“In a single institution study reported in JAMA Surgery, Chung et al found a low axillary recurrence rate and low mortality among women with clinical T1–2N0 breast cancer aged ≥ 70 years who underwent breast-conserving surgery without sentinel node biopsy.
“The study involved 140 women treated at Cedars-Sinai Medical Center between January 2000 and December 2011. Patients had a median age of 83 years (range = 70–97 years); 74% had T1 tumors; 27% had grade 1, 44% grade 2, and 29% grade 3 tumors; 86% were estrogen receptor–positive; 73% were progesterone receptor–positive; 92% were HER2-negative; and 65% had ductal histology. Overall, 98% received chemotherapy, 76% radiotherapy, and 59% hormonal therapy…
“The investigators concluded: ‘Our study demonstrated low axillary recurrence and low mortality for patients with clinical T1–2N0 breast cancer who were 70 years of age or older and who underwent breast-conserving surgery without a sentinel node biopsy.’ “
“Patients with thick melanoma who had a negative sentinel lymph node biopsy had prolonged RFS, disease-specific survival and OS, according to study results.
“The findings demonstrate the prognostic utility of sentinel lymph node biopsy (SLNB) in these patients and suggest the technique should be indicated for use in this population, researchers wrote.
“ ‘The main goal of the current study was to evaluate the usefulness and prognostic value of SLNB in patients with thick melanoma,’ Maki Yamamoto, MD, of the division of surgical oncology at the University of California at Irvine Medical Center, told HemOnc Today. ‘Despite consensus regarding the role of SLNB in patients with intermediate-thickness melanoma, controversy persists concerning those patients with thin (<1 mm) and thick (>4 mm) melanomas.’
“Yamamoto and colleagues evaluated data from 571 patients without distant metastases who had melanomas at least 4 mm thick (median Breslow thickness, 6.2 mm; range, 4-25). The median age of patients was 66 years and 70.2% were male.”
The gist: This long article discusses concerns about the usefulness of the medical procedure sentinel lymph node biopsy. As explained by the NCI, a sentinel lymph node biopsy is a surgical procedure to remove the first lymph node that cancer cells are likely to spread to from the primary tumor. Removing it and analyzing it to look for cancer cells helps doctors figure out what stage a patient is at and helps them make treatment decisions. However, recent research has called into question whether the benefits of sentinel lymph node biopsy outweigh its costs and risks.
“Sentinel lymph node biopsy has long been the standard staging and prognostic modality for melanoma.
“Final results from the Multicenter Selective Lymphadenectomy Trial (MSLT-1) — published in February in The New England Journal of Medicine — confirmed the prognostic value of sentinel lymph node biopsy (SLNB) for patients with intermediate-thickness melanomas.
“Ten-year melanoma-specific survival was significantly worse among patients identified as having sentinel-node metastases compared with patients with tumor-free nodes (62.1% vs. 85.1%; HR=3.09; 95% CI, 2.12-4.49). Further, biopsy-based management was associated with improved 10-year melanoma-specific survival (HR=0.56; 95% CI, 0.37-0.84) and distant DFS (HR=0.62; 95% CI, 0.42-0.91) among patients with nodal metastases from intermediate-thickness melanomas.
“ ‘I continue to believe very strongly in the value of sentinel node biopsy, and our patients continue to choose it as an ideal way to stage their disease and help them make treatment decisions,’ Vernon K. Sondak, MD, chair of cutaneous oncology at Moffitt Cancer Center and a HemOnc Today Editorial Board member, said in an interview. ‘Accumulating data, including the final results of MSLT-1, have continued to support the role and value of sentinel node biopsy.’ ”
“However, results of MSLT-1 showed SLNB did not improve melanoma-specific survival — the trial’s primary endpoint — in the total study population (81.4% for biopsy vs. 78.3% for observation; HR=0.84; 95% CI, 0.64-1.09). Critics emphasize the melanoma-specific survival and DFS advantages observed in MSLT-1 were results of subgroup analyses.
“Despite the broad acceptance of SLNB’s prognostic utility, the lack of a therapeutic advantage has prompted some clinicians to question whether the procedure — which comes at a considerable financial cost, and also carries risks for overtreatment and morbidity — is justified. Research into alternative prognostic molecular assays also is underway.”
