Re: Sentinel node biopsy for melanoma: unnecessary treatment?
Concerns about the contribution of sentinel node biopsy to the management and welfare of patients with melanoma [1] were raised as early as 1999 to strong protests from its proponents especially from the other side of the Atlantic [2]. Excision of a sentinel node followed by regional lymph-node dissection is conceptually no different from the elective dissection of clinically occult regional lymph-node metastases [3], a practice that has been abandoned because it confers no benefit in terms of the overall survival of patients with malignant melanoma.
The case report that follows exemplifies the complex issues associated with this practice beyond the potential morbidity for the patient undergoing the procedure.
A 34-year old highly qualified female scientist was diagnosed with malignant melanoma whilst 15 weeks pregnant. The offending lesion located on the right shoulder had been present for at least 10 years apparently unchanged, was asymptomatic and was incidentally diagnosed by a dermatologist.
Histology confirmed a melanoma measuring 1.23 mm in Breslow thickness, with no ulceration, infiltrating into Clark’s level IV and exhibiting 5 mitoses /mm2.
Biopsy of a sentinel lymph-node revealed rare isolated neoplastic cells and a small aggregate focus of 3 cells positive for S100; MART1 and HMB45.
She underwent a formal axillary clearance which yielded 23 lymph-nodes all negative on morphology and imunocytochemistry for metastatic melanoma.
She was advised elsewhere to have her pregnancy terminated and enlist in a programme of adjuvant treatment with Interferon. She rejected the option of adjuvant Interferon and decided to complete her pregnancy; she sought a second opinion which endorsed her decision.
She was delivered uneventfully of a healthy boy; a second uneventful pregnancy and delivery of a healthy child followed. The mother remains well and apparently disease-free five years after excision of the primary.
This patient would have been potentially denied her motherhood as a consequence of a staging surgical procedure and subsequently of an adjuvant treatment neither of which have been shown to have an impact on overall survival [3-4].
Furthermore valuable healthy lymphoid tissue has been sacrificed in abundance with unknown consequences for her defences against the disease.
Note: This case was presented at the 7th International Conference on the Adjuvant Therapy of Malignant Melanoma, Marseille, France, 19-21 June 2008.
Patient consent obtained for this rapid response.
References
1.Godlee F. Overtreatment? Only the trial data will tell. BMJ 2013;346:f159
2.Retsas S. Sentinel-Lymph-Node-Biopsy in Malignant Melanoma. New England Journal of Medicine 1999; 340:318.
3.Retsas S. Sentinel node biopsy confers no added protection to patients with melanoma. J R Soc Med. 2007 Aug;100(8):391-2.
4.Janku F and Kurzrock R. Adjuvant interferon in High-Risk melanoma. End of the Era? JCO Jan 10, 2010:e15-e16; published online on November 30, 2009; DOI:10.1200/JCO.2009.24.9326
Rapid Response:
Re: Sentinel node biopsy for melanoma: unnecessary treatment?
Concerns about the contribution of sentinel node biopsy to the management and welfare of patients with melanoma [1] were raised as early as 1999 to strong protests from its proponents especially from the other side of the Atlantic [2]. Excision of a sentinel node followed by regional lymph-node dissection is conceptually no different from the elective dissection of clinically occult regional lymph-node metastases [3], a practice that has been abandoned because it confers no benefit in terms of the overall survival of patients with malignant melanoma.
The case report that follows exemplifies the complex issues associated with this practice beyond the potential morbidity for the patient undergoing the procedure.
A 34-year old highly qualified female scientist was diagnosed with malignant melanoma whilst 15 weeks pregnant. The offending lesion located on the right shoulder had been present for at least 10 years apparently unchanged, was asymptomatic and was incidentally diagnosed by a dermatologist.
Histology confirmed a melanoma measuring 1.23 mm in Breslow thickness, with no ulceration, infiltrating into Clark’s level IV and exhibiting 5 mitoses /mm2.
Biopsy of a sentinel lymph-node revealed rare isolated neoplastic cells and a small aggregate focus of 3 cells positive for S100; MART1 and HMB45.
She underwent a formal axillary clearance which yielded 23 lymph-nodes all negative on morphology and imunocytochemistry for metastatic melanoma.
She was advised elsewhere to have her pregnancy terminated and enlist in a programme of adjuvant treatment with Interferon. She rejected the option of adjuvant Interferon and decided to complete her pregnancy; she sought a second opinion which endorsed her decision.
She was delivered uneventfully of a healthy boy; a second uneventful pregnancy and delivery of a healthy child followed. The mother remains well and apparently disease-free five years after excision of the primary.
This patient would have been potentially denied her motherhood as a consequence of a staging surgical procedure and subsequently of an adjuvant treatment neither of which have been shown to have an impact on overall survival [3-4].
Furthermore valuable healthy lymphoid tissue has been sacrificed in abundance with unknown consequences for her defences against the disease.
Note: This case was presented at the 7th International Conference on the Adjuvant Therapy of Malignant Melanoma, Marseille, France, 19-21 June 2008.
Patient consent obtained for this rapid response.
References
1.Godlee F. Overtreatment? Only the trial data will tell. BMJ 2013;346:f159
2.Retsas S. Sentinel-Lymph-Node-Biopsy in Malignant Melanoma. New England Journal of Medicine 1999; 340:318.
3.Retsas S. Sentinel node biopsy confers no added protection to patients with melanoma. J R Soc Med. 2007 Aug;100(8):391-2.
4.Janku F and Kurzrock R. Adjuvant interferon in High-Risk melanoma. End of the Era? JCO Jan 10, 2010:e15-e16; published online on November 30, 2009; DOI:10.1200/JCO.2009.24.9326
Competing interests: No competing interests