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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
This treatise sets forth the thesis that there is no place in the routine practice of medicine for the procedure known conventionally and universally as sentinel node biopsy for melanoma. The argument is based on assessment of the extensive body of literature devoted to the subject of treatment of melanoma before any metastasis has manifested itself clinically and that body dedicated to therapy of overt metastatic melanoma by a variety of modalities, chief among those addressed here being elective lymph node dissection and sentinel lymph node biopsy. In this era of sentinel lymph node biopsy, elective lymph node dissection has been modified to include only patients with metastasis of melanoma to lymph nodes, a procedure now termed "selective complete lymph node dissection." Among adjuvant medical therapies, the most popular today is interferon alpha-2B. Critical, incisive scrutiny of the literature leads to the conclusion, incontrovertibly, that elective lymph node dissection has no benefit for a patient and that any modification of it also is devoid of value. The reason, logically, for the lack of utility of elective lymph node dissection becomes apparent by virtue of the route taken by cells of melanoma as they metastasize; those cells proceed in the same fashion as does lymph, bacteria, foreign material (including vital dyes and radioactive tracers), and other kinds of cells, to wit, by passing rapidly through nodes, including the sentinel one, and even bypassing the nodes. In reality, cells of metastatic melanoma are not held up in nodes for any significant period of time, in contradistinction to what is contended repeatedly but wholly without basis in fact by many students of the subject. Moreover, not a single adjuvant medical therapy available currently is effective against metastatic melanoma and, therefore, none should be invoked to justify performance of a sentinel lymph node biopsy. Even if the sentinel lymph node is found to house cells of melanoma, which doubtlessly conveys a message in general about prognosis in regard to an individual patient, namely, a grim future, the finding is meaningless; a particular patient may live in harmony with metastases of melanoma for more than 30 years and die from an unrelated malady. In short, no surgeon, pathologist, or oncologist can act authentically as seer, diviner, or prophet concerning the outcome for a patient with metastasis of melanoma; the end could come in weeks, months, or decades. If, however, a sentinel lymph node is found to contain nary a cell of metastatic melanoma, it also means nothing for an individual patient because the existence of metastases widely is not excluded by that finding. In short, sentinel lymph node biopsy cannot be considered the standard of care in the daily practice of medicine; it is woefully substandard because it is of no benefit. There is no justification, whatsoever, for the procedure, scientifically or practically, and for that reason it should be abandoned, without delay, now.
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