Lymph Node Procedures of the Trunk and Extremities
For most solid tumors, lymph node status is an important prognostic factor which suggests that the cancer is no longer localized and has the potential for systemic micrometastatic spread. In patients with Merkel cell carcinoma, regional lymphatic metastas
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Lymph Node Procedures of the Trunk and Extremities Julian Kim
Introduction and History For most solid tumors, lymph node status is an important prognostic factor which suggests that the cancer is no longer localized and has the potential for systemic micrometastatic spread. In patients with Merkel cell carcinoma, regional lymphatic metastasis portends a poor prognosis. Lymph node positive patients are either Stage IIIA (micrometastases in regional lymph node) or Stage IIIB (macrometastases in regional lymph node) and the corresponding survival is significantly worse than patients who have node negative disease. Analysis of 1,034 patients within the Surveillance, Epidemiology and End Results Program (SEER) demonstrated a 5-year relative survival rate of 59 % in patients with nodal metastases as compared to 75 % in patients with node negative Merkel cell carcinoma [1]. A single institution series published from Memorial Sloan Kettering in 2005 in 251 patients demonstrated a 5-year diseasespecific survival of 52 % for patients with Stage III disease as compared to 81 % and 67 % for patients with Stage I and II node negative disease, respectively [2]. Of note is that of patients who were eventually determined to have nodal metastases confirmed by histopathology, those who presented
J. Kim (*) Department of Surgery, University Hospitals Case Medical Center, LKSD 5047, 11100 Euclid Avenue, Cleveland, OH 44106, USA e-mail: [email protected]
with clinically node negative disease had a better disease-specific survival than patients who presented with palpable, clinically suspicious regional lymph nodes. These data directly support the concept that knowledge of nodal status carries important prognostic information. Additionally, there is indirect evidence that identification of nodal disease when it is micrometastatic portends a better prognosis than diagnosis of macrometastatic or clinically evident nodal disease.
Historical Progression of Lymph Node Procedures for Patients with Merkel Cell Carcinoma The rare nature of Merkel cell carcinoma has precluded prospective randomized trials to determine the benefit related to lymph node procedures. Thus, most of the evidence supporting the use of lymph node procedures relates to either single institutional studies or translation of evidence from experience with patients with melanoma. In patients who present with palpable metastatic disease to the regional lymph nodes without evidence of distant metastatic spread, regional lymphadenectomy or complete lymph node dissection of the axilla or groin serves two functions. First, clearance of regional nodal metastatic disease improves local control. Progression of regional nodal metastases in the axilla can lead to fixation of the tumor mass to the underlying chest wall which can lead to severe pain. In more advanced cases, progression of nodal disease in
M. Alam et al. (eds.), Merkel Cell Carcinoma, DOI 10.1007/978-1-4614-6608-6_8, © Springer Science+Business Media New York 2013
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the axilla can result in
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