L@iiph \(d@' 1),@'.@'t,ni@

Neg. nodes: 83% (246).

Pos. nodes: 17%(50)

pClinical Stage I Pathologic Stage I296 Patients 321 Patients

Fig. 1. Pathologicalstagingafter lymphnodedissection.

(75) 16%Neg. nodes

(406) 84% Pos. nodes

Pathologic Stage II456 Patients

Clinical Stage II481 Patients

L@nipli ‘¿�N@dc1)k'..ecti )I1S

>5 years80%(256/321)

>10 years61%(107/176)

>15 years53% (37/70)

Pathologic Stage I321 Patients

>5 years39%(178/456)

>10 years21%(67/314)

>15 years15%(22/145)

Pathologic Stage II456 Patients

Fig. 2. Survival statistics according to pathological staging. Patients in 10 year follow-up group includedatfiveyearlevel;thosein 15yearfollow-upgroupincludedatboth10andfiveyearlevels.

Malignant Melanoma: CurrentConcepts of Lymph NodeDissection*

Harry S. Goldsmith, M.D..Jatin P. Shah, M.D.and Dong-H. Kim, M.D.

The purpose of these studies wasthreefold: (1) toshow that improvementin the survival statistics for malignantmelanoma is continuing; (2) to evaluatewhether the performance of routinelymph node dissection for melanoma isjustified in the absence of palpable regional lymph nodes; and (3) to comparethe results of a lymph-node dissectionperformed as an en bloc (incontinuity)procedure as opposed to a Lymph nodedissection performed separately(discontinuity) from the excision of theprimary melanoma.

The records of 1,483 determinatecases seen at Memorial Hospital from1950 to 1965 were analyzed and evaluated up to 1970, so that there was aminimal follow-up period of five years.There were 707 patients with primarymalignant melanoma and no clinical evidence of regional lymph node involvement or distant spread (Clinical Stage I).There were 537 patients with primarymelanoma associated with palpable enlarged regional lymph nodes but no distant spread (Clinical Stage II). The 239

*Adapted from two articles entitled, “¿�PrognosticSignificance of Lymph Node Dissection in theTreatment of Malignant Melanoma,― and “¿�Incontinuity Versus Discontinuous Lymph Node Dissection for Malignant Melanoma― which appeared inCancer 26: 606—609,610—614, 1970.

Dr. Goldsmith is Samuel D. Gross Professor of Surgery and Chairman, Department of Surgery, Jefferson Medical College, Philadelphia, Pennsylvania.Dr. Shah is a Senior Resident in Surgery, MemorialHospital for Cancer and Allied Diseases, NewYork, New York.Dr. Kim is Instructor in Surgery, Department ofSurgery, Jefferson Medical College, Philadelphia,Pennsylvania.

patients with Clinical Stage Illmelanoma were not included in this study,since they did not serve its purpose.

Of the 707 patients in Clinical StageI, 296(42 percent) were subjected to anelective lymph node dissection in addition to excision of the primary melanoma; 481 patients in Clinical StageII had what was considered a therapeuticlymph node dissection. After the lymphnode dissections had been performed, itwas possible to change the patient's clinical staging to the more accurate pathologic stage based on the histologic findings in the lymph nodes. (Fig. 1.) Figure2 shows the overall five-year survivalin patients with Pathologic Stage 1(80percent—256/32l) and in PathologicStage 11(39 percent— 178/456). Thesepercentages show that the results oftreatment of melanoma in this institutionhas continued to improve over the years.These improvements are attributed toearlier presentation and diagnosis of patients with pigmented lesions as well asearlier treatment when melanoma is confirmed. The five-year survival rateshould not be considered the true indexof control of melanoma as progressivemortality from the disease continues tooccur over the years. The ratio of survival rates between Pathologic Stage Iand IIat the five-year level is approximately 2: 1 (80 percent:39 percent).However, at fifteen years, the ratio of thesurvival rates between these two groupschanges to approximately 3:1(53 percent: 15 percent).

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Lymph Node DissectionThere appears to be little dis

agreement that a patient with melanomaand palpable regional lymph nodesshould have a lymph node dissection.The question that remains to be answered, however, is whether a lymphnode dissection should be performed ona patient who does not have palpable regional nodes. In the past, a routinelymph node dissection for patients withno palpable regional nodes was recommended based on the assumption thatsubsequent development of lymph nodemetastases would result in a drop in thepatient's five-year survival rate from thatof Stage I to Stage II. The authors do notbelieve this is a realistic comparison bywhich to justify a routine lymph nodedissection; the reason being that theoverall majority of patients in StageII have clinically palpable lymph nodesat the time of their initial presentationwhich, on occasion, may even be bulky.One would naturally expect a lower survival rate in patients who present withClinical Stage II melanoma as compared to patients in Clinical Stage I whosubsequently develop lymph node metastases under close follow-up. It is feltthat the decision of whether or not toperform a routine lymph node dissection for nonpalpable regional lymphnodes should be based on the eventualoutcome of only those patients withoutpalpable regional lymph nodes (ClinicalStage I). Of the 707 patients in thisstage, 296(42 percent) had an electivelymph node dissection and 411(58 percent) did not.Overall Survival

