Annals of Surgical Oncology Sign the Guestbook
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow An erratum has been published
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Dessureault, S.
Right arrow Articles by Reintgen, D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dessureault, S.
Right arrow Articles by Reintgen, D.
Related Collections
Right arrow Sentinel lymph node
Annals of Surgical Oncology 8:766-770 (2001)
© 2001 Society of Surgical Oncology

ORIGINAL ARTICLES

Improved Staging of Node-Negative Patients With Intermediate to Thick Melanomas (>1 mm) With the Use of Lymphatic Mapping and Sentinel Lymph Node Biopsy

Sophie Dessureault, MD, Seng-Jaw Soong, PhD, Merrick I. Ross, MD, John F. Thompson, MD, John M. Kirkwood, MD, Daniel G. Coit, MD, Kelly M. McMasters, MD, Charles M. Balch, MD and Douglas Reintgen, MD the American Joint Committee on Cancer (AJCC) Melanoma Staging Committee*

From the H. Lee Moffitt Cancer Center (SD, DR), University of South Florida, Tampa, Florida; the University of Alabama at Birmingham (S-JS), Birmingham, Alabama; the M. D. Anderson Cancer Center (MIR), University of Texas, Houston, Texas; the Sydney Melanoma Unit (JFT), University of Sydney, Sydney, Australia; the University of Pittsburgh Medical Center (JMK), Pittsburgh, Pennsylvania; the Memorial Sloan-Kettering Cancer Center (MGC), New York, New York; the University of Louisville Medical Center (KMM), Louisville, Kentucky; and the John Hopkins Medical Center (CMB), Baltimore, Maryland.

Correspondence: Address correspondence to: Sophie Dessureault, MD, H. Lee Moffitt Cancer Center, Suite 3125, 12901 Magnolia Drive, Tampa, FL 33612; Fax: 813-979-7229; E-mail: sdessure{at}hsc.usf.edu Address reprint requests to: Douglas Reintgen, MD, H. Lee Moffitt Cancer Center, 12901 Magnolia Drive, Tampa, FL 33612; Fax: 813-979-7211; E-mail: reintgds@moffitt.usf.edu.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Elective lymph node dissection (ELND) may contribute to a survival benefit in certain stratified subsets of melanoma patients. We hypothesized that lymphatic mapping and sentinel lymph node (SLN) biopsy (with complete node dissection if metastases are present) may improve both staging and survival of patients with clinically negative nodes, without subjecting all patients to the morbidity associated with complete ELND.

Methods: We reviewed the data for all 14,914 N0 patients of the AJCC Melanoma Staging Database to determine the effect of SLN biopsy and ELND on staging and survival.

Results: Retrospective analysis revealed that there was an apparent statistically significant survival advantage to SLN biopsy in patients with melanomas >1 mm (n = 9024; 68.5% and 26.2% reduction in mortality compared with patients staged to be N0 by clinical exam and ELND, respectively; P < .0001). Five-year survivals were 90.5%, 77.7%, and 69.8%, respectfully, for patients staged by SLN biopsy (n = 2552), ELND (n = 2014), and clinical examination alone (n = 5192). The survival advantage of SLN biopsy was statistically significant for each T-stage category (T2, T3, and T4) and ulceration status. There was no advantage to SLN biopsy in patients with melanomas <1 mm (n = 5890).

Conclusions: SLN biopsy provides more accurate staging and may contribute to a survival benefit in populations of patients with melanoma.

Key Words: Melanoma • Staging • Lymphatic mapping • Sentinel lymph node • Survival


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The role of regional lymph node dissection in the management of melanoma patients with clinically uninvolved nodes has long been controversial. Elective lymph node dissection (ELND) provides valuable staging information that helps to determine patient prognosis and aids in patient selection for adjuvant chemotherapy. It may also contribute to the control of regional disease. Whether ELND can increase overall survival of patients with clinically negative nodes depends on whether regional lymph node micrometastases are simply markers of systemic disease or whether they are deposits of disease that are confined to the regional basin and lie dormant and eventually act as a sink for further systemic metastases. Early retrospective nonrandomized studies demonstrated a survival advantage for patients treated by ELND instead of delayed therapeutic dissection,1–5 but later randomized prospective clinical trials failed to confirm the survival benefit.6–10 Investigators from the Intergroup Melanoma Trial recently demonstrated a survival advantage for ELND in prospectively stratified subsets of patients with nonulcerated melanomas and melanomas with tumor thicknesses from 1 to 2 mm.11,12

