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Cancer-free lymph nodes best left alone

OCTOBER 25, 2017
Clinical Congress Daily Highlights, Wednesday Second Edition

Recent data show that removing disease-negative lymph nodes does not improve patient outcomes in melanoma, and potentially in other cancers, Daniel G. Coit, MD, FACS, Memorial Sloan Kettering, New York, NY, asserted on Wednesday in the Commission on Cancer Oncology Lecture.

The practice of removing lymph nodes as a means to prevent metastasis is built on decades of dogma starting in the early 1900s, Dr. Coit said. But the issue was never quite as black-and-white as it was made out to be, he argued, and today a more measured approach to the use of complete lymph node dissection (CLND) is warranted, particularly in melanoma.

Dr. Coit is an expert in melanoma, and during his 35-year tenure at Memorial Sloan Kettering his views on the metastatic potential of lymph nodes have continuously evolved.

“When I got in the front door 35 years ago, I entered a culture where really the definition of a surgical oncologist was not somebody who could take out an organ, but someone who could elegantly remove lymph nodes.”

When considering metastasis through the lymphatic system, it’s important to consider the level at which a cancer has infiltrated a node. If a tumor has just started to infiltrate, that cancer may remain localized and not serve as a source of metastases. But as tumor burden progresses, the risk for metastases increases.

When it reaches a certain threshold, Dr. Coit said, “these are no longer lymph nodes, but big vascularized tumors. For those patients with a positive node, this may be the only disease they ever have outside of the melanoma. For Stage IIIA melanoma, there is a 75 percent curative rate with this procedure (CLND).”

But unequivocal clinical trial data across various different cancer types show that the extended dissection of disease-negative lymph nodes provides no benefit.

“In melanoma, there is absolutely no benefit in four prospective randomized trials. If you look at stomach cancer it’s exactly the same thing. So taking out of all of these negative nodes, at the level of a prospective randomized trial, has proved to be not fruitful.”

Dr. Coit said he hopes that surgical oncologists start weighing these data before proceeding with CLND. At a practical level, he believes that for most clinically localized solid tumors, initial surgical management should include resection of the primary tumor and clinically relevant negative nodes sufficient for accurate staging and regional control. But until the development of better biomarkers to predict “nodotrophic” metastatic behavior, Dr. Coit believes there are no data to strongly support the elective removal of more negative lymph nodes than necessary.

Additional Information:
The Commission on Cancer Oncology Lecture was held October 25, at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at FACS.org/clincon2017.

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