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Vol. 113. Núm. 3.
Páginas T332-T335 (Marzo 2022)
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Vol. 113. Núm. 3.
Páginas T332-T335 (Marzo 2022)
Case and Research Letter
Open Access
[Translated article] Cutaneous Melanoma and Sentinel Lymph Node Biopsy: A Single-Center Retrospective Study of 331 Patients in Argentina
Análisis retrospectivo de 331 pacientes con melanoma cutáneo estudiados con ganglio centinela en una sola institución en Argentina
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N.L. Gómeza,
Autor para correspondencia
natalia.gomezzib@gmail.com

Corresponding author.
, L.A. Boccalattea, V. Volonterib, J.J. Larrañagaa
a Sección cirugía de cabeza y cuello, Servicio de cirugía general, Hospital Italino de Buenos Aires, Argentina
b Servicio de Anatomía Patológica, Hospital Italiano de Buenos Aires, Argentina
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N.L. Gómez, L.A. Boccalatte, V. Volonteri, J.J. Larrañaga
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Tablas (3)
Table 1. Characteristics of Patients and Histology.
Table 2. Characteristics of Patients and Histology.
Table 3. Predictive Factors for Disease-Free Survival and Overall Survival: Univariate and Multivariate Analyses.
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To the Editor:

Cutaneous melanoma (CM) is the leading cause of death due to skin cancer.1,2 Sentinel node biopsy (SNB) is a minimally invasive procedure that, following the Multicenter Selective Lymphadenectomy Trial (MSLT-1) protocol, is considered to be a prognostic element for MC.1–5 Other factors associated with prognosis are tumor thickness, mitotic index, location, histologic subtype, ulceration, lymphovascular invasion, regression, lymphocyte infiltrate, age, and sex.1,3

Few representative studies exist in South America and our study therefore provides information to the region.1,6,7 Our objective was to analyze disease-free survival (DFS) and overall survival (OS) in a cohort of patients with CMT1b, assessed using the sentinel node (SN) in a private institution in Argentina. The secondary objective was to identify the risk factors associated with a positive SN.

We performed a retrospective study that included all patients with CM in whom SNB was indicated, between 2006 and 2017. Table 1 summarizes the selection criteria and the variables analyzed. Unfortunately, the mitotic index (MI) was excluded from the analysis due to variability in the histopathology records over the years. Patients were classified by Breslow thickness into 4 groups, and location was divided into head and neck, upper member, lower member, and torso.

Table 1.

Characteristics of Patients and Histology.

Characteristics  Number 
Age, y
<65  195  56.4 
>65  151  43.6 
Sex
Male  192  55.6 
Female  153  44.4 
Location
Head and neck  33  9.6 
Upper member  54  15.7 
Lower member  150  43.5 
Torso  105  30.4 
Other  .8 
Histologic classification
Nodular  152  44.1 
Surface spreading  150  43.5 
Lentigo maligna  10  2.9 
Others  33  9.5 
Growth pattern
Vertical and radial  185  53.6 
Vertical  151  43.8 
Radial 
Not available  0.6 
Breslow thickness
T1 (0–1mm)  90  26.1 
T2 (1.01–2mm)  108  31.3 
T3 (2.01–4mm)  71  20.6 
T4 (>4.01mm)  76  22 
Clark level
Level I  0.6 
Level II  12  3.5 
Level III  177  51.3 
Level IV  140  40.6 
Level V  14 
Ulceration
Yes  103  67.5 
No  233  29.9 
Not available  2.6 
Perineural invasion
Yes  2.6 
No  241  69.9 
Not available  95  27.5 
Lymphovascular invasion
Yes  25  7.3 
No  230  66.7 
Not available  90  26 
Regression
Yes  39  11.3 
No  285  82.6 
Not available  21  6.1 
Inflammatory infiltrate
Yes  186  53.9 
No  138  40 
Not available  21  6.1 

OS, DFS, and the statistical relationship between SN and the different factors were analyzed using Kaplan–Meier curves and a Cox regression. The statistical software package Stata® version 13.1, 2016, was used and significance was established for values of p<.05.

Of the 1505 patients diagnosed with CM in the study period, 345 were included; 192 (55.6%) were men and the median age was 61.5 years (range, 17–94 years). The median Breslow thickness was 1.88mm (range, 0.63–12mm). Table 2 shows a summary of the descriptive analysis.

Table 2.

Characteristics of Patients and Histology.

Characteristics  Number 
Age, y
<65  195  56.4 
>65  151  43.6 
Sex
Male  192  55.6 
Female  153  44.4 
Location
Head and neck  33  9.6 
Upper member  54  15.7 
Lower member  150  43.5 
Torso  105  30.4 
Other  0.8 
Histologic subtype
Nodular  152  44.1 
Surface spreading  150  43.5 
Lentigo maligna  10  2.9 
Others  33  9.5 
Growth pattern
Vertical and radial  185  53.6 
Vertical  151  43.8 
Radial 
Not available  0.6 
Breslow thickness
T1 (≤1mm)  90  26.1 
T2 (1.01–2mm)  108  31.3 
T3 (2.01–4mm)  71  20.6 
T4 (>4.01mm)  76  22 
Clark level
Level II  12  3.5 
Level III  177  51.3 
Level IV  140  40.6 
Level V  14 
Ulceration
Yes  103  29.9 
No  233  67.5 
Not available  2.6 
Perineural invasion
Yes  69.9 
No  241  2.6 
Not available  95  27.5 
Lymphovascular invasion
Yes  25  66.7 
No  230  7.3 
Not available  90  26 
Regression
Yes  39  82.6 
No  285  11.3 
Not available  21  6.1 
Inflammatory infiltrate
Yes  186  53.9 
No  138  40 
Not available  21  6.1 

