis of melanoma or fundamental for pathologic diagnosis. Recommended elements were those considered to be clinically important and recommended for good practice but with lesser degrees of supportive evidence. Sixteen core/required data elements for cutaneous melanoma pathology reports were defined (with an additional 4 core/required elements for specimens received with lymph nodes). Eighteen additional data elements with a lesser level of evidentiary support were included in the recommended data set. Consensus response values (permitted responses) were formulated for each data item. Development and agreement of this evidence-based protocol at an international level was accomplished in a timely and efficient manner, and the processes described herein may facilitate the development of protocols for other tumor types. Widespread utilization of an internationally agreed upon, structured pathology data set for melanoma will lead not only to improved patient management but is a prerequisite for research and for international benchmarking in health care.
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Affiliation(s)
- Richard A Scolyer
- *Melanoma Institute Australia Disciplines of †Pathology **Surgery, Sydney Medical School, The University of Sydney Departments of ‡Tissue Pathology and Diagnostic Oncology ††Melanoma and Surgical Oncology, Royal Prince Alfred Hospital §Royal College of Pathologists of Australasia, Sydney, NSW ¶¶Royal Adelaide Hospital and Flinders University, Adelaide, SA, Australia ∥Department of Pathology, Ninewells Hospital and Medical School, Dundee, Scotland ¶Cedars-Sinai Medical Center, Los Angeles, CA #Departments of Pathology and Dermatology, University of Texas-MD Anderson Cancer Center, Houston, TX ‡‡Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB ∥∥Department of Pathology, Capital District Health Authority and Dalhousie University, Halifax, NS, Canada §§Royal Victoria Hospital, Belfast, UK
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McDonald K, Page AJ, Jordan SW, Chu C, Hestley A, Delman KA, Murray DR, Carlson GW. Analysis of regional recurrence after negative sentinel lymph node biopsy for head and neck melanoma. Head Neck 2012; 35:667-71. [DOI: 10.1002/hed.23013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2012] [Indexed: 11/08/2022] Open
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Azimi F, Scolyer RA, Rumcheva P, Moncrieff M, Murali R, McCarthy SW, Saw RP, Thompson JF. Tumor-infiltrating lymphocyte grade is an independent predictor of sentinel lymph node status and survival in patients with cutaneous melanoma. J Clin Oncol 2012; 30:2678-83. [PMID: 22711850 DOI: 10.1200/jco.2011.37.8539] [Citation(s) in RCA: 570] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
PURPOSE To determine whether density and distribution of tumor-infiltrating lymphocytes (TILs; TIL grade) is an independent predictor of sentinel lymph node (SLN) status and survival in patients with clinically localized primary cutaneous melanoma. METHODS From the Melanoma Institute Australia database, 1,865 patients with a single primary melanoma ≥ 0.75 mm in thickness were identified. The associations of clinical and pathologic factors with SLN status, recurrence-free survival (RFS), and melanoma-specific survival (MSS) were analyzed. RESULTS The majority of patients had either no (TIL grade 0; 35.4%) or few (TIL grade 1; 45.1%) TILs, with a minority showing moderate (TIL grade 2; 16.3%) or marked (TIL grade 3; 3.2%) TILs. Tumor thickness, mitotic rate, and Clark level were inversely correlated with TIL grade (each P < .001). SLN biopsy was performed in 1,138 patients (61.0%) and was positive in 252 (22.1%). There was a significant inverse association between SLN status and TIL grade (SLN positivity rates for each TIL grade: 0, 27.8%; 1, 20.1%; 2, 18.3%; 3, 5.6%; P < .001). Predictors of SLN positivity were decreasing age (P < .001), decreasing TIL grade (P < .001), ulceration (P = .003), increasing tumor thickness (P = .01), satellitosis (P = .03), and increasing mitoses (P = .03). The 5-year MSS and RFS rates were 83% and 76%, respectively (median follow-up, 43 months). Tumor thickness (P < .001), ulceration (P < .001), satellitosis (P < .001), mitotic rate (P = .003), TIL grade (P < .001), and sex (P = .01) were independent predictors of MSS. Patients with TIL grade 3 tumors had 100% survival. CONCLUSION TIL grade is an independent predictor of survival and SLN status in patients with melanoma. Patients with a pronounced TIL infiltrate have an excellent prognosis.
