Clinical value of sentinel lymph node biopsy in patients with cutaneous and acral melanoma

doi:10.19401/j.cnki.1007-3639.2022.12.004

Abstract

Abstract:

Background and purpose: For cutaneous and acral malignant melanoma, sentinel lymph node biopsy (SLNB) is an effective tool to evaluate the situation of regional lymph node metastasis and to determine the pathological stage. As an important part of the standard procedure for surgical diagnosis and treatment, SLNB has been recommended in major guidelines and already has a ten-year clinical application. Since the introduction of targeted therapy and immune therapy for malignant melanoma in 2017, the prognosis of patients has been significantly improved. This study aimed to collect the clinical data of Chinese malignant melanoma cases in recent five years so as to discover, in the era of new drug treatment, the significance of sentinel lymph node (SLN) status in clinical application and its influence on survival outcome. Methods: Data of 381 patients with histologically diagnosed malignant melanoma were retrospectively collected from 2017 to 2021 in Fudan University Shanghai Cancer Center. SLNB was performed with wide resection of the primary lesion for each case, and follow-ups of at least 6 months were taken afterwards. Lymphoscintigraphy or methylene blue dye was applied for identification of SLN. Results: A total of 381 patients were included. The mean Breslow thickness was 3.10 mm, among the 381 patients, 69.8% with acral lesion, 59.7% with ulceration, 34.6% with positive SLN, and the median relapse-free survival (RFS) was 17 months. Patient’s survival was significantly influenced by SLN status. Patients with more than 2 biopsied SLN had significantly better RFS in subgroups of N_1a stage and T₄ stage. There was no significant difference in RFS between patients who received complete lymph node dissection (CLND) and those who did no, and the latter even showed better RFS in subgroups of SLN biopsied number >2 and SLN micrometastasis diameter <1 mm. Conclusion: SLN status remained an important factor influencing the prognosis of melanoma cases with no clinical evidence of significant metastasis, and SLNB should be applied as a routine surgical procedure for malignant melanoma patients. While keeping the operation minimally invasive, the accuracy of SLN locating should be improved, and the sufficiency of biopsy should be ensured. Immediate CLND provides no improvement in the prognosis of cutaneous and acral melanoma patients with positive SLN status.

Key words: Malignant melanoma, Sentinel lymph node biopsy, Complete lymph node dissection, Prognosis

CLC Number:

R739.5

ZOU Zijian, SUN Wei, HU Tu, WANG Chunmeng, YAN Wangjun, LUO Zhiguo, LIU Xin, ZHONG Jingqin, LIN Xinyi, XU Yu, CHEN Yong. Clinical value of sentinel lymph node biopsy in patients with cutaneous and acral melanoma[J]. China Oncology, 2022, 32(12): 1168-1177.

Figures/Tables 7

Tab. 1

Clinicopathological variables categorized by SLN status [n (%)]"

Item	Total (n=381)	SLN negative (n=249)	SLN positive (n=132)	P value
Gender				0.035^*
Female	210 (55.1)	147 (59.0)	63 (47.7)
Male	171 (44.9)	102 (41.0)	69 (52.3)
Age/year				0.031^*
<60	202 (53.0)	142 (57.0)	60 (45.5)
≥60	179 (47.0)	107 (43.0)	72 (54.5)
Subtype				0.226
Acral	266 (69.8)	179 (71.9)	87 (65.9)
Cutaneous	115 (30.2)	70 (28.1)	45 (34.1)
Primary location				0.850
Upper extremity	54 (14.2)	37 (14.9)	17 (12.9)
Trunk	56 (14.7)	37 (14.9)	19 (14.4)
Lower extremity	271 (71.1)	175 (70.3)	96 (72.7)
Palm	2 (0.5)	0 (0.0)	2 (1.5)
Sole	200 (52.5)	133 (53.4)	67 (50.8)
Nail	56 (14.6)	42 (16.8)	14 (10.6)
SLNB basin				0.770
Groin	281 (73.8)	183 (73.5)	98 (74.2)
Axilla	81 (21.3)	53 (21.3)	28 (21.2)
Popliteal	3 (0.8)	3 (1.2)	0 (0)
Bilateral	7 (1.8)	4 (1.6)	3 (2.3)
Multi-basin	9 (2.4)	6 (2.4)	3 (2.3)
Breslow thickness				<0.001
0-1	55 (14.4)	46 (18.5)	9 (6.8)
>1-2	91 (23.9)	68 (27.3)	23 (17.4)
>2-4	123 (32.3)	76 (30.5)	47 (35.6)
>4	112 (29.4)	59 (23.7)	53 (40.2)
Clark level				<0.001
Ⅰ	5 (1.3)	5 (2.0)	0 (0.0)
Ⅱ	25 (6.6)	21 (8.4)	4 (3.0)
Ⅲ	19 (5.0)	14 (5.6)	5 (3.8)
Ⅳ	225 (59.1)	136 (54.6)	89 (67.4)
Ⅴ	57 (15.0)	29 (11.6)	28 (21.2)
Unknown	50 (13.1)	44 (17.7)	6 (4.5)
Ulceration				0.011
No	184 (48.3)	132 (53.0)	52 (39.4)
Yes	197 (51.7)	117 (47.0)	80 (60.6)
Number of biopsied SLN				0.971
1-2	216 (56.7)	141 (56.6)	75 (56.8)
>2	165 (43.3)	108 (43.4)	57 (43.2)
N stage				0.000
N₀	248 (65.1)	-	-
N₁	76 (19.9)	1 (0.4)^#	75 (56.8)
N₂	50 (13.1)	-	50 (37.9)
N₃	7 (1.8)	-	7 (5.3)
TNM stage				<0.001
Ⅰ	95 (24.9)	95 (38.2)	-
Ⅱ	153 (40.2)	153 (61.4)	-
Ⅲ	133 (34.9)	1 (0.4)^	132 (100.0)
Gene mutation				<0.001
BRAF	85 (22.3)	43 (17.3)	42 (31.8)
NRAS	42 (11.0)	26 (10.4)^#	16 (12.1)
C-KIT	24 (6.3)	12 (4.8)	12 (9.1)
BNK wild type	156 (40.9)	105 (42.2)	51 (38.6)
Unknown	74 (19.4)	63 (25.3)	11 (8.3)
Adjuvant therapy				<0.001
Observation	138 (36.2)	114 (45.8)	24 (18.2)
IFN	89 (23.3)	74 (19.4)	15 (11.4)
PD-1	124 (32.5)	53 (21.3)	71 (53.8)
Targeted therapy	22 (5.8)	6 (2.4)	16 (12.1)
Others	8 (2.1)	2 (0.8)	6 (4.5)

