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Melanoma Guidelines Outline Lymph Node Dissection Requirements: Presented at NCCN

By Ed Susman

HOLLYWOOD, FL -- March 15, 2004 -- When malignant melanoma is identified, and a sentinel node biopsy is positive, doctors should be prepared to perform extensive lymph node dissection in order to correctly stage patients.

According to guidelines prepared by an expert panel, that means if the lymph node drainage is in the groin, at least 10 lymph nodes need to be examined, said Daniel Coit, MD, associate professor of surgery at Cornell University Medical School, New York.

"In order to adequately dissect the regional nodal basin in the groin," said Dr. Coit, an attending physician at Memorial Sloan-Kettering Cancer Center in New York, "the surgeon should consider elective iliac and obturator lymph node dissection if clinically positive superficial nodes or if three of more superficial nodes are positive."

In presenting the treatment algorithms for the National Comprehensive Cancer Network here March 13^th at its 9^th Annual Conference on Clinical Practice Guidelines and Data Outcomes in Oncology, Dr. Coit said that surgeons should be prepared to examine a minimum of 15 lymph nodes in the axilla and 15 nodes in the neck.

The guidelines suggest the use of sentinel node biopsy to determine if melanoma has reached the lymphatic system, but Dr. Coit said, "No one should leave the room today thinking that sentinel node biopsy is a form of treatment. It is a very good staging policy. Sentinel node status was the most predictive predictor of outcome. It should be done as a staging procedure among patients at risk."

The new guidelines revise those drawn up 3 years ago, he said. The panel meets about once every 18 months to go over new studies in the field. Pointing out one thing that hasn't changed, Dr. Coit said, "Any treatment of melanoma begins with observation of a suspicious skin lesion. We have to be attentive to the things we see every day."

He said that unlike other cancers, once a suspicious lesion is seen, it requires biopsy, and the biopsy should be performed with the purpose in mind of performing curative surgery, so wide margins are usually required. "There is very good, Level One evidence that wide excision is preferred," he said. Level One evidence is based on results from well-designed clinical trials.

In selecting treatment options for advanced melanoma, John Thompson, MD, professor of oncology at the University of Washington, Seattle, said, "There is a lot of room for practitioner judgment. There has been a lot of attention in use of immunotherapy, but the doctor has to weigh overall improvement at the cost of significant morbidity with those treatments."

In patients with melanoma that has been successfully treated, follow-up is a life-long process, Dr. Thompson said. Regular visits are needed, he said, to detect recurrence; detect second primary cancers; to educate the patient; to identify family kindreds; for psychosocial support, and to screen for other cancers.

However, strategies for follow-up should concentrate on the first 3-5 years after initial surgery, because after that period, recurrence risk is markedly reduced.

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