New findings from a large international clinical trial published in the New England Journal of Medicine this week are likely to change the way melanoma is managed in many patients by reducing the need for major surgery and its associated morbidity and cost. Many Australian patients participated in this trial, and Melanoma Institute Australia was the top recruiting centre in the world.
National and international melanoma management guidelines currently state that patients who are found to have melanoma deposits in a “sentinel” lymph node should undergo immediate completion lymph node clearance — a large operation that removes all remaining lymph nodes in the area (the axilla, the groin or the neck).
However, the initial results of the second Multicenter Selective Lymphadenectomy Trial (MSLT-II) indicate that there is no difference in survival for sentinel-node positive patients who undergo immediate lymph node clearance compared to those who are closely monitored with ultrasound to detect disease progression. The three-year melanoma-specific survival was 86±1.3% in 824 patients who had a completion lymph node dissection versus 86±1.2% in 931 patients who were monitored, after a median follow up of 43 months.
“This change in treatment recommendation is likely to improve the quality of life for many patients around the world,” Professor John Thompson AO
“These results are going to change treatment recommendations for sentinel-node positive patients, most of whom will avoid the short-term and long-term morbidity that may follow a complete lymph node dissection,” said co-author and Senior Surgeon at Melanoma Institute Australia, Professor John Thompson AO.
“Only those who are found to have disease in their lymph nodes during the course of follow-up — about 20% — will ultimately require full regional lymph node dissection. This change in treatment recommendation is likely to improve the quality of life for many patients around the world.”
In particular, this will make a big difference to patients who have disease of the lower limb, by reducing the rate of a common complication, lymphoedema.
Although immediate lymph node clearance in sentinel-node positive patients will no longer be recommended, an initial sentinel lymph node biopsy — a minor procedure able to be performed at the same time as wide excision of the primary melanoma site — will still be required to provide accurate staging and guide treatment planning, as well as to provide a reliable estimate of prognosis.
Although no significant survival benefit was achieved by immediate completion lymph node dissection, the authors noted that the procedure did provide some potential benefits for patients with melanoma, including improved staging which can help identify high-risk patients. As well, it provides information that may be required for inclusion in medical oncology clinical trials of new medical therapies, and improves regional disease control.
“The management of regional lymph nodes has long been controversial in the treatment of many solid tumours, particularly melanoma,” noted Professor Thompson. “But this trial provides robust evidence to change the current practice guidelines to improve our management of patients with melanoma.”
Source: Melanoma Institute Australia
Paper : Faries MB, Thompson JF, Cochran AJ, et al. Completion Dissection or Observation for Sentinel-Node Metastasis in Melanoma. N Engl J Med 2017; 376:2211-2222