Surgical management of regional lymph nodes in patients with melanoma. Experience with 4682 patients

Management of Clitoral Melanoma Presenting as an Exophytic Clitoral Mass: A Case Report and Review of the Literature

Primary mucosal melanomas of the female genital tract account for one percent or less of all cases of melanoma with even fewer originating in the clitoris. Given the rarity of diagnosis of clitoral melanoma, there is a paucity of data guiding management. There is no supporting evidence that radical vulvectomy (with or without inguinal lymphadenopathy) is associated with improved disease-free or overall survival compared to partial vulvectomy or wide local excision. Additionally, there is no data to evaluate the role of sentinel lymph node biopsy or extensive lymphadenectomy in clitoral melanoma, however previous evidence demonstrates the utility of regional lymph node sampling in predicting survival in women with female genital tract mucosal melanoma. Adjuvant therapy considerations are often extrapolated from their use in treating cutaneous melanomas, including immune checkpoint inhibitors and other immunotherapy agents. Adjuvant radiation therapy has limited utility except in cases of bulky, unresectable disease, or when inguinal lymph nodes are positive for metastasis. The 52 year-old patient presented in this review was diagnosed with locally invasive advanced stage clitoral melanoma presenting as an exophytic clitoral mass. She underwent diagnostic primary tumor resection, which demonstrated ulcerative melanoma with spindle cell features extending to a Breslow depth of at least 28 mm. She subsequently underwent secondary wide local excision with groin sentinel lymph node biopsy, and adjuvant treatment with pembrolizumab. This article also emphasizes the importance of a multidisciplinary team involving gynecologic oncology, medical oncology, radiology, and pathology for management of this rare type of primary mucosal melanoma of the female genital tract.

The utility of ICG fluorescence for sentinel lymph node identification in head and neck melanoma

PURPOSE

Perform an evidence-based review to determine the utility of indocyanine green fluorescence (ICG) to detect sentinel lymph nodes (SLN) in patients with head and neck melanoma compared to blue dye or radiocolloid injection (RI).

MATERIALS AND METHODS

A systematic review of the literature was performed to identify patients with head and neck melanoma managed with ICG fluorescence. PubMed, Embase, and Cochrane Library databases were searched. Included studies were assessed for level of evidence. Patient demographics and data on SLN identification were determined.

RESULTS

Twenty-two studies encompassing 399 patients (75% male, 25% female, average age 57.1 years) met inclusion criteria. Publications comprised of two case reports, four retrospective case series, twelve cohort studies, and four clinical trials. Most common site of melanoma was scalp/temple/forehead (35%), cheek/midface (22%), and ear (17%) with an average Breslow thickness of 3.32 mm. SLN was identified in 80.7% (n = 201/249) of patients using ICG-RI, 85.2% (n = 75/88) using RI alone, and 63.4% (n = 52/82) using blue dye-RI.

CONCLUSIONS

ICG-^99mTc-nanocolloid hybrid tracer may be a superior alternative to blue dye + adiocolloid and has theoretical advantages compared to RI alone. Additional prospective randomized controlled trials are needed to further compare these methods and obtain data on false negative rates, operating room time, and cost effectiveness to fully elucidate the utility of ICG-^99mTc-nanocolloid over current methods used for SLN identification in this patient population.

Primary malignant melanomas of the female lower genital tract: clinicopathological characteristics and management

The female lower genital tract melanomas mainly include vulvar, vaginal and cervical melanoma. There is little clinical data on the melanomas thus making them highly lethal with their prognosis being worse than for cutaneous melanoma and other gynecological malignancies. Surgery is still the primary treatment for gynecological melanomas with wide local resection (WLE) of tumors with adequate margins being preferred for early-stage vulvar melanoma while complete resection of the primary tumor is the standard treatment for early-stage cervical and vaginal melanoma. Sentinel lymph node biopsy seems to avoid unnecessary complete regional lymphadenectomy. However, it should be chosen cautiously. Recently discovered molecular changes have provided new hopes for effective systemic treatment of female genital tract melanomas. In this review, we summarize the pathogenesis and clinicopathological characteristics of these rare melanomas with particular emphasis on new therapies and clinical management methods that may affect prognosis. The review aims to provide a viable direction for clinicians to diagnose and treat female lower genital tract melanomas.