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Affiliation(s)
- Farhad Azimi
- Melanoma Institute Australia, 40 Rocklands Rd, North Sydney NSW 2060, Australia
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Increasing Age Is Associated with Worse Prognostic Factors and Increased Distant Recurrences despite Fewer Sentinel Lymph Node Positives in Melanoma. Int J Surg Oncol 2012; 2012:456987. [PMID: 22523678 PMCID: PMC3317190 DOI: 10.1155/2012/456987] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 11/30/2011] [Accepted: 12/20/2011] [Indexed: 02/05/2023] Open
Abstract
Background. Advanced age is associated with a poorer prognosis in patients with melanoma. Despite this established finding, a decreased incidence of positive sentinel lymph nodes (SLNs) with advancing age has paradoxically been described. Methods. Using a single-institution database of melanoma patients between 1994 and 2009, the relationship between standard clinicopathologic variables and recurrence based on age was evaluated. Results. 1244 patients who underwent successful SLN biopsies were analyzed (mean followup 80.3 months). Increasing age was independently associated with worse survival on multivariable analysis (P = 0.02). SLN status was more likely to be negative if the patient was older (P = 0.01). Conclusions. Our data supports the paradox that increasing age is associated with a lower frequency of positive-SLN biopsies despite age itself being a poor prognostic factor. We propose that age-dependent variations in the primary tumor and the patient may predispose to a hematogenous route of spread for the older population, leading to worse survival.
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Murali R, DeSilva C, McCarthy SW, Thompson JF, Scolyer RA. Sentinel lymph nodes containing very small (<0.1 mm) deposits of metastatic melanoma cannot be safely regarded as tumor-negative. Ann Surg Oncol 2012; 19:1089-99. [PMID: 22271204 DOI: 10.1245/s10434-011-2208-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Indexed: 01/26/2023]
Abstract
BACKGROUND Some authors have suggested that patients with very small (<0.1 mm) deposits of metastatic melanoma in sentinel lymph nodes (SLNs) should be considered SLN-negative, whereas others have reported that such patients can have adverse long-term outcomes. The aims of the present study were to determine whether extensive sectioning of SLNs resulted in more accurate categorization of histologic features of tumor deposits and to assess prognostic associations of histologic parameters obtained using more intensive sectioning protocols. METHODS From patients with a single primary cutaneous melanoma who underwent SLN biopsy between 1991 and 2008, those in which the maximum size of the largest tumor deposit (MaxSize) in SLNs was <0.1 mm in the original sections were identified. Five batches of additional sections were cut from the SLN tissue blocks at intervals of 250 μm. The 1st batch was cut from the blocks without any trimming; these sections were therefore immediately adjacent to the original sections. Each batch included 5 sequential sections, the 1st and 5th stained with hematoxylin-eosin, and the 2nd, 3rd, and 4th stained immunohistochemically with S-100, HMB-45, and Melan-A, respectively. In each batch of sections, the following histologic features of tumor deposit(s) in the SLNs were evaluated: MaxSize; tumor penetrative depth (TPD) (defined as the maximum depth of tumor deposit(s) from the inner margin of the lymph node capsule), and intranodal location (classified as subcapsular if the tumor deposit(s) were confined to the subcapsular zone or parenchymal if there was any involvement of the nodal parenchyma beyond the subcapsular zone). The measured histologic parameters were compared in each batch of sections. The association of histologic parameters with overall survival was assessed for the parameters measured in each batch of sections. RESULTS There were 20 eligible patients (15 females, 5 males, median age 60 years). After a median follow-up duration of 40 months, 4 patients had died from melanoma and 2 patients of unknown causes. Completion lymph node dissection (CLND) was performed in 13 cases (65%) and was negative in all cases. Relative to the measured values on the original sections, all 3 parameters were upstaged in subsequent batches of sections, but no further upstaging of MaxSize, TPD, or location was seen beyond batch 3, batch 4, and batch 2, respectively. Increasing MaxSize was associated with significantly poorer overall survival in batches 1, 2, and 3. Parenchymal involvement was significantly associated with poorer survival in batches 2-5. TPD was not significantly associated with overall survival. CONCLUSIONS The results of this study indicate that very small (<0.1 mm) deposits of melanoma in SLNs may be associated with adverse clinical outcomes and that this is due, at least in part, to the underestimation of SLN tumor burden in the initial sections. Our evidence does not support clinical decision-making on the assumption that patients with very small melanoma deposits in SLNs have the same outcome as those who are SLN-negative.
