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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

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CUTANEOUS MELANOMA OF THE HEAD AND NECK: THE ROLE OF NECK DISSECTION

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Cutaneous melanoma of the head and neck the role of neck dissection l.jpg

CUTANEOUS MELANOMA OF THE HEAD AND NECK: THE ROLE OF NECK DISSECTION

JAMES M. ROTH, M.D.

PAUL FRIEDLANDER, M.D.


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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


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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


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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


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ABCD

  • ASSYMETRY- UNEVEN GROWTH RATE

  • BORDER- IRREGULAR (THE STRONGEST PREDICTOR OF MALIGNANCY)

  • COLOR- VARIETIONS AND SHADING

  • DIAMETER- INCREASES IN SIZE OR A DIAMETER >6MM


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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


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HISTORY

  • XERODERMA PIGMENTOSA

    • AUTOSOMAL RECESSIVE

    • MULTIPLE SKIN CANCERS BEFORE AGE 10

    • NUCLEOTIDE EXCISION REPAIR

  • FAMILIAL MELANOMA/ DYSPLASTIC NEVUS SYNDROME

    • p16 GENE ON CHROMOSOME 9p21


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PATHOLOGICAL SUBTYPES

  • LENTIGO MALIGNA MELANOMA

  • SUPERFICIAL SPREADING MELANOMA

  • NODULAR MELANOMA

  • ACRAL LENTIGINOUS MELANOMA

  • DESMOPLASTIC MELANOMA


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LENTIGO MALIGNA MELANOMA

  • 5-10% OF ALL MELANOMA

  • PROLONGED RADIAL GROWTH PHASE

  • INVASION OF THE PAPILLARY DERMIS

  • ULCERATION VERY SIGNIFICANT IN PROGNOSIS


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SUPERFICIAL SPREADING

  • MOST COMMON SUBTYPE (75%)

  • INITIAL RADIAL GROWTH PHASE

  • VERTICAL GROWTH HERALDED BY ULCERATION AND BLEEDING

  • CELLS HAVE A UNIFORM APPEARANCE


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NODULAR MELANOMA

  • 10-15%

  • NO RADIAL GROWTH PHASE

  • VERTICAL GROWTH FROM THE ONSET


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ACRAL LENTIGINOUS

  • PALMS AND SOLES

  • MOST COMMON MELANOMA IN AFRICAN AMERICANS


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DESMOPLASTIC MELANOMA

  • SPINDLE CELLS AMONG A FIBROUS STROMA “SCHOOLS OF FISH”

  • OFTEN NOT PIGMENTED

  • PROPENSITY TO SPREAD PERINEURALLY


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STAGING SYSTEMS

  • CLARK LEVEL

  • BRESLOW THICKNESS

  • AJCC TNM CLASSIFICATION

  • MODIFICATIONS OF THE AJCC


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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


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CLARK LEVEL

  • LEVEL IV

    • INVASION INTO THE RETICULAR DERMIS

  • LEVEL V

    • INVASION THROUGH THE RETICULAR DERMIS INTO THE SUBCUTANEOUS TISSUE


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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REGIONAL LYMPHATICS

  • POSTERIOR NECK/ SCALP HAD NO INVOLVEMENT OF THE PAROTID GLAND, LOW INVOLVEMENT OF LEVEL 1 , AND INCREASED INVOLVEMENT OF LEVEL 5


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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


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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


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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


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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


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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


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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


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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


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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?


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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SURGICAL MORBIDITY

  • SUPERFICIAL PAROTIDECTOMIES RISK INJURY TO THE FACIAL NERVE AND GUSTATORY SWEATING

  • POSTOPERATIVE HEMATOMA

  • CHYLOUS FISTULA

  • SKIN FLAP NECROSIS

  • COSMETIC AND FUNCTIONAL DEFECT


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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


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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


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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


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SENTINEL NODE BIOPSY

  • TECHNICHALLY A DEMANDING PROCEDURE THAT REQUIRES MORE DATA TO SUPPORT ITS USE IN THE HEAD AND NECK


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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


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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


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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


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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


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CONCLUSIONS

  • NODE (-) NECKS

    • LACK OF RANDOMIZED PROSPECTIVE DATA

    • ROLE OF SENTINEL NODE BIOPSY AND RADIATION THERAPY HOLD PROMISE BUT NEED FURTHER INVESTIGATION

    • PET SCAN?