A Randomized Trial Comparing the Efficacy of Methylene Blue Dye Alone Versus Combination of Methylene Blue Dye and Radioactive Sulfur Colloid in Sentinel Lymph Node Biopsy for Early Stage Breast Cancer Patients

Although sentinel lymph node biopsy (SLNB) has become a standard of care for management of axilla in breast cancer patients, the technique of SLNB is still not well defined. Unlike radioactive sulfur colloid which requires nuclear medicine facilities, methylene blue dye is readily available. The purpose of this study is to validate the use of methylene blue dye alone for SLNB in early breast cancer patients. 60 patients of early breast cancer were randomized to receive either methylene blue alone (Group A-30 patients) or a combination of both methylene blue and radioactive colloid (Group B-30 patients) for detection of sentinel lymph nodes. Sentinel lymph node biopsy was done followed by complete axillary dissection in all patients. In both Groups A and B, sentinel node was identified in all 30 patients, giving identification rate of 100%. In group A, sentinel node was the only positive node in 1 patient, with a false-positive rate of 14.2%. The negative predictive value was 91.3%. The sensitivity of the procedure in predicting further axillary disease was 75% with a specificity of 95.45%. The overall accuracy was 90%. In group B, sentinel node was the only positive node in 2 cases, giving a false-positive rate of 28.7%. The negative predictive value was 95.65%. The sensitivity of the procedure in predicting further axillary disease was 83.33% with a specificity of 91.67%. The overall accuracy was 90%. Although the false-negative rate was slightly higher with methylene blue alone than that using combination (8.6%-4.3%), it was statistically insignificant. Similarly the sensitivity (75%-83.33%), specificity (95.45-91.67%), and negative predictive value (91.3%-95.67%) were also comparable between groups A and B, respectively. Negative predictive value and false-negative rates are comparable, whether blue dye is used alone or a combination of blue dye and radioactive colloid is used. Sentinel lymph node biopsy with blue dye alone is reliable and can be put to clinical practice more widely, even if nuclear medicine facilities are not available in resource constrained centers, so as to reduce long-term morbidity of axillary dissection, with similar oncological outcomes.

Mapping the Sentinel Lymph Node in Malignant Melanoma by Blue Dye, Lymphoscintigraphy and Intraoperative Gamma Probe

Eighty-eight consecutive patients (48 men and 40 women; mean age, 58.9 years; range, 16–84 years) with clinically localized cutaneous melanoma involving the trunk, extremities or head and neck underwent lymphatic mapping at our institution. The primary melanoma had a mean thickness of 2.74 mm (range, 0.95 to 9 mm). Patients were divided into two groups: group A (39 patients) underwent only vital blue dye (VBD) mapping, while group B (49 patients) underwent lymphatic mapping with VBD and radio-guided surgery (RGS) combined. In all patients 1-1.5 mL of VBD was injected subdermally around the biopsy scar 10–20 min before surgery. In group B 37 MBq in 150 μL of 99mTc-HSA nanocolloid was additionally injected intradermally 18 h before surgery (3–6 aliquots injected perilesionally). In all lymphatic basins where drainage was noted the sentinel lymph nodes (SNs) were identified and marked with a cutaneous marker. Final identification of the SN was then performed externally by a hand-held gamma probe. After the induction of anesthesia 0.5–1-0 mL of patent blue V dye was injected intradermally with a 25-gauge needle around the site of the primary melanoma. SNs were examined by routine hematoxylin and eosin (H&E) staining and immunohistochemistry. Patients with histologically positive SN(s) underwent standard lymph node dissection (SLND) in the involved lymph node basin.

The SN was identified in 37/39 patients (94.9%) of group A and in 48/49 patients (98.0%) of group B. Blue dye mapping failed to identify the SN in 5 of the 88 patients (5.8%), while the radioisotope method failed in only 1 of 49 patients (2.0%). Similar results were obtained with the combined use of the two probes. The average number of SNs harvested was 1.9 per basin sampled, which does not differ significantly from the numbers reported by other authors114. The SN was histologically positive in 18 patients (20.5%). None of the 12 patients with a Breslow thickness less than 1.5 mm had positive SNs, whereas 18 of the 77 patients (23.4%) with a Breslow index exceeding 1.5 mm showed metastatic SNs with H&E or immunohistochemistry. The latter all underwent SLND of the affected basin. In 10 patients (55.6%) the SN was the only site of tumor invasion; eight patients (44.4%) with positive SNs had one or more metastatic lymph nodes in the draining basin.

Metastases of malignant neoplasms: Historical, biological, & clinical considerations

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.

Sentinel Lymph Node Status is a Main Prognostic Parameter Needful for the Correct Staging of Patients with Melanoma Thicker than 4 mm: Single-Institution Experience and Literature Meta-Analysis

PURPOSE OF THE STUDY

The usefulness of sentinel lymph node biopsy in thick melanomas is debated. The aim of this study was to evaluate the possible prognostic significance of sentinel lymph node biopsy in T4 melanoma patients and to verify whether this was a homogeneous group of patients with similar poor behavior.

MATERIALS AND METHODS

A retrospective observational study was performed. Data were extracted from the Tuscan Regional Referral Center database. The outcome of sentinel lymph node-negative and sentinel lymph node-positive T4 melanomas were compared. A systematic review of published series on this issue and a meta-analysis were performed.

RESULTS

Among 125 T4 melanoma patients, 53 patients (42.4%) were sentinel lymph node-positive and 72 (57.6%) patients were sentinel lymph node-negative. The 5-year and the 10-year melanoma specific survival were 81.9% and 72.3% for sentinel lymph node-negative patients and 42.4% and 17.9% (P < 0.001) for sentinel lymph node-positive patients. A positive sentinel lymph node showed an HR of 3.08. The meta-analysis confirmed that there was a significantly greater risk of death for patients with thick melanoma and positive sentinel lymph node (RR 1.75).