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Affiliation(s)
- Rajmohan Murali
- Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, and Discipline of Pathology, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
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Abstract
A proportion of patients who develop regional and distant recurrences of melanoma after a pathologically negative sentinel lymph node (SN) biopsy are reported to have enhanced signals for melanoma-associated messenger ribonucleic acid (mRNA) when sensitive molecular approaches such as reverse transcriptase polymerase chain reaction (RT-PCR) are used to evaluate their SN tissue. The significance of these findings remains controversial, because the cellular source of the augmented signals cannot be known as the nodal tissue is destroyed during preparation for RT-PCR. Nevertheless, it is claimed that the source of the augmented signal is covert metastatic melanoma cells. To determine whether there are histologically occult metastases in SN and whether there are sources of augmentable melanoma-associated mRNA other than melanoma cells, we applied reverse transcriptase in situ polymerase chain reaction (RT in situ PCR) to formalin-fixed paraffin-embedded nodal tissue. This approach amplifies small amounts of melanoma-associated mRNA and permits identification of cells that express that mRNA. Cells containing MART-1 mRNA were detected in 6 of 21 SNs (29%) and 2 of 16 nonsentinel lymph node (NSNs) (13%) that were tumor negative on hematoxylin and eosin and on immunohistochemical assessment for S-100, MART-1, and HMB-45. In patients with microscopic evidence of melanoma in their SN, MART-1 mRNA-positive cells were identified in 2 of 7 NSNs (29%) that were histologically tumor free. MART-1 mRNA-positive cells were also detected in tumor-negative SN sections from 6 of 7 (86%) nodes that had tumor present in areas of the node not represented in the studied sections. Some cells that expressed MART-1 mRNA that was diffusely distributed in the cytoplasm appeared to be melanoma cells, whereas others resembled macrophages. The latter cells expressed augmented mRNA on granules that were intermixed with melanin granules. In other cases, MART-1 mRNA-positive macrophage-like cells contained nuclei and nucleoli more typical of melanoma cells and may represent the macrophage-melanoma hybrids that have been previously reported. Combination of RT in situ PCR for MART-1 mRNA and immunohistochemistry for CD68 revealed that CD68 was colocalized in some cells that expressed MART-1 mRNA. Some lymph nodes that are tumor negative by histology and immunohistochemistry contain cells that express mRNA for MART-1. Some of these cells may be interpreted as "stealth" melanoma cells in which, despite the presence of MART-1 mRNA, there is an absence of immunohistochemically detectable MART-1 protein. Other cells that contain MART-1 mRNA are clearly not melanoma cells or may represent melanoma hybrids. These findings should be taken into account when interpreting and applying the results of RT-PCR analysis of nodal (and other) tissues.
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Wick MR, Marchevsky AM. Evidence-Based Principles in Pathology: Existing Problem Areas and the Development of “Quality” Practice Patterns. Arch Pathol Lab Med 2011; 135:1398-404. [DOI: 10.5858/arpa.2011-0181-sa] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Contrary to the intuitive impressions of many pathologists, several areas exist in laboratory medicine where evidence-based medicine (EBM) principles are not applied. These include aspects of both anatomic and clinical pathology. Some non-EBM practices are perpetuated by clinical “consumers” of laboratory services because of inadequate education, habit, or overreliance on empirical factors. Other faulty procedures are driven by pathologists themselves.
Objectives.—To consider (1) several selected problem areas representing non-EBM practices in laboratory medicine; such examples include ideas and techniques that concern metastatic malignancies, “targeted” oncologic therapy, general laboratory testing and data utilization, evaluation of selected coagulation defects, administration of blood products, and analysis of hepatic iron-overload syndromes; and (2) EBM principles as methods for remediation of deficiencies in hospital pathology, and implements for the construction of “quality” practices in our specialty.
Data Sources.—Current English literature relating to evidence-based principles in pathology and laboratory medicine, as well as the authors' experience.
Conclusions.—Evidence-based medicine holds the promise of optimizing laboratory services to produce “quality” practices in pathology. It will also be a key to restraining the overall cost of health care.
