Journal of Clinical Oncology, Vol 6, 163-172, Copyright © 1988 by American Society of Clinical Oncology
The role of elective lymph node dissection in melanoma: rationale, results, and controversies
CM Balch
Department of General Surgery, M.D. Anderson Hospital and Tumor Institute, Houston, TX 77030.
Elective lymph node dissection (ELND) for patients with clinically occult
metastatic melanoma in regional lymph nodes has the goal of curing
metastases with a surgical treatment. This is in contrast to the low
probability for surgical cure in patients with clinically detectable lymph
node metastases. The rationale for elective node dissection is based on a
hypothesis that melanoma metastasizes sequentially via lymph nodes and then
to distant sites. A subgroup of melanoma patients with high risk for
regional node micrometastases but low risk for distant micrometastases has
been identified from prognostic factors analysis of large patient series,
as well as surgical results of nonrandomized clinical trials. However, two
nonrandomized surgical trials have failed to show a survival benefit for
ELND. These studies were largely performed in female patients with
extremity melanomas and there were limitations that preclude a definitive
conclusion. No randomized trials have been conducted involving melanomas of
the trunk or head and neck. Two prospective randomized surgical trials are
now being conducted in North America and in Europe. Until the results of
these trials are available, physicians are encouraged to enter patients
into these ongoing clinical trials or consider ELND in selected patients
where the benefit-risk ratio justifies it. Factors to be considered in this
decision include intermediate tumor thickness (ie, 1 to 4 mm thickness),
anatomic site, histology (ulceration and growth pattern), and the risk of
the operation in individual patient settings.
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