A recent New England Journal of Medicine article is the best evidence we have thus far showing the lack of survival benefit from sentinel lymph node biopsy (SLNB) in malignant melanoma (MM) patients.1 This multi-center trial randomly assigned 1,269 patients with MM at least 1.2 mm in thickness into two groups:
1. wide excision and SLNB (the biopsy group)
2. wide excision and postoperative observation of the regional nodal basin (the observation group).
Delayed lymphadenectomy was performed if nodal disease was clinically detectable in the observation group, and lymphadenectomy was performed in the biopsy group if micrometastases were detected in SLNB.
SLNB Benefits Difficult to Quantify
The results of this study were what many expected. The rate of melanoma-specific death was similar in both groups at 5 years: 13.8% in the observation group and 12.5% in the biopsy group. The melanoma-specific survival rate was also similar in both groups: 90.1% vs. 93.2% at 3 years and 86.6% vs. 87.1% at 5 years, in the observation group and biopsy group, respectively.
By doing some “fancy” statistics that even Mark Twain would be proud of, the authors were able to find a small subset of patients that actually benefited from SLNB that was followed by immediate lymphadenectomy. Despite lack of survival efficacy, SLNB did provide valuable prognostic information: the estimated disease-free survival rate was approximately 50% if the SLNB contained metastases and approximately 80% if the node was free of metastases.
Should SLNB be Accepted Standard of Care for MM?
Based on the aforementioned data, and other data that are available, it is difficult to prove that SLNB should be a standard of care for MM patients. Despite this, many physicians and the general public have accepted SLNB in patients with MM as dogma. Moreover, currently it is not only the high-risk patients who undergo SLNB, but also those patients with relatively thin melanomas.
But this is more than a standard of care argument; this is also a scope of practice argument and one that should concern dermatologists, many of whom perform definitive surgical excisions of melanomas. As it may be preferable to perform a SLNB during the time of re-excision, these patients can find themselves suddenly whisked away to surgical oncology.
Cost-Benefit Considerations
Furthermore, we need to consider this from a cost-benefit point of view. SLNB is an expensive procedure, with hospital, pathology, and surgical fees. With the cost of our medical care ballooning out of control, we need to be prudent about our healthcare dollars. Performing a SLND in a patient with a thin MM certainly does not fall into that category.
I propose that we instead use our healthcare dollars to educate our patients and our medical colleagues to facilitate prevention, early detection, and removal of MM.
Use Should be Limited to High-Risk MM
It seems evident that SLNB provides useful prognostic information, and the entire story of SLNB is still unknown. Several large trials are currently underway to assess potential benefits of this procedure. It may very well be that the next trial will definitively show survival benefit of SLNB. But until then, I believe that SLNB should be restricted to high-risk MM in a clinical trial setting.
A recent New England Journal of Medicine article is the best evidence we have thus far showing the lack of survival benefit from sentinel lymph node biopsy (SLNB) in malignant melanoma (MM) patients.1 This multi-center trial randomly assigned 1,269 patients with MM at least 1.2 mm in thickness into two groups:
1. wide excision and SLNB (the biopsy group)
2. wide excision and postoperative observation of the regional nodal basin (the observation group).
Delayed lymphadenectomy was performed if nodal disease was clinically detectable in the observation group, and lymphadenectomy was performed in the biopsy group if micrometastases were detected in SLNB.
SLNB Benefits Difficult to Quantify
The results of this study were what many expected. The rate of melanoma-specific death was similar in both groups at 5 years: 13.8% in the observation group and 12.5% in the biopsy group. The melanoma-specific survival rate was also similar in both groups: 90.1% vs. 93.2% at 3 years and 86.6% vs. 87.1% at 5 years, in the observation group and biopsy group, respectively.
By doing some “fancy” statistics that even Mark Twain would be proud of, the authors were able to find a small subset of patients that actually benefited from SLNB that was followed by immediate lymphadenectomy. Despite lack of survival efficacy, SLNB did provide valuable prognostic information: the estimated disease-free survival rate was approximately 50% if the SLNB contained metastases and approximately 80% if the node was free of metastases.
Should SLNB be Accepted Standard of Care for MM?
