Surveillance of Sentinel Node-Positive Melanoma Patients with Reasons for Exclusion from MSLT-II: Multi-Institutional Propensity Score Matched Analysis.
BACKGROUND: In sentinel lymph node (SLN)-positive melanoma, two randomized trials demonstrated equivalent melanoma-specific survival with nodal surveillance vs completion lymph node dissection (CLND). Patients with microsatellites, extranodal extension (ENE) in the SLN, or >3 positive SLNs constitute a high-risk group largely excluded from the randomized trials, for whom appropriate management remains unknown. STUDY DESIGN: SLN-positive patients with any of the three high-risk features were identified from an international cohort. CLND patients were matched 1:1 with surveillance patients using propensity scores. Risk of any-site recurrence, SLN-basin-only recurrence, and melanoma-specific mortality were compared. RESULTS: Among 1,154 SLN-positive patients, 166 had ENE, microsatellites, and/or >3 positive SLN. At 18.5 months median follow-up, 49% had recurrence (vs 26% in patients without high-risk features, p < 0.01). Among high-risk patients, 52 (31%) underwent CLND and 114 (69%) received surveillance. Fifty-one CLND patients were matched to 51 surveillance patients. The matched cohort was balanced on tumor, nodal, and adjuvant treatment factors. There were no significant differences in any-site recurrence (CLND 49%, surveillance 45%, p = 0.99), SLN-basin-only recurrence (CLND 6%, surveillance 14%, p = 0.20), or melanoma-specific mortality (CLND 14%, surveillance 12%, p = 0.86). CONCLUSIONS: SLN-positive patients with microsatellites, ENE, or >3 positive SLN constitute a high-risk group with a 2-fold greater recurrence risk. For those managed with nodal surveillance, SLN-basin recurrences were more frequent, but all-site recurrence and melanoma-specific mortality were comparable to patients treated with CLND. Most recurrences were outside the SLN-basin, supporting use of nodal surveillance for SLN-positive patients with microsatellites, ENE, and/or >3 positive SLN.
Broman, KK; Hughes, TM; Dossett, LA; Sun, J; Carr, MJ; Kirichenko, DA; Sharma, A; Bartlett, EK; Nijhuis, AA; Thompson, JF; Hieken, TJ; Kottschade, L; Downs, J; Gyorki, DE; Stahlie, E; van Akkooi, A; Ollila, DW; Frank, J; Song, Y; Karakousis, G; Moncrieff, M; Nobes, J; Vetto, J; Han, D; Farma, J; Deneve, JL; Fleming, MD; Perez, M; Baecher, K; Lowe, M; Bagge, RO; Mattsson, J; Lee, AY; Berman, RS; Chai, H; Kroon, HM; Teras, RM; Teras, J; Farrow, NE; Beasley, GM; Hui, JY; Been, L; Kruijff, S; Boulware, D; Sarnaik, AA; Sondak, VK; Zager, JS; International High-Risk Melanoma Consortium,
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