CONCLUSIONS

The results of the study point out that the sentinel lymph node biopsy is required for the correct staging of patients with melanoma thicker than 4 mm and that the status of sentinel lymph node is a significant predictor of melanoma specific survival. This knowledge allows early surgical and adjuvant treatment as well as appropriate trial enrollment and tailored follow-up.

Clinical parameters associated with anti-programmed death-1 (PD-1) inhibitors-induced tumor response in melanoma patients

Background The identification of the melanoma patients sensitive to anti-PD-1 inhibitors, nivolumab or pembrolizumab, is a major therapeutic challenge and an urgent need. We hypothesized that the natural history of the disease might partly reflect the immune state of the patients. Methods We analyzed our cohort of melanoma patients treated with anti-PD-1 from August 2014 to January 2016 in our institution. Objective response was defined as a complete or partial response according to v1.1 RECIST criteria. Results Among 63 metastatic melanoma patients, the overall response rate was 43%. Median time from diagnosis to anti-PD-1 initiation was longer among responders than non-responders (64 months vs. 35 months, p = 0.02). The response rate was 10% in patients starting anti-PD-1 within 1 year, 35% after 1 to 5 years and 63% after 5 years. Performance status (PS) 0 was also associated with enhanced tumor response: 70% of responders were PS 0 vs. 36% of non-responders (p = 0.04). PS 0, normal LDH levels and wild-type BRAF status were significant predictors of progression free survival. Conclusion A long time lapse from diagnosis to anti-PD-1 initiation and PS 0 are associated with higher sensitivity to anti-PD-1 in melanoma patients. These two clinical features might reflect a potentially intact immune system of the host.

Surgical Management of Melanoma

The surgical management of melanoma has undergone considerable changes over the past several decades, as new strategies and treatments have become available. Surgeons play a pivotal role in all aspects of melanoma care: diagnostic, curative, and palliative. There is a high potential for cure in patients with early-stage melanoma and the selection of an appropriate operation is very important for this reason. Staging the nodal basin has become widespread since the adoption of sentinel lymph node biopsy (SLNB) for the management of melanoma. This operation provides the best prognostic information that is currently available for patients with melanoma. The surgeon plays a central role in the palliation of symptoms resulting from nodal disease and metastases, as melanoma has a propensity to spread to almost any site in the body.

Intraoperative mapping of sentinel lymph node metastases using a clinically translated ultrasmall silica nanoparticle

The management of regional lymph nodes in patients with melanoma has undergone a significant paradigm shift over the past several decades, transitioning from the use of more aggressive surgical approaches, such as lymph node basin dissection, to the application of minimally invasive sentinel lymph node (SLN) biopsy methods to detect the presence of nodal micrometastases. SLN biopsy has enabled reliable, highly accurate, and low-morbidity staging of regional lymph nodes in early stage melanoma as a means of guiding treatment decisions and improving patient outcomes. The accurate identification and staging of lymph nodes is an important prognostic factor, identifying those patients for whom the expected benefits of nodal resection outweigh attendant surgical risks. However, currently used standard-of-care technologies for SLN detection are associated with significant limitations. This has fueled the development of clinically promising platforms that can serve as intraoperative visualization tools to aid accurate and specific determination of tumor-bearing lymph nodes, map cancer-promoting biological properties at the cellular/molecular levels, and delineate nodes from adjacent critical structures. Among a number of promising cancer-imaging probes that might facilitate achievement of these ends is a first-in-kind ultrasmall tumor-targeting inorganic (silica) nanoparticle, designed to overcome translational challenges. The rationale driving these considerations and the application of this platform as an intraoperative treatment tool for guiding resection of cancerous lymph nodes is discussed and presented within the context of alternative imaging technologies. WIREs Nanomed Nanobiotechnol 2016, 8:535-553. doi: 10.1002/wnan.1380 For further resources related to this article, please visit the WIREs website.

Efficacy of superficial and deep regional hyperthermia combined with systemic chemotherapy and radiotherapy in metastatic melanoma

BACKGROUND AND OBJECTIVE

Response rates of cutaneous-subcutaneous or lymph node metastases of melanoma to systemic chemotherapy are rather low. We report our clinical experience with superficial and deep regional hyperthermia in combination with radiotherapy and/or chemotherapy with carboplatin.

PATIENTS/METHODS

We treated 15 patients with metastatic melanoma (6 men, 9 women; age 39-84 years, mean age 60 years) by using superficial or deep regional hyperthermia produced by electromagnetic energy. Superficial hyperthermia was delivered to skin or lymph node metastases in combination with radiochemotherapy in 12 patients, while deep regional hyperthermia was administered with an annular array applicator to lymph node metastases either in combination with radiochemotherapy (1 patient) or with carboplatin alone (2 patients). The clinical response was assessed by clinical evaluation and/or computer tomography and/or ultrasonography at monthly intervals.

