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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sentinel lymph node &#40;SLN&#41; involvement is one of the most important prognostic factors in melanoma&#46; Even in patients with micrometastases&#44; SLN involvement is associated with a poorer prognosis&#44; similar to that of patients with clinically detectable metastases&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Current international guidelines recommend that lymph node dissection be performed as soon as SLN involvement is demonstrated&#46; However&#44; lymph node dissection does carry the risk of morbidity&#44; and there is no prospective evidence demonstrating the impact of this technique on disease prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Faries et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> recently published the results of the Multicenter Selective Lymphadenectomy Trial II &#40;MSLT-II&#41;&#44; a prospective multicenter randomized clinical trial whose main objective was to evaluate the benefits of immediate lymph node dissection in patients with SLN involvement&#46; Patients assigned to the dissection group underwent lymph node dissection &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>967&#41;&#44; while patients assigned to the observation group underwent observation with frequent nodal ultrasonography &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>967&#41;&#46; Patients in the observation group who developed clinically or sonographically detected nodal metastasis underwent immediate lymph node dissection&#46; Nodal metastasis was determined by means of immunohistochemical tests or reverse-transcriptase&#8211;polymerase-chain-reaction &#40;RT-PCR&#41; assay&#46; Patient randomization was stratified according to Breslow thickness&#44; ulceration&#44; and method of nodal metastasis detection &#40;histologic versus RT-PCR assay&#41;&#46; Patients underwent a clinical examination every 4 months for the first 2 years&#44; every 6 months until the fifth year&#44; and annually thereafter&#46; The observation group underwent nodal sonographic assessment at each follow-up visit for the first 5 years&#46; The median follow-up period was 43 months&#46; Results after 3 years of follow-up&#58; Intention-to-treat analysis and per-protocol analysis found no significant differences in the rate of melanoma-specific survival between the dissection group and the observation group &#40;86&#37; in both groups&#59; <span class="elsevierStyleItalic">P</span> &#61; 0&#46;42 by the log-rank test&#59; per-protocol analysis&#41;&#46; Likewise&#44; there were no significant differences between subgroups based on prognostic factors or in distant metastasis&#8211;free survival&#46; However&#44; the disease-free survival rate was higher in the dissection group than in the observation group &#40;68&#37; vs 63&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; as was the rate of disease control in locoregional lymph nodes &#40;92&#37; vs 77&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The main adverse effect&#44; lymphedema&#44; was more frequent in the dissection group &#40;24&#37; vs 6&#46;3&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; However&#44; lymphedema was severe in just 3&#37; of the patients who had this condition&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In summary&#44; in the MLST-<span class="elsevierStyleSmallCaps">II</span> study&#44; early dissection allowed greater locoregional control of melanoma but had no impact on melanoma-specific survival and was associated with a higher rate of adverse effects&#46; These results are consistent with those of retrospective studies<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> and the DeCOG-SLT prospective clinical trial&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> which studied 483 patients using a methodology comparable to that of MLST-<span class="elsevierStyleSmallCaps">II</span>&#46; Finally&#44; EORTC-1208 &#40;MINITUB&#41;&#44; a prospective study currently underway&#44; is evaluating observation only as an alternative in patients with SLN involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The results are expected to be published in 2019 or 2020&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The MSLT-<span class="elsevierStyleSmallCaps">II</span> results add to the existing body of evidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4&#44;5</span></a> In patients with SLN involvement&#44; it appears logical to propose a more conservative management approach consisting of frequent clinical and sonographic monitoring with immediate dissection in the event of clinical or sonographic detection of metastasis&#46; This approach would achieve adequate disease control with fewer adverse events and probably at lower cost&#46;</p></span>"
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Residents’ Forum
Immediate Lymph Node Dissection on Detection of Sentinel Lymph Node Involvement Does Not Increase Survival in Cutaneous Melanoma
FR-La linfadenectomía inmediata tras la afectación tumoral del ganglio centinela no aumenta la supervivencia en el melanoma cutáneo
D. Morgado-Carrasco
Autor para correspondencia
morgado@clinic.cat

Corresponding author.
