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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article provides an overview of the fundamentals of recent guidelines concerning sentinel lymph node biopsy (SLNB) in melanoma. It goes on to discuss the risk of recurrence associated with positive, and negative SLNB results and the value of SLNB for thin melanomas (T1, Breslow thickness =1.00 mm),\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EOncology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESoft Tissue Cancers\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ELymphatic Diseases\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EOncology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ESoft Tissue Cancers\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ELymphatic Diseases\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EOncology\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EGUIDELINE FUNDAMENTALS FOR SLNB IN MELANOMA\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EVernon K. Sondak, MD, Chair, Moffitt Cancer Center, Tampa, Florida, USA, provided an overview of the fundamentals of recent guidelines concerning sentinel lymph node biopsy (SLNB) in melanoma. Lymphatic flow drains from skin regions to one or a few SLNs. If the SLNs are negative for melanoma, it is unlikely that other nodes will contain cancer cells.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EDetailed examination of biopsied SLN tissue is possible; serial sectioning and immunohistochemistry can reveal even a handful of tumor cells within the lymph node, which can be indicative of stage III melanoma. Identification can be followed by surgical excision utilizing a radioactive tracer and a dye to precisely target the region of concern.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EThere are several potential benefits of SLNB:\u003C\/p\u003E\n         \u003Cp\u003E\n            \u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n                  \u003Cp id=\u0022p-6\u0022\u003E\u25aa Staging is paramount; accurate tumor staging aids the prognosis of the risk of recurrence and melanoma-related death\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n                  \u003Cp id=\u0022p-7\u0022\u003E\u25aa Prolonged relapse-free survival\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n                  \u003Cp id=\u0022p-8\u0022\u003E\u25aa Lymphadenectomy for micrometastatic disease, rather than waiting for classical palpation\/radiologic clinical detection of metastasis, can reduce regional failure\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n                  \u003Cp id=\u0022p-9\u0022\u003E\u25aa Lymphadenectomy for micrometastatic disease is associated with fewer complications than surgery for clinically evident disease, and less lymphedema\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n         \u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe ultimate goal of SLNB is improved melanoma-specific survival. Lymphadenectomy for micrometastatic disease and early use of adjuvant therapy, rather than treatment upon clinical detection of the tumor, could increase the cure rate.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EHowever, SLNB poses potential risks. Seroma and wound infection may require drainage or antibiotic therapy. A false-negative result can delay recognition, and hence treatment, of regional lymph node metastasis. In-transit recurrence caused by interruption of the lymphatic pathway was once thought capable of trapping tumor cells between the primary location and the lymphatic basin, although this may not be an actual concern. However, lymphedema can result from interrupted flow of lymphatic drainage. Finally, nerve injury can occur, particularly in the head and neck region, since lymph nodes often transit alongside nerves. The potential risks can increase mortality of completion lymphadenectomy (a complete lymph node dissection following a positive SLNB) in contrast to a therapeutic lymphadenectomy following palpable detection of tumor.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003ERecognition of the benefits and risks of SLNB, particularly for intermediate thickness melanoma, has prompted the incorporation of relevant guidelines in the national clinical practice guidelines of many countries. In July 2012, the American Society of Clinical Oncology (ASCO) and the Society of Surgical Oncology (SSO) issued evidence-based joint clinical practice guidelines on SLNB for melanoma (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E) [Wong SL et al. \u003Cem\u003EAnnals Surg Oncol\u003C\/em\u003E 2012; \u003Cem\u003EJ Clin Oncol\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13463\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13463\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13463\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003ESummary of ASCO\/SSO Joint Guidelines for SLNB\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ERISK OF RECURRENCE ASSOCIATED WITH POSITIVE AND NEGATIVE SLNB RESULTS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-16\u0022\u003ESandra L. Wong, MD, MS, University of Michigan, Ann Arbor, Michigan, USA, discussed the risk of recurrence associated with positive and negative SLNB results and their implications for adjuvant clinical trial design and enrollment.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EThe ASCO\/SSO 2012 guidelines were largely based on a meta-analysis of the pertinent literature comprising 71 studies and 25,240 patients [Valsecchi ME et al. \u003Cem\u003EJ Clin Oncol\u003C\/em\u003E 2011] that focused on the indications for SLNB and the role of completion lymph node dissection (CLND). The overall false-negative rate was 12.5% and the post-test probability negative (PTPN) rate was 3.4%. The PTPN, which differs from a false-negative rate, is calculated as the number of patients with negative SLNB who recurred divided by all patients with negative SLNB. Both statistics are important in defining recurrence, particularly the risk that a negative result was incorrect.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EHowever, the PTPN result may be the more important of the two values in assessing the risk of recurrence after a negative SLNB result. Data from studies examining the cumulative incidence of detection of nodal metastases detection by SLNB versus observation have demonstrated a similar rate (\u223c21%) after 10 years, indicating the accuracy of the biopsy approach as a predictor of the development of nodal metastases (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). The appreciable time gap between biopsy-mediated and clinical detection supports the prognostic value of CLND, which is currently recommended for SLNB-positive patients.