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Abstract
The presence of S100-positive dendritic cells hinders the identification of isolated melanoma tumor cells and micrometastases in sentinel lymph nodes. Sox-10, a transcription factor that plays an important role in schwannian and melanocytic cell development, is not expressed in dendritic cells. We investigated the diagnostic utility of Sox-10 in the identification of metastases in sentinel and nonsentinel lymph nodes for melanoma. We examined the expression pattern of Sox-10, as compared with S100, Melan-A, and HMB-45 in 93 lymph nodes (40 originally reported as positive and 53 originally reported as negative for metastasis) from 33 sentinel lymph node biopsies and regional lymphadenectomies. Sox-10 and S100 both highlighted metastases in 43 of 43 (100%) positive lymph nodes identified in this study; however, Sox-10 immunohistochemical staining significantly improved the detection of nodal metastases. The nuclear staining of Sox-10 promoted improved distinction between heavily pigmented melanophages and melanocytic metastases in 3 positive lymph nodes. In 2 lymph nodes, Sox-10 was critical in distinguishing S100-positive atypical nodal dendritic cells from tumor cells. Also, Sox-10 significantly improved the identification of micrometastases and isolated tumor cells as compared with S100 in 10 positive lymph nodes. Most importantly, Sox-10 identified micrometastases in 2 lymph nodes, originally reported as negative on S100, Melan-A, and HMB-45 immunostains. Therefore, Sox-10 is a comparable marker to S100 in identifying nodal metastases in melanoma and is especially useful in the setting of lymph nodes with heavily pigmented metastases, numerous S100-positive nodal dendritic cells, micrometastases, and isolated tumor cells.
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Rughani MG, Swan MC, Adams TS, Middleton MR, Ramcharan RN, Pay A, Birch JF, Coleman DJ, Cassell OC. Sentinel lymph node biopsy in melanoma: The Oxford ten year clinical experience. J Plast Reconstr Aesthet Surg 2011; 64:1284-90. [DOI: 10.1016/j.bjps.2011.05.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 03/20/2011] [Accepted: 05/01/2011] [Indexed: 11/29/2022]
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Atypical Spitzoid melanocytic tumors: a morphological, mutational, and FISH analysis. J Am Acad Dermatol 2011; 64:919-35. [PMID: 21496703 DOI: 10.1016/j.jaad.2010.05.043] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 04/26/2010] [Accepted: 05/13/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Identification of the clinical behavior of atypical Spitzoid tumors with conflicting histopathologic features remains controversial. OBJECTIVE We sought to assess whether molecular findings may be helpful in the diagnostic and prognostic assessment of atypical Spitzoid tumors. METHODS A total of 38 controversial, atypical Spitzoid lesions (≥ 1 mm in thickness) were analyzed for clinicopathological features, chromosomal alterations by fluorescence in situ hybridization (FISH) analysis (RREB1/MYB/CCND1/CEP6), BRAF(V600E) mutation by allele-specific real-time polymerase chain reaction confirmed by sequencing, and H-RAS gene mutation by direct sequencing. RESULTS Atypical Spitzoid lesions developed in 21 female and 17 male patients (mean age 22 years). Nine patients underwent sentinel lymph node biopsy and a sentinel lymph node micrometastasis was detected in 4 of these 9 cases. Four additional patients, who did not receive a sentinel lymph node biopsy, experienced bulky lymph node metastases and one experienced visceral metastases and death. Lesions from patients with lymph node involvement showed more deep mitoses (P < .01), less inflammation (P = .05), and more plasma cells (P = .04). FISH analysis demonstrated the presence of chromosomal alterations in 6 of 25 cases. Correlation with follow-up data showed that the only case with fatal outcome showed multiple chromosomal alterations by FISH analysis. BRAF(V600E) mutation was detected in 12 of 16 cases (75%) and H-RAS mutation on exon 3 was found in 3 of 11 cases (27%). LIMITATIONS Our results require validation in a larger series with longer follow-up information. CONCLUSIONS FISH assay may be of help in the prognostic evaluation of atypical Spitzoid tumors. Diagnostic significance of BRAF(V600E) and H-RAS mutations in this setting remains unclear.
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Richtig E, Komericki P, Zalaudek I. Response to the letter, “Underpowered conclusions can be potentially misleading with regards to the number of lymphoscintigraphy identified and surgically excised sentinel nodes in melanoma patients” by Nicholas C. Lee and Andrew J. Spillane. Eur J Surg Oncol 2011. [DOI: 10.1016/j.ejso.2011.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Baldwin BT, Cherpelis BS, Sondak V, Fenske NA. Sentinel lymph node biopsy in melanoma: Facts and controversies. Clin Dermatol 2010; 28:319-23. [PMID: 20541686 DOI: 10.1016/j.clindermatol.2009.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Three decades after its introduction in the 1990s, the sentinel lymph node biopsy for patients with localized cutaneous melanoma is still the subject of great debate in dermatology. Many questions remain unanswered, and studies currently in progress may or may not bring us any closer to determining the truth about sentinel lymph node biopsy and melanoma. We discuss the effect of sentinel lymph node biopsy on overall survival, the clinical and therapeutic implications of sentinel lymph node biopsy, and the melanoma patients who might be candidates for sentinel lymph node biopsy.
