Cranial nerve outcomes in regionally recurrent head & neck melanoma after sentinel lymph node biopsy

Abstract

Objective Characterize long‐term cranial nerve (CN) outcomes following sentinel lymph node biopsy (SLNB) based management for head and neck cutaneous melanoma (HNCM). Methods Longitudinal review of HNCM patients undergoing SLNB from 1997–2007. Results Three hundred fifty‐six patients were identified, with mean age 53.5 ± 19.0 years, mean Breslow depth 2.52 ± 1.87 mm, and 4.9 years median follow‐up. One hundred five (29.4%) patients had SLNB mapping to the parotid basin. Eighteen patients had positive parotid SLNs and underwent immediate parotidectomy / immediate completion lymph node dissection (iCLND), with six possessing positive parotid non‐sentinel lymph nodes (NSLNs). Fifty‐two of 356 (14.6%) patients developed delayed regional recurrences, including 20 total intraparotid recurrences: five following false negative (FN) parotid SLNB, three following prior immediate superficial parotidectomy, two following iCLND without parotidectomy, and the remaining 12 parotid recurrences had negative extraparotid SLNBs. Parotid recurrences were multiple (4.9 mean recurrent nodes) and advanced (n = 4 extracapsular extension), and all required salvage dissection including parotidectomy. Immediate parotidectomy/iCLND led to no permanent CN injuries. Delayed regional HNCM macrometastasis precipitated 16 total permanent CN injuries in 13 patients: 10 CN VII, five CN XI, and one CN XII deficits. Fifty percent (n = 10) of parotid recurrences caused ≥1 permanent CN deficits. Conclusions Regional HNCM macrometastases and salvage dissection confer marked CN injury risk, whereas early surgical intervention via SLNB ± iCLND ± immediate parotidectomy yielded no CN injuries. Further, superficial parotidectomy performed in parotid‐mapping HNCM does not obviate delayed intraparotid recurrences, which increase risk of CN VII injury. Despite lack of a published disease‐specific survival advantage in melanoma, early disease control in cervical and parotid basins is paramount to minimize CN complications. Level of Evidence 4 (retrospective case series) Laryngoscope, 130:1707–1714, 2020

Sentinel Lymph Node Biopsy in Head and Neck Melanoma: Long‐term Outcomes, Prognostic Value, Accuracy, and Safety

“…There were no permanent CN injuries. 21 One case of mild submental lymphedema following iCLND was noted, resolving spontaneously within 4 postoperative weeks. Perioperative myocardial infarctions, strokes, or deaths were not encountered.…”

Management of the positive sentinel lymph node in the post‐MSLT‐II era

“…Studies evaluating specifically patients with melanoma of the head and neck region have, though retrospective in nature, have nevertheless shown little to no difference in disease‐specific survival after CLND 12,13 . Second, the head and neck region includes many crucial structures in close proximity, 14 thus making a nodal recurrence potentially more morbid and technically more challenging 15 . Third, lymphedema after modified radical neck dissection lymph node dissection for head and neck cancer is less common, making the procedure less morbid overall 13,14 .…”

“…12,13 Second, the head and neck region includes many crucial structures in close proximity, 14 thus making a nodal recurrence potentially more morbid and technically more challenging. 15 Third, lymphedema after modified radical neck dissection lymph node dissection for head and neck cancer is less common, making the procedure less morbid overall. 13,14 Although many studies do in fact report lymphedema in head and neck cancer patients, no robust studies looking at lymphedema-related quality of life in head and neck melanoma patients have been performed.…”

Should Neck Dissection Be Done After Positive Sentinel Node Biopsy for Head and Neck Melanoma?

“…In the head and neck, CLND constitutes a cervical lymphadenectomy and possibly a parotidectomy, both of which have a theoretical risk of cranial nerve injury, amongst other surgical risks. Hanks et al performed a retrospective study on HNCM patients undergoing SLNB between 1997 and 2007 at a single institution 5 . Of 356 patients, 355 were successfully mapped with 76 having positive SLNBs.…”