RESULTS

Both superficial and deep regional hyperthermia was well tolerated. We observed 5 complete local remissions (34%), 6 partial local remissions (40%) and 2 patients with stable disease (13%). The best results were obtained in cutaneous or retroperitoneal metastases.

CONCLUSIONS

Local response can be achieved in inoperable metastatic melanoma using superficial or deep regional hyperthermia in combination with radiochemotherapy or chemotherapy.

Sentinel node biopsy for melanoma: an update after two decades of experience

When detected and treated early, melanoma has an excellent prognosis. Unfortunately, as the tumor invades deeper into tissue the risk of metastatic spread to regional lymph nodes and beyond increases and the prognosis worsens significantly. Therefore, accurately detecting any regional lymphatic metastasis would significantly aid in determining a patient's prognosis and help guide his or her treatment plan. In 1991, Don Morton and colleagues presented new paradigm in diagnosing regional lymphatic involvement of tumors termed sentinel lymph node biopsy (SLNB). By mapping the regional lymph system around a tumor and tracing the lymphatic flow, a determination of the most likely lymph node or nodes the cancer will spread to first is made. Then, a limited biopsy of the most likely nodes is performed rather than a more-invasive removal of the entire local lymphatic chain. In 20 years that have followed, a great deal of information has been gained as to its accuracy, prognostic value, appropriate candidates, and its impact on regional disease control and survival. The SLNB has been shown to accurately stage regional lymph node basins in stage I and II melanoma patients with minimal morbidity. More sensitive histologic techniques are now being applied that may allow even greater accuracy in the staging of melanoma patients. Although specific percent risk thresholds are still in question, recommendation for SLNB when melanomas are 1 mm or thicker has gained wide acceptance. SLNB may also be appropriate for patients with melanomas that are between 0.76 and 1 mm thick and have ulceration, high mitotic rates, or reach a Clark level IV. Therefore, melanomas with IB or greater staging should be considered for SLNB.

Regional control and morbidity after superficial groin dissection in melanoma

BACKGROUND

There is no consensus about the optimal extent of surgery for patients with melanoma metastases to inguinal nodes, and this is further complicated by variations in terminology for these dissections. In patients without clinical evidence of iliac metastases, we routinely perform a superficial groin dissection (SGD), which clears node-bearing tissue superficial to the fascia lata. We hypothesized that SGD provides regional tumor control comparable to published experience with deep groin dissection (DGD) and iliac and obturator dissection (IOD), but with less morbidity.

MATERIALS AND METHODS

A retrospective review of a prospectively collected database evaluated patients undergoing SGD April 1994 through May 2008. Patients with clinical evidence of iliac metastases were excluded. Clinical and pathologic data regarding recurrence and survival were evaluated.

RESULTS

We identified 53 primary SGD: 27 for clinically palpable disease, and 25 for microscopic disease. Number and percentage of positive nodes were similar between groups. Median follow-up was 39 months, and 2 patients had primary recurrence in the groin (1 in each group). Two additional patients had concurrent groin and systemic recurrence. Ipsilateral groin recurrence rate prior to systemic disease was similar at 4% and 3.7% for microscopic and palpable disease, respectively. Similarly, survival was comparable between groups (82% and 73%). Toxicities were comparable to previously published data.

CONCLUSION

SGD provides regional control rates similar to DGD and IOD, for lymph node metastases clinically limited to the groin, whether occult or clinically evident.

Importance of tumor load in the sentinel node in melanoma: clinical dilemmas

There are two hypotheses to explain melanoma dissemination: first, simultaneous lymphatic and hematogeneous spread, with regional lymph nodes as indicators of metastatic disease; and second, orderly progression, with regional lymph nodes as governors of metastatic disease. The sentinel node (SN) has been defined as the first draining lymph node from a tumor and is harvested with the use of the triple technique and is processed by an extensive pathology protocol. The SN status is a strong prognostic factor for survival (83-94% for SN negative, 56-75% SN-positive patients). False-negative rates are considerable (9-21%). Preliminary results of the MSLT-1 trial did not demonstrate a survival benefit for the SN procedure, although a subgroup analysis indicates a possible benefit. A mathematical model has demonstrated 24% prognostic false positivity. SN tumor burden represents a heterogeneous patient population and is classified most frequently with the Starz, Dewar or Rotterdam Criteria. A completion lymph-node dissection might not be indicated in all SN-positive patients. Patients classified with metastases <0.1 mm by the Rotterdam Criteria have excellent survival rates. Ultrasound-guided fine-needle aspiration cytology is emerging as a staging tool for high-risk patients, but more research is necessary before this can change clinical practice.

Melanoma without a detectable primary site with metastases to lymph nodes

OBJECTIVE

To compare outcomes of patients with clinical nodal melanoma metastases that occurred without a detectable primary tumor (melanoma of unknown primary site; MUP) with those with a known primary site (KPM).

