TRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope article free of charge, visit Laryngoscope.
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April 2022BACKGROUND
Sentinel lymph node biopsy (SLNB), first introduced in the 1990s, has become standard of practice for most initial presentations of cutaneous melanoma without gross nodal involvement. Traditionally, a completion lymph node dissection (CLND) was performed after a positive SLNB; however, the landmark Multicenter Selective Lymphadenectomy Trial II (MSLT-II), published in 2017, showed no melanoma-specific survival advantage with this practice (N Engl J Med. 2017;376:2211-2222). The current National Comprehensive Cancer Network guidelines state that observation is the preferred approach following a positive SLNB in cutaneous melanoma, with CLND still being an option that should be discussed and offered to patients (https://www.nccn.org/professionals/physician_gls/pdf/cutaneous_melanoma.pdf. Accessed on September 29, 2021).
Head and neck cutaneous melanoma (HNCM) has a number of unique features that potentially differentiate it from cutaneous melanoma of the rest of the body. Importantly, head and neck melanoma carries a worse prognosis. Also, due to the proximity of critical anatomic structures, it is potentially more difficult to achieve wide peripheral and deep surgical resection margins. Such resections can have major cosmetic and functional sequelae. In addition, rates of lymphedema following CLND in the head and neck are lower compared to other sites. For these reasons, and because the existing data is much more limited in the head and neck, the value of CLND has been more controversial in this specific anatomic site.
BEST PRACTICE
Observation following a positive SLNB for HNCM is likely a reasonable approach to offer patients, as survival is unchanged in prospective clinical trials. Caution is advised before broadly applying such results to all HNCM patients, however, as the data in this subset of patients is not as robust as it is for all cutaneous melanoma. CLND is still also reasonable to offer patients, with consideration given to the benefits of locoregional control and the associated potential for quality of life improvement. It is possible that certain subsets of patients may specifically benefit from CLND; however, further study is needed in this area. Care should be individualized based on informed shared decision making with patients until further data is available, including a frank discussion with patients about the scientific uncertainty in HNCM.