Optimal extent of completion lymphadenectomy for patients with melanoma and a positive sentinel node in the groin

Abstract

BackgroundThe optimal extent of groin completion lymph node dissection (CLND) (inguinal or ilioinguinal dissection) in patients with melanoma is controversial. The aim of this study was to evaluate whether the extent of groin CLND after a positive sentinel node biopsy (SNB) is associated with improved outcome.MethodsData from all sentinel node‐positive patients who underwent groin CLND at four tertiary melanoma referral centres were retrieved retrospectively. Baseline patient and tumour characteristics were collected for descriptive statistics, survival analyses and Cox proportional hazards regression analyses.ResultsIn total, 255 patients were included, of whom 137 (53·7 per cent) underwent inguinal dissection and 118 (46·3 per cent) ilioinguinal dissection. The overall CLND positivity rate was 18·8 per cent; the inguinal positivity rate was 15·5 per cent and the pelvic positivity rate was 9·3 per cent. The pattern of recurrence, and 5‐year melanoma‐specific survival, disease‐free survival and distant‐metastasis free survival rates were similar for both dissection types, even for patients with a positive CLND result. Cox regression analysis showed that type of CLND was not associated with disease‐free or melanoma‐specific survival.ConclusionThere was no significant difference in recurrence pattern and survival rates between patients undergoing inguinal or ilioinguinal dissection after a positive SNB, even after stratification for a positive CLND result. An inguinal dissection is a safe first approach as CLND in patients with a positive SNB.

Laparoscopically Assisted Ilio-Inguinal Lymph Node Dissection Versus Inguinal Lymph Node Dissection in Melanoma

“…First, it is worth highlighting the methodological problem that Kaplan–Meier survival curves lose reliability with an N below 30. Nevertheless, other authors found better survival from OIL to LIIL; however, unlike our results, statistical significance was not demonstrated [ 16 , 18 ]. Contrary to the findings of Rossi et al [ 15 ], the greater number of resected nodes has not been associated with a better prognosis of LIIL ( Figure 3 ).…”

“…Our local recurrence rate was higher than in the literature, which varies from one digit to 35% [ 6 , 16 , 17 ]. The fact that 60% of the patients in our series had macroscopic inguinal involvement, with a LN ratio category B (10–25%) and more than 40% of T4s, reflect a locally advanced melanoma case series, with an expected worse local recurrence rate.…”

“…The fact that 60% of the patients in our series had macroscopic inguinal involvement, with a LN ratio category B (10–25%) and more than 40% of T4s, reflect a locally advanced melanoma case series, with an expected worse local recurrence rate. It has been proposed that there are differences between microscopic and macroscopic inguinal involvement in relation to tumor biology, incidence of lymph node involvement and recurrence pattern or survival [ 16 ]. Perhaps our high incidence of macroscopic node involvement justifies the higher incidence of local recurrence and even the paradox of a worse incidence of local recurrence with more extensive surgery.…”

“…The EAGLE-FM trial, currently recruiting, is intended to corroborate if the extent of lymphadenectomy (adding pelvic lymphadenectomy to inguinal lymphadenectomy) influences local control and patient survival [ 16 ]. It has been advocated that pelvic lymphadenectomy should be added to inguinal lymphadenectomy when there is clinically gross involvement of the groin, when there are clinically detectable deep lymph nodes, when Cloquet’s node is histologically positive or when pelvic CT scan demonstrates pelvic lymphadenopathy [ 17 ].…”

CT diagnosis of ilioinguinal lymph node metastases in melanoma using radiological characteristics beyond size and asymmetry

“…In patients with evidence of only inguinal disease, the survival benefit of performing an ilioinguinal dissection over an inguinal dissection alone is unknown. High-level evidence regarding which operation offers most oncological benefit does not yet exist, and is currently being investigated as part of the Evaluation of Groin Lymphadenectomy Extent for Metastatic Melanoma (EAGLE-FM) (NCT02166788) RCT 4 . Under current National Institute for Health and Care Excellence guidance, patients with melanoma AJCC stage IIC (melanoma larger than 4 mm with ulceration) or above (stage III (any lymph node involvement) and stage IV (any metastatic disease)) should have staging CT of the chest, abdomen and pelvis, and MRI of the brain.…”