METHODS

We included data from 459 consecutive patients treated from 1994 to 2007 with radical therapeutic lymph node dissection (LND; stage IIIB, C) due to clinically palpable and pathologically confirmed lymph node metastases (229 axillary; 230 ilioinguinal). The median follow-up was 49 months.

RESULTS

LND was performed in 59 cases (12.9%; 29 men, 30 women) due to MUP nodal metastases, including 33 axillary (14.4%) and 26 ilioinguinal (11.3%). In the MUP group, the 3- and 5-year survival rates were 48% and 41%, respectively. Similar rates were observed in patients with KPM, even with matched-pair analyses. Established prognostic factors (number of metastatic nodes, p=.005; extracapsular extension of metastases, p=.002) influenced survival in the MUP group. Relapses occurred in 31 (53%) and 299 (74.7%) cases in the MUP and KPM groups, respectively.

CONCLUSIONS

Survival rates in the MUP and KPM groups were similar, and the same prognostic factors affected both. Thus, all MUP cases should be treated as standard stage III melanomas.

A triangular intermuscular space sentinel node in melanoma: association with axillary lymphatic drainage

BACKGROUND

Large centers have described triangular intermuscular space (TIS) sentinel nodes (SNs) for some melanomas of the back. However, their management remains controversial and poorly characterized, especially as related to the ipsilateral axillary node basin. The aim of this study was to summarize our experience with TIS SN, which may contribute to defining their appropriate surgical management.

METHODS

We performed a retrospective review on surgical patients from January 1993 to April 2009. Among 293 patients with upper back melanoma, data were collected on those with TIS SN.

RESULTS

Fourteen patients (5%) with melanoma of the upper back had a TIS SN, 6 of whom (43%) were incorrectly identified at lymphoscintigraphy as axillary, and 11 of whom (79%) had a concurrent axillary SN. Micrometastatic disease was identified in TIS SN in two patients (14%) and in an axillary SN in one (9%). We found direct lymphatic drainage independently to the TIS and to the axilla, as well as a more typical pattern of drainage first to the TIS node and then to axillary nodes.

CONCLUSIONS

We defined three patterns of lymphatic drainage to TIS and axillary nodes. The TIS and axilla are anatomically linked; patients with SN in both locations should undergo biopsies of both for optimal nodal staging. We recommend directed evaluation for TIS SN in patients with upper back melanomas and recommend clearing the TIS at the time of TIS SN biopsy. Melanoma can metastasize to TIS SN, and we discuss considerations for management of the axilla in patients with positive TIS nodes.

Modification of lymphoscintigraphic sentinel node identification before and after excisional biopsy of primary cutaneous melanoma

The aim of this study was to determine whether excision biopsy and primary closure of primary cutaneous melanoma modifies lymphatic drainage and accuracy of sentinel node biopsy. Thirty patients with 31 cutaneous melanomas were prospectively enrolled to undergo lymphoscintigraphy (LS) before and after excision biopsy. Tc-human serum albumin nanocolloid was first injected intradermally around the primary tumor and subsequently, after excision biopsy, adjacent to the scar. Sentinel nodes were identified by preoperative LS and the gamma-probe. Patent Blue V dye was injected intraoperatively before sentinel node biopsy. Intraoperative sentinel node identification was 100%. In 23 of 31 cases, both LSs were concordant in terms of nodal basins visualized. Two patients had a basin downstaged and six patients had a basin upstaged by the second LS. Only 50% of LS hot nodes stained blue (42 of 84). In 24 of 31 cases, the sentinel node was negative for metastases. Seven patients underwent complete lymph node dissection because of sentinel node positivity. Only one patient had metastases also to a non-sentinel node. After a median follow-up of 30 months lymph node metastases have not been observed in the eight discordant cases. This study shows that sentinel node identification and biopsy after lymphatic mapping is accurate after excision biopsy of primary cutaneous melanoma. Excision biopsy may, however, modify lymphatic drainage and a narrow excision margin should be performed if melanoma is suspected.

Factors influencing time between biopsy and definitive surgery for malignant melanoma: do they impact clinical outcome?

BACKGROUND

Whether time between biopsy and surgery for malignant melanoma affects clinical outcomes is sparsely defined. This study evaluated factors influencing surgical interval and surgical interval effect on outcomes.

METHODS

We performed a review of a prospective 10-year, single-institution database.

RESULTS

There were 473 patients treated for 478 malignant melanomas. The mean surgical interval was 30.5 days. The mean thickness was 2.1 mm; 46% of patients had a surgical interval of more than 28 days whereas 8% had a surgical interval of more than 56 days. Residual melanoma was found at excision in 170 (36%) patients. Age, sex, and referral source significantly affected surgical interval, however, lesion thickness, sentinel lymph node status, ulceration, and residual melanoma at excision did not. In univariate Cox models, neither a surgical interval of 28 or less nor less than 56 days showed better overall survival (OS) or disease-free survival (DFS). In multivariate Cox models of OS and DFS including lesion thickness, sentinel lymph node status, ulceration, and residual melanoma at excision, neither a surgical interval of 28 days or fewer nor a surgical interval of 56 days or fewer significantly affected outcomes.

