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Dermatopathology: Practical & Conceptual January - March 2003
Contrary View on Behalf of Patients: Sentinel lymph node biopsy has no benefit for patients with primary cutaneous melanoma: An assertion based on comprehensive, critical analysis.
Neil Medalie, M.D.
A. Bernard Ackerman, M.D.
1. Elective Lymph Node Dissection: Historical Perspective
2. Diagnosis of Metastasis of Melanoma in Sentinel Nodes: Past and Present.
3. Evolution of Methods for Mapping Lymph Nodes: From Determination of a Regional Node Basin to Detection of a Sentinel Node.
4. Sentinel Node Biopsy: Standard of Care?
5. Concepts regarding the mechanisms of dissemination of melanoma
6. Metastatic Melanoma: No systemic therapy currently available is effective.
7. A Last Word – Sentinel node biopsy provides no benefit to patients and, therefore, should be abandoned now
sentinel lymph node biopsy
When melanoma metastasizes, cells of it do not simply go directly to a SN. In actuality, they may not go to that node at all. Irrespective of whether the sentinel node is visited by cells of melanoma as they flee from the primary malignant neoplasm in the skin, one thing is certain; once the cells of it metastasize they are disseminated far and wide and, once that happens, from that time forth, a patient is likely to be doomed. There is no effective treatment now for metastatic melanoma.
Lymph nodes are filters, not traps or dams. At this moment in the history of medicine, SNB is a mania universally of those who manage patients with melanoma, those physicians agitating that that procedure be made the standard of care. But there is no evidence at all that SNB benefits patients an iota. That being the case, SNB should be used only in clinical trials. Neither is there any reason to perform an END on any patient with melanoma; it does them no good. The use of SNB in the management of patients with primary cutaneous melanoma should be discouraged and the notion that it should be the standard of care for patients with metastatic melanoma should be condemned vociferously. Sentinel lymph node biopsy profits physicians, hospitals, and suppliers of equipment, but not patients.
The time has come for SNB and END to be discarded once and for all not in 25 or 50 years, just as should have been the case for many procedures that have been injurious to patients and now have been relegated to the ash-heap so deserving of them. Wide and deep excision for melanoma, that is, 5.0 cm of normal skin around the primary neoplasm and down to fascia followed by placement of a graft should have been discarded in the 1920's rather than in the 1980's, all that ever needed be done being excision entirely of the primary neoplasm and with a narrow margin at that, a procedure unaffiliated with any number (e.g., 3.0 cm., 2.5 cm., 1.0 cm.) and one that ultimately will prevail because it is irrefutably logical. In the final analysis, physicians with intellect and a conscience are surrogates for patients and, given that sacred responsibility, SNB and END must be jettisoned now, without delay. To do less is an abrogation of the obligation of a physician to a patient and a violation of that Oath a physician has pledged solemnly to uphold.
Dr. Medalie undertook this work during a yearlong Fellowship at the Ackerman Academy of Dermatopathology where Dr. Ackerman is director. He is now an associate at that Academy.
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