Surgery and sentinel lymph node biopsy

Abstract

In patients with melanoma, surgery is pivotal not only for the primary tumor but also for regional and often distant metastases. The minimally invasive technique of sentinel node (SN) biopsy has become standard for detection of occult regional node metastasis in patients with intermediate-thickness primary melanoma; in these patients it has a central role in determining prognosis and a significant impact on survival when biopsy results are positive. Its role in thin melanoma remains under evaluation. The regional tumor-draining SN also is a useful model for studies of melanoma-induced immunosuppression. Although completion lymphadenectomy remains the standard of care for patients with SN metastasis, results of ongoing phase III trials will indicate whether SN biopsy without further lymph node surgery is adequate therapy for certain patients with minimal regional node disease.

Figure 1

A: Comparison of mortality at 8 to 11 years between wide and narrower excision in the 3 follow-up trials of melanoma of the extremities. B: Comparison of local recurrence at 8 to 10 years between wide and narrower excision in the 3 follow-up trials of patients with melanoma of the extremities. Reprinted with permission from Haigh et al.

Figure 2

Nomogram to predict positive sentinel lymph nodes. How to use the nomogram: The patient’s values on each axis are located, and a line is drawn upward to determine how many points the patient receives for each variable value. The points are summed; that number is located on the ‘‘total points’’ axis. A line is drawn downward to then determine the predicted probability of sentinel node positivity. Reprinted with permission from Wong et al.

Figure 3

Kaplan-Meier survival for patients with thick (>4 mm) melanoma by SN status. Disease-free and overall survivals were significantly better for patients with a negative SN biopsy (P<.03 and P=.006, respectively). Reprinted with permission from Gershenwald et al.

Figure 4

Time to local or intransit metastasis according to the type of treatment (wide excision alone or wide excision plus SNB) shows no significant difference.Reprinted with permission from Morton et al.

Figure 5

Melanoma-specific survival among patients with nodal metastases. Subgroup 1 comprised patients with a tumor-positive sentinel node; subgroup 2, the patients in subgroup 1 plus those in subgroup 4 with a nodal recurrence after a negative result on biopsy; subgroup 3, those with nodal recurrence during observation; and subgroup 4, those with nodal recurrence after a negative result on biopsy. Reprinted with permission from Morton et al.

Figure 6

Compartmentalization of intranodal lymph flow as detected in the operating room by radiopharaceutical, blue dye, and carbon dye (left) and confirmed in the pathology department by carbon dye (right). Reprinted with permission from Morton et al.

Figure 7

(A) Kaplan-Meier curve analysis of overall survival (OS) according to multiple marker quantitative realtime reverse transcriptase polymerase chain reaction and histopathology status in 215 patients; (B) Kaplan-Meier curve analysis of OS according to number of molecular markers in 162 SN histopathology-negative patients. H&E, hematoxylin and eosin; IHC, immunohistochemistry. Reprinted with permission from Takeuchi et al.

Figure 8

Relationship between nodal recurrence after a tumor-negative lymphatic mapping and sentinel node biopsy procedure and volume of cases at 10 MSLT-1 centers. Minimum duration of follow-up was 36 months. Reprinted with permission from Morton et al.