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Utility of Computed Tomography and Magnetic Resonance Imaging Staging Before Completion Lymphadenectomy in Sentinel Lymph Node–Positive Melanoma

Department of Surgery, University of California San Francisco, San Francisco, CA

To the Editor:

In their excellent study, Aloia et al have confirmed our results that modern computed tomography and magnetic resonance imaging do not detect distant metastases in patients with melanoma metastatic to sentinel lymph nodes.^1,2 With the addition of their 314 patients to the 185 already reported, the detectable distant metastasis rate in stage III melanoma patients at the time of selective sentinel lymph node dissection (SLND) can be more accurately estimated at approximately 1.2% (range, 0.5% to 1.9%). Furthermore, because Aloia et al had several patients with distant metastases, the risk factors for detectable distant metastasis within 3 months of SLND have been further refined to include patients with very thick (> 3.5 mm) ulcerated melanomas with large tumor burdens metastatic to regional lymph node basins. Conversely, these data should not be interpreted in a way that results in tumors that are thick or ulcerated or have high regional tumor burden being classified as needing further imaging via computed tomography or magnetic resonance imaging. False-positive rates of 12% to 14% make this a potentially dangerous treatment protocol (for example, although ulceration was shown to be an independent risk factor for distant metastasis; P = .018; 107 of 112; 96%; ulcerated melanomas were negative for distant metastasis).

What would be particularly interesting is to know whether or not any of the five patients with distant metastases were symptomatic. In our original study, only asymptomatic patients received SLND. However, when the history of the one patient with true distant metastasis was reviewed, he had developed constitutional symptoms after initial diagnosis but before SLND. If in retrospect these patients were actually symptomatic, a valuable clue would be added to the ones already brought forth by Aloia et al, aiding the discrimination of those patients with stage III disease who do need imaging for staging from the majority who do not.

Author's Disclosures of Potential Conflicts of Interest

The author indicated no potential conflicts of interest.

REFERENCES

1. Aloia TA, Gershenwald JE, Andtbacka RH, et al: Utility of computed tomography and magnetic resonance imaging staging before completion lymphadenectomy in patients with sentinel lymph node-positive melanoma. J Clin Oncol 24 : 2858 -2865, 2006[Abstract/Free Full Text]

2. Miranda EP, Gertner M, Wall J, et al: Routine imaging of asymptomatic melanoma patients with metastasis to sentinel lymph nodes rarely identifies systemic disease. Arch Surg 139:831-836, 2004; discussion 836-837, 2004

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  Thomas A. Aloia and Paul F. Mansfield
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