Judging the therapeutic value of lymph node dissections for melanaoma

Background: The management of the regional lymph nodes remains controversia l for early-stage melanoma and For those patients with lymph node metastase s; American Joint Committee on Cancer stage III. This study examines the im portance of quality of the surgical resection measured by the extent of lym ph node dissection (quartile of the total number of Lymph nodes removed) to determine if this factor is an important prognostic factor for survival. Study Design: We reviewed our computer-assisted database of more than 8,700 melanoma patients prospectively collected from 1971 through the present to identify patients who underwent lymph node dissection for stage III melano ma. We included only patients who had their nodal dissections performed at our institute. Patients who underwent sentinel lymph node dissection were e xcluded. These patients were then analyzed as a group and by individual lym phatic basins: cervical, axillary, and inguinal basins. Univariate and mult ivariate analyses were used to examine the model that included tumor burden , thickness of the primary melanoma, gender, age, clinical status of the ly mph nodes (palpable versus not palpable), and the primary site. The surviva l and recurrence rates were analyzed using the Cox proportional hazards mod el. Results: Five hundred forty-eight patients underwent regional lymph node di ssections. Of these patients, 214 underwent axillary dissections, 181 ingui nal dissections, and 153 cervical dissections. The extent of the nodal diss ections was based on the quartile of nodes excised, ranging from 1 to 98 (m ean +/- SD = 25.8 +/- 15.8). Patients were stratified by tumor burden and q uartile of number of lymph nodes removed. The overall 5-year survival of pa tients with four or more lymph nodes having tumor and the highest quartile of lymph nodes removed was 44% and was 23% for the lowest quartile of total lymph nodes excised (p = 0,05). By univariate analysis, tumor burden (p = 0.0001), quartile of total lymph nodes removed (p = 0.043), and primary sit e (p = 0.047) were statistically significant for predicting overall surviva l. Gender, clinical status of the nodes, primary tumor thickness, age, and dissected basin were not significant (p > 0.05). By multivariate analysis o nly the tumor burden (p = 0.0001) and quartile of lymph nodes resected(p = 0.044) were statistically significant. Conclusions: The extent of lymph node dissection for melanoma when anal)zed by quartiles is an independent factor in overall survival. This factor app ears to be more important with increasing tumor burden in the lymphatic bas in. The extent of lymph node dissection should be considered as a prognosti c factor in the design of clinical trials that involve stage III melanoma. (J Am Coil Surg 2000;191:16-23. (C) 2000 by the American College of Surgeon s).