NEW ORLEANSManagement of some patients with melanoma of the
lower extremity could potentially stop with sentinel lymph node (SLN)
biopsy, according to results presented at the 68th Annual Scientific
Meeting of the American Society of Plastic and Reconstructive
Surgeons. The study suggests that regional micrometastases of
melanoma in the lower extremity are likely confined to the sentinel
lymph nodes harvested by lymphadenectomy in some patients, said Lee
L.Q. Pu, MD, PhD, resident in plastic surgery, University of South
The researchers retrospectively examined charts from their
institution recorded over the last 7 years, identifying 16 patients
with lower-extremity melanoma lesions who underwent subsequent
inguinal complete lymph node dissection after having a positive
sentinel lymph node biopsy and wide local excision of the primary lesions.
Because complete lymph node dissection is associated with high
morbidity, it is important to identify procedures that offer the
least amount of risk and still allow adequate management of these
patients, Dr. Pu said in a postpresentation interview with ONI.
The study identified an average of 2.5 sentinel lymph nodes in each
patient, of which an average 1.5 were positive for micrometastases.
Upon complete lymph node dissection, only one additional positive
lymph node was found in one patient. The other 15 patients had no
further histologically positive lymph nodes confirmed by complete
lymph node dissection. None of the study patients developed regional
recurrence during the mean follow-up of 31.1 months.
The one patient in whom complete lymph node dissection identified an
additional positive lymph node was a 41-year-old woman with a 7.5-mm
primary lesion located on the right knee and ankle. The primary
lesion was ulcerated. One of three sentinel lymph nodes was positive,
with several microscopic foci. Complete lymph node dissection showed
micrometastases in 1 of 12 lymph nodes removed.
These results indicate that some of these patients may be
undergoing complete lymph node dissection unnecessarily, Dr. Pu
said. The results offer further evidence that sentinel lymph node
biopsy can possibly evolve from a staging tool to a therapeutic tool
in some patients, he commented.
Concerns and Reservations
Some physicians at the meeting had reservations about the findings.
I would be a little bit nervous about recommending sentinel
node biopsy as the sole necessary treatment, commented audience
member Jeffrey D. Wagner, MD, associate professor of plastic surgery,
Indiana University, Indianapolis.
Dr. Wagner was specifically concerned about the studys low 6%
incidence of additional positive nonsentinel nodes identified by
complete lymph node dissection and its emphasis on the positive
result in a single thicker lesion. Other studies, he said, have
demonstrated this incidence to be anywhere from 7% to 33%, and his
own group currently has work in press showing a 28% to 40% incidence
that was not predicted by any patient or tumor characteristic.
This and other studies have not subjected nonsentinel nodes to
the same rigorous testing as sentinel nodes, Dr. Wagner said. A
much larger series with longer clinical follow-up will be necessary
to validate the concept of sentinel node biopsy as a stand-alone
therapy, he said.
This is a preliminary study in a small series, Dr. Pu
responded. He emphasized that the sentinel lymph node biopsy
sensitivity and success shown in this study could indeed change with
larger series of patients. The studys main contribution, Dr. Pu
believes, is that it provides evidence to initiate further
studies to identify melanoma patients in whom sentinel lymph node
biopsy can adequately manage micrometastases.