Delayed Surgery Possible With Surveillance in Patients With Sentinel Lymph Node Positive Melanoma

Active surveillance in sentinel lymph node positive melanoma could delay surgery but may result in the same risk of the cancer coming back.

Ultrasound monitoring may be an alternative to surgical removal of remaining lymph nodes in patients with sentinel lymph node positive cutaneous melanoma, according to data published in Cancer.

For patients with melanoma whose disease has spread to the lymph nodes, there is an alternative to surgery: monitoring with ultrasound. Although patients can have cancer spread in the lymph nodes with this strategy, it can typically be removed with delayed surgery.

“Although completion lymph node dissection was previously recommended for patients with positive (sentinel lymph nodes), two large, multi-institutional, randomized-controlled trials have recently demonstrated equivalent oncologic outcomes with active nodal surveillance,” the study authors wrote.

Researchers studied a total of 1,154 patients from Australia, Europe and the United States with sentinel lymph node-positive cutaneous melanoma. These patients received either active surveillance, which included ultrasounds or cross-sectional imaging, (965 patients) or underwent complete lymph node dissection (189 patients). In addition, 38% of patients in the surveillance group and 39% in the complete dissection group also received adjuvant therapy, or additional treatment after the primary treatment to potentially reduce the risk for cancer recurrence.

The primary endpoint was all-site recurrence-free survival, which the study authors defined as “the time from (sentinel lymph node) biopsy to recurrent melanoma at any site.” Other areas of interest included isolated nodal recurrence-free survival, distant metastasis-free survival and disease-specific survival. Follow-up was conducted for a median of 11 months.

During follow-up, 220 patients developed recurrent disease, which consisted of 19% of patients from the surveillance group and 22% of patients from the complete dissection group. Twenty-four patients died from melanoma (2% in surveillance group versus 4% in complete dissection group).

Sixty-eight patients from the study had an isolated nodal recurrence, of whom 6% were from the surveillance group and 4% were from the complete dissection group. Patients treated with adjuvant therapy with prior complete lymph node dissection were able to have all isolated nodal recurrences resected.

When data were adjusted for risk, complete lymph node dissection was linked with an improved isolated nodal recurrence-free survival. This was not observed for all-site recurrence-free survival. Treatment with adjuvant therapy improved all-site recurrence-free survival.

A total of 82 patients in the surveillance group and 25 of those in the complete dissection group developed distant metastasis.

“The current study findings do highlight a current dilemma in managing patients undergoing active surveillance who develop isolated nodal recurrence during the adjuvant treatment period,” the study authors wrote. “Whether these recurrences represent regional failure because of incomplete clearance of the nodal basin or treatment-resistant disease is an area of active controversy. This has implications for whether the patient resumes the same adjuvant treatment after the nodal recurrence is addressed.”

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