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EHowever, \u223c8% of patients who have CLND still experience disease recurrence, indicating that CLND does not provide an absolute guarantee that recurrence will not occur. This has prompted discussion of the therapeutic value of CLND. This issue may be resolved following completion of the ongoing Multicenter Selective Lymphadenectomy Trial-II [MSLT-II; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00297895\u0026amp;atom=%2Fspmdc%2F13%2F6%2F6.atom\u0022\u003ENCT00297895\u003C\/a\u003E] a randomized, open-label study, which will compare CLND with observation in patients with positive SLNB. But the current evidence suggests that patients with positive SLNB undergo CLND, or discuss options such as a clinical trial to evaluate alternative therapies.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/6\/6\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Cumulative Incidence of Nodal Metastases: SLNB Versus Observation\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-797884330\u0022 data-figure-caption=\u0022Cumulative Incidence of Nodal Metastases: SLNB Versus Observation\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/6\/6\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/6\/6\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/6\/6\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13462\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-20\u0022 class=\u0022first-child\u0022\u003ECumulative Incidence of Nodal Metastases: SLNB Versus Observation\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from SL Wong, MD, MS.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-21\u0022\u003ESLNB results have predictive and prognostic value, but not direct therapeutic value in terms of a survival benefit. Importantly, prediction allows patient stratification, which is crucial in clinical trial design and enrollment.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESLNB FOR THIN MELANOMA\u003C\/h2\u003E\n         \u003Cp id=\u0022p-22\u0022\u003EJeffrey E. Gershenwald, MD, University of Texas MD Anderson Cancer Center, Houston, Texas, USA, discussed the value of SLNB for thin melanomas (T1, Breslow thickness \u22641.00 mm). The current American Joint Committee on Cancer classification defines thin melanoma as the absence of ulceration and mitotic activity throughout the tumor \u0026lt;1 mitosis\/mm\u003Csup\u003E2\u003C\/sup\u003E (T1a) or in the presence of ulceration or \u0026gt;1 mitosis\/mm\u003Csup\u003E2\u003C\/sup\u003E throughout the tumor (T1b) [Balch CM et al. \u003Cem\u003EJ Clin Oncol\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EMitotic rate increases fairly linearly and steeply in tumors up to \u223c3 mm in thickness and then slows with increasing tumor thickness. Patients can have a wide range of mitotic activity in thin tumors [Thompson JF et al. \u003Cem\u003EJ Clin Oncol\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-24\u0022\u003EUp to 70% of newly diagnosed melanomas are thin (ie, \u22641 mm tumor thickness). Most have a generally excellent prognosis, with overall survival at 10 years of 92% [Balch CM et al. \u003Cem\u003EJ Clin Oncol\u003C\/em\u003E 2009;]. However, some patients develop clinically evident regional metastasis, usually after a long time [Thompson JF, Shaw HM. \u003Cem\u003EAnn Surg Oncol\u003C\/em\u003E 2006]. The high incidence despite overall low risk translates into a significant absolute number of potential individuals affected, and so is an important public health issue [Andtbacka R et al. \u003Cem\u003EJ Natl Compr Cancer Network\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cp id=\u0022p-25\u0022\u003ESLNB is the standard of care for patients with intermediate thickness melanoma and is recommended for nearly all patients with melanomas \u22651 mm thick. However, use of SLNB in patients with thin melanoma is controversial due to the overall low risk of nodal metastasis, uncertain prognostic value of a positive SLNB, and associated risks and costs. There is insufficient evidence supporting routine SLNB for thin melanomas (T1, \u0026lt;1 mm Breslow thickness), although the approach may be considered in select cases with high-risk features, when the benefits of pathologic staging outweigh procedural risks. However, it is noteworthy that in formulating the ASCO\/SSO guidelines, studies that explored risk of positive SLNB but that did not have follow-up data were excluded, which limited the data available. Long-term follow-up is important to assess the prognostic impact of regional nodal staging [Gershenwald JE et al. \u003Cem\u003EAnn Surg Oncol\u003C\/em\u003E 2012; Wong SL et al. \u003Cem\u003EAnnals Surg Oncol\u003C\/em\u003E 2012; Wong SL et al. \u003Cem\u003EJ Clin Oncol\u003C\/em\u003E 2012]. Some patients have an incidence of positive SLNB that is sufficiently high enough to perhaps justify the procedure. In a pooled series, the overall probability of positive SLNB in patients with melanoma \u0026lt;1 mm who underwent SLNB was \u223c5% (2% to 4% for \u0026lt;0.76 mm and 6% to 11% for 0.76 to 0.99 mm) [Andtbacka R et al. \u003Cem\u003EJ Natl Compr Cancer Network\u003C\/em\u003E 2009; Gershenwald JF et al. \u003Cem\u003EAnn Surg Oncol\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-26\u0022\u003EThe available data highlight the need to determine the appropriate threshold thickness of melanoma when deciding on SLNB. No consensus currently exists. Clinicians should discuss the concept of SLNB with all thin melanoma patients, including providing an explanation of why SLNB is not recommended. SLNB likely provides important prognostic information in a subset of thin melanoma patients with melanomas 0.76 to 0.99 mm in thickness, but is not recommended for the overwhelming majority of patients with melanomas \u0026lt;76 mm in thickness [Gershenwald JF et al. \u003Cem\u003EAnn Surg Oncol\u003C\/em\u003E 2012].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/6\/6.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nznuy2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznuy2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nznuy2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}