Positive Nonsentinel Node Status Predicts Mortality in Patients with Cutaneous Melanoma

Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
Annals of Surgical Oncology (Impact Factor: 3.93). 11/2008; 16(1):186-90. DOI: 10.1245/s10434-008-0187-5
Source: PubMed


While sentinel lymph node biopsy (SLN) is a highly accurate and well-tolerated procedure for patients with cutaneous melanoma, the role of the completion lymph node dissection (CLND) for patients with positive SLN biopsy remains unknown. This study aimed to look at the prognostic value of a positive nonsentinel lymph node (NSLN). A prospectively maintained database identified 222 patients with cutaneous melanoma and a positive SLN biopsy, without evidence of distant disease. All of these patients underwent CLND, and 37 patients (17%) had positive NSLN. With median follow-up of 33 months, patients with negative NSLN had median survival of 104 months, while patients with positive NSLN had median survival of 36 months (p < 0.001). There were no survivors in the patients with positive NSLN beyond 6 years. When patients with an equal number of positive nodes were analyzed, the presence of a positive NSLN was still associated with worse melanoma-specific survival (66 months for NSLN- versus 34 months for NSLN+, p = 0.04). While increasing age, tumor thickness, and male sex were associated with an increased risk of death on multivariate analysis, a positive NSLN was the most important predictor of survival (hazard ratio 2.5). We conclude that positive NSLN is an independent predictor of disease-specific survival in patients with cutaneous melanoma.

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    • "A TLND is usually performed, in which the macrometastasis and the neighboring unsuspicious lymph nodes constituting a nodal basin or a level of a nodal basin are removed. While less than 30 % of completion lymph node dissections are tumor-positive after excision of a micrometastasis in a sentinel lymph node (SLN), this proportion rises to 55–75 % following the diagnostic excision of a clinically enlarged metastatic node.13–18 Moreover, as compared with SLNB and completion lymph node dissection, performed at an early stage, TLND for clinically enlarged metastases has yielded a significantly higher number of affected lymph nodes.19,20 "
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    ABSTRACT: Background The value of a preoperative lymphoscintigraphy in melanoma patients with clinically evident regional lymph node metastases has not been studied. Therapeutic lymph node dissection (TLND) is regarded as the clinical standard, but the appropriate extent of TLND is controversial in all lymphatic basins. Patients and Methods Of the 115 consecutive patients with surgery on palpable lymph node metastases, 34 received a pre-operative lymphoscintigraphy. Lymphatic drainage to a second nodal basin outside the clinically involved basin was found in 15 cases. In 13 patients, the ectopic tumor-draining lymph nodes were excised as in a sentinel node biopsy. The lymph nodes from the TLND specimens were postoperatively separated and classified as either radioactive or non-radioactive. Results A total of 493 lymph nodes were examined pathologically. The largest macrometastasis maintained the ability to take up radiotracer in 77% of cases. Radioactively labeled lymph nodes carried a higher risk of being involved with metastasis. The proportions of tumor involvement for radioactive and non-radioactive lymph nodes were 44.5 and 16.9%, respectively (P=0.00002). Of the 13 ectopic nodal basins surgically explored, six harbored clinically occult metastases. Conclusion In patients undergoing TLND for palpable metastases, tumor-draining lymph nodes in a second, ectopic nodal basin should be excised, because they could be affected by occult metastasis. With respect to radioactive lymph nodes situated within the nodal basin of the macrometastasis but beyond the borders of a less-radical lymphadenectomy, further studies are needed.
    Full-text · Article · Jan 2013 · Annals of Surgical Oncology
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    • "The five-year DFS rates were 85.5, 64.8, and 42.6% respectively (P < 0.001), and the five-year OS rates were 85.5, 64.9, and 49.4%, respectively (P < 0.001) [13]. By utilizing multivariate analysis, the presence of positive NSN in patients with existing positive SLN biopsies was shown to be statistically significantly associated with poorer outcomes independent of other risk factors, i.e., increasing age, male sex, breslow depth, presence of extracapsular extension in SLN, and a positive NSN [14,15]. This data supports the concept that LN metastasis, whether to the initial draining LN or to NSN, is a sign of worsened patient survival. "
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    ABSTRACT: In nearly all human cancers, the presence of lymph node (LN) metastasis increases clinical staging and portends worse prognosis (compared to patients without LN metastasis). Herein, principally reviewing experimental and clinical data related to malignant melanoma, we discuss diverse factors that are mechanistically involved in LN metastasis. We highlight recent data that link tumor microenvironment, including inflammation (at the cellular and cytokine levels) and tumor-induced lymphangiogenesis, with nodal metastasis. Many of the newly identified genes that appear to influence LN metastasis facilitate general motility, chemotactic, or invasive properties that also increase the ability of cancer cells to disseminate and survive at distant organ sites. These new biomarkers will help predict clinical outcome and point to novel future therapies in metastatic melanoma as well as other cancers.
    Full-text · Article · Dec 2011 · Cancers
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    ABSTRACT: The incidence of melanoma has increased in North America, Europe, Australia, and New Zealand in the past decade. Currently, the mainstay treatment for patients with primary cutaneous melanoma is surgery, as adjuvant systemic therapy has limited efficacy. The role of sentinel node biopsy has been debated since its introduction 20 years ago. A review of the role of this technique in the management of patients with stage I and II melanoma in terms of staging, prognosis, morbidity, therapeutic benefit, and enrollment in clinical trials appears to be timely.
    Full-text · Article · Jun 2012
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