Lee David Y, Lau Briana J, Huynh Kelly T, Flaherty Devin C, Lee Ji-Hey, Stern Stacey L, O'Day Steve J, Foshag Leland J, Faries Mark B
Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA.
Department of Biostatistics, The John Wayne Cancer Institute at Providence St John's Health Center, Santa Monica, CA.
J Am Coll Surg. 2016 Jul;223(1):9-18. doi: 10.1016/j.jamcollsurg.2016.01.045. Epub 2016 Jan 29.
Whether patients with positive SLNB should undergo complete lymph node dissection (CLND) is an important unanswered clinical question.
Patients diagnosed with positive SLNB at a melanoma referral center from 1991 to 2013 were studied. Outcomes of patients who underwent CLND were compared with those who did not undergo immediate CLND (observation [OBS] group).
There were 471 patients who had positive SLNB; 375 (79.6%) in the CLND group and 96 (20.4%) in the OBS group. The groups were similar except that the CLND group was younger and had more sentinel nodes removed. Five-year nodal recurrence-free survival was significantly better in the CLND group compared with the OBS group (93.1% vs 84.4%; p = 0.005). However, 5-year (66.4% vs 55.2%) and 10-year (59.5% vs 45.0%) distant metastasis-free survival rates were not significantly different (p = 0.061). The CLND group's melanoma-specific survival (MSS) rate was superior to that of the OBS group; 5-year MSS rates were 73.7% vs 65.5% and 10-year MSS rates were 66.8% vs 48.3% (p = 0.015). On multivariate analysis, CLND was associated with improved MSS (hazard ratio = 0.60; 95% CI, 0.40-0.89; p = 0.011) and lower nodal recurrence (hazard ratio = 0.46; 95% CI, 0.24-0.86; p = 0.016). Increased Breslow thickness, older age, ulceration, and trunk melanoma were all associated with worse outcomes. On subgroup analysis, the following factors were associated with better outcomes from CLND: male sex, nonulcerated primary, intermediate thickness, Clark level IV or lower extremity tumors.
Treatment of positive SLNB with CLND was associated with improved MSS and nodal recurrence rates. Follow-up beyond 5 years was needed to see a significant difference in MSS rates.
前哨淋巴结活检（SLNB）结果为阳性的患者是否应接受完整淋巴结清扫术（CLND）是一个重要的、尚未解决的临床问题。
对1991年至2013年在一家黑色素瘤转诊中心被诊断为SLNB阳性的患者进行研究。将接受CLND的患者的结果与未立即接受CLND的患者（观察组[OBS]）的结果进行比较。
共有471例SLNB阳性患者；CLND组375例（79.6%），OBS组96例（20.4%）。除CLND组患者更年轻且切除的前哨淋巴结更多外，两组相似。CLND组的5年无淋巴结复发生存率显著优于OBS组（93.1%对84.4%；p = 0.005）。然而，5年（66.4%对55.2%）和10年（59.5%对45.0%）无远处转移生存率无显著差异（p = 0.061）。CLND组的黑色素瘤特异性生存率（MSS）高于OBS组；5年MSS率分别为73.7%对65.5%，10年MSS率分别为66.8%对48.3%（p = 0.015）。多因素分析显示，CLND与MSS改善（风险比 = 0.60；95%可信区间，0.40 - 0.89；p = 0.011）和更低的淋巴结复发率（风险比 = 0.46；95%可信区间，0.24 - 0.86；p = 0.016）相关。Breslow厚度增加、年龄较大（、溃疡形成）和躯干黑色素瘤均与更差的预后相关。亚组分析显示，以下因素与CLND的更好预后相关：男性、原发性无溃疡、中等厚度、Clark分级IV级或下肢肿瘤。
用CLND治疗SLNB阳性与MSS和淋巴结复发率改善相关。需要超过5年的随访才能观察到MSS率的显著差异。 （括号内内容原文未明确提及，根据语境补充以使译文更通顺）
