A proposal for the timing of management of patients with melanoma presenting during pregnancy.

The treatment of melanoma during and immediately after pregnancy poses a significant challenge to surgeons, oncologists, and patients alike. With the overall increase in incidence of melanoma in the United States and worldwide, it is likely that more surgeons will be faced with management decisions regarding pregnant patients with melanoma. We report on five patients who presented to the Yale Melanoma Unit with melanoma during their pregnancy. We propose the management option of resection of the primary tumor under local anesthesia, and postponing of the sentinel lymph node biopsy until after the birth of the child. The completion lymphadenectomy can be performed if these nodes are found to be harboring metastases. We further discuss treatment options and propose an algorithm for management of patients diagnosed with melanoma while pregnant.

Level I sparing radical neck dissections for cutaneous melanoma in the lymphoscintigram era.

INTRODUCTION: Excision of regional lymph nodes (LNs) in the neck as part of the management for tumors of the head and neck dates back to the 19th century. Crile originally reported the technique of performing a radical neck block dissection in 1905, with notable modifications to the extensive dissection reported throughout the 20th century by Suarez, Ballantyne, Ariyan, and Shah among others. These modifications have aimed to reduce the morbidity encountered by performing the radical neck dissection while balancing the need to remove diseased structures in the head and neck. In this report, we evaluate the outcomes of performing a functional radical neck dissection while sparing the level I LNs as indicated by lymphoscintigraphy. METHODS: The charts of patients from the Yale Melanoma Unit who underwent resection of their head and neck melanoma from January 2000 to December 2006 were reviewed. The location of the primary melanoma and clinical course was noted. Those patients who underwent neck dissections were documented and the extent of the dissections from the operative reports was noted. Demographic and outcome data were recorded, including clinical course of melanoma presentation, local recurrence, and postoperative management. Student t test and χ tests were used to determine statistical significance between groups. P values less than 0.05 were considered statistically significant. RESULTS: A total of 41 patients who were documented to have had a head and neck primary melanoma underwent a functional radical neck dissection. Level I dissections were deemed necessary in 39% of these cases, whereas 61% of patients received functional radical neck dissections with sparing of level I LNs. Specific recurrence of melanoma in the submandibular basin was equivocal for LN sparing dissections (n=1) as compared to excision of level I LNs (n=1) (4% vs 6.25%, P=0.488). Follow-up metastatic rates between the 2 groups were also comparable (44% vs 56%, P=0.328). Overall metastatic rate in follow-up for all patients undergoing LN dissection was 48.8%. There was no statistically significant difference between the average age of patients at diagnosis, Breslow depth, Clark level, and staging between patients who underwent functional radical neck dissections with either excision or sparing of level I LNs. CONCLUSIONS: Clinical and pathological presentation between patients who needed level I sparing dissections and those who did not, failed to demonstrate a statistically significant difference allowing for an adequate comparison. Our results indicate that if lymphoscintigraphy does not show drainage to level I LNs, the functional radical neck dissection can be tailored to spare level I LNs without affecting local recurrence. When not indicated by lymphoscintigram, sparing of level I nodes can be performed safely without changing clinical outcomes, while saving operating room time and minimizing potential damage to the buccal branch of facial nerve and the submandiblular gland.

A targeted approach to sentinel lymph node biopsies in the parotid region for head and neck melanomas.

