In view of the lack of any clear benefits for elective lymph node dissection in the RCTs mentioned above, elective lymph node dissection has been largely abandoned in favour of sentinel lymph node biopsy (SLNB), which is considered separately.
The technique of SLNB involves the identification and biopsy of the first-station lymph node draining an affected area. Its use in MM was pioneered by Morton.40
The SLN is found by injecting blue dye and/or radiolabelled colloid into the skin surrounding the primary lesion. The technique enables the identification of patients with micro-metastases affecting the regional lymph nodes and can successfully identify the sentinel node in up to 97% of cases. Patients so identified as having micro-metastases are submitted to a therapeutic lymph node dissection.
The technique is well established and is reproducible.41 It is now regarded as an excellent indicator of prognosis and has therefore been incorporated into the new American staging system for MM (AJCC staging).42 Gershenwald demonstrated that of 580 patients who underwent SLNB, 85 patients (15%) were positive and 495 were negative. This study showed that SLN status was the most significant prognostic factor with respect to disease-free and disease-specific survival. Although tumour thickness and ulceration influenced survival in SLN-negative patients, they provided no additional prognostic information in SLN-positive patients.43 The psychological benefits of accurate staging for a patient have not been studied extensively but one small questionnaire study of 110 patients did show a slight psychological benefit in those who underwent SNLB, regardless of the result of the biopsy.44
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