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Affiliation(s)
- Brooke T Baldwin
- Department of Dermatology and Cutaneous Surgery, University of South Florida, College of Medicine, 12901 Bruce B. Downs Blvd., Tampa, FL 33612, USA
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NORO S, YAMAZAKI N, NAKANISHI Y, YAMAMOTO A, SASAJIMA Y, KAWANA S. Clinicopathological significance of sentinel node biopsy in Japanese patients with cutaneous malignant melanoma. J Dermatol 2010; 38:76-83. [DOI: 10.1111/j.1346-8138.2010.01002.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Richtig E, Komericki P, Trapp M, Ott A, Bisail B, Egger JW, Zalaudek I. Ratio of marked and excised sentinel lymph nodes and scintigraphic appearance time in melanoma patients with negative sentinel lymph node. Eur J Surg Oncol 2010; 36:783-8. [PMID: 20510570 DOI: 10.1016/j.ejso.2010.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 03/31/2010] [Accepted: 05/04/2010] [Indexed: 10/19/2022] Open
Abstract
AIM Metastases can occur in up to 15% of all melanoma patients with negative sentinel lymph node examination (SN -). We retrospectively investigated the number of preoperatively marked sentinel lymph nodes (SNs) with lymphoscintigraphy and effectively surgically removed SNs in SN--patients with cutaneous melanoma >or=0.5 mm. Ratio of these parameters was calculated and impact of this ratio as well as impact of scintigraphic appearance time (SAT) on disease progression was studied. MATERIALS AND METHODS Data on 122 SN--patients--70 women (58%), mean age 56.5 years--were analyzed. Mean follow-up time was 58 months. RESULTS Mean tumour thickness of all patients was 2.3 mm. In 51 patients (42%) the number of SNs marked in lymphoscintigraphy was higher than excised in surgery, in 47 patients (38%) the same number as marked was excised and in 24 patients (20%) a lower number was marked than excised. Metastases occurred in 17 patients (14%) after a mean time of 24.8 months. Mean tumour thickness (5.4 mm) was significantly higher in these patients than in the other patients (p = 0.000). Ratio of marked and excised SNs had no influence on disease progression; the only parameter influencing outcome was tumour thickness (p = 0.000). Short SAT was significantly associated with higher tumour thickness (p = 0.004). CONCLUSION Our study indicates that, in routine clinical practice, it suffices to harvest the first SN, as the ratio of marked and excised SNs has no impact on disease progression.
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Affiliation(s)
- E Richtig
- Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, 8036 Graz, Austria.
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Wiener M, Acland KM, Shaw HM, Soong SJ, Lin HY, Chen DT, Scolyer RA, Winstanley JB, Thompson JF. Sentinel node positive melanoma patients: prediction and prognostic significance of nonsentinel node metastases and development of a survival tree model. Ann Surg Oncol 2010; 17:1995-2005. [PMID: 20490699 DOI: 10.1245/s10434-010-1049-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Completion lymph node dissection (CLND) following positive sentinel node biopsy (SNB) for melanoma detects additional nonsentinel node (NSN) metastases in approximately 20% of cases. This study aimed to establish whether NSN status can be predicted, to determine its effect on survival, and to develop survival tree models for the sentinel node (SN) positive population. MATERIALS AND METHODS Sydney Melanoma Unit (SMU) patients with at least 1 positive SN, meeting inclusion criteria and treated between October 1992 and June 2005, were identified from the Unit database. Survival characteristics, potential predictors of survival, and NSN status were assessed using the Kaplan-Meier method, Cox regression model, and logistic regression analyses, respectively. Classification tree analysis was performed to identify groups with distinctly different survival characteristics. RESULTS A total of 323 SN-positive melanoma patients met the inclusion criteria. On multivariate analysis, age, gender, primary tumor thickness, mitotic rate, number of positive NSNs, or total number of positive nodes were statistically significant predictors of survival. NSN metastasis, found at CLND in 19% of patients, was only predicted to a statistically significant degree by ulceration. Multivariate analyses demonstrated that survival was more closely related to number of positive NSNs than total number of positive nodes. Classification tree analysis revealed 4 prognostically distinct survival groups. CONCLUSIONS Patients with NSN metastases could not be reliably identified prior to CLND. Prognosis following CLND was more closely related to number of positive NSNs than total number of positive nodes. Classification tree analysis defined distinctly different survival groups more accurately than use of single-factor analysis.
