BOB Ped Surg 2023 - Steven Scoville, IPSO - Presentation

Who's speaking

• Steven Scoville — guest

Chapters

• 0:11Introduction and Background — Introduction of study comparing surveillance ultrasound versus completion lymph node dissection in pediatric melanoma. Reviews epidemiology of pediatric melanoma, management principles based on tumor depth, and recent adult trials (DCOG SLT and MSLT2) showing no difference between observation and CLND, but notes absence of pediatric data.
• 1:54Study Design and Patient Cohort — Description of multi-institutional study through Pediatric Surgical Oncology Research Collaborative (PSORC) including 252 patients ≤18 years old diagnosed 2010-2020. Details patient demographics, tumor characteristics, and breakdown of treatment groups: 46 ultrasound observation versus 67 completion lymph node dissection patients.
• 3:22Results and Outcomes Analysis — Presentation of comparative outcomes showing no significant difference in recurrence or death between ultrasound observation and CLND groups. Subgroup analyses reveal 18% recurrence in positive sentinel node patients versus 3% in negative, only 21% additional positive nodes in CLND group, and recurrence associated with positive nodal disease, deeper Breslow depth, and adjuvant therapy use.
• 4:23Conclusions and Acknowledgments — Summary of key findings: high rate of positive sentinel nodes in pediatric melanoma, no impact of nodal management approach on outcomes, low yield of additional nodes in CLND, and strongest recurrence association with positive sentinel nodes and Breslow depth. Acknowledgment of 14-institution collaboration.

Key claims

• 0:26Pediatric melanoma has approximately 500 new cases diagnosed annually in children less than or equal to 18 years old — Steven Scoville
• 0:33Childhood melanoma is associated with delayed diagnosis and more frequently has nodal involvement compared to adults — Steven Scoville
• 0:42Childhood melanoma has unique disease mechanisms compared to adult melanoma — Steven Scoville
• 0:44Management of pediatric melanoma is based on adult studies — Steven Scoville
• 0:49Melanoma management is largely based on depth of the tumor and presence of metastatic disease — Steven Scoville
• 0:55Tumors less than 8 millimeters thick are largely managed with wide local excision — Steven Scoville
• 1:07Tumors greater than or equal to 8 millimeters or less than 8 millimeters with high risk features without metastatic involvement typically undergo wide local excision with sentinel lymph node biopsies — Steven Scoville
• 1:20Completion lymph node dissection has a high risk of morbidity — Steven Scoville
• 1:29Two adult trials (DCOG SLT and MSLT2) showed no significant difference in outcomes for low to intermediate risk patients with positive sentinel lymph node biopsies who were followed with ultrasound observation versus completion lymph node dissections — Steven Scoville
• 1:47There is no pediatric data to support ultrasound observation versus completion lymph node dissection — Steven Scoville
• 1:54The study included 252 patients less than or equal to 18 years old diagnosed with cutaneous melanoma between 2010 and 2020 from 14 institutions through PSORC — Steven Scoville
• 2:10Race was predominantly white in the study cohort, consistent with prior literature — Steven Scoville
• 2:21Breslow depth ranged from tumor in situ to 20 millimeters with a median of 2.55 millimeters — Steven Scoville
• 2:21Extent of disease was nearly split between localized and regionalized disease — Steven Scoville
• 2:40Of 227 patients who underwent wide local excision with sentinel lymph node biopsies, 115 had positive sentinel lymph nodes (approximately 51%) — Steven Scoville
• 3:22Patients who underwent completion lymph node dissection were significantly older than those who underwent ultrasound observation — Steven Scoville
• 3:22Patients who underwent completion lymph node dissection were more likely to receive adjuvant therapy — Steven Scoville
• 3:34There was no significant difference in recurrence or death from disease between ultrasound observation and completion lymph node dissection groups — Steven Scoville
• 3:41Positive sentinel lymph node biopsies had significantly higher rate of disease recurrence at 18% compared to 3% for negative sentinel lymph node biopsy group — Steven Scoville
• 3:52Only 21% of those who underwent completion lymph node dissection had additional positive nodal disease — Steven Scoville
• 4:01Rate of recurrence was not significantly different between completion lymph node dissection patients with or without additional nodal burden — Steven Scoville
• 4:11Recurrence was associated with positive nodal disease, deeper Breslow depth, greater use of adjuvant therapy, and higher rate of death — Steven Scoville
• 4:23Pediatric melanoma presents as advanced disease with nearly 50% positive sentinel lymph node biopsy rate — Steven Scoville
• 4:30Management of nodal disease had no significant impact on disease outcomes with respect to recurrence or death from disease — Steven Scoville
• 4:38Findings of additional nodal disease in completion lymph node dissection did not significantly correlate with recurrence — Steven Scoville
• 4:47Recurrence most strongly associated with positive sentinel lymph node biopsies and deeper Breslow depth — Steven Scoville

Open questions

• Why do completion lymph node dissection patients receive adjuvant therapy more frequently despite no difference in outcomes?
• What are the unique disease mechanisms of pediatric melanoma compared to adult melanoma?
• What specific high-risk features in tumors <0.8mm warrant sentinel lymph node biopsy?