Tab. 1

Tab. 2

Fig. 1

Tab. 3

Fig. 2

Fig. 3

Tab. 4

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Item	Risk	Univariate analysis			Multivariable analysis
Item	Risk	OR	95% CI	P value	OR	95% CI	P value
Gender	Female vs male	0.634	0.414-0.969	0.035^*
Age	<60 years vs ≥60 years	0.628	0.411-0.960	0.032^*	0.610	0.393-0.947	0.028^*
Subtype	Acral vs cutaneous	0.756	0.480-1.190	0.227
Breslow thickness	0-1 mm	1.000	-	<0.001^*	1.000	-	<0.001^*
Breslow thickness	1-2 mm	1.729	0.734-4.072	0.210	1.927	0.810-7.620	0.138
Breslow thickness	2-4 mm	3.161	1.418-7.046	0.005^*	3.394	1.512-4.583	0.003^*
Breslow thickness	>4 mm	2.053	2.053-10.269	<0.001^*	4.868	2.162-10.959	<0.001^*
Ulceration	Yes vs no	1.736	1.130-2.665	0.012^*
Number of biopsied SLN	>2 vs ≤2	0.992	0.648-1.519	0.992

Item	Risk	Univariate analysis			Multivariable analysis
Item	Risk	OR	95% CI	P value	OR	95% CI	P value
Gender	Female vs male	0.575	0.379-0.872	0.009^*
Age	<60 years vs ≥60 years	0.751	0.497-1.136	0.176
Subtype	Acral vs cutaneous	1.169	0.916-1.492	0.210
SLN status	Positive vs negative	2.862	1.885-4.346	<0.001^*	2.103	1.377-3.213	0.001^*
Breslow thickness	0-1 mm	1.000	-	<0.001^*	1.000	-	<0.001^*
Breslow thickness	1-2 mm	2.747	0.593-12.715	0.196	2.240	0.481-10.430	0.304
Breslow thickness	2-4 mm	8.935	2.140-37.304	0.003^*	4.420	1.022-19.117	0.047^*
Breslow thickness	>4 mm	20.295	4.903-84.010	<0.001^*	8.635	1.983-37.604	0.004^*
Ulceration	Yes vs no	5.007	3.017-8.312	<0.001^*	2.813	1.561-4.631	<0.001^*
Number of biopsied SLN	>2 vs ≤2	0.774	0.505-1.186	0.239

Item	CLND (n=101)	No CLND (n=31)	P value	Item	CLND (n=101)	No CLND (n=31)	P value
Gender			0.620	Breslow thickness/mm			0.507
Male	54 (53.5)	15 (48.4)		0-1	7 (6.9)	2 (6.5)
Female	47 (46.5)	16 (51.6)		1-2	16 (15.8)	7 (22.6)
Age/year				2-4	34 (33.7)	13 (41.9)
<60	50 (49.5)	10 (32.3)	0.092	>4	44 (43.6)	9 (29.0)
≥60	51 (50.5)	21 (67.7)		Ulceration			0.741
Subtype			0.806	No	39 (38.6)	13 (41.9)
Acral	66 (65.3)	21 (67.7)		Yes	62 (61.4)	18 (58.1)
Cutaneous	35 (34.7)	10 (32.3)		Positive SLN number			0.766
Primary location			0.950	1	70 (68.6)	23 (74.2)
Upper extremity	13 (12.9)	4 (12.9)		2	28 (27.5)	7 (22.6)
Trunk	14 (13.9)	5 (16.1)		3	2 (2.0)	1 (3.2)
Lower extremity	74 (73.3)	22 (71.0)		4	1 (1.0)	0 (0.0)