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Future of sentinel lymph node biopsy

A dermatologist highlighted the extensive contemporary data pertaining to sentinel lymph node biopsy (SLNB) to help formulate interpretation of data into clinical practice during a plenary session at the 25th European Academy of Dermatology and Venereology Congress in Vienna.

“Dermatologists are on the front lines and play a critical role in patient decisions and counselling including sentinel lymph node biopsy,” said Dr. Tim Johnson, the Lewis and Lillian Becker Professor at the University of Michigan in Ann Arbor, Mich., during his opening remarks on Sept. 29, 2016.

During the main part of his talk Dr. Johnson said, “I understand that variable interpretation of the data may respectfully occur. That said, current practice guidelines involving every discipline and major guideline organization from all over the world provide relatively uniform recommendations; and are consistent in interpretation of both the value and limitations of sentinel node biopsy for melanoma. Accurate staging whether of the primary lesion, regional lymph nodes or other, drives to a great extent treatment and treatment options. The staging accuracy of sentinel node biopsy is not argued anymore.”

He continued, “there is a small likelihood of identifiable distant disease if the sentinel node biopsy is negative. Staging tests are not validated based on their ability to improve survival. They are validated based on their sensitivity and specificity of which this test represents the ‘gold’ standard for nodal staging in appropriate candidates.”

The majority of patients with melanoma do not need consideration for SLNB, however, those with Breslow depth ≥1 mm, or 0.75-0.99 mm with higher risk factors may benefit, according to Dr. Johnson. “Delayed treatment of occult regional nodal disease in adults with intermediate thickness melanoma may increase the extent or tumor burden of nodal disease upon early clinical detection, increase the morbidity of treating that disease, increase the chance of loss of regional control, and increase the likelihood of dying from that disease, in the subset with occult nodal disease,” he said.

SLNB results in the new era of systemic therapy will determine the need for adjuvant therapy based on prognosis, and the type of adjuvant therapy based on tumor burden and molecular profile. Eventually effective adjuvant therapy will eradicate the need for complete lymph node dissection after a positive SLNB. In the nearer future sentinel lymph nodes staging may become more relevant and frequent while completion lymph node dissection less frequent as more adjuvant trials come online. Clinicians will likely perform few if any sentinel node biopsies once we have true precision medicine, according to Dr. Johnson's presentation.

“The next time you are in the moment with that patient with melanoma, you should view them through the eyes of many specialties, and with the most contemporary knowledge base,” said Dr. Johnson.

“And that approach will help you treat every patient like you would your own family member, which I’m sure is your goal like mine.”

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