New study finds that lymph node removal isn't necessary for all melanoma patients

July 17, 2017, Intermountain Medical Center
Many patients with melanoma need a sentinel-lymph-node biopsy to determine if cancer cells have spread there, but a positive finding doesn't mean all the lymph nodes in the area must be removed, according to new international study. Credit: Intermountain Medical Center

Many patients with melanoma need a sentinel-lymph-node biopsy to determine if cancer cells have spread there, but a positive finding doesn't mean all the lymph nodes in the area must be removed, according to new international study.

Many with melanoma need a biopsy to determine if cancer cells have spread there, but a positive finding doesn't mean all the lymph nodes in the area must be removed, according to a new international study conducted in part by researchers in Utah that may change standard treatment for melanoma patients whose cancer has spread.

The international study involving 63 centers, including Intermountain Healthcare's Intermountain Medical Center and the Huntsman Cancer Institute in Salt Lake City, involving more than 3,500 patients, suggests any survival advantage associated with removing all the lymph nodes in the area closest to the melanoma is too small to justify the complications patients may suffer from having them removed.

Approximately one-fourth of the patients in the randomized phase-three trial were treated for melanoma at Intermountain Medical Center or the Huntsman Cancer Institute.

Findings from the study were published in the New England Journal of Medicine.

Melanoma is a comparatively rare but potentially deadly form of skin cancer. Although it makes up fewer than one percent of all skins cancers, melanoma is responsible for most skin cancer deaths, according to the American Cancer Society. Roughly 87,000 new cases of invasive melanoma are diagnosed in the United States each year.

Lymph nodes are small glands that carry fluids, nutrients, and waste between tissue and the bloodstream. The lymphatic system plays a key role in the body's immune response to infection and disease.

Because melanoma can spread to the lymph nodes, a routine step in treatment often involves removing the closest draining lymph node, called the sentinel node, and checking it for melanoma cells. For melanoma on an arm, for example, that nearest lymph node would be in the armpit, while the nearest lymph node for melanoma on the foot would be in the groin.

When a biopsy detects melanoma in a sentinel node, standard treatment has been to remove all the nearby nodes, which sometimes triggers complications, said Tawnya L. Bowles, MD, one of the study authors, and principal site investigator at Intermountain Medical Center.

"It can be a very big deal for patients," said Dr. Bowles. "They can have repeat hospitalizations for infections in their extremities. They can have life-limiting, painful swelling where they can't do the activities they like to do or wear their usual clothing. It's a significant, real problem for patients who are affected."

The new study, called the Multicenter Selective Lymphadenectomy Trial II, enrolled 3,531 patients who had melanoma. Of those, 1,939 patients had an abnormal and were randomly assigned to one of two groups for further study and treatment.

One group received the standard of care and had all the lymph nodes in the area removed. The other group had ultrasounds of the remaining lymph nodes instead of more surgery. For the first two years, they had ultrasounds every four months, followed by ultrasounds every six months out to five years. Two years and five years are significant time points for recurrence, Dr. Bowles said.

In the ultrasound group, if the lymph node got bigger or other abnormalities were detected, a needle biopsy was done to look for melanoma. If it was detected, the other lymph nodes were removed. If the ultrasound was normal over the study period, patients kept all but their sentinel lymph nodes and didn't have more surgery.

The survival rates of the two groups were compared to see if patients who had multiple lymph nodes removed were more likely to be alive three years later compared to those who kept them.

The study found no significant difference in melanoma-specific survival at three years. But for patients who had those lymph nodes removed, the risk of swelling in the affected arm or leg was four times greater compared to whose lymph nodes were intact.

Some in the group whose lymph nodes were left in place had a recurrence in their lymph nodes. When melanoma recurred in a lymph node, the patients were treated and mortality didn't significantly increase during the study.

Removing the sentinel lymph node for biopsy is of major importance, according to the study authors.

"If the sentinel-node biopsy hadn't been done, the tumor present in the lymph node would have grown and progressed," said Dr. Bowles. "Checking that lymph node is really important, but many patients can be spared taking out the others."

The study raises another question that's yet to be sorted out. With melanoma, immune therapy is often given as an added, or adjuvant, treatment. But most studies of adjuvant therapy have been done in patients who had all their lymph nodes removed after an abnormal sentinel-lymph-node biopsy. That means researchers know how well the therapies work in those patients, but not whether immune therapy results would change if the nodes remain in place. The treatment could be just as effective, but isn't yet proven in clinical studies.

