THEORETICAL AND EMPIRICAL ARGUMENTS IN RELATION TO ELECTIVE LYMPH-NODE DISSECTION FOR MELANOMA

Nearly a century of clinical inquiry has failed to incontrovertibly re solve the question of whether elective lymph node dissection is therap eutically beneficial in the management of clinically localized melanom a. The controversy has been renewed by a recent interim update from th e Intergroup Melanoma Surgical Program, sponsored by the National Canc er Institute, which has indicated a small survival benefit in a narrow ly defined subgroup of patients with primary melanoma. That report sti mulated this review of the data, which are presented in the historical context that originally prompted the Intergroup study. Case selection bias has intractably hindered firm conclusions from the numerous nonr andomized studies of elective lymphadenectomy. The two original random ized trials that were executed during the 1970s failed to uncover any significant effect of the procedure on survival. Definitive conclusion s from the recent Intergroup report are limited by the likelihood that the observed therapeutic benefits are a chance occurrence resulting f rom uncorrected multiple subgroup comparisons. It remains uncertain wh ether elective lymphadenectomy can be therapeutically beneficial in th e management of melanoma. Nevertheless, it is clear that the procedure , or preferably sentinel lymphatic mapping with selective lymphadenect omy, can provide clinically relevant prognostic information, as well a s the staging data requisite to adjuvant interferon alfa-2b therapy or enrollment into other adjunctive trials for patients at high risk of clinical relapse.