cutaneous melanoma of the head and neck: the role of neck dissection james m. roth, m.d. paul...
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CUTANEOUS MELANOMA OF THE HEAD AND NECK: THE ROLE OF NECK DISSECTION
JAMES M. ROTH, M.D.
PAUL FRIEDLANDER, M.D.
CUTANEOUS MELANOMA
• IN 2001, 47,700 NEW CASES WILL BE DIAGNOSED
• INCIDENCE IS INCREASING AT 5% PER YEAR
• BY THE YEAR 2000 1 IN 75 PEOPLE WILL DEVELOP MELONAMA
• THIS INCREASE IS GREATER THAN ANY OTHER CANCER IN MEN AND SECOND ONLY TO LUNG CANCER IN WOMEN
CUTANEOUS MELANOMA• 15-30% OF MELANOMA OCCUR IN
THE HEAD AND NECK
• 10 YEAR SURVIVAL FOR STAGE 1 MELANOMA OF THE HEAD AND NECK IS 69% COMPARED TO 89% WITH MELANOMA OF THE EXTREMITY
• 50% RECCURRENCE RATE AFTER 5 YEARS FOR HEAD AND NECK COMPARED TO 50% IN 10 YEARS FOR EXTREMITY
RISK FACTORS
• SUN EXPOSURE: UV B AND TO SOME EXTENT UV A/ VISIBLE
• CONTROVERSY OVER CUMULATIVE EXPOSURE AND EARLY EXPOSURE
• PRE-EXISTING LESION: 1/3 ARISE IN CONGENITAL NEVI; 1/3 IN NEVI > 5 YEARS; 1/3 IN NEVI < 5 YEARS
• BLUE/GREEN EYES; BLOND/RED HAIR; FAIR CMPLEXION; INABILITY TO TAN
ABCD
• ASSYMETRY- UNEVEN GROWTH RATE
• BORDER- IRREGULAR (THE STRONGEST PREDICTOR OF MALIGNANCY)
• COLOR- VARIETIONS AND SHADING
• DIAMETER- INCREASES IN SIZE OR A DIAMETER >6MM
HISTORY
• MAJORITY ARE DETECTED BY THE PATIENT WITH ONLY 25% BEING DETECTED BY PHYSICIANS
• GROWTH OR COLOR CHANGE IN A PRE-EXISTING LESION
• BLEEDING, ITCHING, ULCERATION, AND PAIN- ALL OF THESE ARE USUALLY LATE SIGNS
HISTORY
• XERODERMA PIGMENTOSA– AUTOSOMAL RECESSIVE– MULTIPLE SKIN CANCERS BEFORE AGE
10– NUCLEOTIDE EXCISION REPAIR
• FAMILIAL MELANOMA/ DYSPLASTIC NEVUS SYNDROME– p16 GENE ON CHROMOSOME 9p21
PATHOLOGICAL SUBTYPES
• LENTIGO MALIGNA MELANOMA
• SUPERFICIAL SPREADING MELANOMA
• NODULAR MELANOMA
• ACRAL LENTIGINOUS MELANOMA
• DESMOPLASTIC MELANOMA
LENTIGO MALIGNA MELANOMA
• 5-10% OF ALL MELANOMA
• PROLONGED RADIAL GROWTH PHASE
• INVASION OF THE PAPILLARY DERMIS
• ULCERATION VERY SIGNIFICANT IN PROGNOSIS
SUPERFICIAL SPREADING
• MOST COMMON SUBTYPE (75%)
• INITIAL RADIAL GROWTH PHASE
• VERTICAL GROWTH HERALDED BY ULCERATION AND BLEEDING
• CELLS HAVE A UNIFORM APPEARANCE
NODULAR MELANOMA
• 10-15%
• NO RADIAL GROWTH PHASE
• VERTICAL GROWTH FROM THE ONSET
ACRAL LENTIGINOUS
• PALMS AND SOLES
• MOST COMMON MELANOMA IN AFRICAN AMERICANS
DESMOPLASTIC MELANOMA
• SPINDLE CELLS AMONG A FIBROUS STROMA “SCHOOLS OF FISH”
• OFTEN NOT PIGMENTED
• PROPENSITY TO SPREAD PERINEURALLY
STAGING SYSTEMS
• CLARK LEVEL
• BRESLOW THICKNESS