CONCLUSIONS

Age, sex, referral source, and lesion thickness were associated with surgical interval. Immediate surgery for malignant melanoma does not significantly impact OS or DFS.

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

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

Melanoma of the Ear

BACKGROUND

In 2005, it is now estimated that one in 62 Americans have a lifetime risk of developing invasive melanoma. Melanoma of the ear accounts for 1% of all cases of melanoma and 14.5% of all head and neck melanomas. With this increase in incidence, plastic surgeons will likely have to treat and manage more of these patients in the future.

METHODS

A retrospective chart review was performed on 199 patients diagnosed with primary melanoma of the ear. Specimens were reviewed by same center dermatopathologists (Duke University Medical Center, Durham, NC) for standardization of histologic criteria in all but 10 patients. Surgical treatment and outcomes were reviewed and survival rates based on thickness and stage were calculated. Metastases information, anatomic location on the ear, and histologic subtype were recorded and analyzed.

RESULTS

The median length of follow up was 3.3 years with a range of 0.4 to 24.9 years. Eighty-six patients were known to be dead at the last known follow-up date. The median survival time among these patients was 7.9 years. The most common histologic classification of the lesions were superficial spreading type (45.2%) and were most likely to be localized to the anterior helix (49.3%). One hundred sixty-one of 199 (80.9%) patients underwent wide local excision with local recurrence rate of 10.6%. Overall, 43.2% of patients developed a local recurrence or metastatic spread. Ulceration, thickness, and stage all negatively affected survival.

CONCLUSIONS

This is the largest review of primary ear melanoma cases reported to date. Survival probabilities at 2, 5, and 10 years for melanoma of the ear based on thickness and stage are presented. Ulceration adversely affected survival probability (P < 0.003). Lesion excision with confirmed negative margins on permanent section pathology should be the goal of initial surgical therapy, and there is no apparent role for elective lymph node dissection in treatment of melanoma of the ear.

[Anatomical location of the primary tumor as a variable to be considered in sentinel node biopsy of cutaneous melanoma]

INTRODUCTION

The anatomical location of cutaneous melanoma has been suggested to be an independent prognostic factor. The aim of the present study was to determine whether the location of the primary tumor influences sentinel node detection in cutaneous melanoma.

PATIENTS AND METHOD

Two hundred twelve patients with primary cutaneous melanoma (96 of the limbs, 89 of the trunk and 27 of the head or neck) who underwent sentinel lymph node biopsy were studied. Adequate lymphoscintigraphic and surgical localization was evaluated and epidemiological and histopathological variables, the number of lymph nodes draining the site of the primary lesion, sentinel nodes per drainage basin, and tumor-positive nodes were compared.

RESULTS

Localization was less successful for tumors of the head and neck (88.8%), both with lymphoscintigraphy (P<.001) and surgery (P<.0005), especially for lymph nodes adjacent to salivary glands (P<.0005). Melanomas of the trunk showed a greater number of nodes per lesion and wider variability in drainage pathways (P<.0005), although there were no differences in the number of sentinel nodes per drainage basin (P=.455).

CONCLUSIONS

Sentinel node detection with less successful in cutaneous melanomas located in the head and neck. Location of the sentinel node adjacent to a salivary gland is a factor that influences its detection. Cutaneous melanomas of the trunk showed a higher number of draining nodes per lesion than those located in the limbs or head and neck.

Evidence-based principles and practices in pathology: selected problem areas

Contrary to the intuitive impression of most pathologists, there are still many areas 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 over-reliance on empirical factors. Other faulty procedures are pathologist-driven, with similar underpinnings. This overview considers several exemplary problem areas representing non-EBM practices in the hospital laboratory. Such examples include ideas and techniques centering on metastatic malignancies, "targeted" oncological therapy, analysis of surgical margins in the excision of neoplasms, general laboratory testing and data utilization, evaluation of selected coagulation defects, administration of blood products, and analysis of hepatic iron-overload syndromes. The concepts illustrating departures from EBM are discussed for each of those topics.

Sentinel lymph node biopsy in head and neck cancer

Sentinel lymph node biopsy (SLNB) offers a minimally invasive technique to examine the proximal lymph node basin for micrometastases in clinically N0 necks in patients head and neck cancer. This technique has been validated in the management of breast cancer and cutaneous malignant melanoma (CMM) and is under active investigation in the management of multiple other solid tumors.SLNB is used routinely in the management of head and neck melanoma and is investigational for other cancers of the head and neck. SLNB provides prognostic information for patients with CMM and identifies those patients that may benefit from additional treatment. This article examines the history, rationale,science, and current status of SLNB in head and neck with emphasis on melanoma.

