Department of Surgery, Endocrine and Oncologic Surgery Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA.
Ann Surg Oncol. 2018 Nov;25(12):3469-3475. doi: 10.1245/s10434-018-6647-7. Epub 2018 Jul 24.
While recent trial data have demonstrated no survival benefit to immediate completion lymph node dissection (CLND) for positive sentinel lymph node (SLN) disease in melanoma, prediction of non-SLN disease may help risk-stratify patients for more intensive observation of the nodal basin.
A retrospective cohort of patients with positive SLN biopsy (SLNB) who underwent CLND was identified (1996-2016). A risk score for likelihood of CLND-positive disease was developed based on factors associated with presence of CLND metastases identified on logistic regression. Survival outcomes were analyzed.
Among 312 patients with positive SLN, 192 underwent CLND and had complete pathologic data for evaluation. The median age of the study cohort was 53 years [interquartile range (IQR) 43-66 years], and 112 (58%) were male. Thirty-one (16%) had non-SLN metastatic disease on CLND. The four factors independently associated with CLND positivity and thus included in the risk score were Breslow thickness ≥ 3 mm [odds ratio (OR) 2.56, p = 0.047], presence of primary tumor-infiltrating lymphocytes (OR 0.33, p = 0.013), ≥ 2/3 positive-to-total SLN ratio (OR 4.35, p = 0.003), and combined subcapsular and parenchymal metastatic SLN location or metastatic deposit ≥ 1 mm (OR 4.45, p = 0.013). The four-point risk score predicted CLND positivity well with area under the curve of 0.82 (0.80-0.85). Increasing risk score was independently associated with increasingly worse melanoma-specific survival [hazard ratio (HR) = 1.54, p = 0.001].
Likelihood of residual nodal disease after positive SLNB and survival can be predicted from primary tumor and SLN characteristics. High-risk patients may warrant more intensive surveillance of the nodal basin to reduce risk of loss of regional control.
尽管最近的临床试验数据表明，对于黑色素瘤阳性前哨淋巴结（SLN）疾病，立即进行完全淋巴结清扫术（CLND）并不能提高生存率，但预测非 SLN 疾病可能有助于对患者进行风险分层，以便更密切地观察淋巴结区域。
本研究回顾性分析了 1996 年至 2016 年间接受 CLND 的阳性 SLN 活检（SLNB）患者的队列。根据 logistic 回归分析确定的与 CLND 转移相关的因素，建立了一个预测 CLND 阳性疾病可能性的风险评分。分析了生存结果。
在 312 例阳性 SLN 患者中，192 例行 CLND 且有完整的病理数据进行评估。研究队列的中位年龄为 53 岁[四分位距（IQR）43-66 岁]，112 例（58%）为男性。31 例（16%）在 CLND 时存在非 SLN 转移性疾病。四个独立的与 CLND 阳性相关的因素，包括 Breslow 厚度≥3mm（比值比（OR）2.56，p=0.047）、存在原发性肿瘤浸润淋巴细胞（OR 0.33，p=0.013）、≥2/3 的阳性至总 SLN 比值（OR 4.35，p=0.003）以及包膜下和实质内转移性 SLN 位置或转移性沉积物≥1mm（OR 4.45，p=0.013），均被纳入风险评分。四点风险评分对 CLND 阳性预测良好，曲线下面积为 0.82（0.80-0.85）。风险评分的增加与黑色素瘤特异性生存时间的恶化独立相关[风险比（HR）1.54，p=0.001]。
可根据原发肿瘤和 SLN 的特征预测 SLNB 阳性后残留淋巴结疾病的可能性和生存情况。高危患者可能需要更密切地监测淋巴结区域，以降低区域控制失败的风险。