There was a 10 percent variation inthe overall survival rate in ClinicalStage I patients who had a lymph. nodedissection (78 percent—232/296) ascompared to those who did not (68 percent—280/4l 1). One may questionwhether a 10 percent difference in theoverall survival between these two

groups is a large enough difference tojustify a routine lymph node dissection,if for no other reason than to spare alarge number of patients from a majorsurgical procedure. The answer to this isaffirmative since a 10 percent improvement in survival in a large series of patients is a significant figure and shouldnot be minimized. In addition, the 68percent survival rate may be a weightedfigure since a large number of small melanomas, which would.be expected tohave a better prognosis, may well havebeen included in the nondissected group(411). This possibility is raised becauseof the tendency of most surgeons to doonly a wide local excision of a melanoma if it is small and/or superficial. Insupport of this possibility is the fact that39 superficial melanomas wereincluded in the nondissected group (411)out of a total of 79 superficial melanomas treated in the entire series of1,483 patients.Microscopic Metastases

In the 296 patients who were subjected to a prophylactic lymph node dissection for nonpalpable regional lymphnodes, 17 percent (50/296) were foundto harbor histologic foci of melanoma intheir excised lymph nodes. Electing topermit one out of every five or six patients to retain lymph nodes that harbormicroscopic melanoma is a decisionwhich is difficult to justify based on ourpresent knowledge.Recurrent Disease

The lower incidence of recurrent melanoma observed in patients treated byroutine lymph node dissection was animportant justification for advocatinglymph node dissection for nonpalpableregional lymph nodes (see Table). Fiftytwo percent (212/411) of the patients notsubjected to a routine lymph node dissection developed recurrent melanomaas opposed to only 19 percent (54/296)of the patients subjected to a routinelymph node dissection.

218

- -@-@—

Dissection@-@-----—@-@--@NodissectionLocal

recurrence124%8220%Node

metastases155%83.20%Distant

metastases2710%4712%Total54/29619%Total

212/41152%

Table —¿�Clinical Stage 1(707 patients)Recurrences

Incontinuity Versus DiscontinuousLymph Node Dissection

Removing regional lymph nodeswhich drain lymphatics from the site ofmalignant melanoma is considered to bean important part of the treatment of thistumor. When the melanoma is close tothe lymph node area, the lymph nodedissection is usually carried out in an enbloc fashion. However, such an operation may not be technically feasiblewhen the primary melanoma is situatedat a distance from the regional lymphnodes. In order to evaluate the benefitsof an incontinuity versus discontinuitylymph node dissection, comparisons aremade under three major headings:(1) stage of disease at the time of lymphnode dissection; (2) site of primary melanoma in relation to lymph node dissection; and (3) timing of lymph node dissection in relation to the removal of theprimary melanoma.Stage of Disease

Of the 296 patients who had a lymphnode dissection, 228 had an incontinuitydissection, i .e., the wide removal of theprimary melanoma or the scar from aprevious local excision of the melanoma, in association with en bloc excision of regional lymph nodes and inter

vening subcutaneous lymphatics. Theremaining 68 patients in this group hadtheir primary melanoma excised and theregional lymph nodes removed withoutattempting to excise the intervening lymphatic channels, i.e., a discontinuouslymph node dissection. The five-yearsurvival rates for those Stage I patients,regardless of the lymph node dissectiontechnique, were similar (77 percentversus 75 percent). Stage Il—Of the 435patients in this group who had a knownlocation of their primary melanoma, 220had an incontinuity lymph node dissection and 215 a discontinuous lymphnode dissection. The survival rates inboth groups were similar (42 percentversus 40 percent).Site of Primary

Head and Neck: All patients withStage I melanomas on the face, scalpand neck had an incontinuity lymphnode dissection which eliminated comparison of this type of procedure to a discontinuous lymph node dissection.Stage lI—The five-year survival ratesfor patients with primary melanoma ofthe face and scalp undergoing either anincontinuity or discontinuous lymphnode dissection were similar (44 per

219

cent). The number of patients with a primary melanoma of the neck was toosmall to arrive at any conclusions.

Trunk: Survival rates for Stage I patients, regardless of whether an incontinuity or discontinuity lymph node dissection was performed, were similar (67percent). Stage Il—The incontinuitylymph node dissection gave a 39 percentfive-year survival rate as compared to 31percent of patients who underwent a discontinuous lymph node dissection.

Extremities: The five-year survivalrates for patients with melanoma of theupper or lower extremity in both Stage!and Stage II were similar, regardless ofthe type of lymph node dissection performed.Timing of Lymph Node Dissection

The third method used to evaluatebenefits of an incontinuity versus a discontinuous lymph node dissection wasto compare the survival rates of thesetwo procedures in relation to the time ofexcision of the primary melanoma.When the regional lymph nodes wereexcised at the same time as the primarymelanoma, this was considered a simultaneous lymph node dissection. If thelymph nodes were removed at any timeafter the excision of the primary melanoma, this was considered a delayedlymph node dissection.

Simultaneous Lymph Node Dissection: Stage I—Even though the majorityof patients in this group had an incontinuity dissection performed simultaneously with the removal of the primarymelanoma, the results with the discontinuous lymph node dissection performed simultaneously were comparable (76 percent versus 73 percent). StageTI—Patientshaving a simultaneous incontinuity lymph node dissection had aslightly improved survival (42 percent)

over those patients who had a simultaneous lymph node dissection performedin a discontinuous fashion (35 percent).

Delayed Lymph Node Dissections: Stage I—Results of incontinuity versus discontinuous lymphnode dissections were comparable (78percent versus 75 percent). Stage!!—Results of incontin.uity versus discontinuous lymph node dissections wereagain comparable (42 percent versus41 percent).

SummaryThe results of this study indicate that

the survival statistics from melanomacontinue to improve over the years; thatwide excision of the primary lesion anda routine lymph node dissection havepositive factors which justify an electivelymph node dissection; that a discontinuous lymph node dissection is equallysatisfactory and gi.ves comparable fiveyear survival statistics if a melanoma isin an anatomical position which doesnot lend itself readily to incontinuitydissection.

220