Dissection of regional lymph nodes in cutaneous melanoma

Abstract

Author's reply Sir—Results of the updated analysis of WHO trial 14 are not intended to be interpreted as a final solution of the long running debate between those who advocate elective lymph-node dissection in melanoma and those who prefer to wait until there is clinically evident disease. Our data strongly suggest that early detection of occult nodal metastasis may substantially affect the final outcome in these patients. Your correspondents' comments can be answered at least in part by the introduction of the sentinel-node biopsy technique. One useful way to use this technique is to limit full anatomical lymph dissection to patients who have pathologically proven metastasis in the appropriate draining lymph-node basin, and thus avoid unnecessary morbidity in those who are sentinel-node negative. Spyros Retsas makes suggestions concerning postoperative adjuvant therapy involving vindesine and interferon. He no doubt is aware that the melanoma community keenly awaits the publication of the Eastern Oncology Group's trial 1690 by Kirkwood and colleagues, which is the study designed to confirm the encouraging results reported in their earlier trial.1Kirkwood JM Strawderman MH Ernstoff MS et al.Interferon alfa-2b adjuvant therapy of high-risk resected cutaneous melanoma: the Eastern Cooperative Oncology Group Trial EST 1684.J Clin Oncol. 1996; 14: 7-17Crossref PubMed Scopus (1798) Google Scholar We are not aware of any published randomised controlled trial reporting the value of adjuvant vindesine in a similar setting. Dissection of regional lymph nodes in cutaneous melanomaNatale Cascinelli and colleagues (March 14, p 793)1 confirm that elective block dissection of regional lymph nodes in cutaneous malignant melanoma confers no survival advantage: in short, it is excessive treatment adding morbidity and no benefit. They conclude that “multivariate analysis showed that routine use of immediate [elective] node dissection had no impact on survival”, and state that “node dissection [elective?] offers increased survival in patients with node metastases only”. The latter statement presumably implies that the observed 5-year survival of 48·2% of patients with occult regional metastases undergoing elective lymph-node dissection versus 26·6% of patients having surgery when metastases become clinically apparent, is due to treatment effect from elective surgery. Full-Text PDF Dissection of regional lymph nodes in cutaneous melanomaNatale Cascinelli and colleagues1 rely too heavily on significance testing when they suggest that their trial may be interpreted as “finally settling the debate between advocates and opponents of elective lymph-adenectomy” for melanoma of the trunk. This conclusion implies that their trial was merely a test to establish whether elective lymphadenectomy is better than delayed surgery. Full-Text PDF Dissection of regional lymph nodes in cutaneous melanomaThe trial reported by Natale Cascinelli and co-workers1 asked an important question regarding the management of regional nodes in truncal melanoma. Although the investigators conclude that their results may finally settle the debate between advocates and opponents of elective lymphadenectomy, it would seem that the trial has insufficient numbers to allow this conclusion. Full-Text PDF