Definitive Study Shows That People with Melanoma Do Not Need Immediate Lymph Node Removal

By Matthew Tontonoz,

Lymph nodes and lymphatic vessels with adjacent blood vessels
Summary

A large study of nearly 2,000 people has answered an important question about the surgical treatment of melanoma, a type of skin cancer. For people with cancer detected in their sentinel lymph node, a watch-and-wait approach rather than immediate removal of all regional lymph nodes is a safe option. 

Highlights
  • To determine the stage of melanoma, doctors often surgically remove the sentinel lymph node, the one closest to the tumor.
  • People who test positive for melanoma in their sentinel lymph node are at a higher risk of recurrence.
  • The results of a new study indicate that immediate surgical removal of remaining lymph nodes does not improve survival compared with a watch-and-wait approach.

People with melanoma who test positive for cancer in their sentinel lymph node do not need to have their remaining regional lymph nodes immediately removed to improve their survival.

This is the conclusion of a large, randomized clinical trial, the results of which are published in the New England Journal of Medicine. The study found that melanoma patients who follow a watch-and-wait approach — with later surgery, if necessary — fare equally well in terms of survival compared with those who have their regional lymph nodes immediately removed. That procedure, called a completion lymph node dissection, is currently the standard of care, but it can cause serious side effects.

The results of this study herald an immediate change in practice.

“The main take-home message is that more surgery done in a prophylactic [preventive] fashion is not associated with better outcomes,” says Charlotte Ariyan, a cancer surgeon at Memorial Sloan Kettering and co-author on the new study. “I think nowadays we can be much smarter about selecting the patients who need to have additional procedures.”

Writing in an accompanying editorial, MSK surgical oncologist Daniel Coit calls the study results “definitive” and “unequivocal.” He adds that they should be viewed as practice changing.

A Definitive Trial

The second Multicenter Selective Lymphadenectomy Trial (MSLT-II) included nearly 2,000 patients with melanoma in their sentinel lymph node, the one closest to the tumor. They were divided into two therapy groups. The first group underwent immediate surgical removal of all remaining regional lymph nodes. The second group took a watch-and-wait approach; they had follow-up doctor visits every four months for the first two years, every six months in the following three years, and then annually after that.

Doctors analyze the sentinel lymph node for signs of melanoma cells in order to stage the cancer and determine if it has spread beyond its primary location.

For watch-and-wait patients, their remaining lymph nodes were examined by ultrasound during the follow-up visits. If cancer was detected, a completion lymph node dissection was performed. The study was conducted at 63 medical centers around the world.

The results of the decade-long study were clear: There was no significant difference in the rate of deaths due to melanoma between the two groups. In both groups, 86% of the participants were still alive after three years of follow-up.

What’s more, the study echoes the findings of an earlier, somewhat smaller randomized trial conducted in Germany and published last year. “This is the second prospective randomized trial that came to the same conclusion,” Dr. Ariyan says. “There’s a tremendous amount of power in that.”

“It’s rare that we get such a clean, consistent result,” Dr. Coit adds.

Back to top Arrow (up) icon.Icon pointing upwards. Usually means that the containing element can be opened and closed.

Avoiding Unnecessary Side Effects

The finding of similar outcomes between immediate surgery and the watch-and-wait approach is important because removing lymph nodes can have complications. A major one is lymphedema, an uncomfortable and sometimes permanent and disfiguring swelling of the arms or legs. Roughly 24% of patients in the surgery group experienced lymphedema compared with 6% in the watch-and-wait group. (The lymphedema was mild in 64% of the surgery patients, moderate in 33%, and severe in 3%.)

If surgery is not going to affect your survival, why subject yourself to all of those risks?
Charlotte E. Ariyan
Charlotte E. Ariyan cancer surgeon

Lymph node dissection can also lead to problems with wound healing, the need for additional time off from work, and chronic pain.

In some instances, Dr. Ariyan notes, the risk of these side effects may be acceptable if there is reason to believe that people will live longer as a result of a treatment or procedure. But in this case, there was no added benefit. “If surgery is not going to affect your survival,” Dr. Ariyan asks, “why subject yourself to all of those risks?”

