• Kristy K Broman, Tasha M Hughes, Lesly A Dossett, James Sun, Michael J Carr, Dennis A Kirichenko, Avinash Sharma, Edmund K Bartlett, Amanda Ag Nijhuis, John F Thompson, Tina J Hieken, Lisa Kottschade, Jennifer Downs, David E Gyorki, Emma Stahlie, Alexander van Akkooi, David W Ollila, Jill Frank, Yun Song, Giorgos Karakousis, Marc Moncrieff, Jenny Nobes, John Vetto, Dale Han, Jeffrey Farma, Jeremiah L Deneve, Martin D Fleming, Matthew Perez, Kirsten Baecher, Michael Lowe, Roger Olofsson Bagge, Jan Mattsson, Ann Y Lee, Russell S Berman, Harvey Chai, Hidde M Kroon, Roland M Teras, Juri Teras, Norma E Farrow, Georgia M Beasley, Jane Yc Hui, Lukas Been, Schelto Kruijff, David Boulware, Amod A Sarnaik, Vernon K Sondak, Jonathan S Zager, and International High-Risk Melanoma Consortium.
• Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL; Department of Oncologic Sciences, University of South Florida, Tampa, FL; Department of Surgery, University of Alabama at Birmingham. Electronic address: kristybroman@uabmc.edu.
• J. Am. Coll. Surg. 2021 Apr 1; 232 (4): 424431424-431.

BackgroundIn sentinel lymph node (SLN)-positive melanoma, two randomized trials demonstrated equivalent melanoma-specific survival with nodal surveillance vs completion lymph node dissection (CLND). Patients with microsatellites, extranodal extension (ENE) in the SLN, or >3 positive SLNs constitute a high-risk group largely excluded from the randomized trials, for whom appropriate management remains unknown.Study DesignSLN-positive patients with any of the three high-risk features were identified from an international cohort. CLND patients were matched 1:1 with surveillance patients using propensity scores. Risk of any-site recurrence, SLN-basin-only recurrence, and melanoma-specific mortality were compared.ResultsAmong 1,154 SLN-positive patients, 166 had ENE, microsatellites, and/or >3 positive SLN. At 18.5 months median follow-up, 49% had recurrence (vs 26% in patients without high-risk features, p < 0.01). Among high-risk patients, 52 (31%) underwent CLND and 114 (69%) received surveillance. Fifty-one CLND patients were matched to 51 surveillance patients. The matched cohort was balanced on tumor, nodal, and adjuvant treatment factors. There were no significant differences in any-site recurrence (CLND 49%, surveillance 45%, p = 0.99), SLN-basin-only recurrence (CLND 6%, surveillance 14%, p = 0.20), or melanoma-specific mortality (CLND 14%, surveillance 12%, p = 0.86).ConclusionsSLN-positive patients with microsatellites, ENE, or >3 positive SLN constitute a high-risk group with a 2-fold greater recurrence risk. For those managed with nodal surveillance, SLN-basin recurrences were more frequent, but all-site recurrence and melanoma-specific mortality were comparable to patients treated with CLND. Most recurrences were outside the SLN-basin, supporting use of nodal surveillance for SLN-positive patients with microsatellites, ENE, and/or >3 positive SLN.Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.

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