Patterns of recurrence in patients with melanoma after radical lymph node dissection

Hypothesis: Previous interventions (excisional biopsy, incomplete dissection) in the regional basin that drain a melanoma site prior to definitive surgical procedures significantly increase the risk of melanoma recurrence in the surgical field. Design: Retrospective analysis. Setting: Tertiary care referral center. Patients: One hundred forty-one consecutive patients who underwent radical lymph node dissection (RLND) either in the groin or the axilla owing to malignant melanoma were followed up for a median period of 41 months. Interventions: All of the 141 patients received either elective or therapeutic RLND. Their medical records were analyzed for demographic data, disease history, previous treatments, recurrence patterns, and survival. Main Outcome Measures: Patterns of first recurrence after RLND and survival. Results: Radical lymph node dissection was performed on 148 lymph node basins (141 patients; 86 axillae and 62 groins). Nineteen patients (13%) received previous open interventions in the lymph node basin (tampering) other than radical dissection. Radical lymph node dissection was performed prophylactically in 38 basins (26%), for palpable disease in 75 (51%), and for a positive sentinel node in 35 (24%). There were 74 failures (52%) of RLND: 51 patients (70%) with systemic disease, 12 (16%) with recurrence in the surgical field, 9 (11%) with in-transit metastases, and 2 (3%) with local recurrence. On multivariate analysis, the only significant predictors of recurrence after RLND were Breslow thickness of greater than 4 mm (P=.02), tampering (P=.01), and lymph node capsular invasion (P=.001). Tampering was the only independent prognosticator of failure in the surgical field, as tampering was noted in 10 (83%) of 12 patients with failure in the surgical field as compared with 6 (10%) of 62 patients with other types of first failures (P<.001). This effect did not translate into a survival difference (P=.54). Failure in the surgical field was not detected in any of the patients who underwent sentinel lymph node biopsy. Conclusions: Previous interventions (excisional biopsy, incomplete dissection) in the regional basin that drain a melanoma site prior to definitive surgical procedures significantly increase the risk of melanoma recurrence in the surgical field, and they should be avoided. Fine-needle aspiration and sentinel node biopsy, performed with strict surgical oncologic techniques, are safe with regard to failure in the surgical field.