Age-related disparities in use of completion lymphadenectomy for melanoma sentinel lymph node metastasis

doi:10.1016/j.jss.2013.05.090

Journal of Surgical Research

Volume 185, Issue 1, November 2013, Pages 240-244

https://doi.org/10.1016/j.jss.2013.05.090 Get rights and content

Abstract

Background

Guidelines recommend that patients with melanoma metastatic to the sentinel lymph node (SLN) undergo a completion lymphadenectomy (CLND) of the affected lymph node basin. We have previously reported on decreased use of SLN biopsy among elderly patients. We hypothesized that elderly patients with SLN metastases would have lower rates of CLND relative to their younger counterparts.

Methods

The Surveillance, Epidemiology, and End Results database was queried for patients who underwent SLN biopsy for intermediate thickness cutaneous melanoma (Breslow thickness 1.01 mm–4.00 mm) from 2004 to 2008 and were found to have SLN metastasis. Patients were categorized according to age by decade. We then used multivariate logistic regression models to predict receipt of CLND. Additional covariates included sex, race/ethnicity, T stage, tumor histology, tumor location, and ulceration. The likelihood of receiving a CLND was reported as OR with 95% CI; significance was set at P ≤ 0.05.

Results

Entry criteria were met by 765 patients. Of these, 548 (71.6%) patients underwent CLND. On multivariate analysis, patients in the age groups 70–79 y old (OR 0.39, CI 0.20–0.78; P = 0.007) and ≥80 y old (OR 0.27, CI 0.12–0.61; P = 0.001) were less likely to undergo CLND than the youngest age group (1–39 y old).

Conclusions

Elderly patients with SLN metastasis are less likely to receive CLND than their younger counterparts. A multi-center randomized clinical trial evaluating the potential survival benefit of CLND is ongoing. Further research to assess reasons why the elderly are less likely to receive CLND are needed.

Introduction

Lymphatic mapping and sentinel lymph node biopsy (SLNB) is the standard method of staging the lymph node basin in patients with cutaneous melanoma. Approximately 16% of patients with intermediate thickness melanoma will have sentinel lymph node (SLN) metastasis [1]. Data suggest that the majority of patients will have the SLN as their only source of lymph node metastasis [2], [3]. Unfortunately, despite several statistical models and nomograms utilizing known clinicopathologic factors, it remains difficult to predict which patients will have non-SLN metastasis [4], [5]. Because of this and because adjuvant therapies for stage III melanoma are limited, current recommendations suggest that all patients with SLN metastasis be offered a completion lymphadenectomy dissection (CLND) of the affected lymph node basin [6].

Health services research has documented several disparities in the cancer treatment of minority populations, most notably among racial and ethnic groups. Less commonly noted are disparities in treatment based upon age. Data suggest that elderly patients are more likely to receive inferior treatment relative to younger patients with similarly staged disease [7], [8], [9]. In fact, we have previously noted that elderly patients with cutaneous melanoma are less likely to be offered SLNB than their younger counterparts [10]. Given this, we hypothesized that older patients with SLN metastasis would be less likely to receive an indicated CLND than their younger counterparts.

Section snippets

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients who underwent SLNB for intermediate thickness cutaneous melanoma (Breslow thickness 1.01–4.00 mm) from 2004 to 2008 and were found to have SLN metastasis. SEER collects cancer incidence, prevalence, and survival data from 17 population-based cancer registries representing 28% of the US population. SEER furthermore provides information on patient demographics, primary tumor site, tumor morphology, stage at

Results

Entry criteria were met by 765 patients. Of these, 548 (71.6%) patients underwent CLND. The baseline patient, tumor, and treatment characteristics of the study population are summarized in Table 1. Briefly, the median age of study participants was 55 y. The majority of patients were White (94%) males (64%) with T2 (43%) or T3 (57%) primary melanomas of superficial spreading or nodular histology (84.6%). In this population, about 40% of tumors originated on the trunk with upper extremity (20.5%)

Discussion

We have previously demonstrated that elderly patients with intermediate thickness melanoma are less likely to receive a lymphatic mapping and SLNB than their younger counterparts [10]. Having defined this age-based disparity, we wondered if elderly patients with SLN metastases would also be less likely to receive a CLND. Our data show that patients ≥70 y were 61%–73% less likely to receive this indicated therapy.

