Less Is More
June 25, 2012

What the Surgeon Should Have Said to My Patient With Thin Malignant Melanoma

Author Affiliations

Author Affiliations: The SouthEast Alaska Regional Health Consortium (SEARHC), Ethel Lund Medical Center, Juneau (Dr Benjamin); and Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel (Dr Froom).

Arch Intern Med. 2012;172(12):906. doi:10.1001/archinternmed.2012.1246

A 46-year-old man incidentally discovered a pigmented lesion near the medial edge of his right scapula. There were no palpable lymph nodes. The biopsy revealed a malignant melanoma with favorable prognostic indicators: 0.5 mm deep, with focal infiltration of the papillary dermis; less than 1 mitosis per mm2; no ulceration; and areas with reactive lymphocytic and plasma cell infiltration (99% chance of 10-year survival1). A renowned surgical oncologist recommended wide excision with sentinel lymph node biopsy, saying,

It is up to you, but you have a risk that there is spread into your lymph nodes. It has been shown that patients with nodal disease operated on at an early stage do better than those having total lymph node resection at a later stage when an enlarged lymph node is palpable. By doing this procedure, I could save your life.

The only randomized controlled study on sentinel lymph node biopsy did not include patients with thin melanoma but only those with lesions of at least 1.2 mm2; the death rate from malignant melanoma was nearly identical in the group with sentinel lymph node biopsies compared with those whose lymph nodes were biopsied only if enlarged. However, those with microscopic disease did better than those with palpable lymphadenopathy. This comparison, however, is unwarranted and misleading.3

It is incorrect to compare outcomes of patients with palpable lymphadenopathy with those with normal-sized lymph nodes. Obviously, the disease is at an earlier stage, and incidentally discovered disease is on average less aggressive, with a possibility that positive sentinel nodes might not progress because of the body's natural immunity. There also could be adverse effects from the intervention itself. The unambiguous finding of this trial is that there was no advantage of sentinel node biopsy over observation.3

Expert opinion recommends discussing treatment options in patients with thin malignant melanoma and poorer prognostic factors. Even that recommendation is not evidence based and is influenced by the public and the medical establishment's belief that catching disease early on gives a better chance for cure and a longer life.

The surgeon should have said,

A wide excision alone gives you an excellent chance of cure. No studies have shown that sentinel node biopsy will improve your chances, and we do not know if you would benefit from the discovery of microscopic lymph node disease.

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Article Information

Correspondence: Dr Froom, Department of Epidemiology and Preventive Medicine, School of Public Health, Tel Aviv University, Maagan Michael, DN Menashe 37805, Israel (

Financial Disclosure: None reported.

Funding for Less Is More: Staff support for topics research funded by grants from the California Health Care Foundation and the Parsemus Foundation.

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Retsas S. Sentinel-node biopsy in malignant melanoma [letter].  N Engl J Med. 2007;356(4):419PubMed