Incidence and location of positive nonsentinel lymph nodes in head and neck melanoma☆
Introduction
Approximately 20% of primary cutaneous melanomas arise in the head and neck.1 Sentinel lymph node (SLN) biopsy (SLNB) is able to accurately identify early nodal micrometastatic disease, and lymph node status is the strongest prognostic factor for patients with clinically lymph node negative melanoma. For patients with a positive SLNB, the standard of care is completion lymph node dissection (CLND), although a recent meta-analysis reported that only 14% of SLNB positive patients will have additional positive nodes found at CLND.1
Most studies of CLND for patients with positive SLNB have included patients with primary melanoma of all sites.2, 3, 4, 5 This information may therefore not be relevant to the head and neck because completion neck dissection has some unique features when compared with CLND in the axilla or groin,6 including the complex anatomy and structures at risk, the frequent proximity of the primary lesion to the lymph node basin as well as the lower rates of long term morbidity, specifically lymphedema. These factors have lead to a lack of consensus on the need for CLND for patients with a positive SLN in the head and neck, as demonstrated by a recent SEER data analysis which reports that only 60% of patients with a positive SLN in the head and neck underwent CLND.7 This paper describes a single center experience with positive SLNB for melanoma of the head and neck, and details the incidence and location of positive nonsentinel lymph nodes (NSLN) in these patients.
Section snippets
Patients
All patients undergoing SLNB at Memorial Sloan-Kettering Cancer Center since January 1996 have been prospectively entered into a comprehensive melanoma database. Follow up data is maintained regularly. All patients with a melanoma in the head and neck region who had a positive sentinel lymph node identified were included in the analysis. Patient records were reviewed for details of the SLNB and CLND pathology specimens. The use of patient records for this study was approved by the institutional
Patient details
Between January 1996 and June 2012, 387 patients with a primary cutaneous melanoma of the head and neck underwent SLNB at our institution. At least one positive SLN was identified in 54 patients (14%) and these patients constitute the study population. Immediate CLND was performed in 36 of these patients (67%); ten patients underwent CLND at the time of SLNB on the basis of positive frozen section diagnosis while five patients had a negative frozen section result with metastatic melanoma found
Discussion
SLNB has become routine in many centers since the publication of the multicenter selective lymphadenectomy trial-1 (MSLT-1) in 2006.9 Although this trial did not show a benefit in overall survival for SLNB and subsequent CLND over observation and delayed lymphadenectomy, it did demonstrate the strong prognostic significance of a positive SLNB. This trial also found a lower accuracy of SLNB in head and neck melanoma patients compared to other anatomic sites. This difference can be attributed to
Conclusion
The optimal management of patients with positive SLNs in head and neck cutaneous melanoma remains controversial. This study describes a single center experience of CLND for head and neck melanoma and demonstrates that after a positive SLNB in the neck, the NSLN positive rate is 22%. Furthermore, the majority of positive NSLNs are found within or immediately adjacent to the nodal level containing the SLN. Positive intraparotid NSLNs are only found in cases of positive periparotid SLNs and if
Acknowledgments
Thankyou to Kita Bogatch for database assistance and Frank Palmer for statistical assistance.
References (28)
- et al.
Predictors of nonsentinel lymph node positivity in patients with a positive sentinel node for melanoma
J Am Coll Surg
(2005) - et al.
Prediction of potential metastatic sites in cutaneous head and neck melanoma using lymphoscintigraphy
Am J Surg
(1995) - et al.
Patterns of regional lymph node metastases from cutaneous melanomas of the head and neck
Am J Surg
(1991) - et al.
Reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of nonsentinel nodes following completion lymphadenectomy for melanoma
J Surg Res
(2001) - et al.
Sentinel node biopsy for head and neck melanoma: a systematic review
Otolaryngol Head Neck Surg
(2011) - et al.
Microscopic tumor burden in sentinel lymph nodes predicts synchronous nonsentinel lymph node involvement in patients with melanoma
J Clin Oncol
(2008) - et al.
Non-Sentinel Node Risk Score (N-SNORE): a scoring system for accurately stratifying risk of non-sentinel node positivity in patients with cutaneous melanoma with positive sentinel lymph nodes
J Clin Oncol
(2010) - et al.
Criteria in sentinel lymph nodes of melanoma patients that predict involvement of nonsentinel lymph nodes
Ann Surg Oncol
(2008) - et al.
Completion node dissection in patients with sentinel node-positive melanoma of the head and neck
Otolaryngol Head Neck Surg
(2012) - et al.
Sentinel lymph node biopsy for cutaneous head and neck melanomas
Arch Otolaryngol Head Neck Surg
(2002)
Sentinel-node biopsy or nodal observation in melanoma
N Engl J Med
Sentinel node biopsy for early-stage melanoma: accuracy and morbidity in MSLT-I, an international multicenter trial
Ann Surg
Melanoma patients with positive sentinel nodes who did not undergo completion lymphadenectomy: a multi-institutional study
Ann Surg Oncol
Sentinel lymph node biopsy for melanoma: American Society of Clinical Oncology and Society of Surgical Oncology joint clinical practice guideline
Ann Surg Oncol
Cited by (20)
Anatomical location of the primary tumour and its relationship to regional lymph node metastasis in cutaneous head and neck melanoma: Is selective neck dissection appropriate?
2021, Journal of Plastic, Reconstructive and Aesthetic SurgeryMeasuring the quality of melanoma surgery – Highlighting issues with standardization and quality assurance of care in surgical oncology
2017, European Journal of Surgical OncologyCitation Excerpt :However, is on-going whether to avoid dissecting LNs of level III, where metastatic disease is found in less than 5% of SLN-positive patients.51 For neck dissection, recent research has shown that after a positive SLN, if non-SLN involvement is later found, the majority of metastatic LNs are located at the same anatomic level as the SLN, supporting the idea a less extensive lymphadenectomy may be adequate for SLNB-positive patients.52 Inguinal lymphadenectomy is routinely performed in patients with groin metastasis, while pelvic dissection is recommended by several national clinical practice guidelines and by several authors in patients with radiological imaging showing pelvic LN metastasis or defined risk factors for pelvic LN involvement (more than three positive inguinal LNs and metastasis in Cloquet's LN), though it is well established that lymph flow more often enters the pelvis by other routes.45,46
Head and Neck Melanoma
2014, Surgical Clinics of North AmericaCitation Excerpt :The extent of neck dissection depends on the level of the SLN and the location of the primary lesion. Gyorki and colleagues60 reported that positive nonsentinel lymph nodes were mostly identified within or adjacent to the nodal level containing the SLN. A parotidectomy is indicated with positive parotid SLN as well if clinically apparent disease is present in the parotid.
Contemporary controversies and perspectives in the staging and treatment of patients with lymph node metastasis from melanoma, especially with regards positive sentinel lymph node biopsy
2014, Cancer Treatment ReviewsCitation Excerpt :In the aforementioned international survey, 35% of responders routinely performed a full-level one-five neck dissection, and 62% based the extent of neck dissection on the primary tumor site and lymphatic mapping [16]. Interestingly, recent research in head and neck patients has shown that after a positive SLN if there is later found to be non-SLN involvement, the majority of metastatic LNs are located in the same anatomic level as the SLN, supporting the idea of a less extensive lymphadenectomy may be adequate for SLNB-positive patients [29]. Conversely, axillary dissection represents a more standardized operation, as 81% of the survey responders routinely performed a three-level lymphadenectomy [16].
- ☆
Presented at the meeting of the Society of Surgical Oncology, Washington DC, 2013.