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Vol. 114. Núm. 5.
Páginas 462-466 (Mayo 2023)
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Vol. 114. Núm. 5.
Páginas 462-466 (Mayo 2023)
Case and Research Letter
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Sentinel Lymph Node Biopsy in Elderly Melanoma Patients: A Real Practice Cohort
Biopsia del ganglio centinela en pacientes mayores con melanoma: cohorte en la práctica real
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1253
P. Rodríguez-Jiméneza,b,
Autor para correspondencia
, A. Reymundo-Jiméneza,b, Y. Delgado-Jiméneza,b, E. Galloa,b, R. Navarroa,b, E. Vargasa,b, V. Castilloc, I. Hernándezc, E. Torresd, F. Rodríguez-Campoe, A. Tejera-Vaquerizof
a Department of Dermatology, Hospital Universitario de La Princesa, Madrid, Spain
b Instituto de Investigación Sanitaria Princesa (IIS-IP), Hospital Universitario de La Princesa, Madrid, Spain
c Department of Nuclear Medicine, Hospital Universitario de La Princesa, Madrid, Spain
d Department of General Surgery, Hospital Universitario de La Princesa, Madrid, Spain
e Department of Oral and Maxillofacial Surgery, Hospital Universitario de La Princesa, Madrid, Spain
f Instituto Globalderm, Palma del Río, Córdoba, Spain
Contenido relaccionado
P. Rodríguez-Jiménez, A. Reymundo-Jiménez, Y. Delgado-Jiménez, E. Gallo, R. Navarro, E. Vargas, V. Castillo, I. Hernández, E. Torres, F. Rodríguez-Campo, A. Tejera-Vaquerizo
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Tablas (3)
Table 1. Clinical and histopathological characteristic of study patients.
Table 2. Superior: Bivariate studies between study category and outcome using X2, Fisher, Mann–Whitney U or independent samples T test as necessary.
Table 3. Logistic regression model the behaviour of the variables is studied using a backward stepwise selection model. The variables selected to perform the study are chosen among the ones that showed statistical significance on the regression model.
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To the Editor:

Melanomas in the elderly account for 40% of diagnosed melanomas and account for 60.2% of deaths.1 Sentinel lymph node biopsy (SLNB) is currently recommended as a staging method for intermediate-thickness melanoma (Breslow thickness, ≥0.8mm). The ASCO guidelines state that SLNB may be recommended at all ages after discussion of the potential benefits and risks of harm.2

Data from the Surveillance, Epidemiology and End Results Program (SEER) suggest that the incidence of thick melanoma is significantly higher in patients over 60 years of age and that mortality is higher than in other age groups. The age group with the highest percentage of death from melanoma is patients aged 75–84 years. In addition, a study analysing 3 different cohorts – including the SEER cohort – with more than 300,000 patients found that age predicts a worse melanoma-specific survival.3,4 SLNB remains controversial and the peculiarities in the elderly have not been thoroughly studied.

The primary objective of our study was to determine if there is a difference in SLNB status predictors in two different age groups, younger and older than 75 years old. A secondary objective was to describe the difference in complications in both groups.

A cohort, retrospective, single centre, longitudinal, observational study was performed with all the patients that have underwent SNLB from January 2008 to December 2020. Inclusion criteria were the following: All consecutive adult patients with cutaneous melanoma that underwent SLNB. The cohort was divided in two age groups for age related analysis, younger and older than 75 years old. The study protocol was approved by institutional review board and informed consent was obtained from all patients.

The following clinical and histologic characteristics were selected as independent variables: sex, age, anatomic location, histologic subtype, Breslow thickness, ulceration, regression, lymphovascular invasion, mitosis, SLNB location, and SLNB complications.

Statistical analyses were performed using SPSS software ver. 22.0 (IBM®, Armonk, NY, USA). Group comparisons were performed using the Fisher test or Mann–Whitney U-test, Pearson chi-square test or independent samples T test as necessary. Multivariate logistic regression analysis with backward stepwise selection was performed to assess associations (p<0.1).

Patient characteristics are summarized in Table 1. The sample includes a total of 150 patients who have underwent SLNB. The SLNB was identified in 146 patients (97.3%). The mean age of the participants was 70.6 years old. Positive SLNB was more frequent in ≥75-year-old group (29.3% vs. 18.3%). Although this result was not statistically significant (p=0.114).

