Melanoma in the elderly and sentinel lymph node biopsy: a single center experience of 124 consecutive patients
© Mainente et al; licensee BioMed Central Ltd. 2009
Published: 1 April 2009
The best treatment for patients with pathological stage I–II malignant melanoma (sec AJCC) remains controversial because patients are unlikely to benefit from routine lymphoadenectomy (over treatment risk 80%) in this stage. On the other hand, pitfalls in the identification of occult melanoma are significant (20%). Our objective was to evaluate the single center application of sentinel lymphoadenectomy for the management of early stage melanoma. The sentinel lymph node biopsy (SLN) is a minimally invasive technique of staging the regional lymph nodes for melanoma that balance risks and effectiveness.
From April 2002 a total of 124 patients with mean age of 56.9 (range 21–90) years, were studied in the multidisciplinary outpatient clinic for melanoma at "Ospedale di Valdagno – ULSS 5". We analyzed 83 patients treated from 2002 through 2008 who underwent SLN biopsy for melanoma. Candidates for SLN are patients with thick primary melanoma (>1 mm sec Breslow) or less if ulcerated or with regression. One day before surgery, lymphoscintigraphy has been performed using 99 mTc-human serum albumin. Intraoperatively, blue dye was injected around the primary site and the nodes were identified using both blue dye and hand-held gamma probe.
Of the 124 patients, 44 were over 65 years old (35.4%); 27 male and 17 female with mean age of 75.3 years (66–90). Primaries were on head/neck (n = 18), trunk (n = 11), upper extremities (n = 7), lower extremities (n = 8). The most common histology was superficial spreading (18) followed by: 11 nodular melanoma, 12 melanoma on lentigo maligna, 1 acral melanoma, 2 metastases of unknown origin. The median tumour thickness was 3.56 mm (0.5–10) and 7 were melanoma ulcerated; 5 melanoma with regression. Among these patients we performed 17 SLN. Metastases in sentinel node were present in 2 cases (11.6%). A man with ulcerated melanoma of the trunk with tumor thickness >5 mm underwent axillaries lymphoadenectomy (25 lymph node removed, 0 metastases) and an 88 year-old female with in-transit metastases (primary knee melanoma) underwent inguinal-crural-otturatory lymphadenectomy (27 nodes removed, 0 metastases). Median hospital stay for the last 2 patients was 5 days and the post-operative course was uneventful.
SLN status is the most important prognostic factor in stage I–II malignant melanoma. Indeed, after 27 months follow-up in 612 SLN-negative patients, disease-free survival was 91%, recurrence rate was 9% and mortality rate was less than 2%. In the SLN-positive group overall survival was 77% and recurrence rate of 33% with a mortality rate of 16%. The procedure helps to identify high-risk recurrence patients, and stratify these patients into more aggressive adjuvant therapy. SLN is widely accepted even in older population however in those patients relationship between age and SLNB is not established.
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