Is Surgery Necessary for Melanoma with Sentinel Node Metastasis?

Dr. Jeffrey M. Farma
Dr. Jeffrey M. Farma

Melanoma is on the rise in the United States, with new cases and 7,230 deaths expected this year. “We are seeing an increased incidence of melanoma among younger women who are tanning and older patients who did not know about skin protection in earlier years,” said Jeffrey M. Farma, MD, FACS,  surgical oncologist and Surgical Director of the Melanoma and Skin Cancer Program at Fox Chase Cancer Center. “The disease can be aggressive.”

Guidelines recommend sentinel lymph node biopsy for melanomas >0.8 mm in depth or with high-risk features, and until two years ago, completion lymph node dissection was standard for patients with sentinel node metastases.

Practice-changing results published in the New England Journal of Medicine found that completion node dissection did not afford longer survival than active surveillance and ultrasound for patients with metastases; however, patients who had surgery were less likely to have a recurrence in that lymph node basin.

These results were reported by Farma and other investigators overseeing the MSLT-II study, which evaluated whether surgery was associated with increased survival for 1,939 patients with sentinel node metastases or if active surveillance and ultrasound could provide similar outcomes.

Since the study, rates of lymphadenectomy have decreased. “While surgery can be done safely, 20­-25 percent of patients develop chronic lymphedema after the procedure and some patients develop chronic nerve pain,” Farma said. “Active surveillance works for patients who are willing to come in every three months, and it is an alternative for patients who do not want, or are not good candidates for, surgery.”

While many patients no longer undergo a lymphadenectomy, it is still a consideration in some cases. “Surgery may be best for patients with a higher risk of recurrence, like those with extranodal extension or multiple affected lymph nodes,” Farma said.

Due to the complexities of selecting the appropriate treatment for each individual, Farma recommends that patients be seen by surgeons with extensive experience in treating melanoma. “It is critical to send patients to high-volume centers with experienced surgeons, and this is especially true for cervical, axillary, or groin lymph node dissections,” Farma said. “The Fox Chase team sees multiple patients with all stages of melanoma every week, and our physicians are part of cooperative groups and national panels, including the NCCN melanoma panel. We understand the latest research, have many clinical trial options, and discuss each patient’s case in our multidisciplinary melanoma tumor board.”

There are more options today than ever before for the treatment of melanoma, and advances are being discovered regularly through new research such as the MSLT-II study. “We are curing a subset of patients who have stage 4 melanoma, which we never thought possible,” Farma said. “While surgery is still very important, a selective approach makes more sense.”

Three Things to Know About Melanoma and Sentinel Node Metastases:

  1. A major study found completion node dissection was not associated with longer survival than active surveillance and ultrasound.
  2. Surgery remains a valuable option for select patients. These are often the most complicated cases, underlining the need for highly experienced surgeons and a multidisciplinary melanoma team.
  3. Having more treatment options creates an opportunity for patients to discuss what is best for them with experts who are able to customize their treatment plans.

MSLT-II=Multicenter Selective Lymphadenectomy Trial II

NCCN=National Comprehensive Cancer Network