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How is it determined if melanoma metastases is in the regional lymph nodes after finding metastases in the sentinel lymph node? Is surgery required?
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VernonSondakMD (Physician - Surgery - Surgical Oncology (Verified) ) - 06 / 07 / 2012
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murray
The “Sentinel” lymph node is the first regional lymph node that receives the lymphatic fluid draining from the primary melanoma site on the skin. It is identified at the time of surgery by the combination of injecting a radioactive tracer and injecting a blue-colored dye around the melanoma or the melanoma biopsy scar, and surgically removing any lymph nodes that turn blue or become radioactive. The tracer and dye only show the connection between the melanoma site and the sentinel lymph node, they do not specifically indicate whether there is melanoma in the node. That determination can only be made by careful pathology analysis of the removed lymph node. In fact, one of the main advantages of the sentinel node procedure is that we are giving the pathologist only one or a few nodes and they can examine these nodes extremely carefully. Even very small areas of melanoma metastasis, sometimes no more than a few cells’ worth, can be detected this way. If no tumor is found in the sentinel node or nodes, the accuracy of that negative finding is greater than 95% - meaning fewer than 5% of people with a negative sentinel node ever develop melanoma in other lymph nodes in the same or nearby regional nodes. So it is important to realize that the sentinel node test is not 100% accurate for determining if there is melanoma in the lymph nodes, there are occasional cases that are missed. Furthermore, there are cases in which the test is accurate for the lymph nodes being clear, but the melanoma bypasses the lymph nodes entirely and spreads to other sites. This can happen in anywhere from 5% to 25% of cases, depending on the thickness of the original melanoma. This means that patients with a negative sentinel node must be aware that there is still a possibility for their melanoma to reoccur, although this possibility is much lower than for cases with a positive sentinel node.
On the other hand, if the sentinel node is found to be positive for melanoma cells, this does not mean invariably that the melanoma has spread throughout the body or even to other lymph n odes in the same area. In fact, because we can detect such small amounts of melanoma in the sentinel node, it is often the only area where anything can be found. The standard recommendation for anyone with a positive sentinel node (or any form of melanoma-involved lymph node for that matter) is complete removal of the other nodes in that region, called a “radical” or “completion” lymph node dissection. Many times, the additional nodes removed – which are not evaluated as thoroughly as the sentinel node was – do not show any melanoma in them. So some surgeons – and many patients – have wondered if the completion surgery is really necessary in every case. X-rays and scans do not really help – the tiny areas of melanoma routinely found in lymph nodes are too small to be reliably detected by any form of scan we have available today. So on the one hand, some of the completion lymph node dissections we do today may be unnecessary, but for other patients they may have more problems if the node dissection is not done and the melanoma develops in those remaining lymph nodes. So, until we gain more knowledge, we continue to recommend complete lymph node dissection for patients with a positive sentinel node. However, to try and gain more knowledge about whether some patients might be okay without the dissection, we are one of the centers participating in a worldwide clinical trial (called MSLT-2) in which patients with positive sentinel nodes are randomized (assigned by chance, not by choice) to either complete node dissection or no further lymph node surgery. This is the best way to scientifically answer this important question that affects so many patients today.
On the other hand, if the sentinel node is found to be positive for melanoma cells, this does not mean invariably that the melanoma has spread throughout the body or even to other lymph n odes in the same area. In fact, because we can detect such small amounts of melanoma in the sentinel node, it is often the only area where anything can be found. The standard recommendation for anyone with a positive sentinel node (or any form of melanoma-involved lymph node for that matter) is complete removal of the other nodes in that region, called a “radical” or “completion” lymph node dissection. Many times, the additional nodes removed – which are not evaluated as thoroughly as the sentinel node was – do not show any melanoma in them. So some surgeons – and many patients – have wondered if the completion surgery is really necessary in every case. X-rays and scans do not really help – the tiny areas of melanoma routinely found in lymph nodes are too small to be reliably detected by any form of scan we have available today. So on the one hand, some of the completion lymph node dissections we do today may be unnecessary, but for other patients they may have more problems if the node dissection is not done and the melanoma develops in those remaining lymph nodes. So, until we gain more knowledge, we continue to recommend complete lymph node dissection for patients with a positive sentinel node. However, to try and gain more knowledge about whether some patients might be okay without the dissection, we are one of the centers participating in a worldwide clinical trial (called MSLT-2) in which patients with positive sentinel nodes are randomized (assigned by chance, not by choice) to either complete node dissection or no further lymph node surgery. This is the best way to scientifically answer this important question that affects so many patients today.
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