Unfortunately, ELND can be associated with significant morbidity, including paresthesias, wound infection, seroma formation, drain complications, and lymphedema, both acute and chronic. Lymphatic mapping and sentinel lymph node (SLN) biopsy is a minimally invasive procedure that has not been associated with any significant morbidity. The SLN is defined as the first lymph node or nodes to receive lymphatic drainage from the primary cancer and, as such, the node or nodes most likely to contain metastatic deposits.13,14 The SLN in fact reflects the tumor status of the entire nodal basin: an SLN negative for malignancy by both hematoxylin and eosin staining and cytokeratin immunohistochemistry accurately predicts the absence of metastatic cells in all other regional nodes.14–19

We hypothesized that lymphatic mapping and SLN biopsy (with complete node dissection if metastases were present) would improve both the staging and the survival of patients with clinically negative regional nodes (American Joint Committee on Cancer [AJCC] stages I and II), without subjecting all patients to the morbidity associated with complete ELND.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The following 12 institutions and cooperative study groups contributed prospectively accumulated staging and melanoma-specific survival data on 30,450 melanoma patients to the AJCC Melanoma Staging Database: Sydney Melanoma Unit, Royal Prince Alfred Hospital; the University of Texas M. D. Anderson Cancer Center; Memorial Sloan-Kettering Cancer Center; University of Alabama at Birmingham Cancer Center; H. Lee Moffitt Cancer Center at the University of South Florida; National Tumor Institute in Milan; University of Washington Cancer Center; Eastern Cooperative Oncology Group; Southwest Oncology Group; Intergroup Melanoma Surgical Trial; World Health Organization (WHO) Melanoma Program; and the Sunbelt Melanoma Group. All data were transferred electronically to the Biostatistics Unit of the Comprehensive Cancer Center at the University of Alabama at Birmingham. The Biostatistics Unit converted the data file from each institution or group into a SAS (SAS Institute, Cary, NC) data set. After quality-control checks, all data sets were integrated into a single large AJCC Melanoma Staging Database (n = 30,450 patients) for statistical analysis and report generation.

All patients with clinically negative lymph nodes (n = 15,767) underwent wide local excision of their primary melanoma. Regional nodal basins were staged by one of three methods: clinical examination alone, ELND, or lymphatic mapping and SLN biopsy. Patients underwent complete node dissection if SLN biopsy revealed metastatic disease. Preoperative lymphoscintigraphy was used to identify all basins at risk for disease, and all identified at-risk basins were addressed. A total of 14,914 patients were found to have N0 disease. All patients with pathologically positive nodes (853 of 15,767; 5.4%) were excluded from subsequent analysis.

Mean follow-up for this group of node-negative patients was 5.0 years; median follow-up was 3.5 years. A total of 5575 patients (37.4%) had at least 5 years of follow-up information. Survival times were calculated from the onset of primary melanoma diagnosis and considered censored for patients who were alive at the last follow-up or who died without evidence of melanoma. Survival curves were generated for each T category according to the Kaplan-Meier product-limit method and were compared by using the log-rank test. Data were reviewed to determine the effect of clinical examination, ELND, and SLN biopsy of the regional lymph node basin on survival. Differences were considered significant at P < .05.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Patient Demographics
A total of 53% of patients were men; 47% were women. The median age at diagnosis was 50 to 59 years for both men and women. The largest age group overall was from 40 to 49 years of age. Figure 1 shows the age distribution among the three groups of patients (P < .0001).



View larger version (44K):
[in this window]
[in a new window]
  		FIG. 1. Age distribution of node-negative melanoma patients staged by clinical examination alone, elective lymph node dissection (ELND), and lymphatic mapping and sentinel lymph node biopsy (SLN bx).