Back to top Arrow (up) icon.Icon pointing upwards. Usually means that the containing element can be opened and closed.

Less Is More

In his accompanying editorial, Dr. Coit draws a parallel with recent findings obtained in women with sentinel node positive breast cancer. In that group, a completion lymph node dissection did not improve outcomes either.

MSK has a long history in improving treatment options for people with melanoma, including through surgery. It was Dr. Coit who, more than 25 years ago, brought the technique of sentinel lymph node biopsy to MSK. Dr. Coit was a student of Donald Morton, the doctor who pioneered the method and showed that it was an effective way to gauge a patient’s prognosis. Doctors analyze the sentinel lymph node for signs of melanoma cells in order to stage the cancer and determine if it has spread beyond its primary location. Until this study, it was unclear whether someone with melanoma in their sentinel node should have immediate surgery to remove other nodes in the region or not.

Dr. Coit emphasizes that the people in all of these randomized trials deserve a lot of credit for their participation, noting that it takes courage to have your choice of treatment determined randomly by a computer. “The patients are the real heroes here,” he says. “They put themselves on the line so that thousands and thousands of other patients could be spared the morbidity of unnecessary surgery. It’s really extraordinary what they did.”

Back to top Arrow (up) icon.Icon pointing upwards. Usually means that the containing element can be opened and closed.

This study was supported by grants from the National Cancer Institute and by funding from the Borstein Family Foundation, Amyx Foundation, Dr. Miriam and Sheldon G. Adelson Medical Research Foundation, and John Wayne Cancer Institute Auxiliary.

Comments

Dr. Ariyan & Dr. Coit both operated on me and did an amazing job. Truly a miracle meeting these two awesome Doctors who with the help of a procedure that was a clinical study at the time kept me from getting lymphadema in my leg!!

Thank you for your nice note, Tom! We forwarded your comment to Drs. Ariyan and Coit.

My oncologist told me today that MDAnderson recommends further removal of all my lymph nodes under my right arm, to lower my risk of returning cancer. I'm super afraid of those risks associated with complete removal, I have enough effects from 2 nodes removed. He also said they don't recommend treatment just surgery.

Dear Tracey,
Unfortunately, we cannot comment on people's personal medical histories or offer advice on the blog, as each case is affected by a large number of factors. If you would like to make an appointment with a Memorial Sloan Kettering physician, please call our Physician Referral Service at
800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment

Thanks for your comment.

I had positive SLNB after WLE of medial thigh melonoma back in 2012. I struggled with side effects from the SLNB, and after the option to have full groin lymph node dissection OR follow up monitoring, I decided to continue with the surveillance option 5 years, 2 PET scans and 6 monthly check ups later I am reassured with a) the advice given by The Alfred hospital staff in Melbourne and the follow up surveillance back in christchurch NZ. This study is also a positive finding and I am pleased to read the results. And thankful for all participants! Rgds Warren

Dear Warren, thank you for sharing your story. Best wishes to you.

Wow, more good news on the melanoma homefront, and MSKCC at the cutting edge! I have been in the care of Dr Coit, Dr Ariyan and currently, Dr Wolchok for the past 8 years, and am very grateful for their knowledge, expertise, and comforting patient care. These doctors are keeping me alive, without a doubt, and I am ever grateful for all the new discoveries/therapies they are initiating at MSKCC. Congrats on Dr Ariyan's latest success!

Dear Anne, we're so glad to hear you're doing well. We will share your kind works with your medical team. Thank you for your comment, and best wishes to you!

Add new comment

We welcome your questions and comments. While we share many of them with our world-class doctors and researchers, we regret that in order to protect your privacy, we are not able to make personal medical recommendations on this forum, nor do we publish comments that contain your personal information. If you would like to consult with an MSK doctor, we encourage you to make an appointment at 800-525-2225 or request an appointment online.

Your email address is kept private and will not be shown publicly.