29 September 2016

Melanoma sentinel node biopsy: Past, present and future in the new era of systemic therapies

Vienna, 29/09/16. The field of melanoma crosses many specialties with a wide spectrum of disease. Dermatologists are on the front lines and play an important role in patient decisions and counseling. Patients look to their dermatologist as a primary melanoma caregiver for information and guidance, including sentinel lymph node biopsy (SLNB).

Dr. Tim Johnson from Ann Arbor, US, took the floor during Thursday’s afternoon plenary lecture to highlight the extensive contemporary data pertaining to SLNB to help formulate interpretation of data into clinical practice. “I appreciate the opportunity, honor, and privilege to speak today. Dermatologists are on the front lines and play a critical role in patient decisions and counseling including sentinel lymph node biopsy,” Dr. Johnson said in his opening remarks.

During the main part of his talk, Dr. Johnson explained: “I understand that variable interpretation of the data may respectfully occur. That said, current practice guidelines involving every discipline and major guideline organization from all over the world provide relatively uniform recommendations; and are consistent in interpretation of both the value and limitations of sentinel node biopsy for melanoma. Accurate staging whether of the primary lesion, regional lymph nodes or other, drives to a great extent treatment and treatment options. The staging accuracy of sentinel node biopsy is not argued anymore. There is a small likelihood of identifiable distant disease if the sentinel node biopsy is negative. Staging tests are not validated based on their ability to improve survival. They are validated based on their sensitivity and specificity of which this test represents the “gold” standard for nodal staging in appropriate candidates. While the majority of patients with melanoma do not need consideration for sentinel lymph node biopsy, those with Breslow depth ≥ 1 mm, or 0.75-0.99 mm with higher risk factors may benefit. Delayed treatment of occult regional nodal disease in adults with intermediate thickness melanoma may increase the extent or tumor burden of nodal disease upon early clinical detection, increase the morbidity of treating that disease, increase the chance of loss of regional control, and increase the likelihood of dying from that disease, in the subset with occult nodal disease.”

Sentinel lymph node biopsy results in the new era of systemic therapy will determine the need for adjuvant therapy based on prognosis, and the type of adjuvant therapy based on tumor burden and molecular profile. Eventually effective adjuvant therapy will eradicate the need for completion lymph node dissection after a positive SLNB. In the nearer future sentinel lymph nodes staging may become more relevant and frequent while completion lymph node dissection less frequent as more adjuvant trials come online.  In our lifetime, we will likely perform few if any sentinel node biopsies once we have true precision medicine.

“As a dermatologist, you, me, we should be one of the lead dogs with respect to counseling, knowledge and guidance for patients with melanoma. However, to do that most effectively we must learn from, and work closely with many other disciplines collegially, collaboratively, and humbly. I learned, that the best way to take care of patients, like you would your own family, is to advance your field through research, apply that to your patient care, and use your clinic as your laboratory. The pace of medical knowledge advancement is breathtaking. The next time you are in the moment with that patient with melanoma, you should view them through the eyes of many specialties, and with the most contemporary knowledge base. And that approach will help you treat every patient like you would your own family member, which I’m sure is your goal like mine,” concluded Dr. Johnson.

About the Speaker:

Dr. Tim Johnson is the Lewis and Lillian Becker Professor at the University of Michigan. He received his medical degree and dermatology residency training at the University of Texas at Houston. After completing fellowship training in cutaneous surgery and oncology at both the University of Michigan and University of Oregon, he joined the Michigan faculty in 1990 with appointments in Dermatology, Otolaryngology and Surgery. He has served as clinical director of the Comprehensive Cancer Center Multidisciplinary Melanoma and Cutaneous Oncology Programs since 1990. 

He has received many clinical, teaching, and research honours; delivered numerous national and international keynote and named lectureships over the last two decades; and is a benchmark for clinical care. He served on the board of directors and executive committees of several national and international organizations that impact dermatology, melanoma and non-melanoma skin cancer. He was an invited founding member of the National Comprehensive Cancer Network Guideline Committees for Skin Cancer and serves on the American Joint Committee on Cancer Staging.

He is an investigator on grants, clinical trials, and numerous research activities. He established robust tissue banks in non-melanoma and melanoma with linkable comprehensive clinical databases. His research is focused on integration of data and specimens with experimental models to identify molecular mechanisms of disease; as well as development of evidence-based strategies for better treatment. His publication portfolio includes over 230 original peer-reviewed publications and over 50 invited/other publications/chapters published in mainstream dermatology, surgery, and oncology journals; including top impact journals such as Nature, Nature Medicine, Journal of Clinical Oncology, Cancer Research, Nature Cell Biology, and JAMA. Dr. Johnson practices medicine exclusively at the University of Michigan, where he is an internationally acclaimed leader in dermatology; and more specifically, cutaneous oncology.

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