 
Site of Primary Melanoma
Most primary tumors were found on the trunk (35%); 29% of lesions were found on the lower extremity, 21% on the upper extremity, and 15% on the head and neck region. Figure 2 shows the distribution of tumor sites among the three study groups (P < .0001).



View larger version (46K):
[in this window]
[in a new window]
  		FIG. 2. Distribution of primary melanoma sites for node-negative patients staged by clinical examination alone, elective lymph node dissection (ELND), and lymphatic mapping and sentinel lymph node biopsy (SLN bx).

 
Tumor Thickness
Distribution of the Breslow thickness for the entire group is displayed in Fig. 3. Overall, 39.4% of tumors were <1.0 mm, 28.4% were 1.01 to 2.0 mm, 21.7% were 2.01 to 4.0 mm, and 10.3% were >4.0 mm. The vast majority (5192 of 5890; 88.1%) of patients who had tumors measuring <1.0 mm were staged by clinical examination alone. Most patients (5,192 of 10,348; 50.2%) staged by clinical examination alone had tumors measuring <1.0 mm. Patients who were staged pathologically, either by ELND or by SLN biopsy, were more likely to have had tumors measuring 1.1 to 4.0 mm.



View larger version (33K):
[in this window]
[in a new window]
  		FIG. 3. Distribution of primary tumor thickness in node-negative melanoma patients staged by clinical examination alone, elective lymph node dissection (ELND), and lymphatic mapping and sentinel lymph node biopsy (SLN bx).

 
Nodal Assessment
A total of 10,348 patients (69.4%) were staged by clinical examination alone, 2,014 (13.5%) were staged by ELND, and 2,552 (17.1%) were staged by SLN biopsy.

Survival
There was no advantage to pathologic staging with SLN biopsy or ELND in patients with thin (<1 mm) melanomas (n = 5890; Fig. 4). These patients presumably do not have a sufficiently high risk for occult regional metastases for node dissection to yield any survival benefit. Patients with intermediate to thick (>1 mm) melanomas (n = 9024), however, had better 5-year survivals when they were staged by either ELND (n = 1836; 5-year survival = 77.7% ± 1.0%) or SLN biopsy (n = 2032; 5-year survival = 90.5% ± 1.1%) than after clinical examination alone (n = 5156; 5-year survival = 69.8% ± .8%). This corresponds to a 68.5% and 26.2% reduction in mortality in patients staged to be N0 by SLN biopsy compared with patients staged to be N0 by clinical examination alone or by ELND, respectively (P < .0001; Fig. 5). The survival advantage of SLN biopsy over ELND or clinical examination was statistically significant for each T-stage category (T2, T3, and T4) and whether or not the tumor was ulcerated (Fig. 6).



View larger version (37K):
[in this window]
[in a new window]
  		FIG. 4. Five-year survival of node-negative melanoma patients staged by clinical examination alone, elective lymph node dissection (ELND), and lymphatic mapping and sentinel lymph node (SLN) biopsy. There was no statistically significant difference in survival among the three groups of patients when tumor thickness was <=1 mm. Patients with tumors >1 mm thick had a statistically significantly better survival when staged pathologically, with the best survival achieved in the group of patients staged by lymphatic mapping and SLN biopsy (P < .0001; n = 9024).

 


View larger version (20K):
[in this window]
[in a new window]
  		FIG. 5. Kaplan-Meier survival curves for node-negative melanoma patients with tumors >1 mm thick. Patients were staged by clinical examination alone, elective lymph node dissection (ELND), or lymphatic mapping and sentinel lymph node (SLN) biopsy. Differences among the three groups of patients were statistically significant (P < .0001).

