The role of sentinel lymph node biopsy in patients with thick melanoma. A single centre experience.
ABSTRACT To evaluate the role, if any, of sentinel lymph node mapping (SLNM) with biopsy (SLNB) in patients with thick cutaneous melanoma.
Consecutive patients with thick (Breslow ≥4 mm) cutaneous melanoma, undergoing SLNB were identified from a departmental database comprising 550 patients in total from 2000 to 2010. Factors examined included demographic data, histological subtype, site and depth of lesion, percentage of positive SLNs, regional recurrence in the setting of a negative SLNB result (false-negative rate), complications, further lymphadenectomy, and follow-up (disease free and overall survival), where available.
Sixty-four eligible patients (37 men, 27 women) underwent primary excision and SLNM. Median patient age was 59 years (range 8-82 years). Mean Breslow depth was 7 mm (range 4-19 mm). Thirty melanomas were located on the limbs, 19 on the head and neck and 15 on the trunk. Twenty-three (35%) were ulcerated. Of the 57 patients who had a sentinel node identified, 18 (31%) had metastatic melanoma identified. The mean survival time for patients with a negative SLN was 79 months versus 18 months for those with a positive node. Patients with a negative SLN have a 5 year disease free survival of 79% versus 11% (p < 0.001) and an overall 5 year survival rate of 85% versus 32% when compared to node positive patients.
The status of the SLN is predictive of disease recurrence and overall survival in patients with a thick primary cutaneous melanoma. This modality should be employed, where applicable, in this cohort of patients.
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ABSTRACT: Thick melanomas (TM) ≥4 mm have a high risk for nodal and distant metastases. Optimal surgical management, prognostic significance of sentinel node biopsy (SLNB), and benefits of interferon (IFN) for these patients are unclear. As a continuum of increasing tumor thickness is placed into a single TM group, differences in biologic and clinical behavior may be lost. The purpose of this study was to better characterize the diverse biology in TM, including the value of increasing thickness and nodal status information, potentially identifying high risk TM subgroups that may warrant more aggressive treatment/follow up. 155 consecutive TM patients treated at a single institution between 1971 and 2007 were retrospectively reviewed. Patient, disease and treatment features were analyzed with respect to disease-free (DFS) and overall survival (OS). Median patient age was 66 years and 68% of patients were men. The trunk was the most common TM location (35%), followed by the head and neck (29%) and lower extremities (20%). Median thickness was 6 mm and 61% were ulcerated. 6% patients had stage IV disease, 12% had clinical nodal metastases. Clinically negative lymph node basins were treated by observation (22 patients--15.4%), elective lymph node dissection (ELND) (24 patients--17.6%) or SLNB (91 patients--67%). 75% of ELND's and 53% of SLNB's were positive. Completion node dissection was performed in 38 SLNB+ patients and 22% had additional positive nodes. 17% of the study patients received IFN. At median follow up of 26 months, 5 year DFS and OS were 42% and 43.6%. For SLNB positive vs negative, median DFS were 22 vs 111 months (p = 0.006) and median OS were 41 vs 111 months (p = 0.006). When stratified by tumor thickness ≤ vs > 6 mm, 5 year DFS was 58.3% vs 20% (p < 0.0001) and OS was 62% vs 20% (P < 0.0001). IFN had no impact on DFS or OS (p = 0.98 and 0.8 respectively). Within the high risk group of patients with TM, cases with tumor thickness > 6 mm or a positive SLNB had a significantly worse DFS and OS (p < .0001, <.0001 and .006, .006).World Journal of Surgical Oncology 01/2011; 9:40. · 1.09 Impact Factor
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ABSTRACT: The value of sentinel lymph node biopsy (SLNB) as a useful strategy to assess the risk of future metastasis in high-risk melanomas (>4.0 mm) is controversially discussed. In a single-center retrospective study, the prognostic relevance of SLNB and other risk factors in the subgroup of melanomas >4.0 mm was investigated and compared to previously published results. Using Kaplan-Meier estimates and Cox regressions, we assessed the prognostic relevance of SLNB in our subcohort of 87 patients with thick melanomas >4.0 mm (T4). The mean follow-up for this subgroup was 51 months. We compared SLN value as compared to ulceration. SLN and ulceration, analyzed as separate risk factors as well as their combination, predicted a highly reduced life expectancy in terms of recurrence-free survival (RFS) in our cohort of patients. SLN, but not ulceration, also predicted overall survival (OS). Positive SLNB is an essential predictor of RFS and OS in T4 melanoma patients, whereas ulceration lacked significance with respect to OS in our cohort. Our data thus suggest the routine use of SLNB also for T4 melanoma and may therefore allow to optimize risk-stratified therapeutic regimens.Dermatology 01/2011; 222(1):59-66. · 2.02 Impact Factor
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ABSTRACT: To determine U.S. treatment patterns for pathologic staging practices in patients with thick head and neck melanomas (HNM). Patients with thick HNM without clinical evidence of in-transit, regional, or distant metastatic spread at presentation were identified from the Surveillance Epidemiology and End Results database. Treatment trends for patients were summarized, and univariate and multivariate analyses were performed to identify associations between varying practice patterns. A total of 1,230 patients with HNM meeting the inclusion criteria were identified. Surgical staging procedures were utilized in 53.5 %, including both sentinel lymph node biopsy (37 %) and elective neck dissection (16 %). Patients undergoing a surgical staging procedure were younger (64 vs. 77 years, p < 0.001) with smaller tumors (6.3 vs. 6.6 mm, p = 0.008). The rate of occult nodal disease was 22 % in patients undergoing a surgical staging procedure. The presence of a positive regional node in this subgroup of patients was associated with a significant reduction in disease-specific (44 vs. 59 months, p < 0.001) and overall survival (40 vs. 53 months, p < 0.001) on univariate analysis. On multivariate analysis, the presence of a positive node was the most significant factor for reduced overall survival (hazard ratio 2.36, 95 % confidence interval 1.71-3.23) and disease-specific survival (hazard ratio 2.84, 95 % confidence interval 1.99-4.06). Pathologic staging procedures provide independent prognostic information for patients with thick HNM. Despite this, current practice patterns demonstrate underutilization, particularly in elderly patients. Further work is needed to address the barriers to pathologic staging implementation in patients with thick HNM.Annals of Surgical Oncology 08/2013; · 4.12 Impact Factor