Superficial and deep lymph node dissection for stage III cutaneous melanoma: clinical outcome and prognostic factors
World Journal of Surgical Oncology
Superficial and deep lymph node dissection for stage III cutaneous melanoma: clinical outcome and prognostic factors
Nicola Mozzillo 2
Corrado Carac 0
Ugo Marone 0
Gianluca Di Monta 0
Anna Crispo
Gerardo Botti
Maurizio Montella
Paolo Antonio Ascierto 1
0 Division of Melanoma and Skin Cancer , Via Mariano Semmola, Naples 80131 , Italy
1 Division of Oncology , Via Mariano Semmola
2 Department of Melanoma, Sarcoma and Skin Cancer , Via Mariano Semmola, Naples 80131 , Italy
Background: The aims of this retrospective analysis were to evaluate the effect of combined superficial and deep groin dissection on disease-free and melanoma-specific survival, and to identify the most important factors for predicting the involvement of deep nodes according to clinically or microscopically detected nodal metastases. Methods: Between January 1996 and December 2005, 133 consecutive patients with groin lymph node metastases underwent superficial and deep dissection at the National Cancer Institute, Naples. Lymph node involvement was clinically evident in 84 patients and detected by sentinel node biopsy in 49 cases. Results: The 5-year disease-free survival was significantly better for patients with superficial lymph node metastases than for patients with involvement of both superficial and deep lymph nodes (34.9% vs. 19.0%; P = 0.001). The 5-year melanoma-specific survival was also significantly better for patients with superficial node metastases only (55.6% vs. 33.3%; P = 0.001). Conclusions: Metastasis in the deep nodes is the strongest predictor of both disease-free and melanoma-specific survival. Deep groin dissection should be considered for all patients with groin clinical nodal involvement, but might be spared in patients with a positive sentinel node. Prospective studies will clarify the issue further.
Cutaneous melanoma; Sentinel biopsy; Lymph node metastases
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Background
Lymph node metastasis is a powerful predictor of
recurrence and death in patients with cutaneous melanoma.
Metastasis to regional lymph nodes develops during the
course of the disease in approximately 30% of patients
with cutaneous melanoma [1,2]. Radical lymph node
dissection, defined as the removal of all lymph node levels
of the involved basin, is recognized as the treatment of
choice after histological or cytological evidence of lymph
node involvement. For metastasis to inguinal lymph
nodes, disagreement exists about the extent of surgical
dissection and whether an iliac-pelvic lymphadenectomy
is always mandatory. Many support the idea that
iliacpelvic metastatic involvement indicates systemic disease
and that an aggressive surgical approach will not
improve melanoma-specific survival [3,4]. Data on the
long-term follow-up of patients with stage III melanoma
(regional lymph node metastases) have demonstrated
that about 20% of patients with involvement of deep
(iliac and obturator) nodes were alive at 20 years, which
suggests that surgical excision of nodal metastases is
more than a staging or palliative procedure [5,6].
The aims of this retrospective analysis were to
determine disease-free and melanoma-specific survival in the
case of combined superficial and deep groin dissection,
to identify the most important factors for predicting the
involvement of deep nodes, and to describe differences
in melanoma-specific survival and disease-free survival
according to clinically or microscopically detected nodal
metastases.
Methods
Between January 1996 and December 2005, 520 patients
underwent surgical lymph node dissection for
metastases at the National Cancer Institute, Naples. Of these
patients, 315 (60.6%) had metastases in lymph node
basins other than the groin and 205 (39.4%) had inguinal
lymph node metastases. Among the patients with
inguinal lymph node metastases, combined superficial and
deep groin dissection was considered the treatment of
choice in patients with either a positive sentinel node or
clinical groin disease. Superficial groin dissection only
was limited to 72 patients for a variety of clinical reasons
(such as anesthetic risk, age or life expectancy) and these
cases were excluded from the present analysis.
The main clinical characteristics of the 133 patients
included in the study are summarized in Table 1. The
mean age was 50 years (range 21 to 83 years). The primary
melanoma was located in the lower extremity in most
patients (70.7%). The mean Breslow thickness of the
primary melanoma was 4.0 mm and 77 melanomas (69.3%)
were classified as T3 to T4. In 22 patients, histological
findings of the primary melanoma were not available. In
84 patients (63.1%) (16 of whom had false negative
sentinel nodes), adenopathy localized to the superficial groin
area was clinically detected, with cytological confirmation
of metastatic involvement, and in 49 patients (36.9%),
micrometastatic disease was identified with sentinel node
biopsy.
Disease was staged in all patients with the use of
computed tomog (...truncated)