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Importance of tumor load in the sentinel node in melanoma: clinical dilemmas

Nature Reviews Clinical Oncology volume 7, pages 446–454 (2010)Cite this article

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Abstract

There are two hypotheses to explain melanoma dissemination: first, simultaneous lymphatic and hematogeneous spread, with regional lymph nodes as indicators of metastatic disease; and second, orderly progression, with regional lymph nodes as governors of metastatic disease. The sentinel node (SN) has been defined as the first draining lymph node from a tumor and is harvested with the use of the triple technique and is processed by an extensive pathology protocol. The SN status is a strong prognostic factor for survival (83–94% for SN negative, 56–75% SN-positive patients). False-negative rates are considerable (9–21%). Preliminary results of the MSLT-1 trial did not demonstrate a survival benefit for the SN procedure, although a subgroup analysis indicates a possible benefit. A mathematical model has demonstrated 24% prognostic false positivity. SN tumor burden represents a heterogenous patient population and is classified most frequently with the Starz, Dewar or Rotterdam Criteria. A completion lymph-node dissection might not be indicated in all SN-positive patients. Patients classified with metastases <0.1 mm by the Rotterdam Criteria have excellent survival rates. Ultrasound-guided fine-needle aspiration cytology is emerging as a staging tool for high-risk patients, but more research is necessary before this can change clinical practice.

Key Points

  • The sentinel lymph-node biopsy (SLNB) is a very accurate staging procedure for stage I–II melanoma patients, which provides the most important prognostic information for survival

  • The SLNB procedure followed by immediate completion lymph-node dissection (CLND) does not improve survival, although further studies are needed to determine if it might be beneficial for some patients

  • Sentinel node tumor burden determines survival and the need for CLND

  • Patients with sentinel node micrometastases <0.1 mm have a clinical course that is indistinguishable from sentinel-node-negative patients and routine CLND may not be indicated in these patients

  • The EORTC Melanoma Group recommends the use of the Rotterdam Criteria for the measurement of sentinel node tumor burden

  • Sentinel node staging is the most accurate staging in melanoma patients, but future staging approaches might include a role for ultrasound-guided fine-needle aspiration cytology

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  1. Department of Surgical Oncology, Erasmus University Medical Center, Daniel den Hoed Cancer Center, Groene Hilledijk 301, Kamer A1-41, 3075 EA, Rotterdam, The Netherlands

    Alexander C. J. van Akkooi, Cornelis Verhoef & Alexander M. M. Eggermont

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van Akkooi, A., Verhoef, C. & Eggermont, A. Importance of tumor load in the sentinel node in melanoma: clinical dilemmas. Nat Rev Clin Oncol 7, 446–454 (2010). https://doi.org/10.1038/nrclinonc.2010.100

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