 


View larger version (78K):
[in this window]
[in a new window]
  		FIG. 6. Five-year survival (by T-stage category) of node-negative melanoma patients staged by clinical examination alone, elective lymph node dissection (ELND), and lymphatic mapping and sentinel lymph node (SLN) biopsy. There was a statistically significant survival advantage in patients with T2, T3, and T4 melanomas staged as N0 by lymphatic mapping and SLN biopsy versus ELND or clinical examination alone.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Balch et al.11 recently reported results of the Intergroup Melanoma Surgical Trial. In this large, prospective, multicenter randomized trial, 740 patients with clinically node-negative melanomas 1.0 to 4.0 mm thick (T2 or T3, N0) were randomized to either ELND or nodal observation. They demonstrated a 25% to 30% relative reduction in the mortality rate of patients without tumor ulceration (P = .03) and with tumor thickness from 1.0 to 2.0 mm (P = .03). This selected population was believed to have had a sufficiently high risk for occult regional metastases to justify surgical excision of regional lymph nodes but a sufficiently low risk for distant occult metastases for ELND to have had a therapeutic benefit.

Three previous prospective, randomized studies also addressed the efficacy of ELND in melanoma. The WHO Melanoma Program Trial No. 1, reported in 1977,6 involved only extremity melanoma and did not stratify for major prognostic factors of melanoma. The Mayo Clinic study,8 a three-armed study with only 115 patients, did not control for tumor thickness or ulceration and did not have enough power to show a difference even if one existed. The second WHO melanoma trial20 (Trial No. 14) ended in 1989 and examined ELND in patients with melanomas of the trunk and tumor thickness >1.5 mm. All three studies were performed before the advent of lymphatic mapping, and no preoperative lymphoscintigraphy was performed to define lymphatic basins at risk. The wrong surgical procedure may have been performed up to 32% of the time for truncal melanomas.21 Despite these limitations, the WHO Trial No. 14 showed that survival was significantly better for patients with microscopic nodal disease that was resected than for patients who did not have an ELND and subsequently developed gross nodal disease.

In our study, N0 patients with tumors >1 mm thick who underwent staging by lymphatic mapping and SLN biopsy had better survivals than N0 patients staged with preoperative lymphoscintigraphy and ELND. This suggests that part of the survival benefit over N0 patients staged by clinical examination alone is likely caused by stage migration, as a result of more accurate staging and selection of a more pure N0 population. In other words, SLN biopsy misses fewer patients with stage III melanoma than clinical examination or ELND. Results from the Intergroup Melanoma Surgical Trial, however, suggest that part of the survival benefit is also probably related to a true therapeutic benefit from the surgical removal of occult regional disease. This argument assumes that metastases may exist in regional lymph nodes in the absence of distant disease and that removal of nodal metastases (by ELND or SLN biopsy) prevents subsequent spread to distant sites. The additional improved survival (from 77.7% to 90.5% 5-year survival) after staging with SLN biopsy over staging by ELND indicates that a subset of N0 patients staged by ELND have occult nodal disease (missed with a superficial histological examination of all nodes removed) and that removal of this disease by complete node dissection does not affect survival, either because there is also occult distant disease at the time or because surgical removal of regional disease is not sufficient to prevent subsequent recurrence or metastasis.

Lymphatic mapping and SLN biopsy provides accurate staging with minimal morbidity and identifies patients with clinically node-negative melanoma who may benefit from adjuvant therapies, such as interferon alfa-2b.22 SLN biopsy, and complete lymphadenectomy in the event of positive disease, may also contribute to a therapeutic benefit and improved survival in patients with tumors >1 mm thickness. Clinical examination of the regional basin and ELND with a superficial histological examination of all nodes removed will consistently miss micrometastatic disease and understage patients. Thus, more uniform populations for treatment arms in clinical trials should be obtained by staging patients with lymphatic mapping and SLN biopsy.


   Footnotes
 
*Members of the AJCC Melanoma Staging Committee: Charles M. Balch, MD, Antonio C. Buzaid, MD, Seng-Jaw Soong, PhD, Michael B. Atkins, MD, Natale Cascinelli, MD, Daniel G. Coit, MD, Irvin D. Fleming, MD, Jeffrey E. Gershenwald, MD, Alan Houghton Jr., MD, John M. Kirkwood, MD, Kelly M. McMasters, MD, Martin F. Mihm, MD, Donald L. Morton, MD, Douglas S. Reintgen, MD, Merrick I. Ross, MD, Arthur Sober, MD, John A. Thompson, MD, and John F. Thompson, MD. Back

Presented in part at the 54th Annual Meeting of the Society of Surgical Oncology, Washington, DC, March 15-18, 2001.

