04 Malignant Skin Lesions

50 in this trial 1973 patients were randomly assigned

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Unformatted text preview: ticenter Selective Lymphadenectomy Trial (MSLT suggest that SLNB with imme-I) diate CLND if the SLN is positive improves disease-free survival but not overall survival.50 In this trial, 1,973 patients were randomly assigned in a 4:6 ratio to undergo either (1) wide excision (WE) followed by nodal observation or (2) WE plus lymphatic mapping and sentinel lymph node biopsy (LM/SLNB) with immediate CLND if the SLN was positive.The two groups were comparable in regard to both patient variables (i.e., age and gender distribution) and lesion variables (i.e., location, thickness, and ulceration status). SLNs were analyzed by means of hematoxylin-eosin staining and immunohisto- © 2006 WebMD, Inc. All rights reserved. 3 BREAST, SKIN, AND SOFT TISSUE chemical staining.The incidence of wound complications at the primary site was comparable in the two groups, though surgical morbidity was significantly greater when SLNB was followed by CLND.50 A planned interim analysis presented at the American Society of Clinical Oncology in 2005 demonstrated a significant difference in disease-free survival between the two groups (73% for WE followed by nodal observation versus 78% for WE plus LM/SLNB); however, the difference in overall survival was not statistically significant (86% for WE followed by nodal observation versus 87% for WE plus LM/SLNB).51 These data led some to suggest that a survival benefit might be gained by performing LM/SLNB followed by CLND in the event of a positive SLN, but this suggestion has not been widely accepted.52 A study now under way, the second Multicenter Selective Lymphadenectomy Trial (MSLT -II), will assess the therapeutic value of CLND against that of SLNB alone in patients who have a positive SLN.51 An important factor in considering whether to perform CLND after a positive SLNB is the likelihood of finding metastases in the remaining non-SLNs. In one series, 90 (14%) of 658 patients had a positive SLN, and only 18 (20%) of the 90 showed evidence of metastases in additional non-SLNs removed during CLND.53 The number of positive nodes clearly has an impact on prognosis (as reflected by its inclusion in the current version of the AJCC’s melanoma staging system34), and this fact lends support to the argument for performing a CLND after a positive SLNB. Another issue that has not yet been resolved is the extent of lymph node dissection required. One group, reviewing their experience with lymph node dissection before the use of SLNB, concluded that the extent of lymph node dissection was a more important concern with higher tumor burdens and a less important one with lower tumor burdens.54 Patients with micrometastatic disease in an SLN are clearly different from patients with bulky nodal disease, and the potential benefits of aggressive lymph node dissection in either group must be carefully weighed against the morbidity of the procedure. Several studies are under way that should help address this issue, including MSLT 55 The roles of lymphadenectomy and adjuvant in-II. terferon alfa-2b (IFN-α2b) may be addressed by results fr...
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This note was uploaded on 03/21/2011 for the course ONC 01 taught by Professor Dzodic during the Spring '11 term at Multimedia University, Cyberjaya.

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