Department of Plastic & Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom.
JAMA Otolaryngol Head Neck Surg. 2023 May 1;149(5):416-423. doi: 10.1001/jamaoto.2023.0076.
Although sentinel lymph node biopsy (SLNB) is a vital staging tool, its application in head and neck melanoma (HNM) is complicated by a higher false-negative rate (FNR) compared with other regions. This may be due to the complex lymphatic drainage in the head and neck.
To compare the accuracy, prognostic value, and long-term outcomes of SLNB in HNM with melanoma from the trunk and limb, focusing on the lymphatic drainage pattern.
DESIGN, SETTING, AND PARTICIPANTS: This cohort observational study at a single UK University cancer center included all patients with primary cutaneous melanoma undergoing SLNB between 2010 to 2020. Data analysis was conducted during December 2022.
Primary cutaneous melanoma undergoing SLNB between 2010 to 2020.
This cohort study compared the FNR (defined as the ratio between false-negative results and the sum of false-negative and true-positive results) and false omission rate (defined as the ratio between false-negative results and the sum of false-negative and true-negative results) for SLNB stratified by 3 body regions (HNM, limb, and trunk). Kaplan-Meier survival analysis was used to compare recurrence-free survival (RFS) and melanoma-specific survival (MSS). Comparative analysis of detected lymph nodes on lymphoscintigraphy (LSG) and SLNB was performed by quantifying lymphatic drainage patterns by number of nodes and lymph node basins. Multivariable Cox proportional hazards regression identified independent risk factors.
Overall, 1080 patients were included (552 [51.1%] men, 528 [48.9%] women; median age at diagnosis 59.8 years), with a median (IQR) follow-up 4.8 (IQR, 2.7-7.2) years. Head and neck melanoma had a higher median age at diagnosis (66.2 years) and higher Breslow thickness (2.2 mm). The FNR was highest in HNM (34.5% vs 14.8% trunk or 10.4% limb, respectively). Similarly, the false omission rate was 7.8% in HNM compared with 5.7% trunk or 3.0% limbs. The MSS was no different (HR, 0.81; 95% CI, 0.43-1.53), but RFS was lower in HNM (HR, 0.55; 95% CI, 0.36-0.85). On LSG, patients with HNM had the highest proportion of multiple hotspots (28.6% with ≥3 hotspots vs 23.2% trunk and 7.2% limbs). The RFS was lower for patients with HNM with 3 or more affected lymph nodes found on LSG than those with fewer than 3 affected lymph nodes (HR, 0.37; 95% CI, 0.18-0.77). Cox regression analysis showed head and neck location to be an independent risk factor for RFS (HR, 1.60; 95% CI, 1.01-2.50), but not for MSS (HR, 0.80; 95% CI, 0.35-1.71).
This cohort study found higher rates of complex lymphatic drainage, FNR, and regional recurrence in HNM compared with other body sites on long-term follow-up. We advocate considering surveillance imaging for HNM for high-risk melanomas irrespective of sentinel lymph node status.
尽管前哨淋巴结活检（SLNB）是一种重要的分期工具，但与其他部位相比，其在头颈部黑色素瘤（HNM）中的应用较为复杂，假阴性率（FNR）更高。这可能是由于头颈部的淋巴引流较为复杂。
比较 HNM 与躯干和四肢黑色素瘤的 SLNB 的准确性、预后价值和长期结果，重点关注淋巴引流模式。
设计、地点和参与者：这是英国一家癌症中心的单中心队列观察性研究，纳入了 2010 年至 2020 年间接受 SLNB 的所有原发性皮肤黑色素瘤患者。数据分析于 2022 年 12 月进行。
2010 年至 2020 年间接受 SLNB 的原发性皮肤黑色素瘤。
本队列研究比较了 FNR（定义为假阴性结果与假阴性和真阳性结果之和的比值）和假遗漏率（定义为假阴性结果与假阴性和真阴性结果之和的比值），按 3 个体区（HNM、四肢和躯干）分层。使用无复发生存率（RFS）和黑色素瘤特异性生存率（MSS）进行 Kaplan-Meier 生存分析比较。通过量化淋巴结和淋巴结盆地的数量，对淋巴闪烁显像（LSG）和 SLNB 上检测到的淋巴结进行比较分析。多变量 Cox 比例风险回归确定了独立的风险因素。
共纳入 1080 例患者（552 例[51.1%]为男性，528 例[48.9%]为女性；中位诊断年龄为 59.8 岁），中位（IQR）随访时间为 4.8（IQR，2.7-7.2）年。HNM 的中位诊断年龄（66.2 岁）和 Breslow 厚度（2.2 mm）更高。HNM 的 FNR 最高（34.5%比躯干或四肢的 14.8%，分别）。同样，HNM 的假遗漏率为 7.8%，而躯干或四肢的假遗漏率分别为 5.7%和 3.0%。MSS 无差异（HR，0.81；95%CI，0.43-1.53），但 HNM 的 RFS 较低（HR，0.55；95%CI，0.36-0.85）。在 LSG 上，HNM 患者具有最高比例的多个热点（28.6%有≥3 个热点，而躯干为 23.2%，四肢为 7.2%）。LSG 上发现 3 个或更多受累淋巴结的 HNM 患者的 RFS 低于发现少于 3 个受累淋巴结的患者（HR，0.37；95%CI，0.18-0.77）。Cox 回归分析显示，头颈部位置是 RFS 的独立危险因素（HR，1.60；95%CI，1.01-2.50），但不是 MSS 的独立危险因素（HR，0.80；95%CI，0.35-1.71）。
本队列研究发现，与其他部位相比，HNM 在长期随访中具有更高的复杂淋巴引流、FNR 和区域复发率。我们主张对 HNM 高危黑色素瘤进行监测影像学检查，无论 SLNB 状态如何。
