Ganglio sentinela y pronostico en Melanoma.
Prognostic Value of Sentinel Lymph Node Biopsy for Cutaneous Melanoma
TAKE-HOME MESSAGE
This retrospective cohort study of 896 patients who underwent sentinel lymph node biopsy (SLNB) for melanoma attempted to determine whether the SLNB status provides improved prognostic information compared with Breslow thickness alone. For a given Breslow thickness, patients with a negative SLNB did not have improved survival vs patients with a positive SLNB. In univariate analyses, both Breslow thickness and SLNB status were predictive of survival. However, in multivariate analyses, SLNB status did not provide independent prognostic information compared with Breslow thickness alone.
Although SLNB is commonly performed for patients with melanoma, the results of this study show that it may not provide improved prognostic information compared with Breslow thickness alone.
– Jeffrey F. Scott, MD
- Written by
Prognostic value of SLNBx status compared with Breslow thickness
This study by Stiegel from Cleveland Clinic comes to a practice-changing conclusion about the purpose of SLNBx in the management of melanoma.
For years, throughout the literature, SLNBx has been claimed to be the "strongest predictor of death from melanoma" referring to one conclusion from MSLT-I.
Stiegel has clearly shown why that claim is false. First, he explains how MSLT -I authors based the conclusion on comparisons of hazard ratios of SLN-negative vs -positive with hazard ratios of Breslow thickness according to 1-mm increments. Second, and more importantly, he has produced the first head-to-head comparison of survival based on SLN status vs Breslow thickness in a large study that was powered to answer the prognosis question. His conclusion was that, when you know the Breslow thickness, there is no significant additional survival information from knowing the SLN status.
Using SLN status as a prognostic test fails most patients. Because 70% of melanomas are thin, most patients are not candidates for SLNBx as a prognostic test. Furthermore, two-thirds of people who die from melanoma are SLN-negative.
Stiegel's study confirms that SLNBx is not a test that should be used for prognostic purposes. Noninvasive tests are better, including Breslow thickness alone or other Web-based models that combine Breslow thickness with other clinicopathologic features such as ulceration, mitotic rate, age, and location (LifeMath.net, Memorial Sloan Kettering Melanoma Nomogram, and AJCC melanomaprognosis.net). Even better may be gene expression profiling alone or in combination with clinicopathologic features.
There is great value for accurate prognostic tests. They are used for staging patients for determining follow-up intervals, for appropriate screening tests for metastatic disease, for choosing available adjuvant systemic therapy, for accurate randomization for clinical trials, and for estimating life expectancy for patient life planning.
Stiegel's practice-changing findings question the continued use of SLNBx as a staging test and suggest re-examination of staging tools for the future.
Abstract
BACKGROUND
Sentinel lymph node biopsy (SLNB) is widely performed for melanoma of certain histologic parameters and offers important prognostic and staging information. Breslow thickness (BT) by itself also provides meaningful prognostic information.
OBJECTIVE
To evaluate whether sentinel lymph node (SLN) status provides independent prognostic information than that which is already provided by BT.
METHODS
We conducted a retrospective cohort study of 896 patients who underwent SLNB for primary cutaneous melanoma. Stratified analysis of the impact of SLN status within BT groups (0.01-1mm, 1.01-2.00mm, 2.01-4.00mm, and >4.00mm) was performed. In addition, a Cox proportional hazard model was fit to evaluate the interaction between BT unadjusted and then adjusted for SLN status to determine if predictive ability is improved.
RESULTS
Having a negative SLN did not confer a statistically significant survival advantage for any BT subgroup (P= 0.54, 0.075, 0.17, and 0.95 for subgroups 0.01-1mm, 1.01-2.00mm, 2.01-4.00mm, and >4.00mm, respectively). In multivariate analysis, SLN status did not demonstrate independent prognostic ability over BT alone (P=0.067).
LIMITATIONS
Retrospective study, single institution.
CONCLUSION
Our data suggest that SLN status does not offer better prognostic information for patients compared to BT alone.
Additional Info
Prognostic Value of Sentinel Lymph Node Biopsy According to Breslow Thickness for Cutaneous Melanoma
J Am Acad Dermatol 2018 Feb 03;[EPub Ahead of Print], E Stiegel, D Xiong, J Ya, P Funchain, R Isakov, B Gastman, A Vijposted by dermatica at
February 23, 2018
0 Comments:
Post a Comment
Subscribe to Post Comments [Atom]
<< Home