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Invited Critique
April 2002

Elective Lymph Node Dissection in Patients With Melanoma—Invited Critique

Arch Surg. 2002;137(4):461. doi:10.1001/archsurg.137.4.461

The optimal surgical management of the regional nodal basin in cutaneous melanoma has long been an area of controversy. Four prospective trials have been conducted to determine whether ELND is superior to observation; unfortunately, no survival benefit has been observed. Lens et al report the results of a meta-analysis combining data from 3 of these trials. Using the end point of overall survival at 5 years, they observed a nonsignificant pooled odds ratio of 0.86 in favor of ELND. The authors assert that the trials are of questionable validity and call for an additional large-scale trial to resolve this issue. It is unlikely that another prospective randomized trial of ELND will be conducted given the development of sentinel lymph node biopsy (SLNB). The goals of surgery directed at the regional nodal basin for cutaneous melanoma include identification of metastases and therapeutic removal of these metastases. Sentinel lymph node biopsy has surpassed ELND as a staging modality and has been widely accepted by surgeons throughout the world. Although Lens et al recognize the continued controversy regarding SLNB, the advantages in staging and subsequent risk stratification outweigh the potential risks, and SLNB has been adopted by most melanoma centers worldwide.1 Furthermore, it is recognized that some patients are indeed cured with ELND; however, these numbers may be small, and accurate identification of these patients remains difficult.2 Approximately 20% of patients will be found to harbor microscopic metastases at ELND; perhaps one quarter to one half of these will achieve a survival benefit from ELND. The majority of patients subjected to ELND will not benefit, further supporting SLNB in the management of cutaneous melanoma. While Lens et al attempt to end the controversy regarding ELND in cutaneous melanoma through the performance of a meta-analysis, the development of SLNB has essentially sealed the fate of ELND.