Incidence and location of positive nonsentinel lymph nodes in head and neck melanoma

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Abstract

Background

The complex lymphatic drainage in the head and neck makes sentinel lymph node biopsy (SLNB) for melanomas in this region challenging. This study describes the incidence, and location of additional positive nonsentinel lymph nodes (NSLN) in patients with cutaneous head and neck melanoma following a positive SLNB.

Methods

A retrospective review was performed using a single institution prospective database. Patients with a primary melanoma in the head or neck with a positive cervical SLNB were identified. The lymphadenectomy specimen was divided intraoperatively into lymph node levels I–V, and NSLN status determined for each level.

Results

Of 387 patients with melanoma of the head and neck who underwent cervical SLNB, 54 had a positive SLN identified (14%). Thirty six patients (67%) underwent immediate completion lymph node dissection (CLND) of whom eight patients (22%) had a positive NSLN. The remaining 18 patients (33%) did not undergo CLND and were observed. Half of positive NSLNs (50%) were in the same lymph node level as the SLN and 33% were in an immediately adjacent level; only two patients were found to have NSLNs in non-adjacent levels. The only factor predictive of NSLN involvement was the size of the tumor deposit in the SLN>0.2 mm (p = 0.05). Superficial parotidectomy at CLND revealed metastatic melanoma only in patients with a positive parotid SLN.

Conclusions

A positive NLSN was identified in 22% of patients undergoing CLND after a positive SLNB. The majority of positive NSLNs are found within or immediately adjacent to the nodal level containing the SLN.

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.

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