Received for publication March 16, 2001. Accepted for publication June 20, 2001.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Roses DF, Provet JA, Harris MN, Gumport SL, Dubin N. Prognosis of patients with pathologic stage II cutaneous malignant melanoma. Ann Surg 1985; 201: 103–7.[Medline]
  2. Callery C, Cochran AJ, Roe DJ, et al. Factors prognostic for survival in patients with malignant melanoma spread to the regional lymph nodes. Ann Surg 1982; 196: 69–75.[Medline]
  3. Milton GW, Shaw HM, McCarthy WH, Pearson L, Balch CM, Soong SJ. Prophylactic lymph node dissection in clinical stage I cutaneous malignant melanoma: results of surgical treatment in 1319 patients. Br J Surg 1982; 69: 108–11.[Medline]
  4. Balch CM, Soong SJ, Murad TM, Ingalls AL, Maddox WA. A multifactorial analysis of melanoma. II. Prognostic factors in patients with stage I (localized) melanoma. Surgery 1979; 86: 343–51.[Medline]
  5. Balch CM. The role of elective lymph node dissection in melanoma: rationale, results, and controversies. J Clin Oncol 1988; 6: 163–72.[Abstract]
  6. Veronesi U, Adamus J, Bandiera DC, et al. Inefficacy of immediate node dissection in stage 1 melanoma of the limbs. N Engl J Med 1977; 297: 627–30.[Abstract]
  7. Veronesi U, Adamus J, Bandiera DC, et al. Delayed regional lymph node dissection in stage I melanoma of the skin of the lower extremities. Cancer 1982; 49: 2420–30.[CrossRef][Medline]
  8. Sim FH, Taylor WF, Ivins JC, Pritchard DJ, Soule EH. A prospective randomized study of the efficacy of routine elective lymphadenectomy in management of malignant melanoma. Preliminary results. Cancer 1978; 41: 948–56.[CrossRef][Medline]
  9. Sim FH, Taylor WF, Pritchard DJ, Soule EH. Lymphadenectomy in the management of stage I malignant melanoma: a prospective randomized study. Mayo Clin Proc 1986; 61: 697–705.[Medline]
  10. Balch CM, Soong SJ, Bartolucci AA, et al. Efficacy of an elective regional lymph node dissection of 1 to 4 mm thick melanomas for patients 60 years of age and younger. Ann Surg 1996; 224: 255–63.[CrossRef][Medline]
  11. Balch CM, Soong S, Ross MI, et al. Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0 to 4.0 mm). Intergroup Melanoma Surgical Trial. Ann Surg Oncol 2000; 7: 87–97.[Abstract]
  12. Reintgen DS. Emerging evidence for a survival benefit associated with regional lymph node dissection for melanoma. Ann Surg Oncol 2000; 7: 75–6.[CrossRef][Medline]
  13. Cabanas RM. Anatomy and biopsy of sentinel lymph nodes. Urol Clin North Am 1992; 19: 267–76.[Medline]
  14. Morton DL, Wen DR, Wong JH, et al. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 1992; 127: 392–9.[Abstract]
  15. Lingam MK, MacKie RM, McKay AJ. Intraoperative identification of sentinel lymph node in patients with malignant melanoma. Br J Cancer 1997; 75: 1505–8.[Medline]
  16. Reintgen D, Rapaport D, Tanabe KK, Ross M. Lymphatic mapping and sentinel node biopsy in patients with malignant melanoma. J Fla Med Assoc 1997; 84: 188–93.
  17. Messina JL, Glass LF. Pathologic examination of the sentinel lymph node. J Fla Med Assoc 1997; 84: 153–6.
  18. Joseph E, Messina J, Glass FL, et al. Radioguided surgery for the ultrastaging of the patient with melanoma. Cancer J Sci Am 1997; 3: 341–5.[Medline]
  19. Morton DL, Thompson JF, Essner R, et al. Validation of the accuracy of intraoperative lymphatic mapping and sentinel lymphadenectomy for early-stage melanoma: a multicenter trial. Multicenter Selective Lymphadenectomy Trial Group. Ann Surg 1999; 230: 453–63.[CrossRef][Medline]
  20. Cascinelli N, Morabito A, Santinami M, MacKie RM, Belli F. Immediate or delayed dissection of regional nodes in patients with melanoma of the trunk: a randomised trial. WHO Melanoma Programme. Lancet 1998; 351: 793–6.[CrossRef][Medline]
  21. Norman J, Cruse CW, Espinosa C, Cox C, Berman C, Clark R, Saba H, Wells K, Reintgen D. Redefinition of cutaneous lymphatic drainage with the use of lymphoscintigraphy for malignant melanoma. Am J Surg 1991; 162: 432–7.[CrossRef][Medline]
  22. Kirkwood JM, Strawderman MH, Ernstoff MS, Smith TJ, Borden EC, Blum RH. Interferon alfa-2b adjuvant therapy of high-risk resected cutaneous melanoma: the Eastern Cooperative Oncology Group Trial EST 1684. J Clin Oncol 1996; 14: 7–17.[Abstract]