• AJCC TNM CLASSIFICATION
• MODIFICATIONS OF THE AJCC
CLARK LEVEL• LEVEL I
– ONLY INVOLVES THE EPIDERMIS
• LEVEL II– INVASION OF PAPILLARY DERMIS BUT
DOES NOT REACH THE PAPILLARY RETICULAR INTERFACE
• LEVEL III– INVASION FILLS AND EXPANDS THE
PAPILLARY DERMIS
CLARK LEVEL
• LEVEL IV– INVASION INTO THE RETICULAR
DERMIS
• LEVEL V– INVASION THROUGH THE
RETICULAR DERMIS INTO THE SUBCUTANEOUS TISSUE
BRESLOW THICKNESS
• STAGE I– 0.75MM OR LESS
• STAGE II– 0.76MM TO 1.50MM
• STAGE III– 1.51MM TO 4.0MM
• STAGE 1V– 4.0MM OR GREATER
AJCC TNM CLASSIFICATION• PRIMARY TUMOR (T)
– TX: CAN NOT BE ASSESSED
– T0: NO EVIDENCE OF PRIMARY TUMOR
– Tis: MELANOMA IN SITU CLARK LEVEL I
– T1: BRESLOW STAGE I CLARK LEVEL II
– T2: BRESLOW STAGE II CLARK LEVEL III
– T3: BRESLOW STAGE III CLARK LEVEL IV
• a- 1.5mm but no more than 3mm
• b- 3mm but no more than 4mm
– T4: BRESLOW STAGE IV CLARK LEVEL V AND/OR SATELLITE LESIONS WITHIN 2CM
• a-> 4mm or invades the subcutaneous tissue
• b- Satellite(s) within 2 cm of the primary
AJCC TNM CLASSIFICATION• REGIONAL LYMPH NODES (N)
– NX: CAN NOT BE ASSESSED
– NO: NO REGIONAL LYMPH NODES
– N1: >3CM DIAMETER IN ANY REGIONAL LYMPH NODE
– N2: >3CM AND OR IN-TRANSIT METASTASIS
• a-> 3cm in diameter
• b- in-transit metastasis
• c- both a and b
• in-transit metastasis involves skin or subcutaneous tissue >2cm from primary but not beyond the regional lymph nodes
AJCC TNM CLASSIFICATION
• DISTANT METASTASIS– MX: CAN NOT BE ASSESSED– MO: NO DISTANT METASTASIS– M1: DISTANT METASTASIS
• a: Metastasis in the skin or subcutaneous nodules beyond the regional lymph nodes
• b: visceral metastasis
AJCC TNM CLASSIFICATION
• STAGE 0: Tis, NO, MO
• STAGE I: T1/2, NO, MO
• STAGE II: T3/4, NO, MO
• STAGE III: ANY T, N1/2, MO
• STAGE IV: ANY T, ANY N, M1
M.D. ANDERSON MODIFICATIONS
• NOT USING OPTIMAL CUTOFFS OF TUMOR THICKNESS
• NO USE OF ULCERATION IN THE SYSTEM DESPITE IT BEING A POWERFUL PROGNOSTIC INDICATOR
• NUMBER OF NODES MORE IMPORTANT THAN SIZE
• SATELLITES, IN-TRANSIT METASTASIS HAVE SIMILAR OUTCOMES
M.D. ANDERSON MODIFICATIONS
• CUTOFFS FOR TUMOR THICKNESS SHOULD BE 1, 2, 4 MM- SIMPLER AND STILL SIGNIFICANT
• INCORPORATE ULCERATION SINCE THIS HAS BEEN SEEN IN MORE AGGRESSIVE LESIONS AND HAS BEEN STRONG IN PREDICTING OUTCOME
M.D. ANDERSON MODIFICATIONS
• NODAL STATUS STRONG INFLUENCE ON SURVIVAL 5YEARS SURVIVAL DATA N+ 32% AND N- 71% IN THICK TUMORS
• REGIONAL SKIN AND SUBCUTANEOUS METASTASIS A SEPARATE CATEGORY
• NUMBER OF NODES POSITIVE SHOULD REPLACE NODAL SIZE
PRIMARY LESIONS• WIDE LOCAL EXCISION