"The question of immune therapy is important, because while removing lymph nodes eliminates the risk that melanoma will spread there, it doesn't stop melanoma from spreading to organs, bones, and distant lymph nodes," Dr. Bowles said. "Patients who die typically die of those distant metastases."

This isn't the first time that spread of cancer through lymph nodes has been studied. Similar findings regarding treatment when breast cancer spreads to lymph nodes have already changed the standard of care for those patients. A positive sentinel node biopsy no longer automatically means all in the area will be removed.

Dr. Bowles hopes that will be the case with melanoma.

"I hope dermatologists and other healthcare professionals who treat melanoma will understand the sentinel node biopsy is still important, but not all patients need to have follow-up surgery to remove all the other nodes if that sentinel node is positive for melanoma," she said.

Intermountain Healthcare researchers plan to follow the study-enrolled patients in their clinic, looking for 10-year survival and recurrence rates.

"Because we have a large group of patients who were in the ultrasound group, we hope to learn more about their outcomes. Did they have immune treatment? How did they do over time?" Dr. Bowles said. "We're looking forward to continued insights and more advancements in the standard of care for patients."

Explore further: Delaying lymph node biopsy after melanoma diagnosis does not affect survival rates

Related Stories

Delaying lymph node biopsy after melanoma diagnosis does not affect survival rates

June 28, 2017
Postponing lymph node biopsy more than 30 days after melanoma diagnosis doesn't adversely impact long-term clinical outcomes, according to new study findings published online as an "article in press" on the Journal of the ...

Study: Common surgical treatment for melanoma does not improve patients' overall survival

June 7, 2017
Patients who receive the standard surgical treatment for melanoma that has spread to one or more key lymph nodes do not live longer, a major new study shows.

Less invasive surgery detects residual breast cancer in lymph nodes after chemotherapy

December 5, 2012
Most patients whose breast cancer has spread to their lymph nodes have most of the lymph nodes in their armpit area removed after chemotherapy to see if any cancer remains. A study conducted through the American College of ...

Sentinel node biopsy safe, effective in head and neck melanomas

August 5, 2011
A common technique for determining whether melanoma has spread can be used safely and effectively even in tumors from the head and neck area, according to a new study from the University of Michigan Comprehensive Cancer Center.

Study finds no need for lymph node surgery in some melanomas

May 30, 2015
Worldwide, people who are diagnosed with melanoma are urged to have any lymph nodes that test positive for cancer removed, but researchers said Saturday the operation doesn't necessarily help patients live longer.

Interferon not beneficial for most stage III melanoma

February 15, 2016
Final results for the Sunbelt Melanoma Trial, published online this month in the Journal of Clinical Oncology, show that thanks to current diagnostic techniques, most stage III melanoma patients do not benefit from treatment ...

Recommended for you

Single blood test screens for eight cancer types

January 18, 2018
Johns Hopkins Kimmel Cancer Center researchers developed a single blood test that screens for eight common cancer types and helps identify the location of the cancer.

How cancer metastasis happens: Researchers reveal a key mechanism

January 18, 2018
Cancer metastasis, the migration of cells from a primary tumor to form distant tumors in the body, can be triggered by a chronic leakage of DNA within tumor cells, according to a team led by Weill Cornell Medicine and Memorial ...

These foods may up your odds for colon cancer

January 18, 2018
(HealthDay)—Chowing down on red meat, white bread and sugar-laden drinks might increase your long-term risk of colon cancer, a new study suggests.

The pill lowers ovarian cancer risk, even for smokers

January 18, 2018
(HealthDay)—It's known that use of the birth control pill is tied to lower odds for ovarian cancer, but new research shows the benefit extends to smokers or women who are obese.

Researchers find a way to 'starve' cancer

January 18, 2018
Researchers at Vanderbilt University Medical Center (VUMC) have demonstrated for the first time that it is possible to starve a tumor and stop its growth with a newly discovered small compound that blocks uptake of the vital ...

Modular gene enhancer promotes leukemia and regulates effectiveness of chemotherapy

January 18, 2018
Every day, billions of new blood cells are generated in the bone marrow. The gene Myc is known to play an important role in this process, and is also known to play a role in cancer. Scientists from the German Cancer Research ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.