Risk of melanoma recurrence linked to prior surgical interventions

According to investigators Nir Nathansohn, M.D.; Haim Gutman, M.D.; and Jacob Schachter, M.D., the study reveals, for the first time, that previous tampering is an independent factor determining increased risk for regional recurrence of melanoma.

Referrals important

"Every lymphadenopathy found in the context of a melanoma may represent a melanoma metastasis. As such, no lymphatic basin should be tampered with until this diagnosis is excluded by fine-needle aspiration (FNA) detecting epithelial or primary lymphatic cytology or by sentinel node biopsy."

The authors add if it becomes evident that the basin contains melanoma, the patient should be referred to a specialist, who must then perform surgery under strict surgical-oncology principles. This will significantly reduce the risk of regional recurrence after radical surgery.

Methodology

The study was launched by Haim Gutman, M.D., who observed that surgical failures appeared related to previous suboptimal interventions.

"In this context," Dr. Nathansohn says, "tampering and suboptimal are synonymous. It means an incisional biopsy of a metastatic lymph node, an excisional biopsy of a lymph node with damage to its capsule, or an open biopsy of a lymph node by a surgeon not trained to treat melanoma metastases, thus leading to either of the above."

A fourth type of suboptimal treatment is a lymph basin dissection that leaves behind lymphatic tissue (nodes) or other anatomical structures that should have been removed during radical oncologic surgery.

The study looked at 141 consecutive melanoma patients who had radical lymph node dissection (inguinal, axillary or popliteal) between 1990 and 2000. The radical lymph node dissection (RLND) was either elective or therapeutic based on the accepted practice at the time of the surgery.

All operations were performed by a single surgical oncologist and followed for a median period of 41 months by the team that published the study. Their goal was to investigate recurrence patterns and survival rates in relation to disease history and previous treatments.

Of the 148 lymphatic basins surgically treated with RLND, 52 percent failed during the follow-up period. Of these failures 70 percent had systemic disease, 16 percent had recurrence in the RLND surgical field, 11 percent had in-transit metastases and 3 percent had a local recurrence.

On multivariate analysis, the only significant predictors of recurrence after RLND were Breslow thickness of greater than 4 mm (P=.02), previous tampering (P=.01) and lymph node capsular invasion (P=.001). Previous tampering was the only independent prognosticator of failure in the surgical field, as tampering was noted in 10 (83 percent) of 12 patients with failure in the surgical field as compared with six (10 percent) of 62 patients with other types of first failures (P<.001). This effect did not translate into a survival difference (P=.54) in this series.