Journal of Surgical Oncology 2007;95:524–525

LETTER TO THE EDITOR

The Value of Sentinel Lymph Node Biopsy in theManagement of Head and Neck Melanoma

Dear Sir,The use of lymphatic mapping for melanoma of the

head and neck region, while technically demanding, has asuccess rate and false negative rate that is acceptablewhen compared to other regions of the body [1,2]. Therecent paper by Doting et al. ‘‘Does Sentinel LymphNode Biopsy in Cutaneous Head and Neck MelanomaAlter Disease Outcome?’’ [3] reiterates the safety andaccuracy of this technique. The authors also comment onin-transit recurrence as a potential ‘‘side effect’’ ofsentinel lymph node biopsy and finally finish with theconclusion ‘‘whether SLNB followed by early regionalnode dissection improves regional tumor control (andpatient survival). . .for head and neck melanoma isquestionable and is not supported by this small study.’’We do not agree that these last two conclusions can bedrawn from a sample size of 36 patients in which only7 were identified to have positive sentinel lymph nodes.In fact, the authors have acknowledged that theirsample size is ‘‘too small to draw any definitiveconclusions.’’

With regards to sentinel lymph node biopsy increasingthe rate of in-transit metastases, this claim can mostcertainly not be made from the authors results in which2/7 patients (29%) with a positive SLNB and 2/26patients (8%) with a negative SLNB had in-transitrecurrences. These numbers fall in the range of expectedregional recurrence rates in the absence of sentinel nodebiopsy. The authors invite the reader to view their table inwhich ‘‘other series are now publishing high incidencerates [of in-transit recurrence] in SLN-tumor positivepatients,’’ but fail to mention the conclusions of the lasttwo series (combined total more than 2,000 patients) intheir table [4,5]: performing a sentinel lymph node biopsydoes not increase the rate of in-transit metastasis. Themost definitive data come from the MSLT-1 [6]. Thisprospective randomized trial involves a direct compar-ison between those patients receiving wide local excision(WLE) plus SLNB and WLE alone. The in-transit/localrecurrence rates were identical for both groups thereforeputting to rest the debate for the time being. In-transitmetastases are caused by inherent adverse biology and

are not the result of surgical interruption of the regionallymphatics.

Finally, we would like to comment on SLN status as itrelates to regional tumor control and patient survival. TheSLN Working Group recently published their results of629 patients with primary head and neck melanoma whohad selective sentinel lymphadenectomy [7]. For disease-free survival SLN status was the most important predictorin a multivariate model (hazard ratio, 2.8). For overallsurvival SLN status did show a trend with respect to itsimpact on overall survival, but this was not statisticallysignificant. The second set of results comes, once again,from the interim analysis of the MSLT-1. Those patientswho underwent WLE and SLNB had a significantimprovement in disease-free survival. In fact the patientswith nodal metastases diagnosed by SLNB followed byCLND had a better survival outcome than those patientswith wide excision alone and CLND when nodes becameclinically apparent (5-year survival 71.2% vs. 53.4%,respectively) [6].

We agree with Doting et al. in that SLNB in the headand neck region is technically challenging, however, withsuch a small number of patients, we do not feel theauthors can make valid inferences regarding in-transitmetastases or the impact of SLNB on clinical outcome.Sentinel lymph node biopsy, when done in experiencedhands, is unquestionably valuable in the management ofhead and neck melanoma as it is in cutaneous melanomaof the truncal and extremity regions.

Michael Alvarado*1600 Divisadero Street2nd floor, San Francisco, California

Vernon Sondak, MDH Lee Moffitt Cancer CenterTampa, Florida

*Correspondence to: Dr. Michael Alvarado, 1600 Divisadero Street, 2ndfloor, Box 1710, San Francisco, CA 94115. Fax: 415 353 9571.E-mail: michael.alvarado@ucsfmedctr.org

Received 4 August 2006; Accepted 10 August 2006

DOI 10.1002/jso.20689

Published online 12 January 2007 in Wiley InterScience(www.interscience.wiley.com).

� 2007 Wiley-Liss, Inc.

P.L. Stanley Leong, MDUniversity of California San FranciscoSan Francisco, CA

REFERENCES

1. de Wilt JH, Thompson JF, Uren RF, et al.: Correlation betweenpreoperative lymphoscintigraphy and metastatic nodal disease sitesin 362 patients with cutaneous melanomas of the head and neck.Ann Surg 2004;239:544–552.

2. McMasters KM, Noyes RD, Reintgen DS, et al.: Lessons learnedfrom the sunbelt melanoma trial. J Surg Oncol 2004;86:212–223.

3. Doting EH, de Vries M, Plukker JT, et al.: Does sentinel lymphnode biopsy in cutaneous head and neck melanoma alter diseaseoutcome? J Surg Oncol 2006;93:564–570.

4. van Poll D, Thompson JF, Colman MH, et al.: A sentinel nodebiopsy does not increase the incidence of in-transit metastasis inpatients with primary cutaneous melanoma. Ann Surg Oncol2005;12:597–608.

5. Pawlik TM, Ross MI, Johnson MM, et al.: Predictors and naturalhistory of in-transit melanoma after sentinel lymphadenectomy.Ann Surg Oncol 2005;12:587–596.

6. Morton DL, Thompson JF, Cochran AJ, et al.: MulticenterSelective Lymphadenectomy Trial G: Interim results of themulticenter selective lymphadenectomy trial (mslt-i) in clinicalstage i melanoma. 2005;23:7500.

7. Leong SP, Accortt NA, Essner R, et al.: Impact of sentinel nodestatus and other risk factors on the clinical outcome of head andneck melanoma patients. Arch Otolaryngol Head Neck Surg 2006;132:370–373.

Journal of Surgical Oncology DOI 10.1002/jso

Letter to the Editor 525