Slingluff C L, Stidham K R, Ricci W M, Stanley W E, Seigler H F
Department of Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia.
Ann Surg. 1994 Feb;219(2):120-30. doi: 10.1097/00000658-199402000-00003.
The purpose of this study was to evaluate a large number of patients with cutaneous melanoma who had or who were at risk for lymph node metastases to contribute to the understanding of the behavior of and appropriate management of draining nodes. A major goal of the study was to reassess the clinical impact of elective lymph node dissections (ELND) in a large patient population.
Large retrospective studies suggest that ELND may improve the prognosis of patients with intermediate thickness melanomas; however, that improvement has not been observed in two randomized prospective controlled trials.
The charts of 4682 patients treated at a single institution for localized or regional disease were reviewed individually. The median follow-up was 4.7 years, with 814 patients followed more than 10 years. The data were tabulated and evaluated with the aid of a computer data base system.
Among patients with nodal metastases, 10% of nodal metastases were to contralateral nodes, and 6% were to nodal basins that would not be predicted by classic models of lymphatic drainage; in 13% of patients, nodal metastases occurred to greater than one nodal basin (3% of the entire study group). For all thickness ranges, the incidence of nodal metastases was comparable to the incidence of distant metastases; intermediate-thickness lesions had no relative predilection for nodal metastases. At the initial evaluation, regional nodal basins were clinically negative in 3550 patients, of whom 911 (25.7%) underwent ELND. Stratified into five thickness groups (< 0.76 mm, 0.76 to 1.5 mm, 1.5 to 2.5 mm, 2.5 to 4 mm, and > 4 mm), pathologically positive nodes were identified in 0%, 5%, 16%, 24%, and 36%, respectively (16% overall). Among the 911 patients who underwent ELND, 214 (23%) had nodal metastases, 143 at the time of ELND and 71 at a later date. Of these 71 patients, 31 (44%) had nodal metastases in a previously dissected nodal basin, and 40 (56%) had them in basins not previously dissected. The survival of patients with clinically negative nodes treated with and without ELND were compared. The two groups were well matched for major prognostic factors. Stratified by Breslow thickness and primary site, no significant improvement in survival was observed with ELND.
Because of the significant incidence of metastases to contralateral and atypical nodal basins, lymphoscintigraphy may be justified for the preoperative evaluation of patients for ELND. However, the therapeutic value of ELND is questionable as a result of (1) the finding that the risk of nodal metastases is not relatively more common than is that of distant metastases among patients with intermediate-thickness melanomas, (2) the fact that only 16% of ELND were positive, (3) the finding that ELND may not prevent recurrent nodal disease in the dissected basin, and (4) the absence of any apparent impact on survival among patients who underwent ELND.
本研究旨在评估大量患有皮肤黑色素瘤且有或有淋巴结转移风险的患者，以促进对引流淋巴结行为及适当管理的理解。该研究的一个主要目标是在大量患者群体中重新评估选择性淋巴结清扫术（ELND）的临床影响。
大型回顾性研究表明，ELND可能改善中等厚度黑色素瘤患者的预后；然而，在两项随机前瞻性对照试验中未观察到这种改善。
对在单一机构接受局部或区域疾病治疗的4682例患者的病历进行了逐一审查。中位随访时间为4.7年，814例患者随访超过10年。借助计算机数据库系统对数据进行列表和评估。
在有淋巴结转移的患者中，10%的淋巴结转移至对侧淋巴结，6%转移至经典淋巴引流模型无法预测的淋巴结区域；13%的患者发生了一个以上淋巴结区域的转移（占整个研究组的3%）。对于所有厚度范围，淋巴结转移的发生率与远处转移的发生率相当；中等厚度病变对淋巴结转移没有相对偏好。在初始评估时，3550例患者的区域淋巴结区域临床检查为阴性，其中911例（25.7%）接受了ELND。分为五个厚度组（<0.76mm、0.76至1.5mm、1.5至2.5mm、2.5至4mm和>4mm），病理检查发现阳性淋巴结的比例分别为0%、5%、16%、24%和36%（总体为16%）。在911例接受ELND的患者中，214例（23%）有淋巴结转移，143例在ELND时发现，71例在之后发现。在这71例患者中，31例（44%）在先前清扫过的淋巴结区域发生了转移，40例（56%）在先前未清扫过的区域发生了转移。比较了接受和未接受ELND治疗的临床阴性淋巴结患者的生存率。两组在主要预后因素方面匹配良好。按Breslow厚度和原发部位分层，未观察到ELND对生存率有显著改善。
由于对侧和非典型淋巴结区域转移的发生率较高，淋巴闪烁显像术可能适用于ELND患者的术前评估。然而，ELND的治疗价值值得怀疑，原因如下：（1）发现中等厚度黑色素瘤患者发生淋巴结转移的风险并不比远处转移的风险相对更高；（2）只有16%的ELND发现有阳性结果；（3）发现ELND可能无法预防清扫区域的淋巴结复发疾病；（4）ELND对接受该手术的患者生存率没有任何明显影响。
