Lymph Node Excision Guidance Given For Cutaneous Melanoma Patients

The number of lymph nodes to be excised to ensure good quality lymphadenectomy for patients with cutaneous melanoma is identified

medwireNews: Italian researchers have identified the minimum number of lymph nodes (LNs) that they believe should be excised to ensure lymphadenectomy quality in patients with cutaneous melanoma.

In all, 90% of the 2526 patients who underwent lymphadenectomy had at least 12 LNs excised at a 3-level axillary dissection, seven LNs were excised at a 3-level or less neck procedure, 14 LNs at a 4-level or more neck procedure, and six and 13 LNs excised at inguinal and ilioinguinal dissections, respectively.

These patients were in the top 10th percentile of the distribution for the different procedures, and this is in line with previous research in a melanoma population, which suggested that the “desirable number of excised LNs should be greater than the 10th percentile of the number of LNs that had been excised”, explain Carlo Riccardo Rossi, from Veneto Institute of Oncology in Padua, and co-authors in JAMA Surgery.

Patients who have fewer LNs dissected are at risk of having had a poor quality lymphadenectomy, they add.

The team assessed cutaneous melanoma patients who underwent lymphadenectomy for regional LN metastasis at one of eight Italian centres, including four cancer centres and four general surgery units, with three institutions reporting findings for more than 300 patients, two for between 200 and 300 patients and four institutions for 100 patients or less.

Analysis revealed that a significantly higher number of LNs were excised from patients aged less than 54 years compared with older patients (21 vs 19), from men than women (21 vs 19) and from patients attending a high-volume institution caring for 300 or more patients than smaller volume clinics (21 vs 18).

In addition, patients had a significantly higher number of LNs excised if their surgery had been performed in 2002 to 2010 rather than 1992 to 2001 (21 vs 18) and if they had LN micrometastasis versus macrometastasis (20 vs 19). The number of positive LNs also significantly correlated with increasing number of LNs dissected.

Nevertheless, the researchers note that the differences between the median number of LNs excised in these patient groups were small and not all the differences in the number of LNs dissected retained their significance after the field of dissection was accounted for.

For example, high-volume institution patients and younger patients only had significantly more LNs excised than low-volume institution patients and older patients, respectively, if they underwent axillary dissections and not other types of procedure.

“These values are reproducible across the institution, patient, and tumor features evaluated and may serve to monitor the quality of surgery within audit processes and for patients who are eligible to be enrolled in trials investigating adjuvant therapies”, Carlo Riccardo Rossi et al conclude.

“Further research is needed to evaluate whether using the number of excised LNs as a quality assurance factor might affect patient outcomes and whether other metrics (eg, morbidity) might be suitable for quality assurance monitoring.”

Reference

Rossi C, Mozzillo R, Maurichi A, et al. Number of Excised Lymph Nodes as a Quality Assurance Measure for Lymphadenectomy in Melanoma. JAMA Surg 2014; Online First 7 May. Doi:10.1001/jamasurg.2013.5676

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