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Sentinel Lymph Node Biopsy versus Nodal Observation in Melanoma

Summary and Comment |
February 12, 2014

Sentinel Lymph Node Biopsy versus Nodal Observation in Melanoma

  1. Hensin Tsao, MD, PhD

Despite a lack of treatment-related survival benefit, SLNB protected against microscopic nodal recurrence, and survival among patients with such disease was significantly better.

  1. Hensin Tsao, MD, PhD

Sentinel lymph node biopsy (SLNB) is now a mainstay of prognostication, but its therapeutic benefit is controversial. In 1994, the Multicenter Selective Lymphadenectomy Trial (MSLT-I) was initiated to determine whether the procedure itself improved overall survival. The 5-year interval report noted no overall survival benefit, but the overall proportion of patients with positive lymph node disease was lower than anticipated. The final report of the MSLT-I trial has now been released.

At 10 years, there was no statistical between-group differences in treatment-related survival among patients with intermediate or thick cutaneous melanomas randomly assigned to nodal observation (wide excision and nodal observation with lymphadenectomy for nodal relapse) or to SLNB (wide excision and SLNB with lymphadenectomy for nodal metastases discovered on biopsy). Disease-free survival rates were significantly higher in the SLNB group than in the observation group. Melanoma-specific survival was significantly better in patients who underwent SLNB, had a positive result, and had early regional lymphadenectomy, compared with those who underwent wide excision but not SLNB, who had regional lymphadenectomy only after clinically detectable relapse. The number of positive nodes was similar in both groups.

Comment

The 10-year final report does not resolve the controversies raised by the 5-year interim analysis. The main message remains the same. Although there was no statistical difference in overall survival between observation and sentinel lymph node biopsy, 10-year survival was significantly lower in patients with clinical nodal recurrence than in patients with microscopic SNL–positivity. Critics will cite the lack of overall survival benefit as a reason not to pursue the procedure in clinical practice. Proponents will point to the protection against microscopic nodal recurrence and the significantly better survival among patients with microscopic disease versus patients with clinically detectable relapse. Because the number of events was lower than expected, the authors conclude that the study was underpowered to detect a difference.

For now, the main utility of sentinel lymph node biopsies remains informational and not therapeutic. Although avoiding bulky nodal disease is a highly desirable benefit, patients should understand that overall survival does not appear to be affected by the procedure itself. If an effective adjuvant treatment is developed, the role of sentinel lymph node sampling could change dramatically.

  • Disclosures for Hensin Tsao, MD, PhD at time of publication Consultant / advisory board Genentech; Quest Diagnostics; WorldCare Clinical Grant / research support NIH; Department of Defense; American Skin Association Editorial boards British Journal of Dermatology; Journal of the American Academy of Dermatology; Journal of Investigative Dermatology Leadership positions in professional societies American Academy of Dermatology (Chair, Skin Cancer and Melanoma Committee); American Board of Dermatology (Director)

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Reader Comments (2)

Bruce Bodner Physician, Surgery, General, Taunton, MA

I would greatly appreciate if any of your readers can present a randomized study which shows a survival benefit for a more aggressive surgical approach versus a less aggressive approach, for any type of solid tumor.

Alvin M. Cotlar, MD Physician, Surgery, General, VA Hospital

As a general surgeon who refers melanoma patients to oncologists for treatment after wide excision, I experience requests by the oncologist for SLNB before their providing further therapy. Is that not a wide-spread practice of oncologists in this country?

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