INTRODUCTION: Cutaneous melanoma is on the rise in the United States, and the head and neck region is the primary site in 20% of patients. Lymph node status is the best indicator of prognosis for melanoma. In the head and neck, sentinel lymph node (SLN) biopsy presents particular challenges, with the parotid region posing difficulties that include locating the lymph nodes, less frequent visualization of blue dye, and the possibility of higher morbidity because of the proximity of lymph nodes to important neurovascular structures. Surgical approaches to the SLN dissection in the parotid region are variable, and may include superficial or total parotidectomies. Parotid-sparing SLN biopsies for head and neck melanomas were evaluated to determine rates of local recurrence. METHODS: The charts of 301 patients from the Yale Melanoma Unit who underwent resection of their head and neck melanoma were reviewed. The location of the primary melanoma was noted, and the sentinel lymph node dissections from the operative reports were documented. Demographic and outcome data were recorded, including course of melanoma management, local recurrence, and postoperative course. RESULTS: Fifty-eight patients underwent SLN biopsy of lymph nodes in the parotid region. Parotid-sparing SLN biopsies comprised 94.8% of total surgical approaches for SLN biopsies in the parotid region. Of the remaining patients who underwent SLN biopsies in the parotid region, 5.17% had a superficial parotidectomy and none had a total parotidectomy. Sentinel lymph nodes were found in all depth layers of the parotid, and LNs were dissected out successfully without the need to remove the parotid in the most cases. The parotid region recurrence rate was 0% for SLN biopsies that either included or spared the parotid gland. There were no localized complications from the sentinel lymph node biopsies. CONCLUSIONS: The parotid-sparing SLN biopsy was performed without any local recurrence in the parotid region. The parotid-sparing SLN biopsy can be carried out in a safe, efficient manner without affecting the rate of local recurrence or postoperative complication. This less-invasive SLN biopsy procedure precludes the complications associated with parotidectomies and may reduce the morbidity for patients with melanomas of the head and neck.

A randomized study comparing the effectiveness of methylene blue dye with lymphazurin blue dye in sentinel lymph node biopsy for the treatment of cutaneous melanoma.

BACKGROUND: Radioactive colloid with a gamma probe is the most effective method of identifying sentinel lymph nodes (SLN). Nevertheless, since vital blue dyes are also helpful for visually identifying SLN during surgical dissection, they are often used together with radioactive colloid. There has occasionally been a shortage of lymphazurin blue (LB) dye for use in sentinel lymph node biopsies (SLNB). There have also been reports of anaphylactic reactions to the use of LB dye. Therefore, we were interested in using methylene (MB) blue dye to aid in the visualization of the SLN for biopsy because of its ready availability and greater safety. The purpose of this study of SLN biopsies was to compare the effectiveness of MB with that of LB dye. STUDY DESIGN: We randomly assigned 159 consecutive patients with intermediate and high-risk melanomas, who were treated by a single surgeon at the Yale Melanoma Unit between January 10, 2005, and June 13, 2007 with SLN biopsy, with radioactive colloid and either LB or MB. RESULTS: A total of 443 SLN were identified and removed from these 159 consecutive patients. MB dye was found to be as effective as LB dye in visually identifying SLN: blue dye was visible in 62% of SLN in the MB group compared with 58% in the LB group. When the SLN were separated into three anatomic locations the visualization results were LB 36% and MB 72% (P = 0.010) for head and neck, LB 65% and MB 61% (P = 0.919) for axilla, and LB 59% and MB 67% (P = 0.001) for groin. CONCLUSION: SLN were identified in all 158 patients. Approximately 60% of these SLN were also visibly blue. In the cervical and groin regions, MB dye was more visible in the SLN than was the LB dye, and in the axilla the SLN were equally stained blue by both dyes. Generally, if surgeons wish to use intradermal injections of vital blue dye to help visualize SLN, we have found in this study that MB is at least as effective as LB for the visualization of these SLN. The cost of MB is less than that of LB.

Reliability of identification of 655 sentinel lymph nodes in 263 consecutive patients with malignant melanoma.

