Letter to the Editor
Sentinel Lymph Node Biopsy in Melanoma Does Have Therapeutic Utility
La biopsia selectiva del ganglio centinela en melanoma sí tiene utilidad terapéutica
Á. Pizarro
Unidad de Prevención y Diagnóstico Precoz de Melanoma, Clínica Dermatológica Internacional, Madrid, Spain
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Patients with negative (green) SLNB and positive SLNB (orange) have been grouped separately. Patients who will die of melanoma after 10 years are indicated in black. Presumably, these are the patients who would benefit most from adjuvant immunotherapy.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. García-Doval, C. Espinosa-Pereiro, A. Zulaica Gárate" "autores" => array:3 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "García-Doval" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Espinosa-Pereiro" ] 2 => array:2 [ "nombre" => "A." 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Similarly, it is easy to distinguish between the positive lateral margin (upper, L) and the positive deep margin (lower, D). B, The specimens removed usually have a lateral margin that angles inward to converge with the deep margin. The exact point at which the lateral margin becomes deep is open to debate. Thus, L1 clearly looks like a lateral margin and D clearly looks like a deep margin. However, should we identify L2 and L3 as lateral margins or as deep margins (D2, D3)? C, The positive margin in this biopsy image is difficult to define as lateral only, deep only, or a combination of both.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Fernandez-Flores, F. Russo de la Torre" "autores" => array:2 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Fernandez-Flores" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Russo de la Torre" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731020301174" "doi" => "10.1016/j.ad.2019.11.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731020301174?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219020301670?idApp=UINPBA000044" "url" => "/15782190/0000011100000006/v1_202008141732/S1578219020301670/v1_202008141732/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Sentinel Lymph Node Biopsy in Melanoma Does Have Therapeutic Utility" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "536" "paginaFinal" => "537" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Á. Pizarro" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Á." "apellidos" => "Pizarro" "email" => array:1 [ 0 => "angelpizarro84@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Prevención y Diagnóstico Precoz de Melanoma, Clínica Dermatológica Internacional, Madrid, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La biopsia selectiva del ganglio centinela en melanoma sí tiene utilidad terapéutica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">I read with interest the report by Espinosa-Pereiro et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> on their study of the complications and sequelae after sentinel lymph node biopsy (SLNB) in routine clinical practice. The authors report high percentages of both complications and sequelae. This morbidity must be a consideration when evaluating with patients whether they should undergo the procedure and discussing the risk-benefit ratio in each case. The authors also highlight the fact that, following the publication of the results of the Multicenter Selective Lymphadenectomy Trial (MSLT) 2 and the DeCOG-SLT clinical trial, lymphadenectomy should no longer be considered the standard option in patients with a positive SLNB. This change in practice could reduce the complications and sequelae associated with the procedure in these patients. I recently discussed this issue in the present journal.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the study by Espinosa-Pereiro et al.,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> SLNB even when not followed by completion lymph node dissection (CLND) was associated with complications in 30.9% of cases and sequelae in 7.5%. I agree with those authors that this information should be taken into account by doctors and patients who are considering a procedure whose benefit, in most cases, lies only in the diagnostic and prognostic information it provides.</p><p id="par0010" class="elsevierStylePara elsevierViewall">However, I disagree with them on one point that has considerable weight in the patient’s decision. In the first sentence of their abstract, the authors state that “SLNB is a staging, not a therapeutic, procedure”. In my opinion, this statement is inaccurate, does not take into account the available evidence, and is based on an incomplete understanding of the natural history of melanoma and the patterns of spread observed in these patients.</p><p id="par0015" class="elsevierStylePara elsevierViewall">An excellent way of analyzing this question is to study the survival curves from the time, several decades ago, when we had no effective treatments for disseminated melanoma and no adjuvant treatments capable of significantly modifying the natural course of the disease. The key is to observe the survival of stage III patients at that time. Long-term survival was good in about one-third of stage III patients overall.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">4</span></a> What does that mean? The answer is simple: in about one third of patients with lymphatic spread, the clinically relevant disseminated disease is exclusively lymphatic and when the affected regional nodes are dissected most of those patients are cured.