Prior epidemiological studies have reported varying compliance rates with current

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Cited by (12)

Use of Completion Lymph Node Dissection for Sentinel Lymph Node-Positive Melanoma
2020, Journal of the American College of Surgeons
Citation Excerpt :
We also found no association between sex and likelihood of CLND, consistent with other data.11,27,32 Tumor location, especially in the lower extremity, is often associated with lower likelihood of CLND in SNPM, likely due to the increased morbidity of the procedure,7,27,31,32 and we found similar results. This effect did not change significantly over time.
For patients with sentinel node-positive melanoma (SNPM), randomized trials, first reported in 2015, found no benefit for routine completion lymph node dissection (CLND) in selected patients. This study examines time trends in CLND and explores institutional and clinical factors associated with CLND.
The National Cancer Database was queried for patients older than 18 years from 2012 to 2016 with SNPM. A high-volume center was defined as >80th percentile for number of sentinel node procedures. Poisson regression assessed temporal trends and identified patient, pathologic, and institutional characteristics associated with CLND.
From 2012 to 2016, we identified 7,146 patients with SNPM. The proportion of patients undergoing CLND was steady in 2012 to 2014 (61% to 63%), but decreased to 57% in 2015 and 50% in 2016 (p < 0.0001). The proportion of patients with SNPM who underwent CLND decreased over time for both high- (66% to 52%; p < 0.0001) and lower-volume centers (55% to 45%; p = 0.06). Female sex (relative risk [RR] 0.97; p < 0.001) and increasing age (RR 0.98; p < 0.0001) were associated with lower likelihood of CLND. Increased Breslow depth (RR 1.015; p = 0.006), ulceration (RR 1.067; p = 0.02), and high-volume centers (RR 1.180; p < 0.0001) were associated with higher likelihood of CLND. Regional differences in likelihood of CLND were also present (p < 0.0001).
Completion lymph node dissection in SNPM decreased over time, with the greatest change in 2016. Several patient, pathologic, and institutional characteristics were associated with likelihood of CLND. As evidence supports close observation for selected patients, efforts should be undertaken to improve and standardize patient selection for CLND across institutions caring for patients with melanoma.
Management of Skin Cancer in the Elderly
2019, Dermatologic Clinics
Citation Excerpt :
However, the rate of successful SLNB has been shown to be up to 98% in individuals greater than 65 years of age.30 Elderly patients with a positive SLNB are less likely to receive systemic treatment compared with their younger counterparts.31,32 Many elderly patients may have been undertreated as a result.
Lymph node dissection in the advanced age patient with melanoma
2018, Piel
Impact of completion lymph node dissection on patients with positive sentinel lymph node biopsy in melanoma
2016, Journal of the American College of Surgeons
Whether patients with positive SLNB should undergo complete lymph node dissection (CLND) is an important unanswered clinical question.
Patients diagnosed with positive SLNB at a melanoma referral center from 1991 to 2013 were studied. Outcomes of patients who underwent CLND were compared with those who did not undergo immediate CLND (observation [OBS] group).
There were 471 patients who had positive SLNB; 375 (79.6%) in the CLND group and 96 (20.4%) in the OBS group. The groups were similar except that the CLND group was younger and had more sentinel nodes removed. Five-year nodal recurrence-free survival was significantly better in the CLND group compared with the OBS group (93.1% vs 84.4%; p = 0.005). However, 5-year (66.4% vs 55.2%) and 10-year (59.5% vs 45.0%) distant metastasis-free survival rates were not significantly different (p = 0.061). The CLND group's melanoma-specific survival (MSS) rate was superior to that of the OBS group; 5-year MSS rates were 73.7% vs 65.5% and 10-year MSS rates were 66.8% vs 48.3% (p = 0.015). On multivariate analysis, CLND was associated with improved MSS (hazard ratio = 0.60; 95% CI, 0.40–0.89; p = 0.011) and lower nodal recurrence (hazard ratio = 0.46; 95% CI, 0.24–0.86; p = 0.016). Increased Breslow thickness, older age, ulceration, and trunk melanoma were all associated with worse outcomes. On subgroup analysis, the following factors were associated with better outcomes from CLND: male sex, nonulcerated primary, intermediate thickness, Clark level IV or lower extremity tumors.