BACKGROUND: The purpose of this study of sentinel lymph node biopsies (SLN) was threefold: to compare the reliability of lymphazurin blue dye to radioactive technetium 99m sulfur colloid (TC); to evaluate the reliability of frozen section examinations of sentinel lymph nodes; and to determine how much SLN dissections prolonged operative time. STUDY DESIGN: We evaluated the records of 263 consecutive patients with intermediate and high-risk melanomas (1.0 mm or thicker, or Clark Level IV or greater), who were treated by a single surgeon at the Yale Melanoma Unit between October 1, 1997, and September 30, 2001, and followed for more than 18 months. RESULTS: A total of 655 SLN were identified and removed from these 263 consecutive patients. Radioactive colloid was found to be more reliable (100%) in identifying the SLN than lymphazurin blue dye (51%) in the nodes of the patients. Twenty-eight patients (11%) had positive sentinel lymph nodes, and 2 patients (7%) had false-negative frozen sections. Three patients (11%) had false-negative frozen sections; tumor was found subsequently on permanent sections only after special immunohistochemical stains were used. The location or removal of SLN did not prolong the operative procedure unreasonably, requiring an average of 7 to 20 minutes for removal of SLN, and 33 minutes for frozen section reports, during which time the primary tumor resection and wound coverage were performed. CONCLUSIONS: SLN were found in all 263 patients. All SLN were identified reliably with radioactive colloid. Because blue dye was found in only half of the radioactive nodes, it is not appropriate to use this as the only marker for locating the SLN. This large series of patients attests to the reliability of frozen sections in identifying SLN harboring metastases, with 82% of the patients with nodal metastases identified in this fashion.

Diagnosis and treatment of interval sentinel lymph nodes in patients with cutaneous melanoma.

BACKGROUND: Interval sentinel lymph nodes in patients with melanoma are occasionally found outside conventional nodal basins. In this study, the authors examined the frequency, location, and incidence of nodal metastasis of such interval nodes in a large cohort of patients with primary cutaneous melanoma. METHODS: Between September of 1997 and February of 2003, 374 consecutive patients at the Yale Cancer Center Melanoma Unit underwent sentinel lymph node biopsy for primary cutaneous melanoma with a Breslow thickness of at least 1.0 mm and/or Clark IV or greater histologic dermal invasion. All patients underwent preoperative lymphoscintigraphy to map the lymphatic drainage for the primary lesion and intraoperative confirmation, and biopsy was performed on all sentinel lymph nodes identified. RESULTS: Unequivocal interval sentinel lymph nodes were identified in eight of 374 patients (2.1 percent). Three of these eight patients had metastatic spread to the interval sentinel nodes. In four of the eight patients, the interval sentinel lymph node was not located in the anticipated lymphatic pathway between the primary tumor and the sentinel lymph node basin. CONCLUSIONS: Interval sentinel nodes seem as likely to contain micrometastatic disease as those in the expected sentinel lymph node basin. Half of the subjects displayed interval sentinel lymph nodes that were not in the anticipated lymphatic pathway between the primary tumor and the sentinel lymph node basin. These findings suggest that adequate preoperative lymphoscintigraphy and intraoperative recognition of interval nodes are of paramount importance in the treatment of melanoma.

Reliability of lymphatic mapping after wide local excision of cutaneous melanoma.

BACKGROUND: Since the advent of sentinel lymph node (SLN) biopsy, patients with cutaneous melanoma have been referred to surgeons for consideration for SLN biopsy, sometimes even after the wide local excision (WLE) of the primary melanoma has been performed. This has raised the question of the reliability and validity of a lymphoscintigram performed for lymphatic mapping of the SLN after there has been anatomic rearrangement of the skin following the WLE of this primary melanoma. METHODS: We conducted a prospective study of 20 consecutive patients with cutaneous melanomas with thickness less than 1.00 mm, who volunteered to undergo preoperative and postoperative lymphatic mapping to determine if there were any changes in the lymph nodes that were identified following the WLE of the primary melanoma. Each of the patients had a resection with a minimum of 1.0 cm margin, and closure of their wounds with either transposition flap or double advancement flaps. RESULTS: Lymphatic mapping was clearly identified in all 20 patients. One patient declined to undergo postoperative lymphatic mapping. Postoperative lymphatic mapping performed in the remaining 19 patients 2-4 weeks following WLE was identical to the preoperative mapping in 13 patients (68%), showed additional lymph nodes in 4-5 patients (21-26%), and showed fewer lymph nodes in 1-2 patients (5-10%). CONCLUSIONS: Lymphatic mapping performed after a WLE of a primary cutaneous melanoma should be as reliable in identifying the SLN as a preoperative lymphatic mapping in 90% of the patients.