• TUMOR THICKNESS MOST SIGNIFICANT FACTOR FOR LOCAL RECURRENCE
• MARGINS RECOMMENDED FOR EXTREMITY NOT ALWAYS POSSIBLE IN THE HEAD AND NECK– <1MM 1CM MARGIN– 1-4MM 2CM MARGIN– >4 MM 2-3CM MARGIN
REGIONAL LYMPHATICS• SHAH 1991 MSK- ANALYZED 111
PATIENTS WITH MELANOMA AND METASTAIC DISEASE
• LESIONS INVOLVING THE EAR, FACE, AND ANTERIOR SCALP WERE AT HIGH RISK FOR PAROTID INVOLVEMENT
• LEVELS II THROUGH IV WERE MOST COMMONLY INVOLVED WITH LEVEL I INVOLVED 23% OF THE TIME AND LEVEL V INVOLVED 19% OF THE TIME
REGIONAL LYMPHATICS
• POSTERIOR NECK/ SCALP HAD NO INVOLVEMENT OF THE PAROTID GLAND, LOW INVOLVEMENT OF LEVEL 1 , AND INCREASED INVOLVEMENT OF LEVEL 5
REGIONAL LYMPHATICS
• LESIONS LESS THAN .76MM RARELY METASTASIZE
• LESIONS .76MM TO 4.0MM METASTASIZE 14-44% OF PATIENTS
• LESIONS >4.00 METASTASIZE 50-60% OF PATIENTS
• LESIONS <1.5MM HAD ONLY 8% METASTASIS
NODE POSITIVE NECK
• RADICAL VERSUS MODIFIED/ SELECTIVE NECK DISSECTION
• RADICAL NECK DISSECTION IS NOT ALWAYS NECESSARY AND MAY NOT PROVIDE ADDITIONAL BENEFIT
• O’BRIEN 1995 SYDNEY MELANOMA UNIT
SYDNEY MELANOMA UNIT
• 175 PATIENTS WITH 183 NECK DISSECTIONS
• 58% HAD A MODIFIED/SELECTIVE NECK DISSECTION IN THE PRESENCE OF CLINICAL NECK DISEASE
• NECK RECURRENCE OCCURRED IN 14% OF RADICAL, 0% OF MODIFIED, AND 23% OF SELECTIVE NECK DISSECTIONS
SYDNEY MELANOMA UNIT
• RADICAL NECK DISSECTIONS WERE MORE LIKELY TO HAVE MULTIPLE POSITIVE NODES AND NO ADJUVANT RADIATION THERAPY
• MODIFIED NECK DISSECTION HAD ONLY ONE NODE INVOLVEMENT
• CLINICAL METASTATIC MELANOMA (N+) CAN BE WELL CONTROLLED BY MRND
SYDNEY MELANOMA UNIT
• SELECTIVE NECK DISSECTION, WHERE ONLY SPECIFIC LEVELS WERE DISSECTED, SEEMED LESS EFFECTIVE
• BYERS 1998 M.D. ANDERSON AGREED THAT LESS THAN RADICAL SURGERY IS AN OPTION SECONDARY TO “PUSHING” CHARACTERISTIC OF THE NODES
NODE POSITIVE NECK
• STAGE III AND IV MELANOMA OF THE HEAD AND NECK SHOULD UNDERGO NECK DISSECTION AND MODIFIED RADICAL NECK DISSECTION APPEARS APPROPRIATE
• LEVELS I-IV IN ANTERIOR LESIONS
• LEVELS II-V IN POSTERIOR LESIONS
NODE NEGATIVE NECKS
• THE ROLE OF ELECTIVE NECK DISSECTION IS EVEN MORE CONTROVERSIAL
• LACK OF DATA TO SHOW ANY SIGNIFICANT SURVIVAL BENEFIT
• TUMOR < 0.75 MM, NONULCERATED ARE VERY RARE TO METASTIASIZE
NODE NEGATIVE NECKS• TUMORS > 4.0MM HAVE A HIGH
RATE OF DISTANT METASTASIS (70%) AND POTENTIAL BENEFIT FROM NECK DISSECTION IS LOW
• >4MM ELND MAY BENEFIT TO HELP STAGE THERE DISEASE AND POSSIBLY QUALIFY FOR ADJUVANT IMMUNOTHERAPY
• WHAT ABOUT TUMORS .76-3.9MM?
