Machet L, Nemeth-Normand F, Giraudeau B, Perrinaud A, Tiguemounine J, Ayoub J, Alison D, Vaillant L, Lorette G
Service de Dermatologie, Centre Hospitalier Universitaire, Hopital Trousseau, 37044 Tours Cedex 1, France.
Br J Dermatol. 2005 Jan;152(1):66-70. doi: 10.1111/j.1365-2133.2004.06262.x.
There is still lack of consensus regarding the most effective follow-up for stage I and II melanoma patients although some consensus conferences have provided guidelines stating that clinical examination should be the standard.
Our aim was to study the value of adding ultrasound lymph node examination (7.5 MHz) to the routine clinical examination recommended by French guidelines in melanoma follow-up.
A cohort of melanoma patients was enrolled between 1 July 1995 and 1 July 2000 in a follow-up protocol including clinical examination performed four times a year for thick melanomas (Breslow index > or = 1.5 mm) and twice a year for thin melanomas (Breslow index < 1.5 mm) according to French guidelines, and ultrasound lymph node examination performed every 6 months for thick melanomas and every year for thin melanomas. Follow-up was continued up to 1 July 2003. When clinical or ultrasound examination indicated signs of node recurrence, surgical biopsy of the involved node was performed. When ultrasound examination was only suspicious, another ultrasound examination was performed within the following 3 months. The results of both clinical and ultrasound examinations were compared with histopathology examination when node biopsy was performed.
Ultrasound follow-up was performed for 373 patients (213 females and 160 males). Mean age at diagnosis of melanoma was 59 years (range 14-90, SD 15). In total, 1909 ultrasound examinations combined with clinical examination were analysed. Node biopsy was performed in 65 patients and demonstrated melanoma metastases in 54. Sensitivity of clinical examination and ultrasound examination was 71.4%[95% confidence interval (CI) 55.4-84.3] and 92.9 (95% CI 80.5-98.5), respectively, P = 0.02. Specificity of clinical examination and ultrasound examination was 99.6% (95% CI 99.2-99.8) and 97.8% (95% CI 97.0-98.4), respectively. Despite this apparent superiority of ultrasound examination over palpation, only 7.2% of the patients really benefited from ultrasound examination (earlier lymph node metastasis detection or avoidance of unnecessary surgery), while 5.9% had some deleterious effect from ultrasound examination (unnecessary stress caused by repetition of ultrasound examination for benign lymph nodes, useless removal of benign lymph node).
This study confirms the greater sensitivity of ultrasound examination to clinical examination in the diagnosis of node metastases from cutaneous melanoma. However, the place of ultrasound in routine follow-up is at least questionable as only a very small proportion of patients (1.3%) really benefited from adding ultrasound examination to clinical examination.
尽管一些共识会议已提供指南指出临床检查应作为标准，但对于I期和II期黑色素瘤患者最有效的随访方式仍缺乏共识。
我们的目的是研究在法国黑色素瘤随访指南推荐的常规临床检查基础上增加超声淋巴结检查（7.5兆赫）的价值。
1995年7月1日至2000年7月1日纳入一组黑色素瘤患者进行随访，根据法国指南，对于厚黑色素瘤（Breslow指数≥1.5毫米）每年进行4次临床检查，对于薄黑色素瘤（Breslow指数＜1.5毫米）每年进行2次临床检查，厚黑色素瘤每6个月进行一次超声淋巴结检查，薄黑色素瘤每年进行一次超声淋巴结检查。随访持续至2003年7月1日。当临床或超声检查显示有淋巴结复发迹象时，对受累淋巴结进行手术活检。当超声检查仅为可疑时，在接下来的3个月内进行另一次超声检查。当进行淋巴结活检时，将临床和超声检查结果与组织病理学检查结果进行比较。
对373例患者（213例女性和160例男性）进行了超声随访。黑色素瘤诊断时的平均年龄为59岁（范围14 - 90岁，标准差15）。总共分析了1909次超声检查与临床检查相结合的情况。65例患者进行了淋巴结活检，其中54例显示有黑色素瘤转移。临床检查和超声检查的敏感性分别为71.4%[95%置信区间（CI）55.4 - 84.3]和92.9%（95%CI 80.5 - 98.5），P = 0.02。临床检查和超声检查的特异性分别为99.6%（95%CI 99.2 - 99.8）和97.8%（95%CI 97.0 - 98.4）。尽管超声检查相对于触诊有明显优势，但只有7.2%的患者真正从超声检查中获益（更早发现淋巴结转移或避免不必要的手术），而5.9%的患者因超声检查有一些有害影响（对良性淋巴结重复进行超声检查导致不必要的压力，对良性淋巴结进行无用的切除）。
本研究证实了在皮肤黑色素瘤淋巴结转移诊断中超声检查相对于临床检查具有更高的敏感性。然而，超声在常规随访中的地位至少是值得怀疑的，因为只有极少数患者（1.3%）真正从在临床检查基础上增加超声检查中获益。