</p><p id="par0020" class="elsevierStylePara elsevierViewall">As I have discussed extensively in earlier articles,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,5</span></a> clinical trials comparing early prophylactic lymph node dissection and CLND following a positive SLNB have never shown any therapeutic benefit on final survival compared to delayed therapeutic lymphadenectomy. But this does not mean that these forms of early lymphadenectomy are of no therapeutic value. What these results indicate is that, in terms of survival, they have no greater therapeutic utility than delayed therapeutic lymphadenectomy.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">3</span></a> Obviously, any form of lymphadenectomy, whether prophylactic or therapeutic, will cure patients with melanoma in whom the spread is exclusively lymphatic, provided that the surgery targets the affected lymphatic basin and the metastasis is entirely confined to the area of intervention and has only affected the lymph nodes that are excised.</p><p id="par0025" class="elsevierStylePara elsevierViewall">It is especially important to remember one fact about the therapeutic utility of SLNB: in around 80% of patients who have a positive SLNB no melanoma will be found in the remaining regional lymph nodes.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Consequently, this early intervention, which is simpler than delayed lymphadenectomy and associated with fewer complications and sequelae, resolves the problem of locoregional lymphatic spread in about 80% of patients in whom the sentinel node is positive, even without CLND.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients should be informed as clearly as possible of these facts. They should be made aware that in about one-third of patients with lymphatic spread, the clinically relevant disease will be exclusively lymphatic. And that for 80% of patients with exclusively lymphatic spread, SLNB will not only be diagnostic, it will also be curative since the surgery will remove the only important focus of metastatic melanoma from their body.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The model of stepwise spread in melanoma has been superseded: it was clearly incorrect and we now know that early intervention on the regional lymph nodes does not prevent the systemic spread of melanoma.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7–9</span></a> However, in around one-third of stage III patients systemic spread does not occur. And in 80% of these patients with exclusively lymphatic spread, SLNB can be curative (although we are, as yet, unable to identify these patients a priori). Furthermore, SLNB can facilitate the selection of patients for adjuvant treatment<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> since a positive biopsy is associated with an increased risk of systemic dissemination. Patients should be informed of all of these facts before deciding whether or not to undergo SLNB when this option may be indicated.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pizarro Á. La biopsia selectiva del ganglio centinela en melanoma sí tiene utilidad terapéutica. Actas Dermosifiliogr. 2020;111:536–537.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complicaciones y secuelas de la técnica de biopsia selectiva del ganglio centinela para el melanoma en una cohorte retrospectiva" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.E. Espinosa-Pereiro" 1 => "A. Zulaica Gárate" 2 => "I. García-Doval" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ad.2019.01.003" "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 3 | 7 |
| 2024 October | 64 | 42 | 106 |
| 2024 September | 64 | 22 | 86 |
| 2024 August | 96 | 48 | 144 |
| 2024 July | 76 | 31 | 107 |
| 2024 June | 89 | 31 | 120 |
| 2024 May | 77 | 30 | 107 |
| 2024 April | 69 | 19 | 88 |
| 2024 March | 57 | 25 | 82 |
| 2024 February | 50 | 27 | 77 |
| 2024 January | 50 | 29 | 79 |
| 2023 December | 38 | 16 | 54 |
| 2023 November | 51 | 22 | 73 |
| 2023 October | 48 | 16 | 64 |
| 2023 September | 45 | 30 | 75 |
| 2023 August | 31 | 15 | 46 |
| 2023 July | 43 | 25 | 68 |
| 2023 June | 37 | 27 | 64 |
| 2023 May | 30 | 23 | 53 |
| 2023 April | 35 | 18 | 53 |
| 2023 March | 48 | 30 | 78 |
| 2023 February | 27 | 23 | 50 |
| 2023 January | 23 | 25 | 48 |
| 2022 December | 36 | 40 | 76 |
| 2022 November | 25 | 30 | 55 |
| 2022 October | 28 | 17 | 45 |
| 2022 September | 27 | 30 | 57 |
| 2022 August | 25 | 37 | 62 |
| 2022 July | 32 | 31 | 63 |
| 2022 June | 37 | 33 | 70 |
| 2022 May | 30 | 41 | 71 |
| 2022 April | 32 | 23 | 55 |
| 2022 March | 36 | 37 | 73 |
| 2022 February | 34 | 20 | 54 |
| 2022 January | 26 | 32 | 58 |
| 2021 December | 24 | 44 | 68 |
| 2021 November | 31 | 35 | 66 |
| 2021 October | 35 | 55 | 90 |
| 2021 September | 34 | 34 | 68 |
| 2021 August | 28 | 32 | 60 |
| 2021 July | 30 | 22 | 52 |
| 2021 June | 23 | 27 | 50 |
| 2021 May | 40 | 36 | 76 |
| 2021 April | 73 | 53 | 126 |
| 2021 March | 55 | 21 | 76 |
| 2021 February | 55 | 20 | 75 |
| 2021 January | 36 | 17 | 53 |
| 2020 December | 30 | 14 | 44 |
| 2020 November | 28 | 12 | 40 |
| 2020 October | 41 | 21 | 62 |
| 2020 September | 47 | 33 | 80 |
| 2020 August | 45 | 22 | 67 |
| 2020 July | 30 | 19 | 49 |
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