Gannon Christopher J, Rousseau Dennis L, Ross Merrick I, Johnson Marcella M, Lee Jeffrey E, Mansfield Paul F, Cormier Janice N, Prieto Victor G, Gershenwald Jeffrey E
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
Cancer. 2006 Dec 1;107(11):2647-52. doi: 10.1002/cncr.22320.
Sentinel lymph node (SLN) status is the most important prognostic factor with respect to the survival of patients with primary cutaneous melanoma. However, lymphatic mapping and SLN biopsies (LM/SLNBs) performed in patients who have had a wide local excision (WLE) may not accurately reflect the pathologic status of the draining lymph node basins. The purpose of this study was to assess the feasibility and accuracy of LM/SLNB in patients who have had a previous WLE.
A single-institution database was examined to identify patients who had a WLE before LM/SLNB and patients who had a concomitant LM/SLNB. Primary clinicopathologic features (age, tumor thickness, and ulceration), SLN identification rate, SLN pathologic status, and the incidence and sites of recurrences were compared between patients with and without prior WLE.
Of the 1395 patients identified, 104 had WLE before LM/SLNB. The mean preoperative WLE radial margin was 1.4 cm (median, 1.0 cm). LM/SLNB was successful in 103 of 104 (99%) patients. Age, tumor thickness, incidence of ulceration, and incidence of SLN positivity in the group with prior WLE were similar to those of the cohort of patients who had concomitant LM/SLNB and WLE (n = 1291). In 97 (93%) of the 104 prior-WLE patients, the surgical defects were closed by either primary closure or skin graft; 7 patients (7%) had rotational flaps. The median follow-up of these 104 patients was 51 months. Among the prior-WLE group, 19 patients (18%) had a positive SLNB; of these 19 patients, 4 (21%) had recurrences (3 distant failures and 1 local and distant failure). There were no lymph node recurrences-in a mapped or unmapped basin-in these 104 patients with a negative or positive SLNB.
SLNs can be successfully identified and accurately reflect the status of the regional lymph node basin in carefully selected melanoma patients with a previous WLE. Prior WLE does not appear to adversely impact the ability to detect lymphatic metastases, although the utility of LM/SLNB in patients who have undergone extensive reconstruction of the primary excision site remains to be defined. Because more extensive surgery may be required to accomplish accurate lymph node staging in patients who have undergone prior WLE-including the possible removal of SLNs from additional lymph node basins and an additional surgical procedure-to minimize morbidity and cost, concomitant WLE and LM/SLNB is strongly preferred whenever possible.
前哨淋巴结（SLN）状态是原发性皮肤黑色素瘤患者生存最重要的预后因素。然而，在已进行广泛局部切除（WLE）的患者中进行的淋巴绘图和前哨淋巴结活检（LM/SLNB）可能无法准确反映引流淋巴结区域的病理状态。本研究的目的是评估在既往接受过WLE的患者中进行LM/SLNB的可行性和准确性。
检查单机构数据库，以识别在LM/SLNB之前接受过WLE的患者以及同时进行LM/SLNB的患者。比较有或无既往WLE患者的主要临床病理特征（年龄、肿瘤厚度和溃疡情况）、SLN识别率、SLN病理状态以及复发的发生率和部位。
在识别出的1395例患者中，104例在LM/SLNB之前接受过WLE。术前WLE的平均径向切缘为1.4 cm（中位数为1.0 cm）。104例患者中有103例（99%）成功进行了LM/SLNB。既往有WLE组的年龄、肿瘤厚度、溃疡发生率和SLN阳性率与同时进行LM/SLNB和WLE的患者队列（n = 1291）相似。104例既往有WLE的患者中有97例（93%）通过一期缝合或植皮关闭了手术缺损；7例（7%）采用了旋转皮瓣。这104例患者的中位随访时间为51个月。在既往有WLE组中，19例患者（18%）的SLNB为阳性；在这19例患者中，4例（21%）出现复发（3例远处转移失败和1例局部及远处转移失败）。在这104例SLNB阴性或阳性的患者中，无论是在已绘图还是未绘图的区域，均未出现淋巴结复发。
在经过精心挑选的既往有WLE的黑色素瘤患者中，可以成功识别SLN并准确反映区域淋巴结区域的状态。既往WLE似乎不会对检测淋巴转移的能力产生不利影响，尽管LM/SLNB在原发性切除部位已进行广泛重建的患者中的效用仍有待确定。由于对于既往有WLE的患者可能需要进行更广泛的手术以完成准确的淋巴结分期，包括可能从其他淋巴结区域切除SLN以及额外的手术操作，以尽量减少发病率和成本，因此只要可能，强烈建议同时进行WLE和LM/SLNB。
