Surgical Treatment of Melanoma Patients with Early Sentinel Node Involvement

Abstract

Sentinel lymph node biopsy (SLNB) is a standard staging procedure for many patients with clinically node negative, invasive melanoma, providing excellent prognostic information in appropriately selected patients. The broad acceptance of SLNB into clinical practice has resulted in substantial numbers of patients found to have microscopic nodal metastases. For patients with a positive sentinel node, a completion lymph node dissection (CLND) is the current standard of care. The majority of patients who undergo CLND are found to have histologically negative non-sentinel nodes, and yet are exposed to the potential morbidity of CLND, including infection, wound complications, and lymphedema. We do not yet know if there is a survival benefit from CLND that justifies its morbidity and we are currently unable to identify clinical and pathologic factors that may be associated with the likelihood of benefit from CLND. Controversy regarding the management of melanoma patients with a positive sentinel node highlights the need for continued investigation in melanoma biology, treatment, and outcomes. Patients with minimal tumor burden in their regional nodes would especially benefit from a better understanding of the appropriate management strategies. Ongoing clinical trials are aimed at determining whether CLND is superior to nodal observation and surveillance in patients with positive sentinel nodes, and at determining the outcome of patients with minimal disease in their sentinel node who forego CLND. These studies may help to resolve the uncertainties of the management in these patients. Until we have further information, CLND for melanoma patients with positive sentinel nodes remains the preferred, standard management strategy.

Update and Review on the Surgical Management of Primary Cutaneous Melanoma

“…CLND serves two purposes: the first is to more accurately assess the stage and prognosis of the melanoma and the second is to prevent relapse in the nodal basin. As noted above, if a SLNB is negative for metastatic disease, it is most likely that the other non-sentinel nodes in the basin are negative for cancer cells as well [ 29 ]. However, distant disease can occasionally occur without nodal metastases, but positive regional nodes are more likely the major markers for distant disease [ 25 ].…”

Current Management of Malignant Melanoma: State of the Art

“…In another case [152], 82-year-old man who presented with rapidly progressing cutaneous melanoma metastases, together with inguinal lymph nodes and bilateral pulmonary involvement, treated with topical immunotherapy with diphencyclopropenone (DPCP) in aqueous cream weekly to elicit moderate contact hypersensitivity. Larger lesions were also treated with intralesional 5-fluorouracil (50 mg/mL).…”

Can SOX-10 or KBA.62 Replace S100 Protein in Immunohistochemical Evaluation of Sentinel Lymph Nodes for Metastatic Melanoma?

“…For patients with a positive sentinel node, complete lymph node dissection is the current standard of care. 1 In some cases of metastatic melanoma to the sentinel lymph node, the neoplastic cells can be easily identified. However, identification of metastatic tumor in cases with few metastatic melanoma cells can be challenging.…”