Lack of survival benefit in sentinel lymph node-positive melanoma with immediate complete lymphadenectomy - a review.

For decades, melanoma surgery has been guided by the Halstedian concept of stepwise metastasis, first into the lymph nodes and subsequently to distant sites. Early complete lymph node dissection (CLND) was therefore recommended in order to improve survival. Four large prospective randomized trials failed to show any survival benefit of CLND in comparison to observation alone. Sentinel lymph node biopsy was introduced in the 1990's, and CLND was limited to patients with positive sentinel nodes. Based on lymphoscintigraphy, it was pointed out that draining lymph nodes can now be detected more accurately. In one large trial, sentinel lymph node-guided CLND was compared to observation alone, and no advantage for melanoma-specific survival was detected. More recently, two prospective randomized studies tested whether CLND improved melanoma-specific survival or overall survival in patients with positive sentinel nodes. Neither study found a better survival rate for patients with CLND than with observation alone. The reason for the failure of CLND to improve survival is clearly parallel development and not stepwise development of lymph node metastasis and distant metastasis. Immediate CLND in melanoma surgery is therefore called into question.