Regional control after precision lymph node dissection for clinically evident melanoma metastasis

Abstract

Introduction Completion lymph node dissection (CLND) for microscopic lymph node metastases has been replaced by observation; however, CLND is standard for clinically detectable nodal metastases (cLN). CLND has high morbidity, which may be reduced by excision of only the cLN (precision lymph node dissection [PLND]). We hypothesized that same‐basin recurrence risk would be low after PLND. Methods Retrospective review at four tertiary care hospitals identified patients who underwent PLND. The primary outcome was 3‐year cumulative incidence of isolated same‐basin recurrence. Results Twenty‐one patients underwent PLND for cLN without synchronous distant metastases. Reasons for forgoing CLND included patient preference (n = 11), comorbidities (n = 5), imaging indeterminate for distant metastases (n = 2), partial response to checkpoint blockade (n = 1), or not reported (n = 2). A median of 2 nodes (range: 1–6) were resected at PLND, and 68% contained melanoma. Recurrence was observed in 33% overall. Only 1 patient (5%) developed an isolated same‐basin recurrence. Cumulative incidences at 3 years were 5.0%, 17.3%, and 49.7% for isolated same‐basin recurrence, any same‐basin recurrence, and any recurrence, respectively. Complications from PLND were reported in 1 patient (5%). Conclusions These pilot data suggest that PLND may provide adequate regional disease control with less morbidity than CLND. These data justify prospective evaluation of PLND in select patients.

A Step Toward Personalized Surgical Decision Making

“…Thus, prognosis may depend more on the extent of LN involvement rather than the extent of the lymphadenectomy performed. Our recent work suggests that patients who underwent a targeted LN excision, most of whom had 1 cLN, had only a 5% risk of recurrence in the same nodal basin before systemic metastasis over a median follow-up of 32 months 12 . It may, therefore, be reasonable to consider treating selected patients with targeted LN excision.…”

“…Our recent work suggests that patients who underwent a targeted LN excision, most of whom had 1 cLN, had only a 5% risk of recurrence in the same nodal basin before systemic metastasis over a median follow-up of 32 months. 12 It may, therefore, be reasonable to consider treating selected patients with targeted LN excision. The selection of patients for less morbid surgery requires accurate identification of those with only 1 pLN.…”