A survey of surgical management of the sentinel node positive melanoma patient in the post‐MSLT2 era

Abstract

Background: The evidence-based management of melanoma patients with a positive sentinel lymph node biopsy (SLNB) has undergone a dramatic shift following publication of practice-changing surgical trials demonstrating no melanoma-specific survival advantage for completion lymph node dissection (CLND) in this scenario.We aimed to survey how surgeons' clinical practice had shifted in response to new evidence from these trials, and at a time when there was starting to become available systemic adjuvant treatments for AJCC Stage III melanoma patients. Methods: A web-based survey consisting of practice-based questions and hypothetical clinical scenarios about current melanoma practice with regard to positive sentinel node biopsy was developed and sent to the surgical members of a Melanoma and Skin Cancer (MASC) Trials group in December 2018. Responses were analysed using descriptive statistics.Results: There were 212 invitations sent and 65 respondents (31%). Respondents were from 17 countries, 94% of whom practice in specialist melanoma centres or at referral centres. Of these 97% were familiar with the MSLT2 and DeCOG-SLT clinical trials. At survey, 5% of respondents reported routinely recommending CLND and 55% recommend CLND in selected cases. Respondents were most likely to recommend CLND when multiple SLNs were positive. Important factors for surgical decision-making mentioned included size of SLN deposit, number of positive SLNs and likely compliance with the recommended surveillance regimen. Conclusion:In line with rapid adoption of published evidence, surgical management of Stage III melanoma has altered significantly, with few surgeons within the cohort now performing routine CLNDs after positive SLNB.

Waiving Subsequent Complete Lymph Node Dissection in Melanoma Patients with Positive Sentinel Lymph Node Does Not Result in Worse Outcome on 20-Year Analysis

“…But only patients with micrometastases beyond the SLN-which only applies to about 20% of SLN-positive cases-benefit from CLND. In contrast, patients with additional non-SLN micrometastases have worse survival rates, and thus having the knowledge about the status of non-SLN tumor load potentially provides prognostic information [14][15][16][17]. Our data confirm the relatively low number of non-SLN micrometastases detected on CLND in 25.8% of cases.…”

“…We did not observe significant differences between both groups for these important prognostic parameters. In a survey from Australia and New Zealand published in 2021, replies were received from respondents in 17 countries [17]. Of these, 97% were familiar with the pivotal clinical trials published by Faries et al [5] and Leiter et al [6] In the survey, 5% of respondents reported routinely recommending CLND and 55% recommend CLND in selected cases.…”

“…Of these, 97% were familiar with the pivotal clinical trials published by Faries et al [5] and Leiter et al [6] In the survey, 5% of respondents reported routinely recommending CLND and 55% recommend CLND in selected cases. Downs et al [17] found that respondents were most likely to recommend CLND when multiple SLNs were positive.…”

Modern Approach to Melanoma Adjuvant Treatment with Anti-PD1 Immune Check Point Inhibitors or BRAF/MEK Targeted Therapy: Multicenter Real-World Report

“…In those trials, no improvement in melanoma-specific survival (MSS) from CLND was demonstrated. Surgeons do not perform routine CLND after positive SNLB anymore, and they refer patients to adjuvant systemic treatment [14,15]. Omitting CLND leaves us without precise information on local disease burden.…”