Evaluation and treatment of regional lymph nodes in melanoma
- Michael Stone, MD
Michael Stone, MD
- Chairman of Surgery
- Stamford Hospital
- Section Editors
- Michael B Atkins, MD
Michael B Atkins, MD
- Section Editor — Malignant Melanoma and Other Cutaneous Neoplasms; Cancer of the Kidney
- Deputy Director
- Georgetown Lombardi Comprehensive Cancer Center
- Russell S Berman, MD
Russell S Berman, MD
- Section Editor — Skin and Soft Tissue Surgery
- Chief of Surgical Oncology
- New York University Langone Medical Center
Surgical excision is the appropriate treatment for melanoma. Although resection usually controls the primary lesion, melanoma often metastasizes through lymphatic channels to regional lymph nodes. Accurate staging at diagnosis is important to assess the prognosis and determine whether the patient is eligible for clinical trials of adjuvant therapies (table 1A-B and table 2A-B). (See "Tumor node metastasis (TNM) staging system and other prognostic factors in cutaneous melanoma".)
The physical examination of regional lymph nodes is often inaccurate, since approximately 20 percent of clinically node-negative patients have metastatic involvement, and 20 percent of those with clinically positive nodes are pathologically negative. More definitive information about the status of the regional nodes can be obtained from sentinel lymph node biopsy (SLNB), elective lymph node dissection, or fine needle aspiration [1,2].
The staging of subclinical disease using lymphatic mapping followed by SLNB, the management of patients with a positive SLNB, and the management of clinically apparent regional lymph nodes will be reviewed here. The surgical management of the primary lesion and adjuvant therapy are discussed separately. (See "Initial surgical management of melanoma of the skin and unusual sites" and "Adjuvant therapy for cutaneous melanoma".)
CLINICALLY NEGATIVE REGIONAL LYMPH NODES
Sentinel lymph node biopsy — Lymphatic mapping and sentinel lymph node biopsy (SLNB) is the standard approach for the management of patients with melanoma in whom there is a substantial risk of regional node metastasis. This approach provides important prognostic information and permits the identification of patients with a positive sentinel lymph node who may be candidates for adjuvant therapy. Proper application of this technique requires sufficient experience to identify the sentinel lymph nodes and ensure a low false negative rate.
Rationale — Lymphatic mapping is based upon the concept that sites of cutaneous melanoma have specific patterns of lymphatic spread and that one or more nodes are the first to be involved with metastatic disease within a given lymph node basin (figure 1). If the sentinel lymph nodes are not involved, the entire basin should be free of tumor [3-5].To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- CLINICALLY NEGATIVE REGIONAL LYMPH NODES
- Sentinel lymph node biopsy
- - Rationale
- - Sensitivity and specificity
- - Multicenter Selective Lymphadenectomy Trial-I
- Prognostic significance of the sentinel node
- Intermediate thickness melanomas
- - Incidence of nodal metastases
- - Melanoma-specific survival
- Thick melanomas
- Thin melanomas
- - Complications of SLNB
- - Minimal metastases
- - Patient selection
- Management of a positive SLNB
- - Multicenter Selective Lymphadenectomy Trial II
- - DeCOG-SLT trial
- Elective lymph node dissection
- CLINICALLY APPARENT REGIONAL LYMPH NODES
- Therapeutic lymphadenectomy
- Extent of dissection and morbidity
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS