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Predicting Nonsentinel Lymph Node Involvement in Stage I/II Melanoma

Department of Surgical Oncology, VU University Medical Center, Amsterdam, The Netherlands
Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands
Department of Surgical Oncology, VU University Medical Center, Amsterdam, The Netherlands

To the Editor:

We read with interest the article by Reeves et al. on the prediction of nonsentinel lymph node status in melanoma. The authors are to be congratulated for developing a scoring system, which predicts the nonsentinel node status in melanoma patients using the characteristics of the primary tumor and the amount of metastasis in the sentinel lymph node (SLN).¹

As mentioned by the authors, at the present moment all melanoma patients with a positive SLN are offered a completion lymph node dissection (CLND), as advised by the American Joint Committee on Cancer. This is associated with a considerable morbidity. However, approximately 80% of these patients do not have positive non-SLN and will thus not benefit from a CLND. If the non-SLN status could be predicted, this group could be spared a CLND. In this study, the authors use the presence of ulceration of the primary melanoma and the maximum diameter of metastatic involvement in the SLN to predict the non-SLN status. Patients with a Size/Ulceration (SU) score of 0 will have no positive additional lymph nodes and could be spared a CLND.

After using this system on our own population, we doubt whether this scoring system is valid for a larger group of patients. Between 1993 and 2001, 454 consecutive patients underwent a selective SLN dissection at the VU University Medical Center. Seventy-one of them had a positive SLN node and underwent a CLND. Of these patients, 19 had one or more positive additional lymph nodes after CLND.² By using the scoring system as suggested by the authors, 44 patients had a SU score of 0, 21 patients had a SU score of 1, and 5 patients had a SU score of 2. Eight of the 44 patients with a SU score of 0, who would not have an additional lymph node dissection in the Reeves system, had positive additional lymph nodes after the dissection. During follow-up, one of these eight patients developed metastasis in the locoregional skin after 8 months and three of them developed systemic metastases after 6–17 months. These four patients have died of disease after 15–26 months follow-up.

So, the scoring system as suggested by the authors would withhold a group of patients at high risk for a CLND. Even when the CLND does not improve survival, this group of patients could have been more accurately staged after CLND.

We agree with the authors that a model to predict the absence of non-SLN involvement could spare many patients an unnecessary surgical procedure, but in our opinion the parameters as used by the authors are not accurate enough to predict non-SLN status. Instead of the scoring system suggested by the authors, our group has recently developed a staging system, which includes Breslow thickness of the primary tumor in combination with the surface area of metastases in the SLN to predict non-SLN involvement.² We have used the surface area of metastasis because in our experience most tumor deposits do not appear to be round. In this study, even patients with a small metastasis in the SLN and without ulceration of the primary tumor but with a thick primary melanoma showed positive additional lymph nodes. Using these parameters we were able to define a group of patients who will not have positive additional lymph nodes and could be spared a CLND. Interestingly, this group of patients had a significantly better disease-free and overall survival (87% and 94%, respectively). The presence of ulceration was not an independent factor after univariate and multivariate analysis in predicting non-SLN involvement.

Further studying other combinations of primary melanoma characteristics in combination with SLN metastases characteristics, such as a combination of Breslow thickness and tumor load in the SLN, would be useful to develop a staging system valid for large groups of cutaneous melanoma patients.

REFERENCES

1. Reeves ME, Delgado R, Busam KJ, Brady MS, Coit DG. Prediction of nonsentinel lymph node status in melanoma. Ann Surg Oncol 2003; 10: 27–31.[Abstract/Free Full Text]
2. Vuylsteke RJCLM, Borgstein PJ, van Leeuwen PAM, et al. Metastatic tumorload in the sentinel lymph node in stage I/II melanoma: a strong predictor of additional lymph node involvement and survival. Ann Surg Oncol 2003; 10: S18.

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