To the Editor:
The report by Morton et al concerning the accuracy and morbidity of sentinel node biopsy (SNB) after wide excision in early melanoma is most welcome.1 This trial is nicely designed to test the strategy of SNB-guided immediate node dissection versus the strategy of observation only, with later therapeutic node dissection if needed. However, the data they have provided to date seem not to show any advantage of the SNB strategy in these patients.
The authors report that, in the SNB-guided group, 234 patients of 1173 had positive sentinel nodes, leading to completion lymphadenectomy (Table 3).1 An additional 59 patients in this group had subsequent regional nodal recurrence after negative SNB (p. 306)1 and also underwent complete lymph node dissection. Thus, after a follow-up of 5 to 6 years, 25% [(234 + 59)/1173] of patients in the SNB group had received regional node dissection.
In the wide excision and observation group, 18% (144 of 800) had required node dissection after the same follow-up period (Discussion, p. 308).1 None in this latter group had been subjected to the time and expense of the SNB procedure, and proportionally fewer of them underwent regional node dissection. Hence the frequency of short- and long-term morbidity due to complete node dissection should be less in this observation group, although the authors do not provide specific data on this. The excess rate of node dissection in the SNB group (25% vs. 18%) is not likely to be due to chance (P < 0.01 by χ2).
Prior randomized trials in similar melanoma patient groups do not demonstrate an overall benefit in survival or disease-specific survival from routine node dissection.2–5 Further, unlike the situation with breast cancer, there is no approved adjuvant therapy for these early-stage melanoma patients. Thus, no useful therapeutic decision is guided by SNB in these patients.
The MSLT1 trial reported here is the only randomized controlled clinical trial addressing whether melanoma patients managed using SNB have better clinical outcomes than those managed any other way. Unless there is a compensating benefit to survival or recurrence found in this trial of which we have not been told, the strategy of SNB-guided immediate node dissection appears to involve more surgery, thus more morbidity, and more expense, for no demonstrated gain. Therefore, declarations that SNB is now the “standard of care” in these patients (with all that implies) seem premature.
Patrick Twomey, MD
Department of Surgery
University of California-San Francisco
(East Bay)
Oakland, CA
patt@itsa.ucsf.edu
REFERENCES
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