Ultrasound-guided fine needle aspiration cytology as an addendum to sentinel lymph node biopsy can perfect the staging strategy in melanoma patients
Introduction
Over recent decades the incidence of malignant melanoma has been rising throughout Europe, the United States of America (USA) and Australia [1], [2], [3], [4], but mortality has remained virtually unchanged [4].
The most important prognostic factor of early stage melanomas (stage I/II) is lymph nodal status. Therefore, adequate staging of these patients is very important to be able to determine their prognosis [5], [6]. Worldwide, the sentinel node (SN) procedure has been accepted during the past two decades as the most accurate staging procedure [7]. Sentinel node biopsy (SNB) is a surgical procedure with a complication rate between 5% and 10% [8], [9]. In the absence of proof that SNB is associated with a survival benefit alternative methods to identify positive SNs are being considered. The diagnostic algorithm of other cancers, such as thyroid and breast cancer, already includes pre-operative ultrasound (US) and fine needle aspiration cytology (FNAC) and it is conceivable to apply this to melanomas.
Previously, we have demonstrated that ultrasound can identify the same node, which is later excised and considered the sentinel node with an accuracy of 79% [10]. Another study by our group has demonstrated that US-FNAC could identify up to 65% of all SN involvement preoperatively [11]. Finally, we have described specific US patterns, which were used to achieve such a high sensitivity, the so called Berlin morphology criteria, which include Peripheral perfusion (PP) as an early sign of involvement followed by loss of central echo (LCE) and balloon shape (BS) as signs of advanced involvement [12].
The number of evaluated patients and their mean and median follow-up have increased significantly. The aim of the current study was to evaluate our increased experience with this modern approach comprising the highest amount of US-FNAC of SNs and to test its application as a completion to SNB. This is especially en vogue with the background of the just now published results of the MSLT1 trial [13], which is literally a confirmation of the results in 2006 and the importance of the non-sentinel node status, which can be assessed by performing completion lymph node dissection (CLND) after a positive sentinel lymph node biopsy (SLNB) [14]; or even – as an alternative-directly after a positive FNAC of the sentinel node.
Section snippets
Patients
Our prospectively collected database includes all patients presenting with a histopathologically proven primary malignant melanoma (at least 1.00 mm Breslow thickness, or if less, at least Clark IV/V, ulcerated and/or regressed) and who were planned for a sentinel node procedure at the Department of Dermatology, Charité, University Medicine Berlin, Germany. The institutional ethics review board (ERB) approved the study and informed consent was obtained from all patients enrolled. Recruitment for
Results
Baseline characteristics of all 1000 patients are described in Table 1. Mean and median age was 59 and 62 years, respectively (range 15–94 years). Mean and median Breslow thickness was 2.58/1.57 mm (0.2–44 mm). Ulceration was present in 24% of primary melanomas. In total 208 patients (21%) had positive lymph node disease on histology, either after positive SN (n = 165, 17% of total, 79% of all lymph node diseases) or directly proceeded to LND (after positive US-FNAC) in 43 cases (4% of total, 21% of
Discussion
Diagnosis of lymph node metastases at the time of SNB has several potential benefits, including more accurate prognostic information, enhanced nodal control and disease-free survival, and improvement in overall survival. However, there is uniformity in agreement that SNB yields the first two benefits, but improvement in overall survival has never been conclusively demonstrated [19]. This present study showed that ultrasound alone is able to identify up to 71% of SN metastases preoperatively.
Conflict of interest statement
None declared.
Acknowledgements
Supported by: Deutsche Krebshilfe (grant: 70-2791-Vo I).
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Ethical Approvals: # 45/95 Ethics committee of the University of Ulm, # 1367/00 of the Ethics Committee of the Charité, Medizinische Fakultät der Humboldt Universität Berlin and Amendment EA1/023/06.
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Shared first authorship.