Evaluation of extensive initial staging procedure in intermediate/high-risk melanoma patients

INTRODUCTION

Early diagnosis and treatment of metastases have been shown to improve overall survival of melanoma patients. The purpose of this study was to evaluate the impact of extensive initial staging, including positron emission tomography (PET) scan on the management of melanoma patients.

PATIENTS AND METHODS

Forty-three patients with intermediate/poor prognosis primary melanoma benefited from complementary excision and sentinel lymph node biopsy (SLB) after clinical and paraclinical staging (computed tomography, nuclear magnetic resonance and whole body fluorodeoxyglucose PET scan).

RESULTS

No systemic metastases were demonstrated, while the SLB procedure emphasized the presence of regional lymph node metastases in 10 patients as suggested by the PET scan in four patients (sensitivity of the PET scan 40%). These 10 patients with early diagnosed lymph node involvement benefited from early surgery and were included in adjuvant treatment protocols. A secondary primary cancer was fortuitously diagnosed and treated early in two patients.

CONCLUSIONS

The development of new adjuvant therapies and therapeutic procedures (specific and non-specific immunotherapy, gamma-knife radiosurgery, etc.) now raises the relevance of extensive staging in intermediate/poor prognosis melanoma patients. We confirm in our series that PET scan is not useful to detect micrometastasis and cannot replace SLB in initial regional staging. However, we show in our study that 12 of 43 patients were treated early or were included early in treatment protocols thanks to the extensive staging procedure. Nevertheless, it seems important to evaluate through larger prospective trials the real impact of these early diagnoses and new treatments on overall survival before defining new diagnostic and therapeutic guidelines.

Sentinel lymph node biopsy in patients with cutaneous melanoma: outcome after 3-year follow-up

AIMS

The management of patients with cutaneous melanoma in the absence of lymph-node metastases is still controversial. The experience of the National Cancer Institute in Naples was analysed to evaluate the 3-year disease free survival and overall survival for all patients submitted to sentinel node biopsy (SNB).

METHODS

Data from 265 sentinel biopsies performed in the last five years were reviewed to determine the effect of the treatment on disease free survival and overall survival stratified the patients for node status and tumour ulceration.

RESULTS

Statistical analysis showed a 3-year survival advantage for sentinel node negative patients compared to sentinel node positive cases with a 88.4 and 72.9%, respectively (p < 0.05).

CONCLUSIONS

SNB provides an accurate staging of nodal status in patients with melanoma in the absence of clinical evidence of metastases. Longer follow-up and final results from multicenter selective lymphadenectomy (MSLT) are needed to clarify the role of this procedure.

Role of Sentinel Lymph Node Biopsy in Patients with Thick (>4 mm) Primary Melanoma

Lymphatic mapping and sentinel lymphadenectomy have become a routine part of the treatment algorithm for primary melanoma. Their role in the management of thick (>4 mm) lesions is evolving. Our purpose was to evaluate the influence of single lymph node (SLN) histology on survival of patients with thick melanomas. A computerized patient database was accessed to obtain records on patients with thick melanomas. Survival curves were constructed with the Kaplan-Meier method, and a Cox regression analysis was used to establish statistical significance. Between 1997 and 2002, 266 SLN biopsy procedures were performed, using both radioisotope and blue dye, in 259 patients with malignant melanoma. Forty-five patients (17%) had thick melanomas. Twenty patients (44%) had at least one positive sentinel lymph node. The mean disease-free survival (DFS) of SLN–positive patients was 44 months compared with 53 months in SLN–negative patients ( P = 0.0221). Increasing Breslow thickness was associated with a decrease in DFS, whereas no other histologic parameters such as Clark level, mitotic rate, or ulceration had an influence on DFS. Our data indicate that the status of the SLN node is predictive of disease-free survival in patients with thick melanomas. SLN biopsy is thus justified in patients with thick melanoma.

Elective radiotherapy provides regional control for patients with cutaneous melanoma of the head and neck

BACKGROUND

In the current study, the authors assessed the efficacy of elective radiotherapy in providing regional (lymph node) control in patients with cutaneous melanoma of the head and neck who were at high risk for lymph node involvement. Toxicity was also assessed.

METHODS

From 1983 to 1998, 157 patients with Stage I or II cutaneous melanoma of the head and neck received elective regional radiotherapy after wide local excision of the primary lesion. None of the patients had received sentinel lymph node biopsy or dissection of the lymph nodes. Their medical records were reviewed retrospectively and analyzed for outcome.

RESULTS

The median follow-up for the current review was 68 months (range, 7-185 months). The disease recurred locally in 9 patients, in the neck lymph nodes in 15 patients, and distantly in 57 patients. The actuarial regional control rate was 89% at both 5 years and 10 years. The actuarial disease-specific survival and distant metastasis-free survival rates were 68% and 63%, respectively, at 5 years and 58% and 49%, respectively, at 10 years. Breslow thickness was a significant determinant of disease-specific survival and distant metastasis-free survival rates. At 10 years, 6% of patients had developed a symptomatic treatment-related complication. There were no treatment-related deaths.

