To assess the real-world benefits of immediate (IM) complete lymph node dissection (CLND) in patients SLN+ melanoma treated with systemic adjuvant therapy, Eroglu, Broman, and Thompson et al. retrospectively analyzed 462 patients. In the subset (n=386) with adjuvant anti-PD-1, the 24-month RFS was comparable among patients with (n=60) and without (n=326) IM CLND and to prior adjuvant anti-PD-1 trials with high rates of IM CLND. Patients without IM CLND had a significantly higher rate of locoregional relapses, and those with SLN tumor deposit >1 mm, stage IIIC/D, and ulcerated primary had worse RFS. Secondary adjuvant therapy did not affect second relapse in patients without IM CLND.
Contributed by Shishir Pant
ABSTRACT: Until recently, most patients with sentinel lymph node-positive (SLN+) melanoma underwent a completion lymph node dissection (CLND), as mandated in published trials of adjuvant systemic therapies. Following multicenter selective lymphadenectomy trial-II, most patients with SLN+ melanoma_no longer undergo a CLND prior to adjuvant systemic therapy. A retrospective analysis of clinical outcomes in SLN+ melanoma patients treated with adjuvant systemic therapy after July 2017 was performed in 21 international cancer centers. Of 462 patients who received systemic adjuvant therapy, 326 patients received adjuvant anti-PD-1 without prior immediate (IM) CLND, while 60 underwent IM CLND. With median follow-up of 21 months, 24-month relapse-free survival (RFS) was 67% (95% CI 62% to 73%) in the 326 patients. When the patient subgroups who would have been eligible for the two adjuvant anti-PD-1 clinical trials mandating IM CLND were analyzed separately, 24-month RFS rates were 64%, very similar to the RFS rates from those studies. Of these no-CLND patients, those with SLN tumor deposit >1_mm, stage IIIC/D and ulcerated primary had worse RFS. Of the patients who relapsed on adjuvant anti-PD-1, those without IM CLND had a higher rate of relapse in the regional nodal basin than those with IM CLND (46% vs 11%). Therefore, 55% of patients who relapsed without prior CLND underwent surgery including therapeutic lymph node dissection (TLND), with 30% relapsing a second time; there was no difference in subsequent relapse between patients who received observation vs secondary adjuvant therapy. Despite the increased frequency of nodal relapses, adjuvant anti-PD-1 therapy may be as effective in SLN+ pts_who forego IM CLND and salvage surgery with TLND at relapse may be a viable option for these patients.
Author Info: (1) Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA zeynep.eroglu@moffitt.org. University of South Florida, Tampa, Florida, USA. (2) Department of Cuta
Author Info: (1) Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA zeynep.eroglu@moffitt.org. University of South Florida, Tampa, Florida, USA. (2) Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA. University of South Florida, Tampa, Florida, USA. (3) Melanoma Institute Australia, North Sydney, New South Wales, Australia. (4) Melanoma Institute Australia, North Sydney, New South Wales, Australia. (5) Department of Surgery, Mayo Clinic, Rochester, New York, USA. (6) Department of Surgery, Mayo Clinic, Rochester, New York, USA. (7) Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA. (8) Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA. (9) Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA. (10) Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA. (11) Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA. (12) Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA. (13) Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA. (14) Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA. (15) Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia. (16) Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia. (17) Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA. (18) Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA. (19) Department of Surgery, New York University, New York, New York, USA. (20) Department of Surgery, New York University, New York, New York, USA. (21) Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands. (22) Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands. (23) Division of Surgical Oncology, Oregon Health and Science University, Portland, Oregon, USA. (24) Division of Surgical Oncology, Oregon Health and Science University, Portland, Oregon, USA. (25) Department of Surgery, Duke University, Durham, North Carolina, USA. (26) Department of Surgery, Duke University, Durham, North Carolina, USA. (27) Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA. (28) Norfolk and Norwich University Hospital, Norwich, UK. (29) Norfolk and Norwich University Hospital, Norwich, UK. (30) Department of Surgery, Emory University, Atlanta, Georgia, USA. (31) Department of Surgery, Emory University, Atlanta, Georgia, USA. (32) Department of Surgery, Emory University, Atlanta, Georgia, USA. (33) Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA. (34) Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA. (35) Department of Surgery, Sahlgrenska Center for Cancer Research, University of Gothenburg, Gothenburg, Sweden. (36) Department of Surgery, Sahlgrenska Center for Cancer Research, University of Gothenburg, Gothenburg, Sweden. (37) Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia. (38) Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia. (39) North Estonia Medical Centre Foundation, Tallinn, Estonia. (40) Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA. (41) Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA. (42) University of South Florida, Tampa, Florida, USA. (43) Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA. (44) Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida, USA. (45) Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida, USA. (46) Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA. University of South Florida, Tampa, Florida, USA. (47) Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA. University of South Florida, Tampa, Florida, USA.
