Division of Surgical Oncology, Jackson Memorial Hospital and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.
Division of Surgical Oncology, Jackson Memorial Hospital and Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.
J Surg Res. 2019 Apr;236:83-91. doi: 10.1016/j.jss.2018.11.015. Epub 2018 Dec 7.
The optimal management of melanoma with positive sentinel lymph node (SLN) remains unclear. Completion lymph node dissection (CLND) only yields additional positive non-SLN in 20% of cases and its benefits on survival remains debatable.
An online database search of Medline was performed; key bibliographies were reviewed. Studies comparing outcomes after CLND versus observation were included. Odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) by random fixed effects models of pooled data were calculated. The primary endpoints were disease-free survival (DFS), melanoma-specific survival (MSS), and overall survival (OS).
Search strategy yielded 117 publications. Twelve studies were selected for inclusion, comprising 7966 SLN-positive patients. Among these patients, 5306 (66.6%) subjects underwent CLND and 2660 (33.4%) patients were observed. Median Breslow thickness and ulceration were similar between groups (2.8 ± 0.6 mm versus 2.5 ± 0.8 mm, P = 0.721; and 38.8% versus 37.2%, P = 0.136, CLND versus observation, respectively). CLND was associated with statistically significant improved 3-y (71.0% versus 66.2%, OR 0.82, 95% CI 0.69-0.97, P = 0.02) and 5-y DFS (48.3% versus 47.8%, OR 0.75, 95% CI 0.59-0.96, P = 0.02) compared with observation. However, no difference was demonstrated in 3-y MSS (83.7% versus 84.7%, OR 1.09, 95% CI 0.88-1.35, P = 0.41), 5-y MSS (68.4% versus 69.8%, OR 1.02, 95% CI 0.88-1.19, P = 0.78), or OS (68.2% versus 78.9%, OR 0.93, 95% CI 0.55-1.57, P = 0.78).
Based on this large-scale analysis, CLND improved both 3- and 5-y DFS, possibly because of increased rates of local control; however, this did not translate in improved MSS or OS. Efforts toward the identification of molecular markers associated with poor outcomes in SLN-positive patients who undergo observation are warranted.
阳性前哨淋巴结（SLN）黑色素瘤的最佳治疗方法仍不清楚。完成淋巴结清扫术（CLND）仅在 20%的病例中发现额外的非 SLN 阳性，其对生存的益处仍存在争议。
对 Medline 进行在线数据库检索；综述了关键的参考文献。纳入比较 CLND 与观察结果的研究。使用随机固定效应模型计算汇总数据的比值比（OR）及其相应的 95%置信区间（CI）。主要终点是无病生存率（DFS）、黑色素瘤特异性生存率（MSS）和总生存率（OS）。
搜索策略产生了 117 篇出版物。选择了 12 项研究纳入，包括 7966 例 SLN 阳性患者。其中 5306 例（66.6%）患者接受了 CLND，2660 例（33.4%）患者接受了观察。两组的中位 Breslow 厚度和溃疡相似（2.8±0.6mm 与 2.5±0.8mm，P=0.721；38.8%与 37.2%，P=0.136，CLND 与观察）。CLND 与 3 年（71.0%比 66.2%，OR 0.82，95%CI 0.69-0.97，P=0.02）和 5 年 DFS（48.3%比 47.8%，OR 0.75，95%CI 0.59-0.96，P=0.02）显著改善相关。然而，在 3 年 MSS（83.7%比 84.7%，OR 1.09，95%CI 0.88-1.35，P=0.41）、5 年 MSS（68.4%比 69.8%，OR 1.02，95%CI 0.88-1.19，P=0.78）或 OS（68.2%比 78.9%，OR 0.93，95%CI 0.55-1.57，P=0.78）方面无差异。
基于这项大规模分析，CLND 改善了 3 年和 5 年的 DFS，可能是由于局部控制率的提高；然而，这并没有转化为 MSS 或 OS 的改善。有必要努力确定 SLN 阳性患者接受观察时与不良结局相关的分子标志物。
