SURGICAL-MANAGEMENT OF REGIONAL LYMPH-NODES IN PATIENTS WITH MELANOMA- EXPERIENCE WITH 4682 PATIENTS

Objective The purpose of this study was to evaluate a large number of patients with cutaneous melanoma who had or who were at risk for lymph node metastases to contribute to the understanding of the behavior of and appropriate management of draining nodes. A major goal or the stu dy was to reassess the clinical impact of elective lymph node dissecti ons (ELND) in a large patient population. Summary Background Data Larg e retrospective studies suggest that ELND may improve the prognosis of patients with intermediate-thickness melanomas; however, that improve ment has not been observed in two randomized prospective controlled tr ials. Methods The charts of 4682 patients treated at a single institut ion for localized or regional disease were reviewed individually. The median follow-up was 4.7 years, with 814 patients followed more than 1 0 years. The data were tabulated and evaluated with the aid of a compu ter data base system. Results Among patients with nodal metastases, 10 % of nodal metastases were to contralateral nodes, and 6% were to noda l basins that would not be predicted by classic models of lymphatic dr ainage; in 13% of patients, nodal metastases occurred to greater than one nodal basin (3% of the entire study group). For all thickness rang es, the incidence of nodal metastases was comparable to the incidence of distant metastases; intermediate-thickness lesions had no relative predilection for nodal metastases. At the initial evaluation, regional nodal basins were clinically negative in 3550 patients, of whom 911 ( 25.7%) underwent ELND. Stratified into five thickness groups (< 0.76 m m, 0.76 to 1.5 mm, 1.5 to 2.5 mm, 2.5 to 4 mm, and > 4 mm), pathologic ally positive nodes were identified in 0%, 5%, 16%, 24%, and 36%, resp ectively (16% overall). Among the 911 patients who underwent ELND, 214 (23%) had nodal metastases, 143 at the time of ELND and 71 at a later date. Of these 71 patients, 31 (44%) had nodal metastases in a previo usly dissected nodal basin, and 40 (56%) had them in basins not previo usly dissected. The survival of patients with clinically negative node s treated with and without ELND were compared. The two groups were wel l matched for major prognostic factors. Stratified by Breslow thicknes s and primary site, no significant improvement in survival was observe d with ELND. Conclusions Because of the significant incidence of metas tases to contralateral and atypical nodal basins, lymphoscintigraphy m ay be justified for the preoperative evaluation of patients for ELND. However, the therapeutic value of ELND is questionable as a result of (1)the finding that the risk of nodal metastases is not relatively mor e common than is that of distant metastases among patients with interm ediate-thickness melanomas, (2) the fact that only 16% of ELND were po sitive, (3) the finding that ELND may not prevent recurrent nodal dise ase in the dissected basin, and (4) the absence of any apparent impact on survival among patients who underwent ELND.