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Management of the regional lymph nodes in patients with cutaneous malignant melanoma

  • World Progress In Surgery
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Abstract

One of the most difficult decisions in the management of patients with melanoma remains whether or not to dissect electively the regional lymph nodes of patients with high risk primary tumors. There is abundant evidence that a proportion of such patients will eventually develop nodal metastases and that the probability of metastasis increases with increasing tumor thickness and depth of invasion. If elective node dissection is performed on all patients with high risk primaries, most patients (who have no tumor in the nodes) will be subjected to a potentially morbid operation from which they can achieve no benefit. On the other hand, a “wait and see” policy accepts that a minority of patients will go on to develop nodal metastases and that if definitive therapy is delayed until metastases are detected clinically their likelihood of survival is much reduced. We describe a new technique of dye-directed selective lymphadenectomy that allows accurate and objective identification of individual patients who have subclinical metastases, the individuals whoa priori are most likely to benefit from lymphadenectomy. We also discuss new approaches to the assessment of prognosis after lymphadenectomy for node-spread melanoma, a group of patients in whom the prognosis is not uniformly bad. We end with a consideration of quality assurance aspects of the pathological evaluation of lymphadenectomy specimens.

Résumé

Une des décisions les plus difficiles dans le traitement des patients ayant un mélanome malin est l'indication de l'ablation élective des chaines ganglionnaires régionales chez les patients à haut risque. Il existe d'abondantes preuves qu'une certaine proportion de ces patients va développer des métastases lymphatiques et que la probabilité de telles métastases augmente avec l'épaisseur de la tumeur et la profondeur de l'envahissement. Si l'on décide de pratiquer le curage à titre systématique, une assez grande proportion de patients (sans atteinte lymphatique) n'en tireront aucun bénéfice mais la morbidité d'un tel geste n'est pas nulle. D'un autre côté l'attitude attentiste veut qu'une petite proportion de patients va développer des métastases lympathiques et si l'on en attend les manifestations cliniques l'espérance de survie est réduite. Nous décrivons une nouvelle technique de lymphadénectomie élective guidée par des colorations qui détermine les métastases infra-cliniques, permettant de cibler des patients qui pourraient tirer les plus grands bénéfices de cette intervention. Nous discutons aussi de nouvelles approaches pour évaluer le pronostic après lymphadénectomie pour maladie métastatique, un sous-groupe de patients dont le pronostic n'est pas forcément mauvais. Nous termínons par des considérations sur le caractère complet de la lymphadénectomie qui assure la qualité de l'intervention.

Resumen

Una de las más difćiles decisiones en el manejo de pacientes con melanoma sigue siendo la referente si se debe o no realizar disección electiva de los ganglios linfáticos regionales en pacientes con tumores primarios de alto riesgo. Existe amplia evidencia que indica que una proporción de tales pacientes eventualmente desarrolla metástasis ganglionares y que la probabilidad de metástasis aumenta en relación directa con el espesor del tumor y el nivel de profundidad de invasión. Si se practica disección electiva en todos los pacientes con tumores primarios de alto riesgo, la mayoría (que no posee tumor en los ganglios) habrá de ser sometida a una operación de potencial morbilidad de la cual no deriva beneficio. Por el contrario, una política de “esperar y ver” acepta que una minoría de los pacientes habrá de desarrollar metástasis ganglionares y que si la terapia definitiva es pospuesta hasta cuando tales metástasis sean clínicamente aparentes su probabilidad de sobrevida resulta considerablemente disminuida. Nuestro grupo describe una nueva tácnica de linfadenectomía selectiva con base en la aparición de un colorante de inyección intradérmica (en una región adyacente al melanoma o en el lugar de la resección o biopsia del melanoma), la cual permite la identificación certera y objetiva de pacientes individuales con metástasis subclínicas, que son los pacientes que a priori más probablemente se beneficia de una linfadenectomía. También se discuten nuevos enfoques para la determinación del pronóstico después de linfadenectomía para melanoma ya extendido a los ganglios, que constitituye un grupo de pacientes cuyo pronóstico no es uniformemente malo. Terminamos con la consideración de los aspectos de garantía de calidad de la valoración patológica de los especímenes de linfadenectomía.

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Authors and Affiliations

  1. Division of Anatomic Pathology, Department of Pathology and Laboratory Medicine, and Division of Surgical Oncology, Department of Surgery, University of California, Los Angeles

    Alistair J. Cochran M.D., Duan-Ren Wen M.D. & Donald L. Morton M.D.

  2. The John Wayne Cancer Institute at Saint John's Hospital and Health Center, Santa Monica, California, USA

    Alistair J. Cochran M.D., Duan-Ren Wen M.D. & Donald L. Morton M.D.

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  1. Alistair J. Cochran M.D.
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  2. Duan-Ren Wen M.D.
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  3. Donald L. Morton M.D.
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Cochran, A.J., Wen, DR. & Morton, D.L. Management of the regional lymph nodes in patients with cutaneous malignant melanoma. World J. Surg. 16, 214–221 (1992). https://doi.org/10.1007/BF02071523

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