Should Neck Dissection Be Done After Positive Sentinel Node Biopsy for Head and Neck Melanoma? Article Swipe
Brent A. Chang
,
Ameya A. Asarkar
,
Thomas H. Nagel
,
Cherie‐Ann O. Nathan
·
YOU?
·
· 2022
· Open Access
·
· DOI: https://doi.org/10.1002/lary.30053
YOU?
·
· 2022
· Open Access
·
· DOI: https://doi.org/10.1002/lary.30053
Sentinel lymph node biopsy (SLNB), first introduced in the 1990s, has become standard of practice for most initial presentations of cutaneous melanoma without gross nodal involvement. Traditionally, a completion lymph node dissection (CLND) was performed after a positive SLNB. However, the landmark Multicenter Selective Lymphadenectomy Trial II (MSLT-II), published in 2017, showed no melanoma-specific survival advantage with this practice.1 The current NCCN guidelines state that observation is the preferred approach following a positive SLNB in cutaneous melanoma, with CLND still being an option that should be discussed and offered to patients.2 Head and neck cutaneous melanoma (HNCM) has a number of unique features that potentially differentiate it from cutaneous melanoma of the rest of the body. Importantly, head and neck melanoma carries a worse prognosis. Also, due to the proximity of critical anatomic structures it is potentially more difficult to achieve wide peripheral and deep surgical resection margins. Such resections can have major cosmetic and functional sequelae. In addition, rates of lymphedema following CLND in the head and neck are lower compared to other sites. For these reasons, and because the existing data is much more limited in the head and neck, the value of CLND has been more controversial in this specific anatomic site. The applicability of MSLT-II trial results to HNCM specifically is an area of ongoing controversy. Of the 1,934 patients enrolled in MSLT-II, only 241 (13.7%) were patients with HNCM. A full summary of the trial is beyond the scope of this article, but a subset analysis of the HNCM patients identified 128 patients undergoing SLNB followed by observation (SLNB+OBS) compared to 113 undergoing SLNB followed by CLND (SLNB+CLND). Similar to the overall trial results, they found that 3 year melanoma-specific survival was not statistically different between the two groups (HR 1.60 (95% CI: 0.96–2.66), P = .07 vs HR 0.81 (95% CI: 0.44–1.48), P = .49).1 Among other considerations of this important trial, the relatively small HNCM subset and possibility of late recurrence outside of the studied 3 year survival window are important to examine. The only other major prospective trial on this topic was performed by the German Cooperative Oncology Group (DeCOG-SLT) and specifically excluded HNCM patients, underscoring the unique nature of this subsite. Although other prospective data is limited, several large retrospective database studies have attempted to shed light on this topic. Smith et al. performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) program database, specifically in HNCM, identifying 350 patients treated between January 1998 and December 2007.3 Multivariate regression analysis revealed that neither SLNB (n = 140) nor SLNB followed by CLND (n = 210) improved 5-year disease specific survival (DSS) (P > .56). Further, patients with poor prognostic factors including tumor thickness > 2 mm (P = .99) and/or tumors with ulceration (P = .84) did not show any difference in survival with the type of lymph node dissection performed. Upon stratifying the data according to age, patients (< 60 years) in the low-risk group (thickness ≤ 2 mm, 1 node positive out of at least 3 excised as sentinel nodes) who underwent CLND had a significantly lower risk of death (P = .003). However, patients with ages >60 years who underwent SLNB followed by CLND had significantly poorer survival when compared to patients who had SLNB alone (P = .028). Huang et al. retrospectively performed a study of similar scope using the National Cancer Database (NCDB) for HNCM