As effective therapies were developed for melanoma patients, folks began to take a harder look at whether or not the removal of all the lymph nodes in the nodal basin, after a positive sentinel lymph node, provided benefit. With no effective treatment for melanoma, the argument for CLND made more sense. These days, as ratties have proved the value of both targeted and immunotherapy as treatment for advanced disease as well as adjuvant (BRAFi and Yervoy were FDA approved for metastatic melanoma in 2011, anti-PD-1 was approved for same in 2014, and nivo was approved for use as adjuvant only in 2017) and are now furthering the examination of NEO-adjuvant treatments, we have learned better. The research and recommendations have vacillated back and forth over the years and the topic has been more than covered in this space with a zillion articles and discussions. Here's a brief review of the value and difference between SLNB (sentinel lymph node biopsy) and CLND (complete lymph node dissection) written in 2016:
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.
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!!!
The difference between the two procedures and reasons for them remains on point. And while there are still occasional valid reasons to consider a complete lymph node dissections - now there's this:
Completion lymphadenectomy for a positive sentinel node biopsy in melanoma patients is not associated with a survival benefit. Kleman, Han, Leong, ..., Sondak, et al. J Surg Oncol. 2019 Mar 18.
Completion lymph node dissection (CLND) for sentinel lymph node (SLN) disease in melanoma patients is debated. We evaluated the impact of CLND on survival and assessed for predictors of nonsentinel node metastasis (positive CLND).
Positive SLN melanoma patients were retrospectively identified in the Sentinel Lymph Node Working Group database. Clinicopathological factors were correlated with CLND status, overall survival (OS), and melanoma-specific survival (MSS).
There were 953 positive SLN patients of whom 831 (87%) had CLND. Positive CLND was seen in 141 (17%) cases and was associated with worse OS and MSS . CLND was not performed (No-CLND) in 122 of 953 positive SLN cases (13%), of whom 100 had follow-up and 18 (18%) developed a nodal recurrence (NR). No significant differences in OS and MSS were seen comparing CLND with No-CLND and comparing positive CLND with No-CLND NR patients. Gender, primary site, ulceration, and number of positive SLNs were correlated with nonsentinel node metastasis.
Performance of CLND provides prognostic information but is not associated with a survival benefit. Clinical variables can predict a positive CLND in patients who may be at high risk of recurrence.
In reviewing the records of 953 melanoma peeps with positive SLN, researchers found that there was no impact on overall survival or melanoma-specific survival, no matter if the CLND was done or not. The usual risk factors of "gender, primary site, ulceration, and number of positive SLNs" were noted to coordinate with metastasis as studies I've reported on previously corroborate.
As someone who has had two CLND's (to both axilla), the first in 2003 and the second in 2007, yet still progressed to Stage IV in 2010, watching the research on the topic unfold has been interesting to say the least. However, given the advances in melanoma therapy, it is probably time to move on! - les
No comments:
Post a Comment