Treatment of positive SLNB with CLND was associated with improved MSS and nodal recurrence rates. Follow-up beyond 5 years was needed to see a significant difference in MSS rates.
Management of regional lymph nodes in the elderly melanoma patient: Patient selection, accuracy and prognostic implications
2015, European Journal of Surgical Oncology
Citation Excerpt :
A common clinical factor associated with non-compliance is advanced age.7 Not only are elderly patients less likely to undergo CLND when indicated, but they are also less likely to have ≥10 lymph nodes examined.7,8 Investigators have cited increased failure rates of lymphatic mapping in the elderly breast cancer patients.9–11
Among older melanoma patients, lymphatic mapping failure, lower rates of SLN positivity and poor prognosis are reported reasons for omission of sentinel lymph node biopsy (SLNB). We investigated reasons for non-compliance with guidelines, sensitivity and prognostic significance of SLNB and completion lymphadenectomy (CLND) for elderly melanoma patients.
Retrospective review of patients ≥65 years with ≥1 mm thick melanoma treated at a single Institution. Wilcoxon, chi-square and Fisher's exact tests were used for analysis as appropriate. Univariable and multivariable Cox regressions were used to analyze time-to-event variables.
72 of 358 patients (20%) did not undergo SLNB. Reasons for omission included selective neck dissection in 26 (7%), patient refusal in 11 (3%), physician recommendation in 15 (4%) and significant comorbidities in 8 (2%). Of the 286 patients undergoing SLNB, only 5 (1.7%) had lymphatic mapping failures. 76 patients (26.6%) were SLN-positive. The sensitivity of SLNB was 90.5%, the negative predictive value was 96.3% and the false negative rate was 3.8%. Sixty-seven (88%) SLN-positive patients underwent CLND and 10 (15%) had positive non-SLNs. Reasons for omission of CLND included patient refusal in 3 (4%), surgeon recommendation in 5 (7%) and postoperative complication in 1 (1%). SLN and non-SLN status were independently associated with disease-free survival. SLN status was independently associated with melanoma-specific survival.
SLNB was successful in 98.7% of elderly patients with high sensitivity and a low false negative rate. Only 2% of our elderly patients appeared too frail for SLNB. Age alone should not be a contraindication to SLNB and CLND for melanoma.
Sentinel lymph node biopsy for melanoma in the older population: A prospective analysis of outcomes
2024, Journal of Surgical Oncology

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Oncology/EndocrineAge-related disparities in use of completion lymphadenectomy for melanoma sentinel lymph node metastasis

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Am J Surg

Am J Med

Lancet Oncol

Sentinel-node biopsy for nodal observation in melanoma

N Engl J Med

Outcome of patients with a positive sentinel lymph node who do not undergo completion lymphadenectomy

Ann Surg Oncol

A nomogram that predicts the presence of sentinel node metastasis in melanoma with better discrimination than the American Joint Committee on Cancer staging system

Ann Surg Oncol

Melanoma patients with positive sentinel nodes who did not undergo completion lymphadenectomy: a multi-institutional study

Ann Surg Oncol

Patients’ age as a determinant of care received following acute stroke: a systematic review

BMC Health Serv Res

Oncology/Endocrine
Age-related disparities in use of completion lymphadenectomy for melanoma sentinel lymph node metastasis