patients diagnosed between January 2012 to December 2014.4 They identified 530 patients with positive SLNBs, with 188 (35.5%) who received SLNB only and 342 (64.5%) who received SLNB followed by CLND. The primary comparison was 5-year overall survival; they showed no statistically significant difference (SLNB+OBS: 67.0% vs SLNB+CLND: 51.0%, P = .56). They also performed a subgroup analysis in patients under 60, nonulcerated tumors, and depth < 2 mm (the same lower-risk group identified by Smith et al. to have a benefit from CLND). Opposingly, they found no statistically significant difference in overall survival within this subgroup (SLNB+OBS: 87.4% vs SLNB+CLND: 80.3%, P = .47). However, due to specific database limitations they could not measure melanoma specific survival. The importance of locoregional control for malignancies of the head and neck cannot be ignored. The head and neck region has a unique importance on quality of life for patients, particularly when locoregional control is not achieved. One of the arguments for avoiding CLND is the associated morbidity of the procedure. In the head and neck, CLND constitutes a cervical lymphadenectomy and possibly a parotidectomy, both of which have a theoretical risk of cranial nerve injury, amongst other surgical risks. Hanks et al. performed a retrospective study on HNCM patients undergoing SLNB between 1997 and 2007 at a single institution.5 Of 356 patients, 355 were successfully mapped with 76 having positive SLNBs. Almost all of these (n = 73, 97.3%) underwent immediate CLND. Morbidity was overall low, with zero patients suffering a permanent cranial nerve deficit following CLND. Only one patient developed mild submental lymphedema. They also noted that patients who developed regional recurrence had a much higher rate of developing permanent cranial nerve deficits (n = 13, 25.0%), due to either subsequent surgery or disease progression. This study illustrates that CLND in the head and neck has relatively low morbidity in skilled, experienced hands and that locoregional recurrence does come at a cost even if survival is not impacted. Of note, regional control in MSLT-II (all anatomic subsites) was improved with SLNB+CLND (92 ± 1.0%), compared to SLNB+OBS (77 ± 1.5%, P < .001). Observation following a positive SLNB for HNCM is likely a reasonable approach to offer patients, as survival is unchanged in prospective clinical trials. However, caution is advised before broadly applying such results to all HNCM patients, as the data in this subset of patients is not as robust as it is for all cutaneous melanoma. CLND is still also reasonable to offer patients, with consideration given to the benefits of locoregional control and the associated potential for quality of life improvement. It is possible that certain subsets of patients may specifically benefit from CLND; however, further study is needed in this area. Care should be individualized based on informed shared decision making with patients until further data is available, including a frank discussion with patients about the scientific uncertainty in HNCM. This Best Practice recommendation is based on level 1 evidence (prospective, randomized controlled trial), level 3 evidence (retrospective case–control studies), level 4 evidence (case series), and level 5 evidence (expert opinion).
Related Topics
Concepts
Medicine
Lymphadenectomy
Sentinel lymph node
Melanoma
Biopsy
Surgery
Neck dissection
Sentinel node
Dissection (medical)
Head and neck
Lymph node
Radiology
Cancer
Internal medicine
Breast cancer
Cancer research
Metadata
- Type
- article
- Language
- en
- Landing Page
- https://doi.org/10.1002/lary.30053
- https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/lary.30053
- OA Status
- bronze
- References
- 4
- Related Works
- 10
- OpenAlex ID
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All OpenAlex metadata
Raw OpenAlex JSON
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https://openalex.org/W4211051476Canonical identifier for this work in OpenAlex