Table 1.

Clinical and histopathological characteristic of study patients.

  Cohort<75 years-old≥75 years-old 
Variable  N  N  N  p 
Sex
Male  85  56.7  40  53.3  45  60  0.410
Female  65  43.3  35  46.7  30  40 
Location
Trunk  61  40.7  28  37.3  33  44  0.337
Head and neck  18  12  10  13.3  10.7 
Upper limb  30  20  19  25.3  11  14.7 
Lower limb  41  27.3  18  24  23  30.7 
Histologic subtype
Lentigo maligno  3.5  6.9  0.006
Superficial spreading melanoma  76  53.5  40  57.1  36  50 
Nodular melanoma  3.5  7.1 
Acral lentiginous melanoma  5.6  8.6  2.8 
Other  48  33.8  19  27.1  29  40.3 
Lymphovascular invasion
Absent  147  98.7  74  98.7  73  98.6  1.000
Present  1.3  1.3  1.4 
Ulceration
Absent  119  79.3  57  76  62  82.7  0.313
Present  31  20.7  18  24  13  17.3 
Regression
Absent  144  96  72  96  72  96  1.000
Present 
SLNB location
Axillar  73  50.7  36  52.2  37  49.3  0.753
Cervical  13  8.7  9.3 
Inguinal  52  36.1  23  33.3  29  38.7 
Other  4.2  5.8  2.7 
SLNB result
Negative  111  76  58  81.7  53  70.7  0.119
Positive  35  24  13  18.3  22  29.3 
Lymphadenectomy result
Negative  21  63.6  10  71.4  11  57.9  0.424
Positive  12  36.4  28.6  42.1 
Nodal metastases on follow-up
Absent  127  84.7  69  92  58  77.3  0.013
Present  23  15.3  17  22.7 
Visceral metastases on follow-up
Absent  132  88  69  92  63  84  0.132
Present  18  12  12  16 
Complications SLNB
No  129  86  64  85.3  65  86.7  0.201
Seroma  14  9.3  10.7 
Paresthesia  1.3  2.7 
SLNB not found  2.7  5.3 
Desenlace complicación BSGC
Complete remission  16  94.1  100  90  1.000
Persistence  5.9  10 
Exitus
No  133  88.7  70  93.3  63  84  0.071
Yes  17  11.3  6.7  12  16 
  Mean  St. dev.  Mean  St. dev.  Mean  St. dev  p 
Age  70.6  15.9  58.4  13.2  82.8  5.6  (<0.001) 
Breslow index  2.6  2.1  2.6  2.1  2.6  2.0  0.914 
Mitosis  3.8  6.1  4.0  5.7  3.6  6.4  0.707 

SLNB: sentinel node biopsy, St. dev: standard deviation.

Bivariate and multivariate analysis are summarized in Tables 2 and 3. The logistic regression multivariate analysis showed that for the ≥75-year-old group, ulceration was associated with SNLB positivity with an Odds Ratio of 13.3 (95%CI 2.7–65.0). Also, the risk grows when age increases, specifically the odds increase by 19% for each year over 82-year-old on the stepwise selection model. As secondary objective regarding complications, 86% of the patients did not experience any, and seroma, affecting 9.6% of the patients was the commonest with no difference among both age groups.

Table 2.

Superior: Bivariate studies between study category and outcome using X2, Fisher, Mann–Whitney U or independent samples T test as necessary.

