Kristy K Broman1, Tasha M Hughes2, Lesly A Dossett2, James Sun3, Michael J Carr4, Dennis A Kirichenko5, Avinash Sharma6, Edmund K Bartlett6, Amanda Ag Nijhuis7, John F Thompson7, Tina J Hieken8, Lisa Kottschade9, Jennifer Downs10, David E Gyorki10, Emma Stahlie11, Alexander van Akkooi11, David W Ollila12, Jill Frank12, Yun Song13, Giorgos Karakousis13, Marc Moncrieff14, Jenny Nobes14, John Vetto15, Dale Han15, Jeffrey Farma16, Jeremiah L Deneve17, Martin D Fleming17, Matthew Perez18, Kirsten Baecher18, Michael Lowe18, Roger Olofsson Bagge19, Jan Mattsson19, Ann Y Lee20, Russell S Berman20, Harvey Chai21, Hidde M Kroon21, Roland M Teras22, Juri Teras22, Norma E Farrow23, Georgia M Beasley23, Jane Yc Hui24, Lukas Been25, Schelto Kruijff25, David Boulware4, Amod A Sarnaik26, Vernon K Sondak26, Jonathan S Zager26. 1. Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL; Department of Oncologic Sciences, University of South Florida, Tampa, FL; Department of Surgery, University of Alabama at Birmingham. Electronic address: kristybroman@uabmc.edu. 2. Department of Surgery, University of Michigan, Ann Arbor, MI. 3. Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL; Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH. 4. Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL. 5. Department of Oncologic Sciences, University of South Florida, Tampa, FL. 6. Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY. 7. Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia. 8. Department of Surgery, Mayo Clinic, Rochester, MN. 9. Department of Oncology, Division of Medical Oncology, Mayo Clinic, Rochester, MN. 10. Division of Cancer Surgery, Peter MacCallum Cancer Center, Melbourne, Australia. 11. Division of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands. 12. Department of Surgery, University of North Carolina, Chapel Hill, NC. 13. Department of Surgery, University of Pennsylvania, Philadelphia, PA. 14. Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, United Kingdom. 15. Department of Surgery, Oregon Health & Science University, Portland, OR. 16. Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA. 17. Department of Surgery, University of Tennessee Health Science Center, Memphis, TN. 18. Department of Surgery, Emory University, Atlanta, GA. 19. Sahlgrenska Center for Cancer Research, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. 20. Department of Surgery, NYU Langone Health, New York, NY. 21. Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia; Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, Australia. 22. Surgery Clinic, North Estonia Medical Centre Foundation, Tallinn, Estonia. 23. Department of Surgery, Duke University, Durham, NC. 24. Department of Surgery, University of Minnesota, Minneapolis, MN. 25. Department of Surgical Oncology, University of Groningen, University Medical Center, Groningen, Netherlands. 26. Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL; Department of Oncologic Sciences, University of South Florida, Tampa, FL.
Abstract
BACKGROUND: In sentinel lymph node (SLN)-positive melanoma, two randomized trials demonstrated equivalent melanoma-specific survival with nodal surveillance vs completion lymph node dissection (CLND). Patients with microsatellites, extranodal extension (ENE) in the SLN, or >3 positive SLNs constitute a high-risk group largely excluded from the randomized trials, for whom appropriate management remains unknown. STUDY DESIGN: SLN-positive patients with any of the three high-risk features were identified from an international cohort. CLND patients were matched 1:1 with surveillance patients using propensity scores. Risk of any-site recurrence, SLN-basin-only recurrence, and melanoma-specific mortality were compared. RESULTS: Among 1,154 SLN-positive patients, 166 had ENE, microsatellites, and/or >3 positive SLN. At 18.5 months median follow-up, 49% had recurrence (vs 26% in patients without high-risk features, p < 0.01). Among high-risk patients, 52 (31%) underwent CLND and 114 (69%) received surveillance. Fifty-one CLND patients were matched to 51 surveillance patients. The matched cohort was balanced on tumor, nodal, and adjuvant treatment factors. There were no significant differences in any-site recurrence (CLND 49%, surveillance 45%, p = 0.99), SLN-basin-only recurrence (CLND 6%, surveillance 14%, p = 0.20), or melanoma-specific mortality (CLND 14%, surveillance 12%, p = 0.86). CONCLUSIONS: SLN-positive patients with microsatellites, ENE, or >3 positive SLN constitute a high-risk group with a 2-fold greater recurrence risk. For those managed with nodal surveillance, SLN-basin recurrences were more frequent, but all-site recurrence and melanoma-specific mortality were comparable to patients treated with CLND. Most recurrences were outside the SLN-basin, supporting use of nodal surveillance for SLN-positive patients with microsatellites, ENE, and/or >3 positive SLN. Crown
BACKGROUND: In sentinel lymph node (SLN)-positive melanoma, two randomized trials demonstrated equivalent melanoma-specific survival with nodal surveillance vs completion lymph node dissection (CLND). Patients with microsatellites, extranodal extension (ENE) in the SLN, or >3 positive SLNs constitute a high-risk group largely excluded from the randomized trials, for whom appropriate management remains unknown. STUDY DESIGN: SLN-positive patients with any of the three high-risk features were identified from an international cohort. CLND patients were matched 1:1 with surveillance patients using propensity scores. Risk of any-site recurrence, SLN-basin-only recurrence, and melanoma-specific mortality were compared. RESULTS: Among 1,154 SLN-positive patients, 166 had ENE, microsatellites, and/or >3 positive SLN. At 18.5 months median follow-up, 49% had recurrence (vs 26% in patients without high-risk features, p < 0.01). Among high-risk patients, 52 (31%) underwent CLND and 114 (69%) received surveillance. Fifty-one CLND patients were matched to 51 surveillance patients. The matched cohort was balanced on tumor, nodal, and adjuvant treatment factors. There were no significant differences in any-site recurrence (CLND 49%, surveillance 45%, p = 0.99), SLN-basin-only recurrence (CLND 6%, surveillance 14%, p = 0.20), or melanoma-specific mortality (CLND 14%, surveillance 12%, p = 0.86). CONCLUSIONS: SLN-positive patients with microsatellites, ENE, or >3 positive SLN constitute a high-risk group with a 2-fold greater recurrence risk. For those managed with nodal surveillance, SLN-basin recurrences were more frequent, but all-site recurrence and melanoma-specific mortality were comparable to patients treated with CLND. Most recurrences were outside the SLN-basin, supporting use of nodal surveillance for SLN-positive patients with microsatellites, ENE, and/or >3 positive SLN. Crown
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