- DOI
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https://doi.org/10.1002/lary.30053Digital Object Identifier
- Title
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Should Neck Dissection Be Done After Positive Sentinel Node Biopsy for Head and Neck Melanoma?Work title
- Type
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articleOpenAlex work type
- Language
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enPrimary language
- Publication year
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2022Year of publication
- Publication date
-
2022-02-11Full publication date if available
- Authors
-
Brent A. Chang, Ameya A. Asarkar, Thomas H. Nagel, Cherie‐Ann O. NathanList of authors in order
- Landing page
-
https://doi.org/10.1002/lary.30053Publisher landing page
- PDF URL
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https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/lary.30053Direct link to full text PDF
- Open access
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YesWhether a free full text is available
- OA status
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bronzeOpen access status per OpenAlex
- OA URL
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https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/lary.30053Direct OA link when available
- Concepts
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Medicine, Lymphadenectomy, Sentinel lymph node, Melanoma, Biopsy, Surgery, Neck dissection, Sentinel node, Dissection (medical), Head and neck, Lymph node, Radiology, Cancer, Internal medicine, Breast cancer, Cancer researchTop concepts (fields/topics) attached by OpenAlex
- Cited by
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0Total citation count in OpenAlex
- References (count)
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4Number of works referenced by this work
- Related works (count)
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10Other works algorithmically related by OpenAlex
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| abstract_inverted_index.groups | 293 |
| abstract_inverted_index.having | 800 |
| abstract_inverted_index.higher | 848 |
| abstract_inverted_index.likely | 934 |
| abstract_inverted_index.making | 1037 |
| abstract_inverted_index.mapped | 797 |
| abstract_inverted_index.nature | 366 |
| abstract_inverted_index.needed | 1024 |
| abstract_inverted_index.nodes) | 514 |
| abstract_inverted_index.number | 99 |
| abstract_inverted_index.option | 82 |
| abstract_inverted_index.poorer | 542 |
| abstract_inverted_index.region | 710 |
| abstract_inverted_index.risks. | 770 |
| abstract_inverted_index.robust | 973 |
| abstract_inverted_index.shared | 1035 |
| abstract_inverted_index.should | 84, 1029 |
| abstract_inverted_index.showed | 51, 612 |
| abstract_inverted_index.single | 789 |
| abstract_inverted_index.sites. | 174 |
| abstract_inverted_index.subset | 249, 322, 967 |
| abstract_inverted_index.topic. | 388 |
| abstract_inverted_index.trial, | 317 |
| abstract_inverted_index.tumors | 463 |
| abstract_inverted_index.unique | 101, 365, 713 |
| abstract_inverted_index.window | 335 |
| abstract_inverted_index.within | 667 |
| abstract_inverted_index.years) | 494 |
| abstract_inverted_index.(13.7%) | 229 |
| abstract_inverted_index.(35.5%) | 590 |
| abstract_inverted_index.(64.5%) | 597 |
| abstract_inverted_index.(SLNB), | 4 |
| abstract_inverted_index.(expert | 1086 |
| abstract_inverted_index.25.0%), | 859 |
| abstract_inverted_index.January | 415, 576 |
| abstract_inverted_index.MSLT-II | 208, 906 |
| abstract_inverted_index.Results | 403 |
| abstract_inverted_index.Similar | 273 |
| abstract_inverted_index.achieve | 140 |
| abstract_inverted_index.advised | 952 |
| abstract_inverted_index.amongst | 767 |
| abstract_inverted_index.because | 179 |
| abstract_inverted_index.benefit | 654, 1017 |
| abstract_inverted_index.between | 290, 414, 575, 783 |
