CUTANEOUS MELANOMA OF THE HEAD AND NECK: THE ROLE OF NECK DISSECTION - PowerPoint PPT Presentation

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

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  1. CUTANEOUS MELANOMA OF THE HEAD AND NECK: THE ROLE OF NECK DISSECTION JAMES M. ROTH, M.D. PAUL FRIEDLANDER, M.D.

  2. 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

  3. 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

  4. 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

  5. ABCD • ASSYMETRY- UNEVEN GROWTH RATE • BORDER- IRREGULAR (THE STRONGEST PREDICTOR OF MALIGNANCY) • COLOR- VARIETIONS AND SHADING • DIAMETER- INCREASES IN SIZE OR A DIAMETER >6MM

  6. 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

  7. HISTORY • XERODERMA PIGMENTOSA • AUTOSOMAL RECESSIVE • MULTIPLE SKIN CANCERS BEFORE AGE 10 • NUCLEOTIDE EXCISION REPAIR • FAMILIAL MELANOMA/ DYSPLASTIC NEVUS SYNDROME • p16 GENE ON CHROMOSOME 9p21

  8. PATHOLOGICAL SUBTYPES • LENTIGO MALIGNA MELANOMA • SUPERFICIAL SPREADING MELANOMA • NODULAR MELANOMA • ACRAL LENTIGINOUS MELANOMA • DESMOPLASTIC MELANOMA

  9. LENTIGO MALIGNA MELANOMA • 5-10% OF ALL MELANOMA • PROLONGED RADIAL GROWTH PHASE • INVASION OF THE PAPILLARY DERMIS • ULCERATION VERY SIGNIFICANT IN PROGNOSIS

  10. SUPERFICIAL SPREADING • MOST COMMON SUBTYPE (75%) • INITIAL RADIAL GROWTH PHASE • VERTICAL GROWTH HERALDED BY ULCERATION AND BLEEDING • CELLS HAVE A UNIFORM APPEARANCE

  11. NODULAR MELANOMA • 10-15% • NO RADIAL GROWTH PHASE • VERTICAL GROWTH FROM THE ONSET

  12. ACRAL LENTIGINOUS • PALMS AND SOLES • MOST COMMON MELANOMA IN AFRICAN AMERICANS

  13. DESMOPLASTIC MELANOMA • SPINDLE CELLS AMONG A FIBROUS STROMA “SCHOOLS OF FISH” • OFTEN NOT PIGMENTED • PROPENSITY TO SPREAD PERINEURALLY

  14. STAGING SYSTEMS • CLARK LEVEL • BRESLOW THICKNESS • AJCC TNM CLASSIFICATION • MODIFICATIONS OF THE AJCC

  15. 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

  16. CLARK LEVEL • LEVEL IV • INVASION INTO THE RETICULAR DERMIS • LEVEL V • INVASION THROUGH THE RETICULAR DERMIS INTO THE SUBCUTANEOUS TISSUE

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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?

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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

  47. 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

  48. SURGICAL MORBIDITY • SUPERFICIAL PAROTIDECTOMIES RISK INJURY TO THE FACIAL NERVE AND GUSTATORY SWEATING • POSTOPERATIVE HEMATOMA • CHYLOUS FISTULA • SKIN FLAP NECROSIS • COSMETIC AND FUNCTIONAL DEFECT

  49. 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

  50. 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