Current management of regional lymph nodes in patients with melanoma

Abstract

I have no conflicts of interest or relevant financial affiliations to disclose. I appreciate the thoughtful comments by Dr Ciancio et al on the recent review, “Current management of regional lymph nodes in patients with melanoma.” They raise two points that were under‐ discussed in the manuscript. First, the management of lymphedema continues to evolve, and additional therapeutic options help to mitigate the percentage of patients who are subjected to this potentially life‐long complication. While avoidance of unnecessary completion lymphadenectomies in favor of nodal observation is likely to be the most impactful way to decrease lymphedema at a population level, melanoma patients will inevitably suffer this complication after therapeutic lymphadenectomy or even sentinel lymph node (SLN) biopsy alone. The efficacy of lymphatic‐ lymphatic bypass, lymphovenous bypass, or lymph node transfer to treat patients with lymphedema that fail nonoperative management is promising and certainly warrants further investigation. Similarly, while the indications remain unclear, prophylactic procedures may also prove to be effective at decreasing the risk of lymphedema. The second issue is the distinct considerations regarding the management of patients with head and neck melanoma. As Dr Ciancio’s study and others demonstrate, the accuracy of SLN biopsy in head and neck melanoma is decreased. Anatomic considerations such as the complex drainage pattern and the difficult logistics associated with mapping clearly contribute. Furthermore, head and neck primaries are more frequently ulcerated, thicker, and tend to occur in older, male patients. These factors are associated both with increased false‐negative SLN biopsy rates as well as risk of recurrence and death from disease. I agree with Dr Ciancio et al that head and neck primaries require specific, thoughtful consideration for all of these reasons. I would propose, however, that disease‐free survival should not be our primary outcome of interest. We know that early detection of microscopic nodal disease is prognostic but not therapeutic. As such, a higher recurrence rate in the head and neck nodal basin is unlikely to translate into worse disease‐specific survival as long as the recurrence is diagnosed in a timely fashion (ie, nodal basin observation by ultrasound in MSLT‐2). Across all patients with head and neck melanoma, the rate of a nodal recurrence after a negative sentinel lymph node biopsy is approximately 5%, but this is certainly increased in patients with additional high‐risk features. Perhaps advanced primary head and neck patients are a cohort in whom follow‐up with nodal basin ultrasound, with or without cross‐sectional imaging, could be considered even after a negative SLN biopsy.