| abstract_inverted_index.broadly | 954 |
| abstract_inverted_index.carries | 121 |
| abstract_inverted_index.caution | 950 |
| abstract_inverted_index.certain | 1011 |
| abstract_inverted_index.control | 695, 724, 904, 997 |
| abstract_inverted_index.cranial | 764, 824, 853 |
| abstract_inverted_index.current | 60 |
| abstract_inverted_index.deficit | 826 |
| abstract_inverted_index.disease | 440, 866 |
| abstract_inverted_index.excised | 511 |
| abstract_inverted_index.factors | 452 |
| abstract_inverted_index.further | 1021, 1041 |
| abstract_inverted_index.initial | 17 |
| abstract_inverted_index.injury, | 766 |
| abstract_inverted_index.limited | 186 |
| abstract_inverted_index.measure | 687 |
| abstract_inverted_index.neither | 425 |
| abstract_inverted_index.offered | 88 |
| abstract_inverted_index.ongoing | 218 |
| abstract_inverted_index.outside | 328 |
| abstract_inverted_index.overall | 276, 609, 665, 816 |
| abstract_inverted_index.patient | 831 |
| abstract_inverted_index.primary | 605 |
| abstract_inverted_index.program | 405 |
| abstract_inverted_index.quality | 716, 1003 |
| abstract_inverted_index.results | 210, 957 |
| abstract_inverted_index.several | 376 |
| abstract_inverted_index.similar | 563 |
| abstract_inverted_index.studied | 331 |
| abstract_inverted_index.studies | 380 |
| abstract_inverted_index.subsets | 1012 |
| abstract_inverted_index.summary | 236 |
| abstract_inverted_index.surgery | 864 |
| abstract_inverted_index.treated | 413 |
| abstract_inverted_index.trial), | 1070 |
| abstract_inverted_index.trials. | 948 |
| abstract_inverted_index.tumors, | 636 |
| abstract_inverted_index.without | 22 |
| abstract_inverted_index.Although | 370 |
| abstract_inverted_index.Database | 569 |
| abstract_inverted_index.December | 418, 579 |
| abstract_inverted_index.Further, | 447 |
| abstract_inverted_index.However, | 39, 528, 678, 949 |
| abstract_inverted_index.MSLT-II, | 226 |
| abstract_inverted_index.National | 567 |
| abstract_inverted_index.Oncology | 355 |
| abstract_inverted_index.Practice | 1059 |
| abstract_inverted_index.SLNB+OBS | 919 |
| abstract_inverted_index.Sentinel | 0 |
| abstract_inverted_index.analysis | 250, 422, 630 |
| abstract_inverted_index.anatomic | 132, 203, 908 |
| abstract_inverted_index.applying | 955 |
| abstract_inverted_index.approach | 69, 937 |
| abstract_inverted_index.article, | 246 |
| abstract_inverted_index.avoiding | 733 |
| abstract_inverted_index.benefits | 994 |
| abstract_inverted_index.cervical | 750 |
| abstract_inverted_index.clinical | 947 |
| abstract_inverted_index.compared | 171, 264, 545, 917 |
| abstract_inverted_index.cosmetic | 153 |
| abstract_inverted_index.critical | 131 |
| abstract_inverted_index.database | 379, 682 |
| abstract_inverted_index.decision | 1036 |
| abstract_inverted_index.deficits | 855 |
| abstract_inverted_index.enrolled | 224 |
| abstract_inverted_index.evidence | 1066, 1073, 1079, 1085 |
| abstract_inverted_index.examine. | 339 |
| abstract_inverted_index.excluded | 360 |
| abstract_inverted_index.existing | 181 |
| abstract_inverted_index.features | 102 |
| abstract_inverted_index.followed | 260, 269, 432, 537, 601 |
| abstract_inverted_index.however, | 1020 |
| abstract_inverted_index.ignored. | 705 |
| abstract_inverted_index.improved | 438, 911 |
| abstract_inverted_index.informed | 1034 |
| abstract_inverted_index.landmark | 41 |
| abstract_inverted_index.limited, | 375 |
| abstract_inverted_index.low-risk | 497 |
| abstract_inverted_index.margins. | 147 |
| abstract_inverted_index.melanoma | 21, 95, 109, 120, 688 |
| abstract_inverted_index.patients | 223, 231, 254, 257, 412, 448, 491, 529, 547, 573, 584, 632, 780, 820, 840, 969, 1014, 1039, 1050 |
| abstract_inverted_index.positive | 37, 72, 505, 586, 801, 929 |
| abstract_inverted_index.possible | 1009 |
| abstract_inverted_index.possibly | 753 |
| abstract_inverted_index.practice | 14 |
| abstract_inverted_index.reasons, | 177 |
