Roka F, Mastan P, Binder M, Okamoto I, Mittlboeck M, Horvat R, Pehamberger H, Diem E
Department of Dermatology, Division of General Dermatology, Medical University of Vienna, AKH-Wien, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
Eur J Surg Oncol. 2008 Jan;34(1):82-8. doi: 10.1016/j.ejso.2007.01.027. Epub 2007 Mar 13.
Sentinel lymph node (SLN) -positive melanoma patients are usually recommended completion lymph node dissection (CLND) with the aim to provide regional disease control and improve survival. Nevertheless, only 20% these patients have additional metastases in non-sentinel lymph nodes (NSLN), indicating that CLND may be unnecessary in the majority of patients. In this retrospective study, we (i) sought to identify clinico-pathological features predicting NSLN status, as well as disease-free (DFS) and -specific (DSS) survival and (ii) evaluated the applicability of previously published algorithms, which were able to define a group of patients at zero-risk for NSLN-metastasis.
This analysis included 504 consecutive melanoma patients stage I and II who underwent successful SLN-biopsy (SLNB) at our institute between 1998 and 2005. Metastatic SLN were re-evaluated for tumor burden and categorized according to two different micro-anatomic classifications and the S/U-score (Size of the sentinel node metastasis > 2 mm/Ulceration of the primary melanoma) was assessed. DFS and DSS were calculated for all analyses.
Out of 504 melanoma patients stage I or II, 85 (17%) were SLN-positive and 18 of 85 (21%) were found with positive NSLN in the CLND specimen. Median follow-up was 31 months. Neither primary tumor characteristics (age, gender, Clark level, Breslow thickness, ulceration of the primary melanoma, site and histological subtype of the primary melanoma), nor features of the sentinel node tumor (number and site of draining lymph node basins, number of positive sentinel nodes and size of sentinel node tumor (< 2 mm vs. > or = 2 mm) were able to predict additional positive lymph nodes in the CLND specimen. Likewise the implementation of published algorithms was not able to identify patients at negligible risk for harboring NSLN metastases. Upon univariate analysis, disease-free survival in SLN-positive patients was correlated with Breslow thickness, sentinel node tumor size > 2 mm and S/U score. In respect to disease-specific survival the significant prognostic parameters were Breslow thickness, ulceration, sentinel node tumor size > 2 mm and the S/U score. After a median follow-up of 31 months recurrence rates (37% vs. 78%, p=0.02) and death from disease (24% vs. 50%, p<0.01) were significantly different in patients with SLN-metastasis only as compared to patients with NSLN-metastasis.
NSLN status cannot be predicted in this data analysis by using clinico-pathological characteristics. Therefore, CLND is recommended for all patients after positive SLNB pending the results of the second Multicenter Selective Lymphadenectomy Trial.
前哨淋巴结（SLN）阳性的黑色素瘤患者通常建议行根治性淋巴结清扫术（CLND），旨在实现区域疾病控制并提高生存率。然而，这些患者中只有20%在非前哨淋巴结（NSLN）有额外转移，这表明大多数患者可能无需行CLND。在这项回顾性研究中，我们（i）试图确定预测NSLN状态以及无病生存期（DFS）和疾病特异性生存期（DSS）的临床病理特征，（ii）评估先前发表的算法的适用性，这些算法能够定义一组NSLN转移风险为零的患者。
本分析纳入了1998年至2005年期间在我院接受成功前哨淋巴结活检（SLNB）的504例连续的I期和II期黑色素瘤患者。对转移的SLN进行肿瘤负荷重新评估，并根据两种不同的微观解剖分类进行分类，同时评估S/U评分（前哨淋巴结转移灶大小>2mm/原发性黑色素瘤溃疡情况）。所有分析均计算DFS和DSS。
在504例I期或II期黑色素瘤患者中，85例（17%）SLN阳性，其中18例（21%）在CLND标本中发现NSLN阳性。中位随访时间为31个月。原发性肿瘤特征（年龄、性别、Clark分级、Breslow厚度、原发性黑色素瘤溃疡情况、原发性黑色素瘤部位和组织学亚型）以及前哨淋巴结肿瘤特征（引流淋巴结区域数量和部位、阳性前哨淋巴结数量以及前哨淋巴结肿瘤大小（<2mm与>或=2mm））均无法预测CLND标本中额外的阳性淋巴结。同样，已发表算法的应用也无法识别NSLN转移风险可忽略不计的患者。单因素分析显示，SLN阳性患者的无病生存期与Breslow厚度、前哨淋巴结肿瘤大小>2mm以及S/U评分相关。关于疾病特异性生存期，显著的预后参数为Breslow厚度、溃疡情况、前哨淋巴结肿瘤大小>2mm以及S/U评分。中位随访31个月后，仅SLN转移患者与NSLN转移患者的复发率（37%对78%，p=0.02）和疾病死亡（24%对50%，p<0.01）有显著差异。
在本数据分析中，无法通过临床病理特征预测NSLN状态。因此，在第二项多中心选择性淋巴结清扫试验结果出来之前，建议对所有SLNB阳性患者行CLND。
