Gershenwald, J. E. et al. Patterns of recurrence following a negative sentinel lymph node biopsy in 243 patients with stage I or II melanoma. J. Clin. Oncol. 16, 2253-2260
Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA. Journal of Clinical Oncology
(Impact Factor: 18.43).
To determine the patterns of recurrence and causes of regional nodal basin failure in stage I or II melanoma patients who had a histologically negative sentinel lymph node (SLN) and whose regional nodal basins were not dissected following lymphatic mapping and SLN biopsy.
The records of 344 patients with primary cutaneous melanoma who underwent lymphatic mapping and SLN biopsy between 1991 and 1995 at The University of Texas M.D. Anderson Cancer Center were reviewed. Of 322 patients who underwent successful lymphatic mapping procedures, 270 had histologically negative SLNs; mapped nodal basins were observed without further surgical intervention in 243 of these 270 patients. Recurrence patterns were analyzed from this cohort and a histologic reevaluation of all previously identified SLNs on which a biopsy had been taken was performed in patients who developed recurrent disease.
Of 243 patients with a histologically negative SLN, 27 (11%) developed local, in-transit, regional nodal, and/or distant metastases after a median follow-up time of 35 months. Ten patients (4.1%) developed a nodal recurrence in the previously mapped basin, either solely or as a component of the first site of recurrence. Detailed analysis of the SLNs in these 10 patients demonstrated evidence of occult metastases in 80% by serial sectioning or immunohistochemical staining.
Regional nodal failures in melanoma patients following a negative SLN biopsy are infrequent and to date have most commonly occurred because conventional histologic evaluation was unable to identify occult metastatic disease. These data provide further evidence that lymphatic mapping and SLN biopsy accurately reflect the status of the regional nodal basin. Specialized pathologic techniques are necessary to reduce further the already low false-negative rates and to improve disease staging.
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- "An explanation of the causes of relapse may be a micrometastasis in missed superficial inguinal lymph nodes during lymphadenectomy procedure. This is in contrast to Gershenwald et al.  who investigated the causes of regional nodal failure in melanoma patients and found that regional nodal recurrence was the result of occult metastatic disease that was not identified using conventional histologic evaluation methods. In the present study, comprehensive retrospective histologic study of superficial lymphadenectomy specimens of the patients who experienced inguinal recurrence did not show any micrometastasis in the previously resected superficial inguinal lymph nodes, however, with immunohistochemistry examinations, the detection of micrometastasis in a previous pN0 node could be as high as 45% . "
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ABSTRACT: To investigate the causes of groin recurrence in patients with vulval cancer who previously had negative nodes following superficial inguinal node dissection (SIND).
Forty-one patients with squamous cell carcinoma of the vulva (stage I or II) were operated upon. The primary treatment was wide local excision with 2cm safety margin and superficial inguinal lymphadenectomy. Six patients had ipsilateral and one patient had bilateral groin recurrence. Those patients were subjected to deep inguinal node dissection (one patient required bilateral node dissection).
The mean age at time of diagnosis was 59years (range 51-68). The median follow-up period for all patients was 63months (range 24-71) and that of the recurrent cases was 20months (range 12-38). The mean depth of invasion of the recurrent cases was 5.5mm (range 5-5.9mm) and the mean diameter of the primary tumor in recurrent cases was 3.8cm (range 3-4.5cm). All recurrent cases had a high grade of the primary tumor. The median interval to recurrence was 21months (range 12-57). The groin recurrence rate after negative SIND was 17% (7/41 patients).The mean number of nodes resected per groin was eight (range 1-17). The nodes ranged in size from 0.2 to 4.0cm.
Carcinoma of the vulva with the following criteria (size of tumor is greater than 3cm, depth of invasion greater than 5mm, and high grade tumors) is at high risk of recurrence.
Available from: Amy P Abernethy
- "The pattern of metastatic disease, in which most patients presented with a distant cutaneous or nodal recurrence, is similar to other reported series, and may be reflective of the fact that many patients were diagnosed prior to the routine use of sentinel lymph node biopsies , . Subsequent analyses in patients who have undergone a sentinel lymph node biopsy suggest that there is a lower proportion of regional nodal recurrences , , , . "
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ABSTRACT: While curable at early stages, few treatment options exist for advanced melanoma. Currently, no consensus exists regarding the optimal surveillance strategy for patients after resection. The objectives of this study were to identify patterns of metastatic recurrence, to determine the influence of metastatic site on survival, and to identify high-risk periods for recurrence.
A retrospective review of the Duke Melanoma Database from 1970 to 2004 was conducted that focused on patients who were initially diagnosed without metastatic disease. The time to first recurrence was computed from the date of diagnosis, and the associated hazard function was examined to determine the peak risk period of recurrence. Metastatic sites were coded by the American Joint Committee on Cancer (AJCC) system including local skin, distant skin and nodes (M1a), lung (M1b), and other distant (M1c).
Of 11,615 patients initially diagnosed without metastatic disease, 4616 (40%) had at least one recurrence. Overall the risk of initial recurrence peaked at 12 months. The risk of initial recurrence at the local skin, distant skin, and nodes peaked at 8 months, and the risk at lung and other distant sites peaked at 24 months. Patients with a cutaneous or nodal recurrence had improved survival compared to other recurrence types.
The risk of developing recurrent melanoma peaked at one year, and the site of first recurrence had a significant impact on survival. Defining the timing and expected patterns of recurrence will be important in creating an optimized surveillance strategy for this patient population.
Available from: Hatem Boulahdour
- "The SLNB was considered false-negative if a primary recurrence developed in the regional lymph node basin from which a tumor-free SLN had been removed. In our study, the number of false-negative (10/153 = 6.5%) was similar (3-8%) to other studies [11,16,17]. However, there is ongoing debate on how to correctly calculate the false-negative rate. "
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Since the introduction of sentinel lymph node biopsy (SLNB), its use as a standard of care for patients with clinically node-negative cutaneous melanoma remains controversial. We wished to evaluate our experience of SLNB for melanoma.
A single center observational cohort of 203 melanoma patients with a primary cutaneous melanoma (tumour thickness > 1 mm) and without clinical evidence of metastasis was investigated from 2002 to 2009. Head and neck melanoma were excluded. SLN was identified following preoperative lymphoscintigraphy and intraoperative gamma probe interrogation.
The SLN identification rate was 97%. The SLN was tumor positive in 44 patients (22%). Positive SLN was significantly associated with primary tumor thickness and microscopic ulceration. The median follow-up was 39.5 (5–97) months. Disease progression was significantly more frequent in SLN positive patients (32% vs 13%, p = 0.002). Five-year DFS and OS of the entire cohort were 79.6% and 84.6%, respectively, with a statistical significant difference between SLN positive (58.7% and 69.7%) and SLN negative (85% and 90.3%) patients (p = 0.0006 and p = 0.0096 respectively). Postoperative complications after SLNB were observed in 12% of patients.
Our data confirm previous studies and support the clinical usefulness of SLNB as a reliable and accurate staging method in patients with cutaneous melanoma. However, the benefit of additional CLND in patients with positive SLN remains to be demonstrated.
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