  <75yo≥75yo 
  SLNB+SLNB  SLNB+SLNB 
  −58−13  −53−22 
Variable  N  %  N  %  p  N  %  N  %  p 
Sex
Male  30  51.7%  53.8%  0.89  33  62.3%  12  54.5%  0.534
Female  28  48.3%  46.2%    20  37.7%  10  45.5% 
Sí  1.7%  7.7%    3.8%  0% 
Location
Trunk  23  39.7%  23.1%  0.725  25  47.2%  36.4%  0.102
Head and neck  10.3%  15.4%    15.1%  0% 
Upper limb  15  25.9%  30.8%    13.2%  18.2% 
Lower limb  14  24.1%  30.8%    13  24.5%  10  45.5% 
Histologic subtype
Lentigo maligno  32  59.3%  41.7%  0.642  9.6%  0%  0.002
Superficial spreading melanoma  7.4%  8.3%    31  59.6%  25.00% 
Nodular melanoma  9.3%  8.3%    3.8%  0% 
Acral lentiginous melanoma  13  24.1%  41.7%    14  26.9%  15  75.00% 
Lymphovascular invasion
Absent  57  98.3%  13  100.00%  52  98.1%  21  100.00%  1
Present  1.7%  0%    1.9%  0% 
Ulceration
Absent  45  77.6%  69.2%  0.496  49  92.5%  13  59.1%  0.001
Present  13  22.4%  30.8%    7.5%  40.9% 
Regression
Absent  55  94.8%  13  100.00%  51  96.2%  21  95.5%  1
Present  5.2%  0%    3.8%  4.5% 
SLNB location
Axillar  30  53.6%  46.2%  0.574  28  52.8%  40.9%  0.056
Cervical  7.1%  15.4%    13.2%  0% 
Inguinal  18  32.1%  38.5%    16  30.2%  13  59.1% 
Other  7.1%  0%    3.8%  0% 
Lymphadenectomy result
Negative  60.00%  77.8%  0.58  0%  11  57.9% 
Positive  40.00%  22.2%    0%  42.1% 
Exitus due to melanoma
Si  100%  100%  –  100%  100%  – 
SNLB complication
No  53  91.4%  11  84.6%  0.553  44  83.00%  21  95.5%  0.333
Seroma  6.9%  15.4%    13.2%  4.5% 
Paraesthesia  1.7%  0%    3.8%  0% 
Complication outcome
Complete remission  100%  100%  –  88.9%  100.00% 
  −SNLB+SNLB   
Variable  N  Media  DT  N  Media  DT  t  p 
Age  53  81.55  4.66  22  85.86  6.61  2.788  0.009 
Breslow index  52  2.25  1.98  20  3.37  1.98  2.148  0.035 
Mitosis  53  3.19  5.74  22  4.50  7.89  0.804  0.424 

SLNB: sentinel node biopsy. Inferior: Bivariate studies between study category and outcome using independent samples T test for quantitative variables in the ≥75 year old group. The p values<0.1 were considered statistically significant and become part of the logistic regression model.

Table 3.

Logistic regression model the behaviour of the variables is studied using a backward stepwise selection model. The variables selected to perform the study are chosen among the ones that showed statistical significance on the regression model.

  Variable forced introductionBackward stepwise selection
          CI95%  OR          CI95%  OR 
  B  ET(BSig.  OR  Inferior  Superior  B  ET(BSig.  OR  Inferior  Superior 
Ulceration  1.046  1.139  0.359  2.846  0.305  26.556  1.945  0.869  0.025  6.997  1.275  38.404 
Age82  .277  0.092  0.003  1.32  1.101  1.581  1.418  0.801  0.077  4.127  0.859  1.834 

Includes all variables that p<0.1 on bivariate analysis. χ2=24.41; gl=3; p0.001; R2L=0.287; R2Cox&Snell=0.288; R2Nagalkerke=0.415.

Many reports have found age-dependent prognostic factors on SLNB status but most randomized trials and major studies have excluded patients older than 70–75 years.5,6 Consequently, data on the feasibility and diagnostic accuracy of the method in this patient group are so far lacking. Also, there are some existing models to predict SN status in melanoma patients that combine clinicopathologic factors depending on the primary tumour, but they do not take age into account or are not specific for the elderly.7 It has been postulated that SLNB is a poor predictor of prognosis in older patients because its positivity declines with increasing age.8 In a large study (n=858), the frequency of sentinel node (SN) metastases decreased with increasing age from 18 to 70 years, despite an increase in other poor prognostic factors. Whether this represents a lower sensitivity of the procedure or a different biological behaviour of melanomas in older patients remains unanswered.9 In our cohort, positivity was 11 points higher in the ≥75-year-old group (29.3% vs 18.3%).

Patients in the ≥75-year-old group, with ulcerated melanoma, older than 82 years-old have the higher likelihood of positivity in SLNB in our cohort. The present study focuses on elderly patients aged 75 years or older. As it is retrospective, bias may exist. The study confirms that SLNB might be recommended in the elder safely. Although SLNB remains controversial due to its lack of impact on survival, it is still the best staging system for micrometastases. It is the authors opinion that it should be offered in elderly patients.

Conflict of interest

The authors declare they have no conflict of interest.

Acknowledgment

The authors are grateful to AM for the statistics and MGG for the correction of English language.

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