Sentinel node biopsy for early-stage melanoma: accuracy and morbidity in MSLT-I, an international multicenter trial.

John Wayne Cancer Institute, Santa Monica, CA 90404, USA.
Annals of Surgery (Impact Factor: 7.19). 10/2005; 242(3):302-11; discussion 311-3.
Source: PubMed

ABSTRACT The objective of this study was to evaluate, in an international multicenter phase III trial, the accuracy, use, and morbidity of intraoperative lymphatic mapping and sentinel node biopsy (LM/SNB) for staging the regional nodal basin of patients with early-stage melanoma.
Since our introduction of LM/SNB in 1990, this technique has been widely adopted and has become part of the American Joint Committee on Cancer (AJCC) staging system. Eleven years ago, the authors began the international Multicenter Selective Lymphadenectomy Trial (MSLT-I) to compare 2 treatment approaches: wide excision (WE) plus LM/SNB with immediate complete lymphadenectomy (CLND) for sentinel node (SN) metastases, and WE plus postoperative observation with CLND delayed until the subsequent development of clinically evident nodal metastases.
After each center achieved 85% accuracy of SN identification during a 30-case learning phase, patients with primary cutaneous melanoma (> or =1 mm with Clark level > or =III, or any thickness with Clark level > or =IV) were randomly assigned in a 4:6 ratio to WE plus observation (WEO) with delayed CLND for nodal recurrence, or to WE plus LM/SNB with immediate CLND for SN metastasis. The accuracy of LM/SNB was determined by comparing the rates of SN identification and the incidence of SN metastases in the LM/SNB group versus the subsequent development of nodal metastases in the regional nodal basin of those patients with tumor-negative SNs. Early morbidity of LM/SNB was evaluated by comparing complication rates between the 2 treatment groups. Trial accrual was completed on March 31, 2002, after enrollment of 2001 patients.
Initial SN identification rate was 95.3% overall: 99.3% for the groin, 95.3% for the axilla, and 84.5% for the neck basins. The rate of false-negative LM/SNB during the trial phase, as measured by nodal recurrence in a tumor-negative dissected SN basin, decreased with increasing case volume at each center: 10.3% for the first 25 cases versus 5.2% after 25 cases. There were no operative mortalities. The low (10.1%) complication rate after LM/SNB increased to 37.2% with the addition of CLND; CLND also increased the severity of complications.
LM/SNB is a safe, low-morbidity procedure for staging the regional nodal basin in early melanoma. Even after a 30-case learning phase and 25 additional LM/SNB cases, the accuracy of LM/SNB continues to increase with a center's experience. LM/SNB should become standard care for staging the regional lymph nodes of patients with primary cutaneous melanoma.


Available from: Brendon Coventry, Apr 21, 2015
  • [Show abstract] [Hide abstract]
    ABSTRACT: A 56-year-old woman with neurofibromatosis type 1 (NF1) presented with a left upper eyelid amelanotic nodule with adjacent eyelid margin hyperpigmentation. Physical examination additionally revealed primary acquired melanosis (PAM) on the palpebral conjunctiva of the same eyelid. Full thickness eyelid excision and conjunctival map biopsy identified desmoplastic melanoma of the eyelid in addition to invasive conjunctival melanoma and conjunctival melanoma in-situ. Sentinel lymph node biopsy was negative for metastasis. She was treated with surgical excision for the eyelid melanoma and topical mitomycin C for the conjunctival melanoma. We discuss the rare entity of desmoplastic melanoma of the eyelid and its possible association with NF1.
    Survey of Ophthalmology 08/2014; 60(1). DOI:10.1016/j.survophthal.2014.08.001 · 3.51 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Although melanoma represents less than 5% of all skin cancers, it is responsible for the bulk of skin cancer-related deaths. Nevertheless, despite this aggressive reputation, most patients with cutaneous melanoma will be surgically cured of their disease. Early detection allows for curative resection, and 5-year survival for all stages of melanoma is 91%. This review outlines the surgical treatment of melanoma, including principles of wide local excision and management of the regional lymph nodes.
    Surgical Clinics of North America 10/2014; 94(5). DOI:10.1016/j.suc.2014.07.002 · 1.93 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Wide local excision is the mainstay in the treatment of the primary lesion with consideration given to specific anatomic constraints in head and neck melanoma. Sentinel lymph node biopsy is considered in all lesions with ulceration, mitoses greater than or equal to 1/mm(2), stage1B or higher, and in all high-risk nonmetastatic melanoma. Reconstructive strategy must be considered in multidisciplinary teams with reconstructive surgeons for large head and neck defects.
    Surgical Clinics of North America 10/2014; DOI:10.1016/j.suc.2014.07.011 · 1.93 Impact Factor