Lo, Michelle

Moncrieff, Marc

Peach, Howard

University of East Anglia digital repository

ASO AUTHOR REFLECTIONSASO Author Reflections: Extracapsular Spread in MelanomaLymphadenopathy: Prognostic Implications, Classification,and ManagementMichelle Lo, MB, BS, MRCS1, Howard Peach, FRCS(Plast.)2, and Marc Moncrieff, MD, FRCS(Plast.)1,31Plastic and Reconstructive Surgery Department, Norfolk and Norwich University Hospital, Norwich, UK; 2PlasticSurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK; 3Norwich Medical School, Faculty of Medicine and HealthSciences, University of East Anglia, Norwich, UKPASTThe current American Joint Committee on Cancer(AJCC) classification system for stage III cutaneous mel-anoma is heterogeneous, with 5-year melanoma-specificsurvival rates ranging from 88% for stage IIIA disease to24% for stage IIID disease. Currently, the stage III clas-sification not only incorporates data from the N stage, butalso qualifies T data from the primary tumour such asBreslow thickness and ulceration status. This takes intoaccount the fact that the risk of distant spread and subse-quent death from melanoma for the stage III group isdependent on the risk of hematogenous spread from adeeply invading primary tumour, in addition to the diseaseburden of the metastatic nodes. Extracapsular spread(ECS), a well-known risk factor for locoregional recur-rence in melanoma patients with macrometastatic disease,is associated with a poor prognosis.1–3 Although ECS is abiomarker for poor prognosis, it is not included in thecurrent AJCC classification system.PRESENTThis multi-center retrospective cohort study of 515patients with nodal metastases4 comprehensively analyzedthe clinical relevance of ECS as a biomarker in nodaldisease and demonstrated that ECS is the most importantprognostic indicator for both macroscopic and microscopicdisease, upstaging patients to the next echelon in a mannercomparable with ulceration of the primary. The authorshave devised a simplified clinically and surgically relevantclassification system for microscopic and macroscopicstage III disease by replacing N stage with ECS status.FUTUREExtracapsular spread was an exclusion criterion for thelast two major phase 3 melanoma surgical trials,5,6 and theauthors suggest that ECS in sentinel node-positive patientsstill may be an indication for lymphadenectomy to achieveregional control of disease as well as for adjuvant systemictherapy. In future versions of the AJCC guidelines, ECSshould be considered as an independent staging variablepending further validation of its relevance.OPEN ACCESS This article is licensed under a Creative CommonsAttribution 4.0 International License, which permits use, sharing,adaptation, distribution and reproduction in any medium or format, aslong as you give appropriate credit to the original author(s) and thesource, provide a link to the Creative Commons licence, and indicateif changes were made. The images or other third party material in thisarticle are included in the article’s Creative Commons licence, unlessindicated otherwise in a credit line to the material. If material is notincluded in the article’s Creative Commons licence and your intendeduse is not permitted by statutory regulation or exceeds the permitteduse, you will need to obtain permission directly from the copyrightholder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.REFERENCES1. Henderson MA, Burmeister BH, Ainslie J, et al. Adjuvant lymph-node field radiotherapy versus observation only in patients with The Author(s) 2020First Received: 24 September 2020Accepted: 24 September 2020;Published Online: 20 October 2020M. Moncrieff, MD, FRCS(Plast.)e-mail: marc.moncrieff@nnuh.nhs.ukAnn Surg Oncol (2021) 28:1654–1655https://doi.org/10.1245/s10434-020-09197-9melanoma at high risk of further lymph-node field relapse afterlymphadenectomy (ANZMTG 01.02/TROG 02.01): 6-year follow-up of a phase 3, randomised controlled trial. Lancet Oncol.2015;16:1049–60.2. Agrawal S, Kane JM III, Guadagnolo BA, Kraybill WG, BalloMT. The benefits of adjuvant radiation therapy after therapeuticlymphadenectomy for clinically advanced, high-risk, lymph node-metastatic melanoma. Cancer. 2009;115:5836–44.3. Lee RJ, Gibbs JF, Proulx GM, Kollmorgen DR, Jia C, KraybillWG. Nodal basin recurrence following lymph node dissection formelanoma: implications for adjuvant radiotherapy. Int J RadiatOncol Biol Phys. 2000;46:467–74.4. LoM,RobinsonA,WadeR, et al. Extracapsular spread inmelanomalymphadenopathy: prognostic implications, classification, andmanagement. Ann Surg Oncol. 2020. https://doi.org/10.1245/s10434-020-09099-w.5. Faries MB, Thompson JF, Cochran AJ, et al. Completiondissection or observation for sentinel-node metastasis in mela-noma. N Engl J Med. 2017;376:2211–22.6. Leiter U, Stadler R, Mauch C, et al. Complete lymph nodedissection versus no dissection in patients with sentinel lymphnode biopsy positive melanoma (DeCOG-SLT): a multicentre,randomised, phase 3 trial. Lancet Oncol. 2016;17:757–67.Publisher’s Note Springer Nature remains neutral with regard tojurisdictional claims in published maps and institutional affiliations.ASO Author Reflections: Extracapsular Spread in Melanoma Lymphadenopathy 1655

ASO author reflections: Extracapsular spread in melanoma lymphadenopathy: Prognostic implications, classification, and management

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ASO author reflections: Extracapsular spread in melanoma lymphadenopathy: Prognostic implications, classification, and management

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