Highlights
- •Regional node recurrence risk ~40% without sentinel node biopsy or immunotherapy
- •Risk lowered to ~27% with adjuvant immunotherapy alone
- •Risk lowered to ~14% with sentinel node biopsy alone
- •Risk lowered to ~9% with both adjuvant immunotherapy and sentinel node biopsy
Abstract
The prognostic value of sentinel node biopsy (SNB) is well established and SNB was
therefore adopted as a requirement for pathological staging of melanomas >1mm thick
in the AJCC-8th edition. Consequently, a negative SNB-status became an eligibility criterion for
clinical trials of adjuvant systemic therapy in resected stage IIB/C melanoma. However,
since the Keynote 716 trial demonstrated an improvement in relapse-free survival (RFS)
in patients with Stage IIB/C melanoma, all of whom had SNB-staging, some have argued
that SNB is no longer required for patients with T3 and T4 primary melanomas. The
rationale for omitting SNB is that these patients will be able to access adjuvant
immunotherapy regardless of SNB-status, avoiding the costs and potential complications
of SNB. However, this argument overlooks the prognostic value of knowing a patient’s
nodal status and the therapeutic benefit of SNB in regional disease control. Based
on extrapolation of data from multiple sources we demonstrate that the risk of regional
node-field relapse with SNB and immunotherapy for T3b and T4 melanomas is around 7-9%
but is 20-27% without SNB. Similarly, the node-field recurrence rate with SNB alone
is around 14% compared to around 40% with no SNB or immunotherapy. Consequently, in
the absence of prospective data, we propose that the optimal management of the regional
node-field for high risk T3b and T4 primary melanomas is likely to be achieved by
combining SNB and adjuvant immunotherapy for those patients who are suitable, rather
than either treatment alone.
Keywords
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Article info
Publication history
Accepted:
March 12,
2023
Received in revised form:
February 15,
2023
Received:
December 14,
2022
Publication stage
In Press Accepted ManuscriptIdentification
Copyright
© 2023 Elsevier Ltd. All rights reserved.
