对于黑色素瘤淋巴结手术的指南遵守度的变异性部分归因于有关患者选择的争议。先前的数据表明，在多中心选择性淋巴结清除试验 II 发表之前，对于前哨淋巴结活检的实践不够理想，以及对于临床淋巴结阳性疾病的治疗不足。为了最小化偏差，我们研究了 T2/T3（中等厚度）黑色素瘤患者对淋巴结手术指南的遵守情况，该情况具有最大的协议一致性。我们从 2004 年至 2018 年的监测、流行病学和结果数据库（Surveillance, Epidemiology, and End Results）中确定了 T2/T3 和转移 0 的黑色素瘤病例。分析使用 Cochran-Armitage 趋势检验、多变量逻辑回归和 Kaplan-Meier 生存估计。在 66,319 例符合条件的 T2/T3 患者中，57,211 例临床淋巴结阴性，2,191 例临床淋巴结阳性，6,197 例临床淋巴结未报告，而 19,044/66,319 例（28.8%）未进行淋巴结手术。在临床淋巴结阴性患者中，36,433 例（63.7%）接受了前哨淋巴结活检，并且 31,026 例（85.2%）是病理淋巴结阴性；1,499 例临床淋巴结阳性患者（68.4%）进行了淋巴结清除术。临床淋巴结清除率从 2004 年至 2018 年下降，对于临床淋巴结阴性／病理淋巴结阳性患者，从 79.8% 下降到 32.0%，对于临床淋巴结阳性／病理淋巴结阳性患者，从 80.4% 下降到 61.2%（P < .0001）。对于临床淋巴结阴性患者，淋巴结手术遵守率从 63.7%（2004 年）提高到 70.4%（2018 年）（P < .0001）。多变量分析中，遵守率与年龄较小、男性、肿瘤有丝分裂率以及部位（极肢 > 躯干/头颈部）相关，并且改善了 5 年癌症特异性生存率（90.0% 对 83.4%）（所有 P 值 < .0001）。尽管有明确的指南，但最近的一组中，三分之一的中等厚度黑色素瘤患者没有接受建议的淋巴结手术。淋巴结状态是补充系统治疗的相对收益以及对于病理淋巴结阳性／临床淋巴结阴性患者进行积极监测的需要的关键决定因素。这些数据突显了临床护理的差距。努力改善指南的遵守情况是提高中等厚度黑色素瘤患者癌症预后的一个合理策略。版权所有 © 2022 Elsevier Inc. 保留所有权利。

Variability in guideline compliance for melanoma lymph node surgery is partially attributable to controversy about patient selection. Prior data has indicated suboptimal practice of sentinel lymph node biopsy and undertreatment of clinically node-positive disease, predating Multicenter Selective Lymphadenectomy Trial II publication. To minimize bias, we studied compliance with lymph node surgery guidelines in T2/T3 (intermediate-thickness) melanoma patients, where the greatest agreement exists.T2/T3 and metastasis 0 melanoma cases were identified from 2004 to 2018 Surveillance, Epidemiology, and End Results data. Analysis used Cochran-Armitage test for trends, multivariable logistic regression, and Kaplan-Meier survival estimates.Of 66,319 eligible T2/T3 patients, 57,211 were clinically node negative; 2,191 were clinically node positive; 6,197 were clinical node unreported; and 19,044/66,319 (28.8%) had no lymph node surgery. Among clinically node-negative patients, 36,433 (63.7%) underwent sentinel lymph node biopsy and 31,026 (85.2%) were pathologically node negative; 1,499 clinically node-positive patients (68.4%) had a lymph node dissection. Lymph node dissection rates declined from 2004 to 2018, 79.8% to 32.0% for clinically node-negative/pathologically node-positive patients and 80.4% to 61.2% for clinically node-positive/pathologically node-positive patients (both P < .0001). For clinically node-negative patients, lymph node surgery compliance improved from 63.7% (2004) to 70.4% (2018) (P < .0001). Compliance correlated with younger age, male sex, tumor mitotic rate, and site (extremity > trunk/head/neck) in multivariable analysis and improved 5-year cancer-specific survival (90.0% vs 83.4%) (all P < .0001).Despite clear guidelines, one-third of intermediate-thickness melanoma patients in a recent cohort did not have recommended lymph node surgery. Lymph node status is a key determinant of the relative benefit of adjuvant systemic therapy and the need for active surveillance of pathologically node-positive/clinically node-negative patients. These data highlighted a clinical care gap. Efforts to improve guideline compliance are a logical strategy to improve cancer outcomes for intermediate-thickness melanoma patients.Copyright © 2022 Elsevier Inc. All rights reserved.