The Role of Clinical Prediction Tools to Risk Stratify Patients with Melanoma After a Positive Sentinel Lymph Node Biopsy

Excerpt

We are currently trying to reconcile two of the greatest paradigm shifts in the treatment of melanoma in the modern era. For the first time, we have effective, safe, and well-tolerated adjuvant therapy options that improve recurrence-free survival for patients with stage III disease.1^–4 The caveat is that all of the patients in these trials were treated with a completion lymphadenectomy, and high-risk patients were selected by either eliminating patients with IIIA disease or allowing only those IIIA patients with a micrometastatic tumor burden in excess of 1 mm. The second paradigm shift relates to the management of the nodal basin after a positive sentinel lymph node; both DeCOG-SLT and MSLT-II have shown that a completion lymphadenectomy does not improve survival in these patients.5,6 Instead, a lymphadenectomy offers only prognostic information and modest improvements in regional disease control. So how do we reconcile these two treatment paradigms? On one hand, we have safe, effective adjuvant therapy options in a well-defined, high-risk, stage III population. On the other hand, we do not know who falls into this well-defined, high-risk, stage III population, because we are no longer performing completion lymphadenectomy routinely. We are left with mostly stage IIIA patients with a single positive sentinel lymph node who need to be risk-stratified to select those who will benefit from adjuvant therapy without any additional lymph node staging. The study by Bertolli et al.7 in this issue presents a valuable tool to help risk-stratify patients using pathologic information available after sentinel lymph node biopsy. …