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CONCLUSIONS

  • WEAR YOUR SUNSCREEN!!!


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BIBLIOGRAPHY

  • Balch, C. et al. Efficacy of an Elective Regional Lymph Node Dissection of 1-4mm Thick Melanoma for Patients 60 Years of Age and Younger. Annals of Surgery. 1996; 224 (3): 255-266

  • Buzaid, A. et al. Critical Analysis of the Current AJCC Staging System for Cutaneous Melanoma and Proposal of a New Staging System. Journal of Clinical Oncology. 1997; 15(3): 1039-51

  • Breslow, A. Thickness, Cross-Sectional Area and Depth of invasion in Prognosis of Cutaneous Melanoma. Annals of Surgery. 1970; 172 (5): 902-8

  • Byers, R. Treatment of the Neck in Melanoma. Otolaryngologic Clinics of North America. 1998; 31 (5): 833-39

  • Drepper, H. et al.Benefit of Elective Lymph Node Dissection in Subgroups of Melanoma Patients. Cancer. 1993; 72(3): 741-49

  • Jansen, L. et al.Sentinel Node Biopsy for Melanoma in the Head and Neck Region. Head and Neck. 2000:27-33

  • Kane, W. et al.Treatment Outcome for 424 Primary Cases of Clinical Stage 1 Cutaneous Malignant Melanoma of the Head and Neck. Head and Neck. 1997:457-65


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BIBLIOGRAPHY

  • Kirkwood, J. et al. Interferon Alfa-2b Adjuvant Therapy of High-Risk Resected Cutaneous Melanoma: the ECOG Trial EST 1684. Journal of Clinical Oncology. 1996; 14(1):7-17

  • Knutson, C. et al.Melanoma of the Head and Neck. American Journal of Surgery. 1972; 124:543-550

  • Lentsch, E. et al.Melanoma of the Head and Neck: Current Concepts in Diagnosis and Management. The Laryngoscope. 2001; 11:1209-22

  • Myers, J. Value of Neck Dissection in the Treatment of Patients with Intermediate- Thickness Cutaneous Malignant Melanoma of the Head and Neck. AOHN. 1999; 125:110-115

  • O’Brien, C. et al.Experience with 998 Cutaneous Melanomas of the Head and Neck over 30 Years. American Journal of Surgery. 1991; 162:310-314

  • O’Brien, C. et al. Radical, Modified, and Selective Neck Dissection for Cutaneous Malignant Melanoma. Head and Neck. 1995:232-41

  • O’Brien, C. et al.Adjuvant Radiotherapy Following Neck Dissection and Parotidectomy for Metastatic Malignant Melanoma. Head and Neck. 1997:589-94.


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BIBLIOGRAPHY

  • Peralta, E. et al. Malignant Melanoma of the Head and neck: Effect of Treatment on Survival. The Laryngoscope. 1998; 108:220-223

  • Shah, J. et al. Patterns of Lymph Node Metastases from Cutaneous Melanomas of the Head and Neck. American Journal of Surgery. 1991; 162: 320-23

  • Shah, P. et al. Adjuvnt Immunotherapy for Patients with Melanoma: Are Patients with Melanoma of the Head and Neck Candidates for This Therapy. Head and Neck. 1997:595-603

  • Stadlemann, W. et al. Cutaneous Melanoma of the Head and neck: Advances in Evolution and Treatment. Plastic and Reconstructive Surgery. 2000; 105(6): 2105-26

  • Urist, M. et al.The Influence of Surgical Margins and Prognostic Factors Predicting the Risk of Local Recurrence in 3445 Patients with Primary Cutaneous Melanoma. Cancer. 1985; 55:1398-1402

  • Urist, M. et al. Head and Neck Melanoma in 534 Clinical Stage 1 Patients. Annals of Surgery. 1984:769-75

  • Wells, K. et al. Sentinel Lymph Node Biopsy in Melanoma of the Head and Neck. Plastic and Reconstructive Surgery. 1997; 100(3):591-94


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