CONCLUSIONS

The results of the current study confirmed the efficacy and safety of elective regional radiotherapy for patients with cutaneous head and neck melanoma predicted to have a high rate of lymph node involvement. Elective irradiation was a viable alternative to elective lymph node dissection. It may also serve as an alternative to sentinel lymph node biopsy, particularly for patients for whom dissection and systemic therapy are not therapeutic options.

Reassessing the role of lymphatic mapping and sentinel lymphadenectomy in the management of cutaneous malignant melanoma

Lymphatic mapping and sentinel lymphadenectomy was developed as a minimally invasive technique to provide regional lymph node staging information for patients at high risk for metastatic melanoma, but without clinically palpable disease. Only patients who demonstrate micrometastases undergo complete regional lymphadenectomy, sparing approximately 80% of patients the expense and morbidity of an elective lymph node dissection. This technique has been widely accepted as the preferred method to determine the pathologic status of the regional lymph nodes and the staging information gained is incorporated into the latest version of the American Joint Committee on Cancer staging system for cutaneous melanoma. Still, there is much controversy as to the use of this technique as a staging procedure and its overall therapeutic benefit in the treatment of patients with melanoma. Currently ongoing clinical trials will determine if lymphatic mapping and sentinel lymphadenectomy directly influences overall survival for patients with malignant melanoma. We review the latest technical aspects of this procedure and discuss the controversies surrounding its use.

Lymph node status and survival in cutaneous malignant melanoma--sentinel lymph node biopsy impact

AIM

The survival benefit of sentinel lymph node biopsy (SLB) with lymphadenectomy for microscopic melanoma metastases to regional lymph nodes (SLND) is uncertain. The aim of the study was to analyse the factors influencing clinical outcome (overall survival (OS) and disease free survival (DFS)) of patients undergone lymph node dissection (LND) as result of positive sentinel lymph node disease (SLND) or as consequence of clinically detected metastases (CLND).

PATIENTS AND METHODS

This was a single-institution retrospective analysis of survival data of 350 consecutive, prospectively collected, melanoma patients who underwent radical LND in 1995-2001. One hundred and forty-five patients underwent SLND and 205 underwent CLND.

RESULTS

The median OS and DFS times of the entire group of melanoma patients, computed from the date of primary lesion excision, were 46.3 months and 26.5 months (5-year OS ratio 41.8% and 5-year DFS ratio 31.5%). The factors which correlated with poor OS by multivariate analysis were: primary tumour Breslow thickness >4 mm (p=0.001), extracapsular extension of lymph node metastases (p=0.004), male sex (p=0.001) and metastases to more than one regional lymph node (p=0.04). The negative factors for DFS were: nodal extracapsular invasion (p=0.00002) and primary tumour Breslow thickness >4 mm (p=0.004). There were no significant differences in OS and DFS between SLND and CLND groups, when calculated from the date of primary tumour excision. However, if OS and DFS were estimated from the date of LND, the SLND group demonstrated significantly better survival in comparison with CLND.

CONCLUSION

The study demonstrates no survival benefit from SLB with subsequent radical regional LND in malignant melanoma patients with lymph node metastases.

Rapid immunohistochemistry of sentinel lymph nodes for metastatic melanoma

Sentinel lymph node (SLN) biopsy is performed on patients with malignant melanoma (MM) to assess the need for selective complete lymphadenectomy. Melanoma metastasis to regional lymph nodes is an important prognostic indicator in patients with MM. This study assesses the sensitivity and specificity of rapid immunohistochemistry (RIHC) in intraoperative delineation of melanoma metastasis to SLN. RIHC for S-100 protein, HMB45, and a melanoma marker cocktail (melan A, HMB45, and tyrosinase) was performed on 71 SLNs obtained from 28 patients with MM. Frozen sections (6 micro thick) on plus slides were fixed for 2 to 3 minutes in cold acetone and then stored at -70 degrees C. The EnVision kit (Dako, Carpinteria, CA) for rapid immunohistochemistry (RIHC) on frozen tissue sections was used, and the staining technique took 19 minutes. Together with preparation of the frozen sections and fixation in acetone, immunostained slides were available in approximately 25 minutes. Of the 71 SNLs examined, 7 showed melanoma metastasis in permanent sections. RIHC of frozen sections detected metastatic melanoma in 6 SLNs, with a sensitivity of 86% for HMB45 and 71% for S-100 protein and the melanoma cocktail and a specificity of 97% for HMB45 and 100% for S-100 and the melanoma cocktail. We conclude that RIHC for HMB45, S-100 protein, and the melanoma cocktail may help detect melanoma metastasis in SLN intraoperatively, leading to total lymph node dissection and obviating the need for 2 surgical procedures. Section folds and background stain can make interpretation difficult. Intraoperative time constraints require a more rapid technique. A recent consensus group has discouraged frozen-section examination of SLN.