This article has been cited by other articles:


Home page
 Arch DermatolHome page
F. Niakosari, H. J. Kahn, D. McCready, D. Ghazarian, L. E. Rotstein, A. Marks, A. Kiss, and L. From
Lymphatic Invasion Identified by Monoclonal Antibody D2-40, Younger Age, and Ulceration: Predictors of Sentinel Lymph Node Involvement in Primary Cutaneous Melanoma
Arch Dermatol, April 1, 2008; 144(4): 462 - 467.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
J. S. Gold, D. P. Jaques, K. J. Busam, M. S. Brady, and D. G. Coit
Yield and Predictors of Radiologic Studies for Identifying Distant Metastases in Melanoma Patients with a Positive Sentinel Lymph Node Biopsy
Ann. Surg. Oncol., July 1, 2007; 14(7): 2133 - 2140.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
A. Govindarajan, D. M. Ghazarian, D. R. McCready, and W. L. Leong
Histological Features of Melanoma Sentinel Lymph Node Metastases Associated with Status of the Completion Lymphadenectomy and Rate of Subsequent Relapse
Ann. Surg. Oncol., February 1, 2007; 14(2): 906 - 912.
[Abstract] [Full Text] [PDF]

Home page
 JCOHome page
T. A. Aloia, J. E. Gershenwald, R. H. Andtbacka, M. M. Johnson, C. W. Schacherer, C. S. Ng, J. N. Cormier, J. E. Lee, M. I. Ross, and P. F. Mansfield
Utility of Computed Tomography and Magnetic Resonance Imaging Staging Before Completion Lymphadenectomy in Patients With Sentinel Lymph Node-Positive Melanoma
J. Clin. Oncol., June 20, 2006; 24(18): 2858 - 2865.
[Abstract] [Full Text] [PDF]

Home page
 Clin. Cancer Res.Home page
M. I. Ross
Early-stage melanoma: staging criteria and prognostic modeling.
Clin. Cancer Res., April 1, 2006; 12(7): 2312s - 2319s.
[Abstract] [Full Text] [PDF]

