Nowecki Zbigniew I, Rutkowski Piotr, Michej Wanda
Department of Soft Tissue, Bone Sarcoma and Melanoma, M Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Roentgena 5, 02-781 Warsaw, Poland.
Ann Surg Oncol. 2008 Aug;15(8):2223-34. doi: 10.1245/s10434-008-9965-3. Epub 2008 May 28.
The survival benefit of sentinel node biopsy is still controversial. The aim of our study was to assess the overall survival (OS; calculated both from the date of primary tumor excision and lymph node dissection) data from two large groups of AJCC 2002 stage-III cutaneous melanoma patients-after completion lymph node dissection (CLND after positive sentinel node biopsy) and after therapeutic LND (TLND for clinically/cytologically detected regional lymph node metastases).
We analyzed the outcomes for 544 consecutive patients, who underwent CLND (47.4%; 258 patients) or TLND (52.6%; 286 patients) at one institution between December 1994 and January 2005. There were no significant differences between the two groups in terms of age and gender distribution and in the parameters of the primary tumor. Median follow-up time was 36 months (range 6-110 months).
We found no significant differences in OS (from the date of primary tumor excision) between CLND and TLND patients in the groups with primary tumor thicknesses of 1.0 mm or less or greater than 4.0 mm (pT1 and pT4); however, in patients with thicknesses greater than 1.0 mm and 4.0 mm or less (in subgroups pT2 and pT3), we found significantly better OS for CLND than for TLND patients-CLND: median OS not reached, 5-year OS was 57.2% (95%CI: 44.4-70.1%); TLND: median OS 42.1 months, 5-year OS was 37.9% (95%CI: 26.5-49.2%) (P = 0.0006). In the entire CLND and TLND groups, the median OS and 5-year OS rates were 60.5 months and 52.5% (95%CI: 45.6-61.5%) and 38.2 months and 39.5% (95%CI: 32.7-46.5%), respectively. Based on multivariate analysis, we have found that in the CLND group the important factors negatively influencing OS (from the date of lymphadenectomy) are: male gender, features of primary tumor (higher Breslow thickness and presence of ulceration) and features of nodal metastases (extracapsular invasion and number of involved nodes). In the TLND group, however, the negative prognostic factors are: male gender and features of nodal metastases (extracapsular invasion and number of involved nodes) without the impact of primary tumor characteristics.
The results of the study demonstrate that the survival benefit after positive sentinel node biopsy with subsequent CLND is probably limited only to the subgroup of patients with primary tumor thicknesses not larger than 4 mm and not less than 1 mm when compared with lymph node dissection of palpable nodes. The primary tumor features have no impact on survival after lymphadenectomy performed for clinically involved nodes.
前哨淋巴结活检的生存获益仍存在争议。我们研究的目的是评估两组AJCC 2002分期III期皮肤黑色素瘤患者的总生存（OS；从原发肿瘤切除和淋巴结清扫日期开始计算）数据，这两组患者分别是在前哨淋巴结活检阳性后完成淋巴结清扫（CLND）以及进行治疗性淋巴结清扫（TLND用于临床/细胞学检测到的区域淋巴结转移）。
我们分析了1994年12月至2005年1月期间在一家机构接受CLND（47.4%；258例患者）或TLND（52.6%；286例患者）的544例连续患者的结局。两组在年龄、性别分布以及原发肿瘤参数方面无显著差异。中位随访时间为36个月（范围6 - 110个月）。
我们发现，在原发肿瘤厚度为1.0 mm及以下或大于4.0 mm（pT1和pT4）的组中，CLND和TLND患者的OS（从原发肿瘤切除日期开始计算）无显著差异；然而，在厚度大于1.0 mm且4.0 mm及以下的患者（pT2和pT3亚组）中，我们发现CLND患者的OS显著优于TLND患者——CLND：中位OS未达到，5年OS为57.2%（95%CI：44.4 - 70.1%）；TLND：中位OS为42.1个月，5年OS为37.9%（95%CI：26.5 - 49.2%）（P = 0.0006）。在整个CLND和TLND组中，中位OS和5年OS率分别为60.5个月和52.5%（95%CI：45.6 - 61.5%）以及38.2个月和39.5%（95%CI：32.7 - 46.5%）。基于多变量分析，我们发现CLND组中对OS（从淋巴结清扫日期开始计算）产生负面影响的重要因素有：男性性别、原发肿瘤特征（较高的Breslow厚度和溃疡存在）以及淋巴结转移特征（包膜外侵犯和受累淋巴结数量）。然而，在TLND组中，负面预后因素为：男性性别和淋巴结转移特征（包膜外侵犯和受累淋巴结数量），而原发肿瘤特征无影响。
研究结果表明，与对可触及淋巴结进行淋巴结清扫相比，前哨淋巴结活检阳性后进行CLND的生存获益可能仅局限于原发肿瘤厚度不大于4 mm且不小于1 mm的患者亚组。对于临床受累淋巴结进行淋巴结清扫后，原发肿瘤特征对生存无影响。
