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Broman KK , Hughes TM , Dossett LA , Sun J , Carr MJ , Kirichenko DA , Sharma A , Bartlett EK , Nijhuis AA , Thompson JF , Hieken TJ , Kottschade L , Downs J , Gyorki DE , Gyorki JJ , Stahlie E , van Akkooi A , Ollila DW , Frank J , Song Y , Karakousis G , Moncrieff M , Nobes J , Vetto J , Han D , Farma J , Deneve JL , Fleming MD , Perez M , Baecher K , Lowe M , Bagge RO , Mattsson J , Lee AY , Berman RS , Chai H , Kroon HM , Teras RM , Teras J , Farrow NE , Beasley GM , Hui JYC , Been L , Kruijff S , Boulware D , Sarnaik AA , Sondak VK , Zager JS , Int High Risk Mela
Surveillance of Sentinel Node-Positive Melanoma Patients with Reasons for Exclusion from MSLT-II: Multi-Institutional Propensity Score Matched Analysis
J Am Coll Surg. 2021 Apr;232(4) :424-431
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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 Copyright (C) 2020 Published by Elsevier Inc. on behalf of the American College of Surgeons. All rights reserved.
Notes
Broman, Kristy K. Hughes, Tasha M. Dossett, Lesly A. Sun, James Carr, Michael J. Kirichenko, Dennis A. Sharma, Avinash Bartlett, Edmund K. Nijhuis, Amanda A. G. Thompson, John F. Hieken, Tina J. Kottschade, Lisa Downs, Jennifer Gyorki, David E. Gyorki, J. Jennifer Stahlie, Emma van Akkooi, Alexander Ollila, David W. Frank, Jill Song, Yun Karakousis, Giorgos Moncrieff, Marc Nobes, Jenny Vetto, John Han, Dale Farma, Jeffrey Deneve, Jeremiah L. Fleming, Martin D. Perez, Matthew Baecher, Kirsten Lowe, Michael Bagge, Roger Olofsson Mattsson, Jan Lee, Ann Y. Berman, Russell S. Chai, Harvey Kroon, Hidde M. Teras, Roland M. Teras, Juri Farrow, Norma E. Beasley, Georgia M. Hui, Jane Y. C. Been, Lukas Kruijff, Schelto Boulware, David Sarnaik, Amod A. Sondak, Vernon K. Zager, Jonathan S. Beasley, Georgia/O-2442-2018 Beasley, Georgia/0000-0001-6387-9030; Kroon, Hidde M/0000-0002-8923-7527; Olofsson Bagge, Roger/0000-0001-5795-0355; Lee, Ann/0000-0002-8143-2635; Hui, Jane Yuet Ching/0000-0002-2628-0720; Berman, Russell/0000-0002-5026-5651; Moncrieff, Marc/0000-0003-4492-235X 1879-1190