Home page
 JCOHome page
J. N. Cormier, Y. Xing, M. Ding, J. E. Lee, P. F. Mansfield, J. E. Gershenwald, M. I. Ross, and X. L. Du
Population-Based Assessment of Surgical Treatment Trends for Patients With Melanoma in the Era of Sentinel Lymph Node Biopsy
J. Clin. Oncol., September 1, 2005; 23(25): 6054 - 6062.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
R. J. C. L. M. Vuylsteke, P. J. Borgstein, P. A. M. van Leeuwen, H. A. Gietema, B. G. Molenkamp, M. G. S. Muller, P. J. van Diest, J. R. M. van der Sijp, and S. Meijer
Sentinel Lymph Node Tumor Load: An Independent Predictor of Additional Lymph Node Involvement and Survival in Melanoma
Ann. Surg. Oncol., June 1, 2005; 12(6): 440 - 448.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
E. C. Starritt, R. F. Uren, R. A. Scolyer, M. J. Quinn, and J. F. Thompson
Ultrasound Examination of Sentinel Nodes in the Initial Assessment of Patients With Primary Cutaneous Melanoma
Ann. Surg. Oncol., January 1, 2005; 12(1): 18 - 23.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
K. B. Stitzenberg, P. A. Groben, S. L. Stern, N. E. Thomas, T. A. Hensing, L. B. Sansbury, and D. W. Ollila
Indications for Lymphatic Mapping and Sentinel Lymphadenectomy in Patients with Thin Melanoma (Breslow Thickness <=1.0 mm)
Ann. Surg. Oncol., October 1, 2004; 11(10): 900 - 906.
[Abstract] [Full Text] [PDF]

Home page
 JCOHome page
A.C. Halpern and A.A. Marghoob
Thin Melanoma: Still "Excellent Prognosis" Disease?
J. Clin. Oncol., September 15, 2004; 22(18): 3651 - 3653.
[Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
C. Caraco, E. Celentano, S. Lastoria, G. Botti, P. A. Ascierto, and N. Mozzillo
Sentinel Lymph Node Biopsy Does not Change Melanoma-Specific Survival Among Patients with Breslow Thickness Greater than Four Millimeters
Ann. Surg. Oncol., March 1, 2004; 11(3_suppl): 198S - 202S.
[Abstract] [Full Text] [PDF]

Home page
 Arch DermatolHome page
T. M. Johnson, C. R. Bradford, S. B. Gruber, V. K. Sondak, and J. L. Schwartz
Staging Workup, Sentinel Node Biopsy, and Follow-up Tests for Melanoma: Update of Current Concepts
Arch Dermatol, January 1, 2004; 140(1): 107 - 113.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
S. H. Estourgie, O. E. Nieweg, R. A. Valdes Olmos, C. A. Hoefnagel, and B. B. R. Kroon
Review and Evaluation of Sentinel Node Procedures in 250 Melanoma Patients With a Median Follow-Up of 6 Years
Ann. Surg. Oncol., July 1, 2003; 10(6): 681 - 688.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
D. L. Rousseau Jr, M. I. Ross, M. M. Johnson, V. G. Prieto, J. E. Lee, P. F. Mansfield, and J. E. Gershenwald
Revised American Joint Committee on Cancer Staging Criteria Accurately Predict Sentinel Lymph Node Positivity in Clinically Node-Negative Melanoma Patients
Ann. Surg. Oncol., June 1, 2003; 10(5): 569 - 574.
[Abstract] [Full Text] [PDF]

Home page
 JCOHome page
R.J.C.L.M. Vuylsteke, P.A.M. van Leeuwen, M.G. S. Muller, H.A. Gietema, D.R. Kragt, and S. Meijer
Clinical Outcome of Stage I/II Melanoma Patients After Selective Sentinel Lymph Node Dissection: Long-Term Follow-Up Results
J. Clin. Oncol., March 15, 2003; 21(6): 1057 - 1065.
[Abstract] [Full Text] [PDF]

Home page
 The OncologistHome page
J. W. Jakub, S. Pendas, and D. S. Reintgen
Current Status of Sentinel Lymph Node Mapping and Biopsy: Facts and Controversies
Oncologist, February 1, 2003; 8(1): 59 - 68.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
R. Essner and D. L. Morton
Does the Tumor Status of the Regional Lymph Nodes Really Matter in Melanoma?
Ann. Surg. Oncol., December 1, 2001; 8(10): 749 - 751.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow An erratum has been published
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Dessureault, S.
Right arrow Articles by Reintgen, D.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dessureault, S.
Right arrow Articles by Reintgen, D.
Related Collections
Right arrow Sentinel lymph node

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS