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Sentinel node biopsy for melanoma: unnecessary treatment?

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.e8645 (Published 08 January 2013) Cite this as: BMJ 2013;346:e8645

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Re: Sentinel node biopsy for melanoma: unnecessary treatment?

Sir

I am surprised that you invited a freelance journalist to review the role of sentinel lymph-node biopsy (SLNB) in melanoma (BMJ Jan 12), as the situation is rather more complex than he allows.

It is certainly true that MSLT-1 does not show any survival advantage (1), but the sub-cohort analysis , whereby patients in the observation arm who relapse with nodal disease are compared with patients undergoing selective lymphadenectomy, would be valid if the percentages at 10 years of follow-up are equivalent. I wrote a detailed review of MLST-1 last year (2) knowing that the numbers would be equivalent, but predicting that there would be no survival advantage for patients undergoing selective lymphadenectomy. If true, this might well account for the delay in publishing the results of the 7 and 10 year follow-up of MSLT-1. Sadly it also undermines the rationale for MSLT-11 as this is predicated on the assumption that selective lymphadenectomy confers a survival benefit.

However the arguments are not all one way. Having established the multidisciplinary melanoma clinic at Guys/St Thomas Hospital 15 years ago, I am acutely aware that many patients request, and are entitled to receive the most accurate information regarding their disease, and pathological staging is only possible following SLNB. There is a morbidity associated with SLNB, but we also know that the procedure does not affect prognosis adversely, does not increase the rate of in-transit metastases, as some authors have claimed (3), and allows lymph-node dissections to be performed at the earliest possible stage. This offers a considerable reduction in morbidity even though it does not benefit survival. Even the sternest critics of SLNB concede that selective lymphadenectomy is worthwhile “if it can be proven that all sentinel node positive patients progress to overt nodal disease”(4) .

Finally SLNB is required not just for entry into surgical trials, but any melanoma trial where accurate staging is obligatory. Adjuvant therapy for Stage 3 disease may not be long coming, at which point this repetitive debate about the value of SLNB will become redundant.

Yours Sincerely

Dr Robin Russell-Jones MA FRCP FRCPath
Cromwell Hospital, Cromwell Rd, London SW5 0TU

1. Morton DL, Thompson JF, Cochran AJ, Mozzillo N, Elashoff R, Essner R, et al. Sentinel-node biopsy or nodal observation in melanoma. N Engl J Med 2006; 355: 1307-17
2. Russell-Jones R When will selective lymphadenectomy become standard of care in melanoma ? Int J Clin Pract 2012; 66: 671-74
3. Meiron Thomas J, Patocskai E. The argument against sentinel node biopsy for malignant melanoma. BMJ 2000; 321: 3-4
4. Hayes A, Meiron Thomas J. Recurrence-free survival after sentinel node biopsy in melanoma. Brit J Dermatol 2006; 155: 631-2

Competing interests: No competing interests

13 March 2013
Robin Russell-Jones
MA FRCP FRCPath
Cromwell Hospital
London