If your sentinel node biopsy is positive (that is, contains cancerous cells), then it's decision time. Should you have all the other lymph nodes in this area removed, in a surgical procedure called completion lymph node dissection (CLND, or lymphadenectomy)? The idea is that a CLND ensures that the melanoma cells in all the other lymph nodes are removed, which then may prevent the disease from spreading farther.
Unfortunately, the evidence is inconclusive, so this decision is not straightforward, even for doctors. Here are some pros and cons to consider.
2. The overall number of nodes containing melanoma cells is a predictor of survival for patients who have stage III disease, and only a CLND can provide this information.
3. Some studies show that 20% of patients who undergo a CLND immediately after finding out they have a positive sentinel lymph node experience improved survival. This is especially true for patients who had intermediate-thickness tumors on their skin (1.2 to 3.5 mm).
4. By stopping the spread of melanoma at the lymph nodes, a CLND optimizes the chance for a cure. Even microscopic amounts of melanoma in lymph nodes can eventually progress over time to be significant and dangerous.
1. Complications of a CLND are significant and occur in up to 67% of patients, especially in those over 60. These include:
- Buildup of fluid at the site of surgery (seroma)
- Swelling of a limb affected by removal of the lymph nodes (lymphedema)
- Numbness, tingling, or pain in the surgical area
- Breakdown (sloughing) of skin over the area
Although swelling after surgery can be prevented or controlled by use of antibiotics, elastic stockings, massage, and diuretics, it can be a debilitating complication.
2. The effectiveness of a CLND may depend on the size of the melanoma tumor. Small tumors (0.1 mm or less in diameter) in the sentinel lymph node may not ever lead to metastasis at all, so performing a CLND may not be necessary. A 2009 study showed that the survival and relapse rates of patients with these small tumors was the same as those who had no melanoma in their sentinel lymph node. Thus, these "low-risk" patients may be able to avoid a CLND and have the same outcome.
The Bottom Line
Electing to undergo a major surgical procedure like a CLND is not a decision you should take lightly, especially if your biopsy shows only a small amount of melanoma in your lymph nodes. Many factors are involved, including the size and location of your primary melanoma, the results of the sentinel lymph node biopsy and other tests, and your age. You may find it helpful to seek out a second opinion.
Boughton B (2009). Should lymphadenectomy be the standard of care in melanoma metastasis to the sentinel lymph nodes? Oncology News Intl. 18(5).
Morton DL, Thompson JF, Cochran A, et al (2006). Sentinel-node biopsy or nodal observation in melanoma. N Engl J Med. 2006 Sep 28;355(13):1307-17.
Thomas JM (2005). Time to Re-Evaluate Sentinel Node Biopsy in Melanoma Post-Multicenter Selective Lymphadenectomy Trial. J Clin Oncol. 2005 Dec 20;23(36):9443-4.
van Akkooi AC, Rutkowski P, van der Ploeg IM, et al (2009). Long-term follow-up of patients with minimal sentinel node tumor burden (< 0.1mm) according to Rotterdam criteria: A study of the EORTC Melanoma Group. J Clin Oncol 27:15s, 2009 (suppl; abstr 9005).