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Affiliation(s)
- Martin Wiener
- Melanoma Institute Australia (formerly Sydney Melanoma Unit), Sydney, NSW, Australia
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Murali R, Thompson JF, Scolyer RA. Location of melanoma metastases in sentinel lymph nodes: what are the implications for histologic processing of sentinel lymph nodes in routine practice? Am J Surg Pathol 2010; 34:127-9; author reply 129-31. [PMID: 20035152 DOI: 10.1097/pas.0b013e3181c70ee8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hur SM, Kim SH, Lee SK, Kim WW, Choi JH, Kim S, Lim SY, Pyon JK, Mun GH, Choe JH, Lee JE, Kim JS, Nam SJ, Yang JH, Kim JH. Clinical Usefulness of Sentinel Lymph Node Biopsy in the Surgical Treatment of Malignant Melanoma. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2010. [DOI: 10.4174/jkss.2010.79.3.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sung Mo Hur
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Hoon Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se Kyung Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wan Wook Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hyuck Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sangmin Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So Young Lim
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jai Kyung Pyon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Goo Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun-Ho Choe
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Eon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jee Soo Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok-Jin Nam
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Hyun Yang
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Han Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Blue nevi and related lesions: a review highlighting atypical and newly described variants, distinguishing features and diagnostic pitfalls. Adv Anat Pathol 2009; 16:365-82. [PMID: 19851128 DOI: 10.1097/pap.0b013e3181bb6b53] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Blue nevi and related entities are a heterogenous group of congenital and acquired melanocytic tumors that includes established entities such as dendritic ("common") blue nevus and cellular blue nevus, and their numerous clinical and pathologic variants, such as deep penetrating nevus. They share several clinical and morphologic features including their blue tinctorial properties, the presence of a dermal proliferation of spindle, fusiform or ovoid cells, associated melanin pigment (both within the melanocytic tumor cells and also within macrophages) and stromal sclerosis and, at least focal positivity for HMB-45 (Gp100). Some variants, such as deep penetrating nevus, often show considerable variation in nuclear size and shape, and, as a consequence, are at risk of being misdiagnosed as melanoma by those unfamiliar with their characteristic morphologic features. The so-called malignant blue nevus is a controversial term denoting melanomas arising in association with or exhibiting some morphologic similarities to blue nevus. There are also lesions that are probably related to blue nevi, such as the recently described pigmented epithelioid melanocytoma and the neurocristic hamartomas, whose nature, biologic behavior, and relationship to the better established entities remains to be clearly established. This review aims to present a brief overview of these lesions, highlighting their pathologic characteristics, distinguishing features and potential diagnostic pitfalls, with particular emphasis on recently described entities, molecular findings, controversial areas, and approaches to diagnosis.
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Page AJ, Carlson GW. Impact of the false-negative sentinel lymph node biopsy in melanoma. Adv Surg 2009; 43:251-7. [PMID: 19845183 DOI: 10.1016/j.yasu.2009.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Andrew J Page
- Department of Surgical Oncology, Emery University School of Medicine, Atlanta, GA, USA
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Atypical spitzoid melanocytic tumors with positive sentinel lymph nodes in children and teenagers, and comparison with histologically unambiguous and lethal melanomas. Am J Surg Pathol 2009; 33:1386-95. [PMID: 19609204 DOI: 10.1097/pas.0b013e3181ac1927] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Children and teenagers with a positive sentinel lymph node (SLN) after a prior diagnosis of an atypical spitzoid melanocytic tumor (ASMT) are usually cared for clinically in the same way as patients with melanoma. Little is known about long-term follow-up of these individuals to determine whether this practice is appropriate. To learn more about the biology of these tumors we retrospectively reviewed the clinical and pathologic findings of children and teenagers (<18 y of age at the time of diagnosis) with an ASMT, positive SLN and follow-up of at least 3 years. Their findings were compared with histologically unambiguous melanomas of children or teenagers, who had a positive SLN or died of metastatic melanoma. Eleven individuals, 6 girls and 5 boys, with primary ASMT and positive SLN were identified. The primary tumors ranged in thickness from 2.1 to 12 mm (median, 4.6 mm; mean, 5 mm). The tumor mitotic rate ranged from 1 to 10 mitoses/mm (median, 3/mm, median, 3/mm). The positive SLNs included 6 nodes with intranodal melanocytic aggregates measuring <1 mm in greatest dimension, and 5 nodes, in which the size of the melanocyte deposits was >/=1 mm. All the patients with ASMT and positive SLN remained free of disease with a median follow-up of 47 months (mean, 61 mo, range: 36 to 132 mo). In contrast, 2 of 5 patients <18 years of age with a histologically unambiguous melanoma and a positive SLN died of metastatic melanoma. The overall disease-specific mortality rate for all patients <18 years of age diagnosed with melanoma was 12%. Our findings confirm that children and teenagers with ASMTs and positive SLNs have a less aggressive clinical course than those with histologically unambiguous melanoma.