NODE NEGATIVE NECKS
• ELECTIVE LYMPH NODE DISSECTION (ELND)
• MAY BE OF THERAPUETIC BENEFIT
• MAY BE USEFUL IN PREDICTING PROGNOSIS AND BENEFIT OF ADJUVANT THERAPY
• STEPWISE PROGRESSION- LOCAL TO REGIONAL TO DISTANT
• HEAD AND NECK MAY NOT FOLLOW THE RULES
NODE NEGATIVE NECKS
• PROPONENTS
• PERALTA 1998 U. OF WASHINGTON
• DREPPER 1993 MULTICENTER STUDY IN GERMANY
• URIST 1984 AND BALCH 1996 INTERGROUP MELANOMA SURGICAL PROGRAM
• IMMUNOTHERAPY
PERALTA 1998 U. OF WASHINGTON
• 1.5-3.9MM LESIONS TREATED WITH AND WITHOUT ELND
• 174 TOTAL MELANOMA TREATED OF THESE 38 HAD CLINICALLY NODE NEGATIVE AND INTERMEDIATE THICKNESS AND 10 UNDERWENT ELND
• THE RATE OF DISTANT METASTASIS AND MORTALITY WERE 44% AND 35% LOWER THAN THOSE WHO DID NOT UNDERGO ELND AFTER 3 YEARS OF FOLLOW UP
• NUMBERS TO SMALL TO BE SIGNIFICANT
DREPPER 1993• 9 MEDICAL CENTERS
• 3616 WITH T2 TO T4 LESIONS (>0.76MM)
• <70 YEARS OLD
• NOT SPECIFIC FOR HEAD AND NECK MELANOMA
• ELND BENEFITTED MALE PATIENTS, NON ULCERATED LESIONS, AXIAL OR ACRAL MELANOMA, TUMORS >1.5MM TO 4.5MM
• 20% INCREASE IN 5 YEAR SURVIVAL
BALCH 1996
• 740 STAGE I AND II , 1-4MM LESIONS
• NOT CONFINED TO THE HEAD AND NECK ONLY 8 WITH HEAD AND NECK
• BENEFIT CONFINED TO PATIENT’S <60YEARS OLD, ESPECIALLY WITHOUT ULCERATION AND WITH THICKNESS OF 1-2MM (88% TO 81%)
• >60 YEARS OLD HAD WORSE SURVIVAL WITH ELND
URIST 1984• 534 PATIENTS WITH STAGE I HEAD AND
NECK MELANOMA PROSPECTIVE NON-RANDOMIZED
• SSM AND NM ELND DID NOT PROVIDE ANY BENEFIT FOR MELANOMA <0.76MM OR >4.0MM
• 1.5-3.99MM SHOWED A STATISTICALLY SIGNIFICANT INCREASE IN SURVIVAL RATE
• .76-1.49MM SHOWED IMPROVEMENT THAT WAS NOT STATISTICALLY SIGNIFICANT
IMMUNOTHERAPY
• KIRKWOOD 1996 U. OF PITTSBURGH
• MELANOMA AS A IMMUNOLOGIC DISEASE– SPONTANEOUSLY REGRESS– INFILTRATES OF B CELLS, T CELLS, AND
MACROPHAGES– VITILIGO AS A RESULT OF
ANTIMELANOCYTE ACTIVITY– SERA CONTAINS MELANOMA BINDING
ANTIBODIES
KIRKWOOD 1996 U. OF PITTSBURGH
• INTERFERON alpha- 2b
• PROLONGATION OF RELAPSE FREE SURVIVAL AND PROLONGATION OF OVERALL SURVIVAL
• BENEFIT GREATEST AMONG NODE POSITIVE PATIENTS
• NOT LIMITED TO THE HEAD AND NECK
NODE NEGATIVE NECKS
• ARGUMENTS AGAINST ELND
• KNUTSON 1972 U. OF MISSOURI
• O’BRIEN 1991 SMU
• KANE 1997 MAYO CLINIC
• SURGICAL MORBIDITY
• SENTINEL LYMPH NODE MAPPING
• RADIATION THERAPY
KNUTSON 1972 U. OF MISSOURI
• 87 PATIENTS MELANOMA OF THE HEAD AND NECK 42 UNDERWENT NECK DISSECTION
• 23 UNDERWENT ELECTIVE RADICAL NECK DISSSECTION
• 21.7% ELND HAD POSITIVE NODES
• 78.2% UNDERWENT A PROCEDURE WITH NO DEFINITIVE BENEFIT
• SMALL NUMBER OF PATIENT’S
O’BRIEN 1991 SMU
• THIS DATA WAS APART OF THE DATA USED BY URIST
• WHEN THE SMU DATA WAS PULLED FROM THIS A SURVIVAL BENEFIT WAS ORIGINALLY SEEN ON UNIVARIATE ANALYSIS
• MULTIVARIATE ANALYSIS ELIMINATED THIS BENEFIT
KANE 1997 MAYO CLINIC• GREATER PROGNOSTIC UTILITY
THAN SURVIVAL BENEFIT
• 180 STAGE 1 UNDERWENT ELND
• 8.3% HAD DISEASE ON PATHOLOGY
• T3 AND T4 LESIONS HAD 14% AND 30% POSITVE PATHOLOGIC SPECIMENS
• NO BENEFIT SEEN IN THESE THICKER LESIONS OR STAGE 1 LESIONS
• STILL RECOMMEND ELND FOR TUMORS >1.5MM
SURGICAL MORBIDITY
• SUPERFICIAL PAROTIDECTOMIES RISK INJURY TO THE FACIAL NERVE AND GUSTATORY SWEATING
• POSTOPERATIVE HEMATOMA• CHYLOUS FISTULA• SKIN FLAP NECROSIS• COSMETIC AND FUNCTIONAL DEFECT
SENTINEL NODE BIOPSY• RECENT ADVANCEMENT IN
MELANOMA THERAPY
• BASED ON THE STEPWISE PROGRESSION OF CANCER
• MOSTLY USED IN TRUNK AND EXTREMITY MELANOMA
• IS THE HEAD AND NECK PREDICTABLE?
