Impact of Completion Lymph Node Dissection on Patients with Positive Sentinel Lymph Node Biopsy in Melanoma - 24/06/16

Doi : 10.1016/j.jamcollsurg.2016.01.045

David Y. Lee, MD ^a, Briana J. Lau, MD ^a, Kelly T. Huynh, MD ^a, Devin C. Flaherty, DO, PhD ^a, Ji-Hey Lee, PhD ^b, Stacey L. Stern, MS ^b, Steve J. O'Day, MD ^c, Leland J. Foshag, MD, FACS ^a, Mark B. Faries, MD, FACS ^a,^⁎
^a Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA
^b Department of Biostatistics, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA
^c Department of Medical Oncology, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA

^∗Correspondence address: Mark B Faries, MD, FACS, Department of Surgical Oncology, John Wayne Cancer Institute, 2200 Santa Monica Blvd, Santa Monica, CA 90404.Department of Surgical OncologyJohn Wayne Cancer Institute2200 Santa Monica BlvdSanta MonicaCA90404

Abstract

Background

Whether patients with positive SLNB should undergo complete lymph node dissection (CLND) is an important unanswered clinical question.

Study Design

Patients diagnosed with positive SLNB at a melanoma referral center from 1991 to 2013 were studied. Outcomes of patients who underwent CLND were compared with those who did not undergo immediate CLND (observation [OBS] group).

Results

There were 471 patients who had positive SLNB; 375 (79.6%) in the CLND group and 96 (20.4%) in the OBS group. The groups were similar except that the CLND group was younger and had more sentinel nodes removed. Five-year nodal recurrence-free survival was significantly better in the CLND group compared with the OBS group (93.1% vs 84.4%; p = 0.005). However, 5-year (66.4% vs 55.2%) and 10-year (59.5% vs 45.0%) distant metastasis-free survival rates were not significantly different (p = 0.061). The CLND group's melanoma-specific survival (MSS) rate was superior to that of the OBS group; 5-year MSS rates were 73.7% vs 65.5% and 10-year MSS rates were 66.8% vs 48.3% (p = 0.015). On multivariate analysis, CLND was associated with improved MSS (hazard ratio = 0.60; 95% CI, 0.40–0.89; p = 0.011) and lower nodal recurrence (hazard ratio = 0.46; 95% CI, 0.24–0.86; p = 0.016). Increased Breslow thickness, older age, ulceration, and trunk melanoma were all associated with worse outcomes. On subgroup analysis, the following factors were associated with better outcomes from CLND: male sex, nonulcerated primary, intermediate thickness, Clark level IV or lower extremity tumors.

Conclusions

Treatment of positive SLNB with CLND was associated with improved MSS and nodal recurrence rates. Follow-up beyond 5 years was needed to see a significant difference in MSS rates.

Le texte complet de cet article est disponible en PDF.

Plan

Patient demographics/tumor characteristics

Nodal basin/sentinel lymph node characteristics

Recurrence patterns

Survival analysis

Comparison of salvage complete lymph node dissection vs immediate complete lymph node dissection with non-sentinel positive nodes

Discussion

Conclusions

Author Contributions

	Disclosure Information: Nothing to disclose.
	Disclosures outside the scope of this work: Dr Faries has served as a consultant for Amgen Inc, Astellas Pharma Inc, Myriad Genetics, Inc, and Genentech, Inc.
	Support: Dr DY Lee is the Harold McAlister Charitable Foundation Fellow. This study was supported by grant R01 CA189163 from the National Cancer Institute and by funding from the Amyx Foundation, Inc, (Boise, ID), The Borstein Family Foundation (Los Angeles, CA), Dr Miriam and Sheldon G Adelson Medical Research Foundation (Boston, MA), and the John Wayne Cancer Institute Auxiliary (Santa Monica, CA). The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Cancer Institute or the National Institutes of Health.