Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Ann Surg Oncol. 2021 Dec;28(13):9031-9038. doi: 10.1245/s10434-021-10212-w. Epub 2021 Jun 3.
Sentinel lymph node biopsy (SLNB) is often omitted in selected patients with advanced primary melanoma, although the justification/criteria for omission have been debated.
We sought to determine whether assessment of frailty could serve as an objective marker to guide selection for SLNB in patients with advanced primary melanoma.
Patients presenting with clinical stage IIC (ulcerated, > 4 mm Breslow thickness) cutaneous melanoma from January 1999 through June 2019 were included. Frailty was assessed using the Memorial Sloan Kettering Frailty Index (MSK FI), a composite score of functional status and medical comorbidities. Five-year melanoma-specific survival (MSS) and overall survival (OS) were estimated using Cox regression, and predictors of OS were identified using competing risk models.
MSS did not differ between patients who did (n = 451) or did not undergo SLNB (n = 179) [63.2% vs. 65.0%, p = 0.14]; however, omission of SLNB was associated with decreased 5-year OS (29% vs. 44%, p < 0.001). In a multivariable competing risk model, selection for SLNB omission was an independent predictor of death from non-melanoma causes (hazard ratio [HR] 1.7, 95% confidence interval [CI] 1.2-2.3, p < 0.001). After incorporation of the MSK FI score into the multivariable model in this subset, MSK FI (HR 2.4, 95% CI 1.5-4.1, p < 0.001), but not SLNB omission, was an independent predictor of poorer OS.
We observed worse OS in patients with thick melanoma selected not to undergo SLNB, which was attributed to death due to non-melanoma causes. Formal assessment of frailty may provide an objective prognostic measure to guide selective use of SLNB in these patients.
在某些选择的晚期原发性黑色素瘤患者中，通常会省略前哨淋巴结活检（SLNB），尽管省略的依据/标准存在争议。
我们旨在确定虚弱评估是否可作为指导晚期原发性黑色素瘤患者 SLNB 选择的客观标志物。
纳入 1999 年 1 月至 2019 年 6 月期间就诊的临床分期为 IIC 期（溃疡，>4mm Breslow 厚度）皮肤黑色素瘤患者。使用 Memorial Sloan Kettering 虚弱指数（MSK FI）评估虚弱情况，该指数是功能状态和合并症的综合评分。使用 Cox 回归估计 5 年黑色素瘤特异性生存率（MSS）和总生存率（OS），使用竞争风险模型确定 OS 的预测因素。
接受 SLNB（n=451）或未接受 SLNB（n=179）的患者之间的 MSS 无差异[63.2% vs. 65.0%，p=0.14]；然而，省略 SLNB 与 5 年 OS 降低相关（29% vs. 44%，p<0.001）。在多变量竞争风险模型中，选择省略 SLNB 是因非黑色素瘤原因死亡的独立预测因素（风险比[HR] 1.7，95%置信区间[CI] 1.2-2.3，p<0.001）。在前哨淋巴结活检组中纳入 MSK FI 评分后，MSK FI（HR 2.4，95% CI 1.5-4.1，p<0.001），而不是省略 SLNB，是 OS 较差的独立预测因素。
我们观察到未接受 SLNB 的厚型黑色素瘤患者 OS 更差，这归因于非黑色素瘤原因导致的死亡。对虚弱进行正式评估可能为指导这些患者选择性使用 SLNB 提供客观的预后指标。
