Faries 2017 - NEJM - Lymph nodes dissection melanoma

Summary

This article reports on a randomized clinical trial comparing completion lymph node dissection to nodal observation in patients with sentinel lymph node metastases from melanoma. Sentinel lymph node biopsy is standard practice for staging melanoma, but the benefit of completing the dissection to remove remaining lymph nodes after a positive sentinel node is unclear.

In this trial, 1939 patients with sentinel node metastases detected by pathology or PCR were randomized to immediate completion dissection or nodal observation with frequent ultrasound follow-up. The primary outcome was melanoma-specific survival. After a median follow-up of 43 months, there was no significant difference in 3-year melanoma-specific survival between the dissection and observation groups (86% in both). Disease-free survival was slightly higher in the dissection group (68% vs 63%, p=0.05) due to better regional disease control (92% vs 77% non-sentinel node disease-free at 3 years). However, immediate dissection did not improve distant metastasis-free or overall survival. Non-sentinel node positivity was an independent poor prognostic factor. Lymphedema occurred in 24% of the dissection group compared to 6% of the observation group.

In summary, this large randomized trial found that immediate completion lymph node dissection after positive sentinel biopsy did not improve melanoma survival compared to nodal observation. While dissection provided better regional control and staging information, it increased morbidity without clear survival benefit. These findings do not support routine use of completion dissection for positive sentinel nodes in melanoma.