Evolving management of positive regional lymph nodes in melanoma: Past, present and future directions

Abstract

Sentinel lymph node (SLN) biopsy has become the standard of care for lymph node staging in melanoma and the most important predictor of survival in clinically node-negative disease. Previous guidelines recommend completion lymph node dissection (CLND) in cases of positive SLN; however, the lymph nodes recovered during CLND are only positive in a minority of these cases. Recent evidence suggests that conservative management (i.e. observation) has similar outcomes compared to CLND. We sought to review the most current literature regarding the management of SLN in metastatic melanoma and to discuss potential future directions.

Management of the positive sentinel lymph node in the post‐MSLT‐II era

“…9 Despite these broad changes in guidelines and professional consensus, some still cautioned against active surveillance in a high-risk subset of patients with tumor features not included in trial criteria (extracapsular nodal extension, involvement of more than one nodal basin, primary tumor microsatellitosis). 10 In this group of patients, there may be an increased risk of understaging with SLNB alone, which has subsequent implications for adjuvant therapy. 11 In addition, MSLT-II included a relatively small cohort of patients with head and neck melanomas (13.7% of study population) and overall sentinel lymph node tumor burden was low (interquartile range [IQR] for the observation group was 0.23-1.38 mm).…”

“…In the latest guidelines from the Society of Surgical Oncology, active surveillance is recommended in most high‐ and low‐risk patients 9 . Despite these broad changes in guidelines and professional consensus, some still cautioned against active surveillance in a high‐risk subset of patients with tumor features not included in trial criteria (extracapsular nodal extension, involvement of more than one nodal basin, primary tumor microsatellitosis) 10 . In this group of patients, there may be an increased risk of understaging with SLNB alone, which has subsequent implications for adjuvant therapy 11 .…”

Evaluation of Sentinel Lymph Node Status and its Association with Clinicopathological Factors in Patients with Cutaneous Melanoma: A Retrospective Study

“…The surgical management of regional Lymph Nodes (LNs) for all patients with CM has been controversial since 1892 when H. Snow rst recommended Elective Lymph Node Dissection (ELND) as a method to prevent tumor progression regardless of the presence of clinical regional nodal metastases (17,18). The main shortcoming of ELND is that only about 20% of patients with middle-thickness primary CM are evaluated to have metastases in the regional lymph nodes, whereas 80% of patients are exposed to the morbidity of lymphadenectomy without the real bene t (19). Moreover, several randomized trials have failed to show an overall survival (OS) bene t for ELND (20)(21)(22)(23).…”

“…As metastases from CM signi cantly progress in LNs, SLNB has emerged as a major diagnostic tool for determining whether cancer has developed beyond the early tumor site to the LNs (26). Therefore, SLNB with lymphatic mapping was developed as a minimally invasive surgical procedure and sensitive prognostic method to stage clinical regional LNs without the associated morbidity of ELND (18,19). This is the surgical technique by which the sentinel LNs are removed and checked for the presence of cancer cells.…”

“…Most surgeons commonly advise the triple manner, which includes preoperative lymphoscintigraphy, perioperative injection of blue dye (isosulfan blue or methylene blue), and intraoperative gamma probe identi cation. The accuracy of this procedure is approximately 99% (19). Presently, several experts advocate SLNB for tumor stages Ib and II (30).…”