Of the 345 patients included because they had undergone SNB, only 331 met all the inclusion criteria for the study. SNB was therefore performed only on those patients. Ninety-four (28.4%) were positive and 75 (81.5%) of these underwent lymphadenectomy, which, in 35.9% of cases, revealed additional positive lymph nodes. The median follow-up time was 45 months (range, 0–153 mo) and 58 patients were lost to follow-up. Furthermore, 86 (25%) patients presented a locoregional and/or distant recurrence. Of these, 37 patients had a positive SN. Estimated OS was 77.9% and 66.4% at 5 and 10 years, respectively, whereas estimated DFS was 70.7% and 63.5% at 5 and 10 years, respectively. The locoregional recurrence rate was 18.8%.

Table 3 shows the independent predictive factors for mortality and disease-free survival. Notable factors were Breslow thickness, ulceration, and positive SN.

Table 3.

Predictive Factors for Disease-Free Survival and Overall Survival: Univariate and Multivariate Analyses.

  DFSOS
  UnivariateMultivariateUnivariateMultivariate
  HR  95% CI  p  HR  95% CI  p  HR  95% CI  p  HR  95% CI  p 
Sex  0.7  0.4–1  .058  —  —  —  0.6  0.4–1  .056  —  —  — 
Age >65 years  1.5  1–2.3  .048      NS  1.5  1–2.3  .048      NS 
Primary tumor site  0.6  0.4–1  .058      —  1.1  0.8–1.4  .747  —  —  — 
Tumor subtype: nodular  3.3  1.9–5.5  <.001      NS  3.6  1.9–6.8  <.001      NS 
Breslow thickness, mm  2.6  2.1–3.4  <.001  1.8  1.1–3.2  0.042  2.6  1.9–3.4  <.001  1.6  1.2–2.5  .045 
Clark Level  2.6  1.9–3.5  <.001      NS  2.7  1.9–3.9  <.001      NS 
Ulceration  2.9  2.1–4.1  <.001      NS  3.8  2.3–6.2  <.001  2.1  1.1–3.9  .026 
Regression  0.2  0.1–0.7  .135  —  —  —  0.1  0.2–0.8  .028      NS 
Inflammatory infiltrate  0.5  0.3–0.9  .02  0.6  0.3–0.95  .03  0.5  0.3–0.9  .02      NS 
Perineural invasion  0.8  0.7–1.1  .242  —  —  —  0.8  0.6–1.1  .311  —  —  — 
Positive sentinel node  4.9  3.1–7.6  <.001  2.8  1.7–4.6  <.001  5.6  3.3–9.5  <.001  3.4  1.9–5.9  <.001 
Extracapsular extension  2.4  1.3–4.3  .005      NS  3.4  1.7–6.6  <.001      NS 

Abbreviations: CI indicates confidence interval; DFS, disease-free survival; HR, hazard Ratio; NS, not significant; OS, overall survival.

Our study, while retrospective, provides epidemiologic value regarding CM in South America and confirms the prognostic value of SNB.

Although only patients with SNB were included, the distribution and frequencies were similar to published cases in terms of sex, age, and location.1,7 The positive-SN rate was 28.4%, which was higher than in other series (15–23%).2,4 Age was linked to OS and DFS only in the univariate analysis. Previous studies have found that the oldest patients had the worst outcome (>65 y).8

The multivariate analysis found that only Breslow thickness (intermediate and thick), ulceration, and positive SN were independent factors for OS and DFS. Inflammation was also significant for DFS only. The classic MSLT-1 protocol determined the importance of SNB for identifying hidden metastasis2,4,5; others also found that thickness, ulceration, location, histologic subtype, and SN status were independent factors.3,8 Other studies also confirmed that ulceration was associated with worse OS and DFS2–4,8,9; today it is considered to be a factor associated with poor prognosis, which changes the staging in CM in which it presents.

Five-year OS was 77.8% (less than reported figures) and 72.7% with positive SNB.2,9 For positive SNB, the multivariate analysis only found Breslow thickness as a prognostic factor, similar to the findings of other studies.9 The MI, while the subject of debate, may be linked to lymph-node metastasis. Tejera-Vaquerizo et al.8 found that the MI directly affected OS, DFS and a positive SN. In our study, it was not possible to analyze the MI due to lack of data.

An interesting point of this study is that the inflammatory infiltrate, defined as the presence of intratumoral lymphocytes, is interpreted as a protective factor in the multivariate analysis for DFS. This continues to be the subject of debate, given that some studies have found that its presence improves survival, whereas others have found the opposite.8,10

Limitations of our study include its retrospective nature and the inability to analyze lymphovascular invasion, MI, and the rate of SN false negatives.

In conclusion, Breslow thickness and SN status are the main prognostic factors associated with OS and DFS. This cohort confirms the prognostic value of SNB and represents a new epidemiologic contribution for South America.

Funding

This study has not received any funding.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

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