National Evaluation of the Management of Melanoma Patients with Multiple Positive Sentinel Lymph Nodes

Clinical trials for melanoma patients demonstrated safety of observation in lieu of completion lymph node dissection (CLND) following positive sentinel lymph node (SLN) biopsy. Patients with two or more positive SLNs were infrequently included in the trials, leaving uncertainty about their management. We aimed to (1) assess national trends of CLND use in patients with two or more positive SLNs; (2) examine factors associated with CLND use; and (3) examine overall survival outcomes.

Patients with stage I-III melanoma who underwent SLN biopsy between 2012 and 2021 were identified from the National Cancer Database. Factors associated with CLND were assessed by hierarchical logistic regression. Overall survival was estimated using Cox proportional hazards models.

Among 151,442 patients (median age 61 years; 41.3% female) who underwent SLN biopsy, 5440 (3.6%) had two or more positive SLNs. CLND in patients with two or more positive SLNs decreased from 73% in 2012 to 14% in 2021, while immunotherapy utilization increased from 38% in 2012 to 76% in 2021. Patients with two or more positive SLNs were more likely to undergo CLND if they had melanoma in the head/neck region (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.39-2.95) or ulcerated lesions (OR 1.42, 95% CI 1.11-1.83). There was no difference in 3-year overall survival (70.5% for two or more positive SLNs with observation vs. 70.8% for two or more positive SLNs with CLND; hazard ratio 1.03, 95% CI 0.77-1.37) for observation vs. CLND.

Utilization of CLND declined for melanoma patients with two or more positive SLNs following major clinical trials, with no difference in overall survival for observation versus CLND. Evolving treatment recommendations have been rapidly incorporated into practice in the United States.