Thursday, August 25, 2016
Sentinel lymph node disection ~ "important diagnostic procedure and might be of therapeutic benefit re: DFS and OS!"
I have long said that sentinel lymph node removal and testing in melanoma seems like a complete no-brainer to me!!! It is done when you return for the needed wide excision around the tumor that was removed. It is minimally invasive considering you're going to have the wide excision anyway. It is the only way to know what stage you really are. You may have only cutaneous disease and therefore are categorized as Stage 1 or 2....based on how thick your lesion was, the presence of ulceration, etc. BUT....if you have a positive node to go with that....you are then Stage 3....and that is a very different place to be.
1. It's important to know that's where you are in melanoma land.
2. It makes a world of difference in recommended follow up.
3. It makes a world of difference in what insurance companies will cover for your follow-up.
4. AND....it makes a world of difference in potential treatment options.
Here is a post from 2013 with some articles discussing the odds of having a positive node: With melanoma, you can never be too rich or too thin!
Here is a post from this year, with several links within, addressing risks for positive nodes in females specifically: Women and melanoma risk
NOW....do NOT confuse sentinel node removal and biopsy with a complete lymph node dissection (CLND). CLND is different. A CLND is when, usually after having one or more positive nodes, all the lymph nodes are removed from the nodal basin (the area in which the positive node was located). This IS invasive surgery and has the potential to cause nerve damage and or lymphedema, among other things. IF you had a positive sentinel node...this would be one of the things you would have to decide about doing or not. The science and data surrounding whether this is helpful or not, worth the potential damage or not, is murky. There are studies that say it helps and others that say is does not. BUT whichever way you decide to go with this...this is a decision made AFTER the sentinel node dissection and separate from it!!!
Here's a post showing three studies addressing the issue: "Patients with microscopically negative/PCR+ SLN have increased risk for nodal recurrence that was mitigated by CLND"!
Now there is this:
The impact of sentinel node dissection on disease-free and overall tumor-specific survival in melanoma patients: a single center group-matched analysis of 1,192 patients. Geimer, Sattler, Flaig, et al. J Eur Acad Dermatol Venereol. 2016 Aug 24.
Sentinel lymph node dissection (SLND) is considered a standard staging procedure providing important prognostic information on melanoma patients. It remains a matter of debate, whether SLND and hence removal of potential lymph node micrometastasis will alter survival outcome.
The aim of this group-matched analysis was to compare survival data of a large cohort of melanoma patients who were treated by wide local excision only (WLE) and nodal observation (WLE group) to a group of patients treated with WLE plus sentinel lymph node dissection (SLND group) to investigate the potential therapeutic benefit of SLND in the treatment of patients with melanoma.
A total of 596 consecutive patients who had undergone WLE plus SLND between 1996 and 2003 were assessed. As a historical control group 596 patients treated with WLE and nodal observation but without SLND between 1986 and 1995 were selected. The groups were matched according to sex, age, Breslow tumor thickness and localization of primary tumor. The adjuvant treatment and follow-up examinations were performed according to protocols of the German Dermatologic Cooperative Oncology Group (DeCOG) and applicable study protocols that our clinic participated in and hence subject to change over time.
Kaplan-Meier testing revealed significant differences in survival in favor of the SLND group. Mean overall tumor specific survival (OS) was 102.7 months in the SLND group vs. 97.0 months in the WLE group, respectively. Disease-free survival (DFS) and time to lymph node progression also differed significantly between the two groups.
SLND is not only an important diagnostic procedure, but might also be of therapeutic benefit in terms of disease-free and overall tumor-specific survival of melanoma patients.
See what I'm saying? Nothing in melanoma is easy. Absolute therapeutic effect of SLND may not be that impressive, though still a positive in this study, but SLND seems rather essential for diagnostic purposes. At least this part seems pretty clear to me. Good luck to all of you and whatever you decide. - les