Abstract Whether cancer cells metastasize from the primary site to the distant sites via the lymphatic vessels or the blood vessels directly into the circulation is still under intense study. In this review article, we follow the journey of cancer cells metastasizing to the sentinel lymph nodes and beyond to the distant sites. We emphasize cancer heterogeneity and microenvironment as major determinants of cancer metastasis. Multiple molecules have been found to be associated with the complicated process of metastasis. Based on the large sentinel lymph node data, it is reasonable to conclude that cancer cells may metastasize through the blood vessels in some cases but in most cases, they use the sentinel lymph nodes as the major gateway to enter the circulation to distant sites. 

Cancer metastasis through the lymphatic versus blood vessels

Familiar controversies in the management of head and neck melanomas are more remarkable in locally advanced cases, and they represent a treatment challenge both surgically and oncologically. In our retrospective study, patients with surgically treated primary malignant melanoma of the head and neck region larger than 3 cm in diameter were included. Five patients met our inclusion criteria. In all cases, wide excision and immediate reconstruction were performed without sentinel lymph node biopsy. The defect on the scalp was covered by a split skin graft, with local flaps chosen for reconstruction on the face on an individual basis. After a 2–6 year follow-up, a good oncological, functional, and esthetic result was achieved. Our results show that in the case of large, locally advanced melanomas, surgical treatment still plays a crucial role that can provide long-term local control and support the effect of systemic treatment.

/pdf/challenges-in-the-complex-management-of-neglected-cutaneous-5imv9lto.pdf

Challenges in the Complex Management of Neglected Cutaneous Melanomas in the Head and Neck Area: A Single Center Experience

BACKGROUND:Regional lymph nodes are a common first site of metastasis in patients diagnosed with invasive melanoma. Knowledge of sentinel lymph node status provides strong prognostic information in melanoma and is important for staging and treatment decisions. The National Comprehensive Cancer Network® (NCCN) recommends performance of sentinel lymph node biopsy (SLNB) for melanoma patients with a T category of ≥T2a. This study aims to assess our academic institution's guideline adherence to improve quality of care. METHODS:Retrospective review of medical records from 2017 to 2023 identified 628 patients referred to our institution for invasive melanoma treatment. Adherence to guidelines was assessed using Chi-square analyses and Fisher's exact tests. RESULTS:In total, 8.2% of cases did not follow the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for SLNB. When justification provided within the medical record was considered adherent to guidelines, our rate of discordance was 1.6%. Head and neck melanomas were more likely to have guideline-discordant SLNB management, regardless of whether or not a justification was provided. CONCLUSION:Greater than 98% of melanoma cases at our institution aligned with the SLNB NCCN Guidelines®. We outlined the complex justifications physicians and patients may use to pursue care that is nonadherent to guidelines. Employment of SLNB may be limited by medical comorbidities, surgical risks, and when the management would not change based on the result. Our study provides a blueprint for institutional assessment of guideline adherence and highlights the importance of documentation and guideline dissemination.

An Evaluation of Sentinel Lymph Node Biopsy Guideline Adherence in Melanoma Patients

BACKGROUND
Melanoma represents a significant public health challenge in Canada, contributing to the deaths of over 1000 individuals each year. Prince Edward Island and Nova Scotia were previously noted to have the highest incidence rates of melanoma in Canada.


METHODS
Data from patients diagnosed with or dying from melanoma was extracted from the Nova Scotia Cancer Registry. TNM stage was available for cases diagnosed 2007 to 2017. Incidence (1992-2019) and mortality (1992-2021) rates were examined using Join Point Trend Analysis Software.


RESULTS
Between 2007 and 2019, 2450 cases of in situ and 4063 cases of invasive melanoma were documented, of which 52.8% were male. The largest number of cases was from the 60- to 79-year age group. The most common site in females was upper limbs (in situ) and lower limbs (invasive), and for males, face, and neck (in situ), and trunk (invasive). The majority of invasive cases (71.5%) were diagnosed at stage I. Invasive melanoma incidence has been increasing by 2.7% per year since 1992, while in situ disease has increased at a greater rate (4.9% per year). The current estimate of 92% for 5 years of net survival has not changed appreciably over the same period. Survival for late-stage melanoma has shown a modest improvement for patients diagnosed over the period.


CONCLUSION
With increasing rates of melanoma in Nova Scotia, there is a need for informed education, directed at the public and physicians, around pigmented skin lesions. This would allow the patient to detect atypical melanocytic lesions at an early stage. Sun safety practices in Nova Scotia should continue to be encouraged.

Trends in Cutaneous Melanoma in Nova Scotia With a Focus on 2007 to 2019.

The benefit of sentinel lymph node biopsy in elderly patients with melanoma: A retrospective analysis of SEER Medicare data (2010-2018).

/pdf/sentinel-lymph-node-biopsy-in-cutaneous-melanoma-a-clinical-3er72nv1.pdf

Sentinel Lymph Node Biopsy in Cutaneous Melanoma, a Clinical Point of View

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Sentinel Lymph Node Biopsy in Cutaneous Melanoma, a Clinical Point of View