Division of Breast and Melanoma Surgical Oncology, Department of Surgery, Mayo Clinic, Rochester, MN.
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
Surgery. 2023 Mar;173(3):626-632. doi: 10.1016/j.surg.2022.08.034. Epub 2022 Oct 29.
Variability in guideline compliance for melanoma lymph node surgery is partially attributable to controversy about patient selection. Prior data has indicated suboptimal practice of sentinel lymph node biopsy and undertreatment of clinically node-positive disease, predating Multicenter Selective Lymphadenectomy Trial II publication. To minimize bias, we studied compliance with lymph node surgery guidelines in T2/T3 (intermediate-thickness) melanoma patients, where the greatest agreement exists.
T2/T3 and metastasis 0 melanoma cases were identified from 2004 to 2018 Surveillance, Epidemiology, and End Results data. Analysis used Cochran-Armitage test for trends, multivariable logistic regression, and Kaplan-Meier survival estimates.
Of 66,319 eligible T2/T3 patients, 57,211 were clinically node negative; 2,191 were clinically node positive; 6,197 were clinical node unreported; and 19,044/66,319 (28.8%) had no lymph node surgery. Among clinically node-negative patients, 36,433 (63.7%) underwent sentinel lymph node biopsy and 31,026 (85.2%) were pathologically node negative; 1,499 clinically node-positive patients (68.4%) had a lymph node dissection. Lymph node dissection rates declined from 2004 to 2018, 79.8% to 32.0% for clinically node-negative/pathologically node-positive patients and 80.4% to 61.2% for clinically node-positive/pathologically node-positive patients (both P < .0001). For clinically node-negative patients, lymph node surgery compliance improved from 63.7% (2004) to 70.4% (2018) (P < .0001). Compliance correlated with younger age, male sex, tumor mitotic rate, and site (extremity > trunk/head/neck) in multivariable analysis and improved 5-year cancer-specific survival (90.0% vs 83.4%) (all P < .0001).
Despite clear guidelines, one-third of intermediate-thickness melanoma patients in a recent cohort did not have recommended lymph node surgery. Lymph node status is a key determinant of the relative benefit of adjuvant systemic therapy and the need for active surveillance of pathologically node-positive/clinically node-negative patients. These data highlighted a clinical care gap. Efforts to improve guideline compliance are a logical strategy to improve cancer outcomes for intermediate-thickness melanoma patients.
黑色素瘤淋巴结手术指南的执行情况存在差异，部分原因是患者选择存在争议。先前的数据表明，前哨淋巴结活检的实践并不理想，临床淋巴结阳性疾病的治疗不足，这早于多中心选择性淋巴结切除术试验 II 的发表。为了最大程度地减少偏差，我们研究了 T2/T3（中厚度）黑色素瘤患者中淋巴结手术指南的执行情况，因为在 T2/T3 患者中存在最大的共识。
从 2004 年至 2018 年的监测、流行病学和最终结果数据中确定了 T2/T3 和转移 0 期黑色素瘤病例。分析使用 Cochran-Armitage 趋势检验、多变量逻辑回归和 Kaplan-Meier 生存估计。
在 66319 名符合条件的 T2/T3 患者中，57211 名患者临床淋巴结阴性；2191 名患者临床淋巴结阳性；6197 名患者临床淋巴结未报告；19044/66319（28.8%）未行淋巴结手术。在临床淋巴结阴性的患者中，36433 名（63.7%）接受了前哨淋巴结活检，31026 名（85.2%）病理淋巴结阴性；1499 名临床淋巴结阳性患者（68.4%）接受了淋巴结清扫术。淋巴结清扫术的比例从 2004 年到 2018 年下降，临床淋巴结阴性/病理淋巴结阳性患者从 79.8%下降到 32.0%，临床淋巴结阳性/病理淋巴结阳性患者从 80.4%下降到 61.2%（均<0.0001）。对于临床淋巴结阴性的患者，淋巴结手术的执行情况从 2004 年的 63.7%（2004 年）提高到 2018 年的 70.4%（2018 年）（均<0.0001）。多变量分析显示，淋巴结手术的执行情况与年龄较小、男性、肿瘤有丝分裂率和肿瘤部位（四肢>躯干/头颈部）相关，并且提高了 5 年癌症特异性生存率（90.0%比 83.4%）（均<0.0001）。
尽管有明确的指南，但在最近的队列中，三分之一的中厚度黑色素瘤患者没有接受推荐的淋巴结手术。淋巴结状态是辅助全身治疗相对益处的关键决定因素，也是对病理淋巴结阳性/临床淋巴结阴性患者进行积极监测的必要条件。这些数据突出了临床护理方面的差距。努力提高指南的执行情况是改善中厚度黑色素瘤患者癌症结局的合理策略。
