Surgically removing all lymph nodes surrounding a melanoma skin cancer—the standard procedure for melanoma patients with lymph node metastases—might not improve a patient's chances of survival, according to study published Wednesday in the New England Journal of Medicine.
For the study, researchers from several institutions conducted an international multicenter trial to evaluate the effectiveness of full lymph-node removal surgery in melanoma patients' sentinel-node metastases by comparing that approach to a less aggressive and invasive option, which involves only removing sentinel nodes and leaving all surrounding nodes in place for further observation.
The researchers conducted the trial at 64 sites, including the Fox Chase Cancer Center, and enrolled more than 1,900 patients whose melanoma had spread from their skin tumors to their lymph nodes, which is the first destination a tumor cell reaches when entering the lymphatic system. Half of the study participants received the full lymph node removal and the other half received the minimally invasive approach. Researchers then monitored both groups over a three year period.
The researchers found the standard medical practice of removing all lymph nodes does have some benefits, such as improving disease control and providing prognostic information, but it does not increase melanoma-specific survival for patients with melanoma and sentinel-node metastases.
After nearly three years, the researchers found no difference in survival rates between patients who underwent the surgery and those who had their tumors regularly monitored via an ultrasound. In both groups, the researchers found the mean three-year survival rate was 86 percent.
According to the study, although the surgery does not improve survival, it does reduce the rate of cancer recurrence when compared with ultrasound monitoring. The researchers found only 1 percent of patients who underwent the full surgery developed cancer in their remaining lymph tissue, while nearly 8 percent of patients who had their lymph nodes regularly monitored developed cancer in their lymph tissue.
In addition, the researchers found that, at three years, 68 percent of patients who had the surgery reported no cancer recurrences anywhere in their bodies, compared with 63 percent of patients who had their lymph nodes regularly monitored.
Mark Faries, the study's lead author and a surgical oncologist at John Wayne Cancer Institute, said the study's results "provide the last piece in the puzzle" of how physicians should treat cancer that has spread from a tumor into a nearby lymph node.
Faries noted that in recent years "it had become apparent" that cancer in sentinel node does not mean nearby nodes have cancer as well, in particular because it is easier for cancer to travel into the sentinel node than it is "for those cells to move to other nodes or through the body."
Daniel Coit, a surgical oncologist at Memorial Sloan Kettering Cancer Center, in an editorial accompanying the study wrote that "these results should be construed as practice-changing." He added that if the findings are "insufficient to extinguish the enthusiasm for immediate completion lymph node (removal), then it is unclear what more is required."
Jeffrey Farma, a co-author of the study and a surgical oncologist at Fox Chase, agreed, but said patients have "to be willing to be on a rigorous monitoring schedule," which would require them to "come in to get an ultrasound" every three to six months (McCullough, Philadelphia Inquirer, 6/7; Bakalar, "Well," New York Times, 6/7; Mozes, U.S. News & World Report, 6/8).
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