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Howman-Giles R, Shaw HM, Scolyer RA, Murali R, Wilmott J, McCarthy SW, Uren RF, Thompson JF. Sentinel lymph node biopsy in pediatric and adolescent cutaneous melanoma patients. Ann Surg Oncol 2009; 17:138-43. [PMID: 19672660 DOI: 10.1245/s10434-009-0657-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 07/14/2009] [Accepted: 07/14/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND The rarity of melanoma in young patients, particularly pediatric ones, has to date precluded any valid comparisons being made between young patients and adults undergoing sentinel lymph node biopsy (SLNB) for intermediate thickness localized melanoma. The present study takes advantage of the large Sydney Melanoma Unit (SMU) database to clarify this issue. MATERIALS AND METHODS Clinical and pathologic data on pediatric and adolescent AJCC Stage I and II cutaneous melanoma patients aged <20 years undergoing SLNB at the SMU between January 1993 and February 2008 were reviewed. SLNB positivity rates and outcomes in these patients were compared with adult SMU patients. RESULTS In 55 young patients, overall median tumor thickness was 1.7 mm (range, 0.6-5.2 mm) and overall SLNB positivity rate was 14 of 55 (25%), tumors tending to be thicker (median, 2.6 mm), and SLNB positivity rate higher (2 of 6; 33%) in patients aged <10 years. Of the 14 patients, 13 underwent immediate completion lymph node dissection (CLND); 2 patients had non-SLN metastases (15.4%). Only 0.7% of a total of 295 lymph nodes removed at CLND were involved with melanoma. In 14 SLNB-positive patients with follow-up data, 3 (21%) have died from melanoma after a median follow-up of 60 months, compared with 42% of 356 SLNB positive adults. CONCLUSIONS Although the SLNB positivity rate was higher in pediatric and adolescent melanoma patients than in adults (25% vs. 17%, respectively), non-SLN positivity and melanoma-specific death rates were low.
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Affiliation(s)
- Robert Howman-Giles
- Sydney Melanoma Unit and Melanoma Institute Australia, Royal Prince Alfred and Mater Hospitals, Sydney, NSW, Australia.
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Abstract
Mutational activation of the BRAF oncogene is the most common genetic alteration in cutaneous melanoma. Potentially, BRAF mutation analysis of sentinel lymph node (SLN) biopsies could enhance the detection of micrometastases and improve the accuracy of nodal staging for patients with melanoma. Nodal nevi are small aggregates of benign nevus cells that are commonly encountered in the SLNs of patients with melanoma. The status of the BRAF gene in nodal nevi is not known, but this unresolved issue is of critical importance to any future detection strategies that use genetic alterations as biomarkers of metastatic spread. Twenty-six nodal nevi from 26 patients were evaluated for the thymine (T)-->adenine (A) missense mutation at nucleotide 1796 of the BRAF gene using the LigAmp assay, which can detect 1 mutant allele among 10,000 wild-type alleles. For each case, a matching volume of adjacent lymphoid tissue was used as a negative control. BRAF mutations were detected in 13 of the 26 nodal nevi, but in just 1 of the 26 adjacent controls (50% vs. 4%, P<0.0005, Fisher exact). Novel strategies that rely on detection of putative melanoma-specific markers for the diagnosis of micrometastatic melanoma in SLNs need to take into account the molecular genetic profile of the benign nodal nevus. Indeed, these nodal nevi, like melanoma, frequently harbor activating mutations of the BRAF oncogene underscoring the potentially confounding impact of these inclusions on melanoma detection.