“Castle Biosciences Inc. today announced results of a 217-patient study demonstrating that its gene expression profile (GEP) test, DecisionDx-Melanoma, identified primary cutaneous (skin) melanoma tumors that were sentinel lymph node biopsy negative but were at high risk of metastasis. The GEP test also identified tumors that were unlikely to become metastatic, independent of nodal status. The data are being reviewed today at the 50th Annual Meeting of the American Society of Clinical Oncology (ASCO) in the Melanoma/Skin Cancers Poster Highlights Session by David H. Lawson, M.D., Professor of Hematology and Medical Oncology, Winship Cancer Institute, Emory University.”
Editor’s note: More and more, doctors are using molecular testing methods to make diagnoses and guide treatment decisions. Now, molecular testing may be able to help determine whether a melanoma tumor is likely to metastasize (spread to other parts of the body). A procedure called sentinel lymph node biopsy is commonly used to measure the severity of a melanoma diagnosis; a “negative” sentinel node biopsy indicates low risk of metastasis. But some patients with negative sentinel node biopsies still go on to experience metastasis. A new molecular test called DecisionDx-Melanoma can identify cutaneous melanoma tumors that are at risk of metastasizing, regardless of sentinel node biopsy results. The test analyzes the activity of 31 genes in a tumor to determine risk of metastasis.
Sentinel lymph node biopsy after wide excision improved DFS compared with wide excision alone among patients with intermediate and thick melanomas, according to final results of the MSLT-1 trial presented at the HemOnc Today Melanoma and Cutaneous Malignancies meeting in New York.
“ ‘We found that performing sentinel lymph node biopsy is very accurate and improves staging in order to determine whether additional treatments are needed, such as additional surgery or adjuvant systemic therapy,’ Robert H.I. Andtbacka, MD, CM, FACS, FRCSC, associate professor of surgery at Huntsman Cancer Institute at the University of Utah, said during a presentation. ‘It also forms a basis for us to perform all the subsequent studies that we do in melanoma to make sure patients we have for our clinical trials are well balanced.’ “
Editor’s note: DFS stands for disease-free survival.
“Nonsentinel lymph node (NSLN) status in patients who underwent complete lymph node dissection after positive sentinel lymph node biopsy (SLNB) had independent prognostic value in patients with two to three positive lymph nodes, according to the results of a study published recently in the Journal of Clinical Oncology.
“Furthermore, researchers led by Sandro Pasquali, MD, of the University of Padova, Italy, found that patients who had metastatic disease in their NSLN had their risk for melanoma death increased by more than one-third.”
Editor’s note: Sentinel lymph nodes (those closest to the tumor) can be examined to predict whether a patient will survive melanoma. This study shows that nonsentinel lymph nodes could potentially be used for survival predictions. We covered a similar story last July.
“New guidelines supporting the broader use of sentinel lymph node biopsy in women with early-stage breast cancer have been issued by the American Society of Clinical Oncology (ASCO). The guidelines were published in the Journal of Clinical Oncology.
“ASCO recommends the use of sentinel node biopsy in most patients, rather than the more invasive axillary lymph node dissection, which is linked to a higher risk of complications.”
“Castle Biosciences Inc. has announced study results showing its gene expression profile (GEP) test (DecisionDx-Melanoma) can identify primary cutaneous (skin) melanoma tumors that are likely to metastasize in patients who had a negative sentinel lymph node biopsy. The data are being presented at the Latest in Dermatology Research Symposium session of the 72nd Annual Meeting of the American Academy of Dermatology. The DecisionDx-Melanoma test completed validation in 2013 and is widely used to determine metastatic risk in Stage I and II melanoma patients.”
“Research at UCLA on a technique for detecting the earliest spread of melanoma, the deadliest form of skin cancer, has confirmed that the procedure significantly prolongs patients’ survival rates compared with traditional “watch and wait” techniques.
“The technique, which combines lymphatic mapping and sentinel-node biopsy, allows doctors to quickly determine whether the disease has spread, or metastasized, to the lymph nodes, which occurs in approximately 20 percent of patients. Patients with cancer in their lymph nodes may benefit from having their other nearby lymph nodes removed. For the other approximately 80 percent of patients in whom the tumors have not spread to the lymph nodes, the technique spares the patient from unnecessary surgery and its associated complications and substantial costs.”