Recently I had a 46-year-old patient with a nodular melanoma on the upper back ( Breslow 2.7 mm, 10 mytoses/mm²; Clark II, no ulceration, no regression… ). The SLNB in the right axilla was negative. Two years after the melanoma excision a lymph node metastasis appeared in the right axilla. It was obviously a false negative SLNB.
Isn't this the case where a prophylactic radical regional lymph node dissection should be performed in spite of a negative SLNB and in spite of very contradictory studies' results concerning prophylactic (elective) radical lymphadenectomy?
In such cases do you propose to the patient an elective radical lymphadenectomy or you suggest to watch and wait?
It is a scholarly query! Of course surgical excision biopsy is advised in all cases of melanomas exceedimg 1mm. Many follow-up studies reveal that 5 yr survival rate and prognosis are better in patients with negative SLNB than the patients under observation alone without SLNB. Moreover, SLNB provides very less or minimal morbidity, but crucial prognostic and staging data that can be used
to identify SLNB -negative patients who would not benefit from a complete nodal dissection. Ultrasonography is very useful in the identification of abnormal LN and also in UGSLNB. The lymph nodes parameters are characteristics: diffuse or focal cortical enlargement, loss of lymph node fatty hilum, and nodal size (long
and short axis). For biopsy in case of multiple abnormal lymphadenopathy, the largest or most malignant imposing lymph node is to be preferably biopsied.
According to my experience with SLNB and with melanoma, the procedure with this patient was correct. It seems it was a stage IIa with a negative SLNB, so lymph node dissection of the axilla was not indicated. Wait-and-see is a valid strategy at this point.
If the SLNB technique and the immunohistochemical analysis of the lymph node were correctly performed, I am not sure I would consider it as a false negative either. With the information you provide, there were no risk factors, though 10 mitosis/mm2 is noteworthy. Moreover, bearing in mind the intrinsic aggressiveness of melanoma, despite having a negative SLNB, a disease relapse can be expected, even if I agree that 2 years after the primary treatment is quite early.
I think the point now is find out if there is disease in other locations and, if not, go for a regional lymph node dissection, as you did not waste this weapon for the initial management.
Thank you both for your very valuable answers. My patient had already underwent a lymphnode dissection. As she told me only one node was affected, and the metastasis was intracapsular.
I was thinking that, since the survival rate in those with a SLNB positive with a radical lymphnode dissection is better than those with a false negative SLNB and later dissection, maybe an elective dissection would prevent a regional node and further metastasis. But maybe my reasoning is not right. I am aware that mostly we are not able to predict a melanoma course.
its debatable! The truth is what u did You did is right procedure! Many studies have demonstrated futility of prophylactic nodal clearance!
- Badges
- Science topic
- Similar topics
- Social Psychology
- Attitude