University Hospital for Dermatology, Johannes Wesling Clinical Centre in Minden, Ruhr University Hospital, Bochum, Germany.
Centre for Dermato-oncology, University Department of Dermatology, Eberhard Karls University, Tübingen, Germany.
J Dtsch Dermatol Ges. 2019 Jan;17(1):7-13. doi: 10.1111/ddg.13707. Epub 2018 Dec 3.
For decades, melanoma surgery has been guided by the Halstedian concept of stepwise metastasis, first into the lymph nodes and subsequently to distant sites. Early complete lymph node dissection (CLND) was therefore recommended in order to improve survival. Four large prospective randomized trials failed to show any survival benefit of CLND in comparison to observation alone. Sentinel lymph node biopsy was introduced in the 1990's, and CLND was limited to patients with positive sentinel nodes. Based on lymphoscintigraphy, it was pointed out that draining lymph nodes can now be detected more accurately. In one large trial, sentinel lymph node-guided CLND was compared to observation alone, and no advantage for melanoma-specific survival was detected. More recently, two prospective randomized studies tested whether CLND improved melanoma-specific survival or overall survival in patients with positive sentinel nodes. Neither study found a better survival rate for patients with CLND than with observation alone. The reason for the failure of CLND to improve survival is clearly parallel development and not stepwise development of lymph node metastasis and distant metastasis. Immediate CLND in melanoma surgery is therefore called into question.
几十年来，黑色素瘤手术一直遵循着哈尔斯特德的逐步转移概念，首先转移到淋巴结，然后转移到远处部位。因此，早期进行完全淋巴结清扫（CLND）被推荐以提高生存率。四项大型前瞻性随机试验未能显示 CLND 与单独观察相比有任何生存获益。前哨淋巴结活检于 20 世纪 90 年代引入，CLND 仅限于前哨淋巴结阳性的患者。基于淋巴闪烁显像，现在可以更准确地检测引流淋巴结。在一项大型试验中，前哨淋巴结引导的 CLND 与单独观察进行了比较，并未发现黑色素瘤特异性生存有优势。最近，两项前瞻性随机研究测试了 CLND 是否能提高前哨淋巴结阳性患者的黑色素瘤特异性生存率或总生存率。两项研究均未发现 CLND 组患者的生存率优于单独观察组。CLND 未能提高生存率的原因显然是淋巴结转移和远处转移的平行发展，而不是逐步发展。因此，黑色素瘤手术中的立即 CLND 受到质疑。
