Critical Review of the Sentinel Lymph Node Surgery in Malignant Melanoma

May 2022 | Volume 21 | Issue 5 | Original Article | 510 | Copyright © May 2022


Published online April 29, 2022

doi:10.36849/JDD.6198

Dipali Rathod DNB DDVL,a George Kroumpouzos MD,b Aimilios Lallas MD,c Babar Rao MD,d Dedee F. Murrell MD,e Zoe Apalla MD,f Stephan Grabbe MD,g Carmen Loquai MD,g Mohamad Goldust MDh

aConsultant Dermatologist, Mumbai, India
bDepartment of Dermatology, Alpert Medical School of Brown University, Providence, RI and Department of Dermatology, Medical School of Jundiaí, São Paulo, Brazil
cFirst Dermatology Department, Aristotle University of Thessaloniki, Greece
dDepartment of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, NJ and Department of Dermatology, Weill Cornell Medical Center, New York, NY
eDepartment of Dermatology, St George Hospital, Faculty of Medicine, University of New South Wales, Sydney, Australia
fSecond Dermatology Department, Aristotle University of Thessaloniki, Greece
gDepartment of Dermatology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
hDepartment of Dermatology, University Medical Center Mainz, Mainz, Germany

Abstract
Malignant melanoma is one of the most aggressive solid tumors but has low morbidity if treated at an early stage. Over the past decade, the advent of targeted therapy and immunotherapy have productively enriched the treatment options for advanced melanomas and further improved the prognosis. The treatment of melanoma is a rapidly evolving field. In patients with sentinel lymph node (SLN)-positive (SLN+) melanoma, the role of complete lymph node dissection (CLND) is still a matter of debate. Sentinel lymph node biopsy (SLNB) is a staging procedure for melanoma that is routinely offered to patients with tumor thickness ≥1 mm or ≥0.8 mm with additional risk factors and is widely accepted as an important diagnostic and prognostic tool, since SLN+ patients can receive adjuvant targeted treatment or immunotherapy. Currently, the role of CLND has largely been replaced by often recommended adjuvant therapies since their approval. This article provides an overview of sentinel lymph-node surgery in cutaneous melanoma.

J Drugs Dermatol. 2022;21(5):510-516. doi:10.36849/JDD.6198

INTRODUCTION

Cutaneous melanoma (CM) is a malignant neoplasm arising from melanocytes.1 Even though melanoma accounts for less than 5% of all skin cancers, the majority of skin cancer deaths are due to melanoma.2 CM is the second most diagnosed cancer in individuals aged 15-29 years in the United States3, while it is the tenth most common cause of death in Australia.4 Recently, an equilibrium has been established in the United States with respect to melanoma mortality.5 Despite a steady increase in the incidence of CM worldwide over the last decades, which might also be due to improved early detection, mortality has remained almost constant in the last decades. The status of the regional lymph nodes is regarded as one of the most important prognostic factors besides the information from the primary melanoma. Traditionally, elective lymph node dissection (ELND) was carried out as a diagnostic and therapeutic procedure in malignant melanomas. However, nowadays sentinel lymph node biopsy (SLNB), a minimally invasive procedure, is considered the gold standard to determine the tumor status of regional nodes and staging of patients with subclinical nodal metastases in patients with tumor thickness ≥1 mm or ≥0.8 mm with additional risk factors. The concept of SLNB was introduced by Morton in the early 90s and it is based on the observation that the lymphatic flow follows a constant anatomical route, with the tumor cells directly draining into one or more lymph nodes. By performing an SNLB, the first lymph nodes (or nodes) will be identified.6 SLNB is considered a feasible and reliable procedure in patients with 1-4 mm and >4 mm thick tumors, which has shown metastases in only 20% of cases and lower complication rates than ELND. A meta-analysis of 71 studies estimated the possibility of nodal recurrence after negative SLNB at ≤5% and recurrence at any site at approximately 10%. However, over the last decade, studies have shown an upward trend of falsenegative findings in SLNB, which may lead to wrong prognostic estimates and treatment strategies in these patients.7

Hematoxylin eosin or immunohistochemical (IHC) staining is currently utilized to delineate microscopic nodal metastases
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