Sunday, February 21, 2016

"Patients with microscopically negative/PCR+ SLN have increased risk for nodal recurrence that was mitigated by CLND"!

Molecular Staging of Sentinel Lymph Nodes Identifies Melanoma Patients at Increased Risk of Nodal Recurrence.  Kimbrough, Egger, McMasters, et al. J Am Coll Surg. 2016 Jan 14.

Molecular staging of sentinel lymph nodes (SLNs) may identify patients who are node-negative by standard microscopic staging but are at increased risk for regional nodal recurrence; such patients may benefit from completion lymph node dissection (CLND).

In a multicenter, randomized clinical trial, patients with tumor-negative SLNs by standard pathology (hematoxylin and eosin [H and E] serial sections and immunohistochemistry [IHC]) underwent reverse transcriptase polymerase chain reaction (PCR) analysis of SLNs for melanoma-specific mRNA. Microscopically negative/PCR+ patients were randomized to observation, CLND, or CLND with high-dose interferon (HDI). For this post-hoc analysis, clinicopathologic features and survival outcomes, including overall survival (OS) and disease-free survival (DFS), were compared between PCR+ patients who underwent CLND vs observation. Microscopic and molecular node-negative (PCR-) patients were included for comparison.

A total of 556 patients were PCR+: 180 underwent observation, and 376 underwent CLND. An additional 908 PCR- patients were observed. Median follow-up was 72 months. Disease-free survival (DFS) was significantly better for PCR+ patients who underwent CLND compared with observation. No statistically significant differences in OS or distant disease-free survival (DDFS) were seen. Regional lymph node recurrence-free survival (LNRFS) was improved in PCR+ patients with CLND compared to observation. The PCR+ patients in the observation group had the worst DFS; those with CLND had similar DFS to that in the PCR- group. 

Patients with microscopically negative/PCR+ SLN have an increased risk of nodal recurrence that was mitigated by CLND. Although CLND did not affect OS, these data suggest that molecular detection of melanoma-specific mRNA in the SLN predicts a greater risk of nodal recurrence and deserves further study. melanoma, decisions are not simple - especially when this study is juxtaposed against the recent release of the Sunbelt Melanoma Trial final report: Sunbelt Melanoma trial final results  I still have to believe that getting that S#!T out of there has got to be a good thing!  But, messing with lymph nodes can be a painful, miserable proposition with the significant risk of lymphedema.  So....could robots do that job better?
Robotic-Assisted Transperitoneal Pelvic Lymphadenectomy for Metastatic Melanoma: Early Outcomes Compared with Open Pelvic Lymphadenectomy.  Dossett, Castner, Pow-Sang, Sondak, et al.  J Am Coll Surg. 2016 Jan 14.

In the absence of iliac or obturator nodal involvement, the role of pelvic lymphadenectomy (PLND) for melanoma is controversial, but for select patients, long-term survival can be achieved with the combination of superficial inguinal (inguinofemoral) and PLND. Open PLND (oPLND) is often limited in visual exposure and can be associated with considerable postoperative pain. Robotic PLND (rPLND) is a minimally invasive technique that provides excellent visualization of the iliac and obturator nodes. Outcomes comparing the open and robotic techniques have not been reported previously for patients with melanoma.

We reviewed our experience with rPLND for melanoma and compared clinical and pathologic results with oPLND. We evaluated operative times, nodal yield, and short-term oncologic outcomes.
Thirteen rPLND (2013 to 2015) (15 attempted, 87% success rate) and 25 oPLND (2010 to 2015) consecutive cases were completed. Pelvic lymphadenectomy was combined with an open inguinofemoral dissection in 8 of 13 (62%) robotic and 17 of 25 (68%) open cases. Median length of stay was shorter in the rPLND group, with 1.0 vs 3.5 days for pelvic-only cases and 2.5 vs 4.0 days for combined ilioinguinal cases. Median operative time (227 vs 230 minutes;) and nodal yield (11 vs 10 nodes) were not different between rPLND and oPLND.

Robotic PLND offers a safe, effective, minimally invasive approach to resect the pelvic lymph nodes in patients with melanoma, with no significant difference in nodal yield or operative times, but a shorter length of stay compared with oPLND.

Well, hmmmmm....again.  No impressive increase in the number nodes removed nor significant decrease in time on the operating table...but a decrease in length of hospital stay.  Perhaps over time we will find that that will contribute to the development of fewer side effects like nerve damage and lymphedema.  Have to wait to see what the ratties tell us.

Hang in there - c

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