• NEED FOR LYMPHOSCINTIGRAPHY?
• WELLS 1997 U. OF SOUTH FLORIDA
WELLS 1997 U. OF SOUTH FLORIDA
• IF PREOPERATIVE LYMPHOSCINTIGRAPHY IS NOT PERFORMED ELND AND NODE BIOPSIES MAY BE MISDIRECTED IN 50% OF CASES
• ALL NODAL BASINS AT RISK
• IN-TRANSIT NODAL AREAS
• NUMBER OF SENTINEL NODES
• LOCATION OF THE SENTINEL NODE IN RELATION TO OTHER NODES
SENTINEL NODE BIOPSY
• USE OF TWO MAPPING TECHNIQUES MAY INCREASE SENSITIVITY TO 95%
• IF PAROTID INVOLVED NEED TO PERFORM SUPERFICIAL PAROTIDECTOMY
• LESSER SURGERY GOES AGAINST SAFE PAROTID SURGERY
• NO PROSPECTIVE RANDOMIZED STUDIES
SENTINEL NODE BIOPSY
• TECHNICHALLY A DEMANDING PROCEDURE THAT REQUIRES MORE DATA TO SUPPORT ITS USE IN THE HEAD AND NECK
RADIATION THERAPY
• ORIGINALLY THOUGHT TO BE OF NO BENEFIT IN MELANOMA
• HYPERFRACTIONATION MAY PROVIDE BENEFIT
• GEARA 1996 M.D. ANDERSON 174 PATIENTS
• >1.5MM + WLE, WLE + TLND, TLND FOR RELAPSE
• 6GY FIVE TIMES OVER 2.5 WEEKS
RADIATION THERAPY• 9 OUT 174 HAD A RECURRENCE
ABOVE THE CLAVICLES
• 58 OUT OF 174 HAD DISTANT FAILURE
• 88% 5 YEAR LOCO-REGIONAL CONTROL
• 47% 5 YEAR SURVIVAL
• O’BRIEN DECREASE IN LOCAL RECURRENCE OF 12.2% IN PATIENTS WITH NODE (+) NECKS
CONCLUSIONS
• MELANOMA IS A COMPLEX AND PERPLEXING DISEASE PROCESS ESPECIALLY IN THE HEAD AND NECK
• CUTANEOUS MELANOMA OF THE HEAD AND NECK MAY BEHAVE DIFFERENTLY THAN MELANOMA OF THE EXTREMITY
CONCLUSIONS
• FOR NODE (+) NECKS- NECK DISSECTION IS APPROPRIATE AND A MODIFIED NECK DISSECTION IS OFTEN POSSIBLE
• IMMUNOTHERAPY WITH INTERFERON alpha- 2b APPEARS PROMISING FOR INDIVIDUALS WITH PATHOLOGICALLY POSITIVE NECK DISEASE
CONCLUSIONS
• NODE (-) NECKS– LACK OF RANDOMIZED PROSPECTIVE
DATA– ROLE OF SENTINEL NODE BIOPSY AND
RADIATION THERAPY HOLD PROMISE BUT NEED FURTHER INVESTIGATION
– PET SCAN?
CONCLUSIONS
•WEAR YOUR SUNSCREEN!!!
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