| abstract_inverted_index.received | 592, 599 |
| abstract_inverted_index.regional | 843, 903 |
| abstract_inverted_index.results, | 278 |
| abstract_inverted_index.revealed | 423 |
| abstract_inverted_index.sentinel | 513 |
| abstract_inverted_index.series), | 1081 |
| abstract_inverted_index.skilled, | 883 |
| abstract_inverted_index.specific | 202, 441, 681, 689 |
| abstract_inverted_index.standard | 12 |
| abstract_inverted_index.subgroup | 629, 669 |
| abstract_inverted_index.subsite. | 369 |
| abstract_inverted_index.surgical | 145, 769 |
| abstract_inverted_index.survival | 54, 285, 334, 442, 475, 543, 666, 897, 942 |
| abstract_inverted_index.Morbidity | 814 |
| abstract_inverted_index.SLNB+CLND | 913 |
| abstract_inverted_index.Selective | 43 |
| abstract_inverted_index.according | 488 |
| abstract_inverted_index.achieved. | 727 |
| abstract_inverted_index.addition, | 158 |
| abstract_inverted_index.advantage | 55 |
| abstract_inverted_index.arguments | 731 |
| abstract_inverted_index.attempted | 382 |
| abstract_inverted_index.cutaneous | 20, 75, 94, 108, 979 |
| abstract_inverted_index.database, | 406 |
| abstract_inverted_index.developed | 832, 842 |
| abstract_inverted_index.diagnosed | 574 |
| abstract_inverted_index.different | 289 |
| abstract_inverted_index.difficult | 138 |
| abstract_inverted_index.discussed | 86 |
| abstract_inverted_index.following | 70, 162, 827, 927 |
| abstract_inverted_index.immediate | 812 |
| abstract_inverted_index.impacted. | 900 |
| abstract_inverted_index.important | 316, 337 |
| abstract_inverted_index.including | 453, 1045 |
| abstract_inverted_index.melanoma, | 76 |
| abstract_inverted_index.melanoma. | 980 |
| abstract_inverted_index.morbidity | 738, 881 |
| abstract_inverted_index.opinion). | 1087 |
| abstract_inverted_index.patients, | 362, 720, 793, 940, 961, 988 |
| abstract_inverted_index.performed | 34, 350, 392, 559, 627, 774 |
| abstract_inverted_index.permanent | 823, 852 |
| abstract_inverted_index.potential | 1001 |
| abstract_inverted_index.preferred | 68 |
| abstract_inverted_index.proximity | 129 |
| abstract_inverted_index.published | 48 |
| abstract_inverted_index.resection | 146 |
| abstract_inverted_index.sequelae. | 156 |
| abstract_inverted_index.studies), | 1076 |
| abstract_inverted_index.submental | 834 |
| abstract_inverted_index.subsites) | 909 |
| abstract_inverted_index.suffering | 821 |
| abstract_inverted_index.survival. | 690 |
| abstract_inverted_index.survival; | 610 |
| abstract_inverted_index.thickness | 455 |
| abstract_inverted_index.unchanged | 944 |
| abstract_inverted_index.underwent | 516, 535, 811 |
| abstract_inverted_index.(MSLT-II), | 47 |
| abstract_inverted_index.(SLNB+OBS) | 263 |
| abstract_inverted_index.(SLNB+OBS: | 617, 670 |
| abstract_inverted_index.(thickness | 499 |
| abstract_inverted_index.SLNB+CLND: | 620, 673 |
| abstract_inverted_index.associated | 737, 1000 |
| abstract_inverted_index.available, | 1044 |
| abstract_inverted_index.comparison | 606 |
| abstract_inverted_index.completion | 28 |
| abstract_inverted_index.controlled | 1069 |
| abstract_inverted_index.developing | 851 |
| abstract_inverted_index.difference | 473, 616, 663 |
| abstract_inverted_index.discussion | 1048 |
| abstract_inverted_index.dissection | 31, 482 |
| abstract_inverted_index.functional | 155 |
| abstract_inverted_index.guidelines | 62 |
| abstract_inverted_index.identified | 255, 582, 646 |
| abstract_inverted_index.importance | 692, 714 |
| abstract_inverted_index.introduced | 6 |
| abstract_inverted_index.lower-risk | 644 |
| abstract_inverted_index.lymphedema | 161 |
| abstract_inverted_index.patients.2 | 90 |
| abstract_inverted_index.performed. | 483 |
| abstract_inverted_index.peripheral | 142 |
| abstract_inverted_index.practice.1 | 58 |
| abstract_inverted_index.procedure. | 741 |
| abstract_inverted_index.prognosis. | 124 |
| abstract_inverted_index.prognostic | 451 |
| abstract_inverted_index.randomized | 1068 |
