Lymph node dissection in cutaneous melanoma: Surgical and oncological implications

Abstract

The concept of Sentinel Lymph Node Dissection (SLND) has strongly influenced the surgical approach towards primary melanoma in the last decade. Initiated by the disappointing results of elective lymph node dissection (ELND) in this malignancy, the concept of analyzing the first draining lymph node (Sentinel) of a regional basin was developed as a diagnostic means to avoid unnecessary ELND in case of negative SLNs. According to recent standards detection of the SLN should be performed by a triple approach: injection of 90 nm Technetium and patent blue in the periphery of the primary melanoma, and intraoperative tracing of radioactivity with the aid of a hand-held gamma probe. Histopathological examination of alternating series sections of the whole lymph node appears to be the best analytic approach. Molecular biologic procedures such as tyrosinase RT-PCR are time-consuming to perform and produce contradictory results. SLND for cutaneous melanoma is an interdisciplinary diagnostic approach involving surgery, dermatology, pathology, and nuclear medicine. In spite of a variety of published promising results derived from clinical trials ranging from a few dozens to several hundred included patients the diagnostic and prognostic value of SLND remains to be confirmed by ongoing controlled prospective clinical trials. At this stage, SLND can by no means be considered a therapeutic procedure. These aspects have to be kept in mind when informed consent is obtained from patients as well as in the individual determination of the risk-benefit ratio.