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False-negative sentinel node biopsy because of obstruction of lymphatics by metastatic melanoma: the value of ultrasound in conjunction with preoperative lymphoscintigraphy. Melanoma Res 2009; 19:94-9. [DOI: 10.1097/cmr.0b013e32832166b7] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE Sentinel lymph node (SLN) biopsy has shown great utility in the management of melanoma. An analysis of regional recurrence in previously mapped negative SLN basins as the first site of relapse is performed. METHODS A retrospective query of a prospective melanoma database from 1994 to 2006 identified 1287 patients who underwent successful SLN biopsy. One thousand sixty patients (82.4%) were SLN negative and 227 (17.6%) patients SLN positive. Clinical variables were examined for the impact on regional recurrence by multivariate analysis. RESULTS Mean follow-up was 44.3 months (range 3-155 months). Thirty-five patients (3.3%) presented with false-negative (FN) SLN biopsy. Pathologic review of the SLNs harvested from these basins found 7 (20.0%) samples positive for metastatic melanoma. Multivariate analysis found head and neck site [hazard ratio 3.67; 95% confidence interval (CI), 1.77-7.60, P < 0.001] and tumor thickness (hazard ratio 1.16; 95% CI, 1.04-1.30, P = 0.01) to be predictive of FN SLN biopsy. The 5-year melanoma specific survival calculated from the date of the SLN biopsy was 57.6% (95%CI, 35.7-41.9) in the FN group, which was not statistically different than the SLN positive group 60.0% (95% CI, 29.6-40.1; P = 0.14). CONCLUSIONS Head and neck tumor site and tumor thickness are predictors of a FN SLN biopsy. Mechanisms other than pathologic SLN sampling error may contribute to the failure of the SLN biopsy in some patients. Patients with regional recurrence after negative SLN biopsy have a similar 5-year survival compared with patients with positive SLNs.
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Scolyer RA, Murali R, McCarthy SW, Thompson JF. Pathologic examination of sentinel lymph nodes from melanoma patients. Semin Diagn Pathol 2008; 25:100-11. [PMID: 18697713 DOI: 10.1053/j.semdp.2008.04.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In melanoma patients, the sentinel node biopsy (SNB) procedure is a highly accurate staging method, and the tumor-harboring status of the sentinel node (SN) is the most important prognostic factor for patients with early stage disease. For the SN to provide accurate prognostic information, however, it is essential that all "true" SNs are removed and examined diligently. Pathologists should examine multiple hematoxylin-eosin and immunohistochemically stained sections from each SN, but it is unclear from the currently available evidence what is the most appropriate sectioning and staining protocol. Relevant factors to consider include the accuracy of the procedure, the time, labor, and costs involved, and clinical follow-up data which are likely to vary between institutions; hence, individual protocols should be developed locally by pathologists in consultation with their surgical colleagues. At the Sydney Melanoma Unit, four sequential sections of both halves of each SN are examined. The first and fourth sections are stained with hematoxylin-eosin, the second section is stained for S-100 protein, and the third section is stained for HMB-45. Pathologists should not only identify the presence of melanoma metastases within the SN, but also record the size of the largest metastatic focus, tumor penetrative depth (measured from the inner margin of the node capsule to the deepest tumor cell within the SN), and the percentage nodal cross-sectional area involved (as measured on the slides). Potential diagnostic pitfalls in SN evaluation include the misinterpretation of nevus cells, macrophages, or antigen-presenting interdigitating dendritic cells as melanoma. Careful assessment of the morphologic characteristics of the cells and their immunohistochemical profile should prevent misdiagnosis. Routine frozen section examination of SNs from melanoma patients is not recommended. The utility of ultrasound to detect SN metastases (confirmed by fine needle biopsy) is currently being investigated. Whereas potentially this may avoid the need for formal sentinel lymphadenectomy and histopathologic evaluation in some patients, the lack of sensitivity of currently available ultrasound technologies to detect the small micrometastases (<2 mm in diameter), that are typically present in most melanoma patients with a positive SN, limits its current role. In the future, other techniques, such as the use of carbon particles or antimony analysis, may better localize the site of metastases within SNs and permit more focused and efficient pathologic examination of SNs. At present, the role of nonhistopathologic methods of SN evaluation, such as reverse transcription polymerase chain reaction (RT-PCR) and magnetic resonance spectroscopy, remains unclear, and these techniques require further evaluation.
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Affiliation(s)
- Richard A Scolyer
- Department of Anatomical Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
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