| abstract_inverted_index.reasonable | 936, 985 |
| abstract_inverted_index.recurrence | 327, 844, 889 |
| abstract_inverted_index.regression | 421 |
| abstract_inverted_index.relatively | 319, 879 |
| abstract_inverted_index.resections | 149 |
| abstract_inverted_index.scientific | 1053 |
| abstract_inverted_index.structures | 133 |
| abstract_inverted_index.subsequent | 863 |
| abstract_inverted_index.ulceration | 465 |
| abstract_inverted_index.undergoing | 258, 267, 781 |
| abstract_inverted_index.(DeCOG-SLT) | 357 |
| abstract_inverted_index.Cooperative | 354 |
| abstract_inverted_index.Multicenter | 42 |
| abstract_inverted_index.Observation | 926 |
| abstract_inverted_index.Opposingly, | 657 |
| abstract_inverted_index.constitutes | 748 |
| abstract_inverted_index.experienced | 884 |
| abstract_inverted_index.identifying | 410 |
| abstract_inverted_index.illustrates | 870 |
| abstract_inverted_index.limitations | 683 |
| abstract_inverted_index.lymphedema. | 835 |
| abstract_inverted_index.observation | 65, 262 |
| abstract_inverted_index.possibility | 324 |
| abstract_inverted_index.potentially | 104, 136 |
| abstract_inverted_index.prospective | 344, 372, 946 |
| abstract_inverted_index.significant | 615, 662 |
| abstract_inverted_index.stratifying | 485 |
| abstract_inverted_index.theoretical | 761 |
| abstract_inverted_index.uncertainty | 1054 |
| abstract_inverted_index.(SLNB+CLND). | 272 |
| abstract_inverted_index.Importantly, | 116 |
| abstract_inverted_index.Multivariate | 420 |
| abstract_inverted_index.controversy. | 219 |
| abstract_inverted_index.improvement. | 1006 |
| abstract_inverted_index.involvement. | 25 |
| abstract_inverted_index.locoregional | 694, 723, 888, 996 |
| abstract_inverted_index.malignancies | 697 |
| abstract_inverted_index.nonulcerated | 635 |
| abstract_inverted_index.particularly | 721 |
| abstract_inverted_index.progression. | 867 |
| abstract_inverted_index.specifically | 213, 359, 407, 1016 |
| abstract_inverted_index.successfully | 796 |
| abstract_inverted_index.underscoring | 363 |
| abstract_inverted_index.(prospective, | 1067 |
| abstract_inverted_index.0.44–1.48), | 307 |
| abstract_inverted_index.0.96–2.66), | 298 |
| abstract_inverted_index.Epidemiology, | 400 |
| abstract_inverted_index.Surveillance, | 399 |
| abstract_inverted_index.applicability | 206 |
| abstract_inverted_index.consideration | 990 |
| abstract_inverted_index.controversial | 199 |
| abstract_inverted_index.differentiate | 105 |
| abstract_inverted_index.institution.5 | 790 |
| abstract_inverted_index.presentations | 18 |
| abstract_inverted_index.retrospective | 378, 394, 776 |
| abstract_inverted_index.significantly | 520, 541 |
| abstract_inverted_index.statistically | 288, 614, 661 |
| abstract_inverted_index.(retrospective | 1074 |
| abstract_inverted_index.Traditionally, | 26 |
| abstract_inverted_index.case–control | 1075 |
| abstract_inverted_index.considerations | 313 |
| abstract_inverted_index.individualized | 1031 |
| abstract_inverted_index.parotidectomy, | 755 |
| abstract_inverted_index.recommendation | 1060 |
| abstract_inverted_index.Lymphadenectomy | 44 |
| abstract_inverted_index.lymphadenectomy | 751 |
| abstract_inverted_index.retrospectively | 558 |
| abstract_inverted_index.melanoma-specific | 53, 284 |
| cited_by_percentile_year | |
| corresponding_author_ids | https://openalex.org/A5076122892 |
| countries_distinct_count | 1 |
| institutions_distinct_count | 4 |
| corresponding_institution_ids | https://openalex.org/I4210136506, https://openalex.org/I81020160 |
| sustainable_development_goals[0].id | https://metadata.un.org/sdg/3 |
| sustainable_development_goals[0].score | 0.6899999976158142 |
| sustainable_development_goals[0].display_name | Good health and well-being |
| citation_normalized_percentile.value | 0.01980678 |
| citation_normalized_percentile.is_in_top_1_percent | False |
| citation_normalized_percentile.is_in_top_10_percent | False |