Management of regional lymph nodes in the elderly melanoma patient: patient selection, accuracy and prognostic implications.

BACKGROUND: Among older melanoma patients, lymphatic mapping failure, lower rates of SLN positivity and poor prognosis are reported reasons for omission of sentinel lymph node biopsy (SLNB). We investigated reasons for non-compliance with guidelines, sensitivity and prognostic significance of SLNB and completion lymphadenectomy (CLND) for elderly melanoma patients. METHODS: Retrospective review of patients ≥65 years with ≥1 mm thick melanoma treated at a single Institution. Wilcoxon, chi-square and Fisher's exact tests were used for analysis as appropriate. Univariable and multivariable Cox regressions were used to analyze time-to-event variables. RESULTS: 72 of 358 patients (20%) did not undergo SLNB. Reasons for omission included selective neck dissection in 26 (7%), patient refusal in 11 (3%), physician recommendation in 15 (4%) and significant comorbidities in 8 (2%). Of the 286 patients undergoing SLNB, only 5 (1.7%) had lymphatic mapping failures. 76 patients (26.6%) were SLN-positive. The sensitivity of SLNB was 90.5%, the negative predictive value was 96.3% and the false negative rate was 3.8%. Sixty-seven (88%) SLN-positive patients underwent CLND and 10 (15%) had positive non-SLNs. Reasons for omission of CLND included patient refusal in 3 (4%), surgeon recommendation in 5 (7%) and postoperative complication in 1 (1%). SLN and non-SLN status were independently associated with disease-free survival. SLN status was independently associated with melanoma-specific survival. CONCLUSIONS: SLNB was successful in 98.7% of elderly patients with high sensitivity and a low false negative rate. Only 2% of our elderly patients appeared too frail for SLNB. Age alone should not be a contraindication to SLNB and CLND for melanoma.

Inhibition of the immune response to experimental fresh osteoarticular allografts.

The immune response to osteoarticular allografts is capable of destroying the cartilage--a tissue that has antigens on its cells identical to those on the bone and marrow cells. Osteoarticular allografts of the distal femur were performed in rats using various methods to attempt to temporarily inhibit the antibody response. The temporary systemic immunosuppressant regimens investigated were cyclophosphamide, azathioprine and prednisolone, cyclosporine A, and total lymphoid irradiation. The most successful appeared to be cyclosporine A, but significant side effects were observed. To specifically inhibit the immune response in the allograft antigens without systemically inhibiting the entire immune system, passive enhancement and preadministration of donor blood were tried. Neither was as effective as coating the donor bone with biodegradable cements, a method previously found to be successful. Cyclosporine A was investigated in dogs in a preliminary study of medial compartmental knee allografts and was found to be successful in inhibiting the antibody response and in producing a more successful graft; however, some significant side effects were similarly observed.