Patterns of Initial Recurrence and Prognosis after Sentinel Lymph Node Biopsy and Selective Lymphadenectomy for Melanoma

Abstract

The histologic status of the sentinel lymph node is a highly significant prognostic factor for patients with clinically localized cutaneous melanoma. The patterns of initial treatment failure of patients with positive sentinel lymph node biopsy versus those with negative results have not been well described. The purpose of this study was to determine the relative prognostic importance of sentinel lymph node status and to compare patterns of initial treatment failure and prognosis of node-positive versus node-negative cutaneous melanoma patients staged by sentinel lymph node biopsy and selective lymphadenectomy. The authors reviewed the pertinent demographic and surgical data in a consecutive series of patients with cutaneous melanoma who underwent sentinel lymph node staging of nonpalpable regional nodes. Sentinel lymph node biopsy was performed using a combination of blue dye and radiolocalization. Patients with positive biopsy results underwent selective lymphadenectomy, whereas those with negative results were observed. Site(s) and date(s) of initial recurrence and death were determined, and disease-free and overall survival probabilities were compared between positive and negative groups using the log-rank test and multivariable Cox regression analysis. Between February of 1994 and August of 2000, 408 patients with melanoma underwent sentinel lymph node biopsy to stage 518 regional lymph node basins. Mean Breslow tumor thickness was 2.27 mm (range, 0.2 to 14.0 mm). Eighty-five patients (20.8 percent) had at least one histologically positive sentinel lymph node, and selective lymphadenectomy yielded additional positive lymph nodes in 18 of 84 patients (21.4 percent). Recurrences were noted in 70 patients (17 percent) at a median follow-up period of 31.4 months. Recurrences were more frequent in patients with positive biopsy results (36.5 percent) than in those with negative results (12.1 percent, p < 0.0001). Distant sites of initial recurrence were more likely in the positive group than in the negative group (71 percent versus 49 percent of recurrences, respectively; p = 0.06). The false-negative rate for sentinel lymph node staging was 4.5 percent and overall accuracy was 99 percent compared with clinical follow-up. Disease-free and overall survival correlated significantly with tumor thickness, ulceration, sentinel lymph node status, and the number of tumor-positive lymph nodes (two-sided p < 0.0001 for all comparisons). Multivariable analysis revealed that sentinel lymph node status (p = 0.003), tumor thickness (p = 0.016), ulceration (p = 0.006), and age (p = 0.003) were significant independent predictors of survival for the entire group. Tumor thickness and ulceration were significant predictors of recurrence and survival in sentinel node-negative patients but not in sentinel node-positive patients. Sentinel lymph node histology is possibly the most important negative predictor of early recurrence and survival in patients with American Joint Committee on Cancer stage I and II melanoma. The number of posi...

Surgical Management of Melanoma

“…Morton et al reported the sensitivity rate of SLNB as 95.3% overall: 99.3% for the groin, 95.3% for the axilla, and 84.5% for the neck basins (15). Reported rates of SN metastasis are 12 to 20% for 1-to 2-mm melanomas, 28 to 33% for 2-to 4-mm melanomas, and 28 to 44% for melanomas thicker than 4 mm (16).…”

“…The landmark Multicenter Selective Lymphadenectomy Trial-I (MSLT-I) is the largest trial comparing the use of SLNB and elective lymph node dissection (ELND) to observe patients with intermediate thickness melanomas in determining prognosis and its impact on survival (15,22). Long-term data from the MSLT-I show improved 10-year disease-free survival but fail to show improved melanoma-specific survival (22).…”

Antimony concentrations in nodal tissue can confirm sentinel node identity

“…With long-term follow-up of patients with negative sentinel nodes there is a small but definite incidence of recurrence in the mapped and sampled nodal basin. 5,[10][11][12][13][14][15][16][17][18][19] These patients may be considered to have a false-negative result of their sentinel node biopsy procedure. Previous reports have suggested that the majority of patients who recur in the relevant node field will, in fact, have identifiable metastases in the biopsied sentinel node if a more comprehensive histopathologic evaluation of the node is undertaken.…”

“…With long-term follow-up of patients with negative sentinel nodes, some develop a recurrence in the mapped and sampled nodal basin and these patients may be considered to have a false-negative result of their sentinel node biopsy procedure. A technique to confirm true sentinel node identity may reduce the false-negative rate of the procedure, which has been disappointingly high (up to 44%) in several recently reported studies, 5,[10][11][12][13][14][15][16][17][18][19] or at least provide a retrospective explanation for a falsenegative result.…”

Non-Invasive Determination of Breslow Index

“…A positive SLNB has been shown to be the best predictor of recurrence and survival in patients with clinically node-negative cutaneous melanoma (Wagner, Ranieri et al 2003). Patient mean charges for SLNB and wide excision alone respectively are $12,193 and $1,466 (Agnese, Abdessalam et al 2003).…”