, A. Combalia, X. Fustà-Novell, L. Ferrandiz
Dermatology Department, Hospital Clínic de Barcelona, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sentinel lymph node &#40;SLN&#41; involvement is one of the most important prognostic factors in melanoma&#46; Even in patients with micrometastases&#44; SLN involvement is associated with a poorer prognosis&#44; similar to that of patients with clinically detectable metastases&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Current international guidelines recommend that lymph node dissection be performed as soon as SLN involvement is demonstrated&#46; However&#44; lymph node dissection does carry the risk of morbidity&#44; and there is no prospective evidence demonstrating the impact of this technique on disease prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Faries et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> recently published the results of the Multicenter Selective Lymphadenectomy Trial II &#40;MSLT-II&#41;&#44; a prospective multicenter randomized clinical trial whose main objective was to evaluate the benefits of immediate lymph node dissection in patients with SLN involvement&#46; Patients assigned to the dissection group underwent lymph node dissection &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>967&#41;&#44; while patients assigned to the observation group underwent observation with frequent nodal ultrasonography &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>967&#41;&#46; Patients in the observation group who developed clinically or sonographically detected nodal metastasis underwent immediate lymph node dissection&#46; Nodal metastasis was determined by means of immunohistochemical tests or reverse-transcriptase&#8211;polymerase-chain-reaction &#40;RT-PCR&#41; assay&#46; Patient randomization was stratified according to Breslow thickness&#44; ulceration&#44; and method of nodal metastasis detection &#40;histologic versus RT-PCR assay&#41;&#46; Patients underwent a clinical examination every 4 months for the first 2 years&#44; every 6 months until the fifth year&#44; and annually thereafter&#46; The observation group underwent nodal sonographic assessment at each follow-up visit for the first 5 years&#46; The median follow-up period was 43 months&#46; Results after 3 years of follow-up&#58; Intention-to-treat analysis and per-protocol analysis found no significant differences in the rate of melanoma-specific survival between the dissection group and the observation group &#40;86&#37; in both groups&#59; <span class="elsevierStyleItalic">P</span> &#61; 0&#46;42 by the log-rank test&#59; per-protocol analysis&#41;&#46; Likewise&#44; there were no significant differences between subgroups based on prognostic factors or in distant metastasis&#8211;free survival&#46; However&#44; the disease-free survival rate was higher in the dissection group than in the observation group &#40;68&#37; vs 63&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; as was the rate of disease control in locoregional lymph nodes &#40;92&#37; vs 77&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The main adverse effect&#44; lymphedema&#44; was more frequent in the dissection group &#40;24&#37; vs 6&#46;3&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; However&#44; lymphedema was severe in just 3&#37; of the patients who had this condition&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In summary&#44; in the MLST-<span class="elsevierStyleSmallCaps">II</span> study&#44; early dissection allowed greater locoregional control of melanoma but had no impact on melanoma-specific survival and was associated with a higher rate of adverse effects&#46; These results are consistent with those of retrospective studies<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> and the DeCOG-SLT prospective clinical trial&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> which studied 483 patients using a methodology comparable to that of MLST-<span class="elsevierStyleSmallCaps">II</span>&#46; Finally&#44; EORTC-1208 &#40;MINITUB&#41;&#44; a prospective study currently underway&#44; is evaluating observation only as an alternative in patients with SLN involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The results are expected to be published in 2019 or 2020&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The MSLT-<span class="elsevierStyleSmallCaps">II</span> results add to the existing body of evidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4&#44;5</span></a> In patients with SLN involvement&#44; it appears logical to propose a more conservative management approach consisting of frequent clinical and sonographic monitoring with immediate dissection in the event of clinical or sonographic detection of metastasis&#46; This approach would achieve adequate disease control with fewer adverse events and probably at lower cost&#46;</p></span>"
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