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The Long Term Outcomes of 375 Head and Neck Melanoma Patients Treated with Excision and Sentinel Lymph Node Biopsy
Brian M. Parrett, MD1, Mohammed Kashani-Sabet, MD2, Rudolf F. Buntic, MD1, Mark I. Singer, MD2, Stanley P.L. Leong, MD3.
1The Buncke Clinic and California Pacific Medical Center, San Francisco, CA, USA, 2Center for Melanoma Research & Treatment, California Pacific Medical Center, San Francisco, CA, USA, 3Department of Surgery, Center for Melanoma Research & Treatment, California Pacific Medical Center, San Francisco, CA, USA.
Purpose: Head and neck melanoma (HNM) is unique as it is associated with a complex lymphatic drainage pattern and high mortality rates. As plastic surgeons who treat patients with HNM, it is important to understand the long-term prognosis and success of current treatment modalities. The goal of our study was to report the long-term outcomes of surgically treated HNM , determine the significance of sentinel lymph node (SLN) biopsy on prognosis, determine false-negative (FN) occurrences, and define risk factors for death and recurrence in patients with HNM.
Methods: A retrospective database review was performed of all patients who underwent excision and SLN biopsy for HNM from 1994 to 2009. Long-term outcomes assessed were SLN status, regional nodal recurrence, 5-year melanoma-specific survival, and percentage of patients with FN SLN results. A FN result was defined as any patient who had a negative SLN but later developed regional nodal disease. Recurrence and survival were compared between SLN-positive and SLN-negative patients and also compared between different head and neck anatomic sites. Risk factors for death, recurrence and FN SLN results were determined. Statistical analysis was performed using the Fisher’s exact test and Student t-test with p< 0.05 considered significant.
Results: Wide excision and SLN biopsy was performed in 375 consecutive patients with HNM. Mean patient age was 60 years, mean tumor thickness was 2.32 mm, the ulceration rate was 18.5%, and mean follow-up was 10 years. The SLN was positive in 11% of patients. SLN-positive patients had significantly thicker melanomas (3.37 vs. 2.21 mm, p= 0.001), higher nodal recurrence rates and a significant decrease in 5-year melanoma-specific survival compared to SLN-negative patients (59% vs. 89%, p<0.0001). Ear melanoma patients had a melanoma-specific 5-year survival of 97.6%, significantly better than all other head and neck sites (p=0.005). Scalp melanomas had a significantly increased mean tumor thickness (2.91 vs. 2.11 mm, p= 0.0012) and a significantly increased risk of SLN positivity and melanoma-specific 5-year mortality compared to all other head and neck sites (22% vs. 12% mortality, p=0.03). A FN SLN was noted in 21 (6.3%) patients with negative SLNs who later developed regional nodal disease. FN patients had significantly decreased 5-year survival compared to true-negative SLN patients. Significant risks for FN results included thick melanomas and scalp melanomas. Scalp melanoma patients had a significantly higher rate of FN results compared to all other head and neck sites (12.5% vs. 4.7%, p = 0.02).
Conclusion: This is one of the largest studies with long-term follow-up for HNM patients. This data demonstrates that SLN status provides significant prognostic data. Scalp melanoma confers an increased risk of SLN positivity, nodal recurrence, FN SLN results and death compared to other head and neck sites. Ear melanoma patients have excellent overall survival using current treatment modalities. SLN negative patients have a false-negative rate of 6.3%, and should be followed closely, especially those with thicker melanomas or scalp melanomas.
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