Based on the aforementioned data, and other data that are available, it is difficult to prove that SLNB should be a standard of care for MM patients. Despite this, many physicians and the general public have accepted SLNB in patients with MM as dogma. Moreover, currently it is not only the high-risk patients who undergo SLNB, but also those patients with relatively thin melanomas.
But this is more than a standard of care argument; this is also a scope of practice argument and one that should concern dermatologists, many of whom perform definitive surgical excisions of melanomas. As it may be preferable to perform a SLNB during the time of re-excision, these patients can find themselves suddenly whisked away to surgical oncology.
Cost-Benefit Considerations
Furthermore, we need to consider this from a cost-benefit point of view. SLNB is an expensive procedure, with hospital, pathology, and surgical fees. With the cost of our medical care ballooning out of control, we need to be prudent about our healthcare dollars. Performing a SLND in a patient with a thin MM certainly does not fall into that category.
I propose that we instead use our healthcare dollars to educate our patients and our medical colleagues to facilitate prevention, early detection, and removal of MM.
Use Should be Limited to High-Risk MM
It seems evident that SLNB provides useful prognostic information, and the entire story of SLNB is still unknown. Several large trials are currently underway to assess potential benefits of this procedure. It may very well be that the next trial will definitively show survival benefit of SLNB. But until then, I believe that SLNB should be restricted to high-risk MM in a clinical trial setting.
A recent New England Journal of Medicine article is the best evidence we have thus far showing the lack of survival benefit from sentinel lymph node biopsy (SLNB) in malignant melanoma (MM) patients.1 This multi-center trial randomly assigned 1,269 patients with MM at least 1.2 mm in thickness into two groups:
1. wide excision and SLNB (the biopsy group)
2. wide excision and postoperative observation of the regional nodal basin (the observation group).
Delayed lymphadenectomy was performed if nodal disease was clinically detectable in the observation group, and lymphadenectomy was performed in the biopsy group if micrometastases were detected in SLNB.
SLNB Benefits Difficult to Quantify
The results of this study were what many expected. The rate of melanoma-specific death was similar in both groups at 5 years: 13.8% in the observation group and 12.5% in the biopsy group. The melanoma-specific survival rate was also similar in both groups: 90.1% vs. 93.2% at 3 years and 86.6% vs. 87.1% at 5 years, in the observation group and biopsy group, respectively.
By doing some “fancy” statistics that even Mark Twain would be proud of, the authors were able to find a small subset of patients that actually benefited from SLNB that was followed by immediate lymphadenectomy. Despite lack of survival efficacy, SLNB did provide valuable prognostic information: the estimated disease-free survival rate was approximately 50% if the SLNB contained metastases and approximately 80% if the node was free of metastases.
Should SLNB be Accepted Standard of Care for MM?
Based on the aforementioned data, and other data that are available, it is difficult to prove that SLNB should be a standard of care for MM patients. Despite this, many physicians and the general public have accepted SLNB in patients with MM as dogma. Moreover, currently it is not only the high-risk patients who undergo SLNB, but also those patients with relatively thin melanomas.
But this is more than a standard of care argument; this is also a scope of practice argument and one that should concern dermatologists, many of whom perform definitive surgical excisions of melanomas. As it may be preferable to perform a SLNB during the time of re-excision, these patients can find themselves suddenly whisked away to surgical oncology.
Cost-Benefit Considerations
Furthermore, we need to consider this from a cost-benefit point of view. SLNB is an expensive procedure, with hospital, pathology, and surgical fees. With the cost of our medical care ballooning out of control, we need to be prudent about our healthcare dollars. Performing a SLND in a patient with a thin MM certainly does not fall into that category.
I propose that we instead use our healthcare dollars to educate our patients and our medical colleagues to facilitate prevention, early detection, and removal of MM.
Use Should be Limited to High-Risk MM
It seems evident that SLNB provides useful prognostic information, and the entire story of SLNB is still unknown. Several large trials are currently underway to assess potential benefits of this procedure. It may very well be that the next trial will definitively show survival benefit of SLNB. But until then, I believe that SLNB should be restricted to high-risk MM in a clinical trial setting.
