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13Jun 2017

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Extensive lymph node removal not necessary for melanoma patients

Melanoom cel kanker uitzaaiing

A large clinical phase 3 study shows that immediate removal of all regional lymph nodes from patients with melanoma and metastases in the sentinel node does not improve their melanoma specific survival. The Netherlands Cancer Institute participated in this study and has stopped carrying out this surgical procedure. The results were published in the New England Journal of Medicine (NEJM) on June 8th.

Many melanoma patients undergo dissection of the sentinel node, the lymph node closest to the tumor. In case a metastasis is found in this node, it used to be common practice to also remove the other lymph nodes in the same regional basin. Earlier clinical studies suggested this would be beneficial for patients. However, this surgical procedure comes with potentially severe side effects and conclusive evidence of the efficacy was lacking. But not anymore. A total of 63 treatment centers all over the world included roughly 2000 patients in a study showing no effect of extensive lymph node dissection on melanoma specific survival compared to observation with ultrasound.

This second Multicenter Selective Lymphadenectomy Trial (MSLT-II) randomly assigned 1943 melanoma patients with metastasis in their sentinel node to either regular observation with ultrasound or immediate removal of the regional lymph nodes. 39 of them were included in the Netherlands Cancer Institute. In total, 1755 patients completed the assigned treatment and could be evaluated. Three years after treatment the melanoma specific survival was the same for both groups. The patients that had additional nodes removed, however, suffered from the potentially severe side effect lymphedema more often (24%) than the control group (6%). NEJM published an informative video about the study results.

One could argue that removing the regional lymph nodes could still be useful for staging the disease and obtaining prognostic information. However, once the results of the MSLT-II study came in, surgeon Alexander van Akkooi and his colleagues at the Netherlands Cancer Institute started a soon to be published study in their own patient database. They found that the tumor staging of only 4.7% percent of the patients who have their regional lymph nodes removed actually changed because of the extra information retrieved from the removed nodes. Van Akkooi: "The potential benefit for this very small group doesn't outweigh the side effects many more patients will experience."

The surgeons of the Netherlands Cancer Institute decided to adjust their treatment strategy last December. Van Akkooi: "The results of this study are very clear and help us prevent unnecessary surgical procedures. We decided to stop doing the regional node dissection in patients with sentinel node metastases. Instead, our standard policy is now to monitor them with ultrasound. In the near future I hope we can offer these patients new forms of adjuvant immunotherapy or targeted therapy instead of surgery. Several of those therapies are being investigated."

As chairman of the national melanoma workgroup of the Netherlands comprehensive cancer organization IKNL Van Akkooi has also initiated the adjustment of the Dutch melanoma treatment guideline. Van Akkooi: "The new guideline will probably be released in 2018. Hopefully, hospitals in The Netherlands and abroad will adapt their treatment strategy well before that."

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