Lymph Nodes Test Helps Fight Melanoma

    Using so-called “sentinel node” biopsies to determine if melanoma has started
    to spread saves some patients the pain of having all their lymph nodes removed,
    U.S. researchers report.

    The strategy can also give patients a
    jump-start on aggressive treatment, they addrf.

    There are few treatment options for
    melanoma unless the disease is caught early. As a result, melanoma is one of the
    deadliest cancers around.

    However, patients whose lymph nodes tested
    positive for cancer, and who had all their lymph nodes removed, had a much
    higher five-year survival rate compared to those who tested positive but delayed
    node removal.

    These results should help make sentinel
    node biopsy standard practice in dealing with this type of malignancy, said lead
    researcher Dr. Donald L. Morton, medical director and chief of the melanoma
    program at John Wayne Cancer Institute at Saint Johns Hospital in Santa Monica,
    Calif.

    His team published its findings in the
    Sept. 28 issue of the New England Journal of
    Medicine
    .

    “People had been skeptical that sentinel
    node biopsy was necessary. This further cements the view that it is,” said Dr.
    Vijay Trisal, an assistant professor of surgical oncology at City of Hope Cancer
    Center in Duarte, Calif. “This gives us an idea about the biology of the cancer,
    and gives us ammunition that this is the right thing to
    do.”

    The findings are “not earth-shattering in
    the sense of treatment, but certainly in terms of prediction,” commented Dr.
    Donald McCain, a surgical oncologist and member of the melanoma division at
    Hackensack University Medical Center Cancer Center, in Hackensack,
    N.J.

    Melanoma is the most rapidly increasing
    malignancy in the world today. According to the American Cancer Society, nearly
    60,000 Americans will be diagnosed with melanoma this year, and almost 8,000
    will die from the disease.

    About 20 percent of patients with melanomas
    of intermediate thickness have a microscopic spread of their cancer to the lymph
    nodes — meaning the metastasis can’t be seen or felt. Generally speaking,
    melanoma that spreads to the lymph nodes has a much poorer
    prognosis.

    Still, physicians haven’t been sure how to
    approach the issue. Experts have tended to split into two camps: one
    recommending that all lymph nodes automatically be removed, and the other
    advocating waiting until the mass can actually be felt in the lymph
    nodes.

    “The problem with [the first] approach is
    that since only 20 percent of patients have nodal metastasis, the other
    80 percent have an operation that they can’t benefit from. They don’t really
    need it,” Morton explained. “The question is how to figure who does and who
    doesn’t need it.”

    Enter sentinel node biopsy, a technique
    developed by Morton and colleagues about 20 years ago. Here, the surgeon tests
    only one or two lymph nodes, where the cancer is most likely to head to first.
    If these are positive, the rest of the lymph nodes are tested and removed. If
    not, the patient is left alone.

    “We found that about 20 percent of people
    of this intermediate thickness would have spread to one to two sentinel nodes,”
    Morton said.

    This trial, which an accompanying editorial
    called the “largest and most important trial of sentinel-lymph-node biopsy for
    melanoma conducted to date,” sought to determine if sentinel node biopsy made
    any difference in survival.

    Investigators randomly assigned 1,269
    patients with intermediate thickness melanoma (1.2 to 3.5 millimeters) to have a
    sentinel node biopsy (followed by removal of lymph nodes if they contained
    cancer) or simply observation. If participants in the observation-only group
    developed a palpable mass in their lymph area, they also underwent removal of
    all lymph nodes.

    Five-year, disease-free survival was
    similar in both groups: 78.3 percent in the biopsy group and 73.1 percent in the
    observation group.

    The difference was in patients with
    cancer-positive vs. negative lymph nodes. Patients whose sentinel nodes were
    tumor-negative had a five-year survival rate of 90.2 percent whereas those with
    tumor-positive sentinel nodes had a survival rate of only 72.3
    percent.

    And for those patients with positive lymph
    nodes, the five-year survival rate was higher among those who immediately had
    all their lymph nodes removed (72.3 percent) vs. those who delayed removal (52.4
    percent).

    “As far as I’m aware, outside of this trial
    there’s never been any randomized trial that showed a survival benefit for
    melanoma with sentinel node biopsy,” Morton said.

    The technique is used routinely by doctors
    for breast, lung and colon cancers. “It is a universal principle that in cancers
    that spread through the lymphatics, if it’s going to spread, it’ll be in the
    sentinel node,” Morton said. “Sentinel node biopsy saves two-thirds of women a
    radical actuary dissection.”

    As for melanoma, experts now
    know there is a survival benefit there, as well. “Those with positive sentinel
    lym

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