Kelsey B. Montgomery, MD
Surgical Resident
University of Alabama at Birmingham
Birmingham, Alabama, United States
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Patients with sentinel lymph node positive (SLN+) melanoma are increasingly undergoing nodal surveillance with ultrasound (US) over completion lymph node dissection (CLND) following the Second Multicenter Selective Lymphadenectomy Trial (MSLT-II). Most nodal recurrences are detected clinically or with ultrasound, however adherence to nodal surveillance in real-world practice remains unknown.
Methods:
In a retrospective cohort of SLN+ melanoma patients who underwent nodal surveillance at a single institution from July 2017 through April 2020, we evaluated adherence to nodal surveillance US, defined as at least one US for each 6-month follow-up interval. We compared adherence to nodal US and other surveillance methods (exam, cross-sectional imaging with CT or PET) based on receipt of adjuvant therapy using Chi-squared and Wilcoxon rank sum tests, as appropriate. Early recurrence data were reported using descriptive statistics.
Results:
Among 109 nodal surveillance patients, 37 (34%) received US surveillance at recommended intervals for the duration of the study. Of the 72 (66%) non-adherent patients, 16 were lost to follow up and 33 had planned follow up at an outside institution without available records. Compared to US surveillance, more patients had a minimum of bi-annual clinic visits (90, 83%) and cross-sectional imaging with CT or PET (57, 53%). Sixty percent of patients received adjuvant therapy; these patients had fewer US (p< 0.01) but more exams (p< 0.01) and trend toward more cross-sectional imaging (p=0.06). Of the overall cohort, 26 (24%) developed recurrence at a median follow-up of 15 months; 10 recurrences were limited to the SLN basin. Among isolated nodal recurrences, 2 were detected with US or exam, and 7 with cross-sectional imaging, 1 unknown.
Conclusions:
Despite evidence from MSLT-II that demonstrated equivalent disease-specific survival for SLN+ patients who undergo nodal surveillance versus CLND, pragmatic challenges to the delivery of surveillance US remain. Further study to improve adherence to nodal surveillance and understand its utility alongside cross-sectional imaging will be critical as SLN+ patients are increasingly managed with nodal surveillance over CLND.