SENTINEL LYMPH NODE- A POSSIBLE GUARANTEE OF RECURRENCE-FREE SURVIVAL.

Dilemmas in the diagnosis and treatment of cutaneous melanoma, concerning the prognosis of patients, are far from finding an adequate or optimal solution at the moment. The issues are multifaceted and encompass a number of key points such as : 1) the choice of resection field, 2) the choice between a one-stage and a two-stage model of surgical removal of the tumor lesion, 3) the removal (or not) of the so-called sentinel lymph node, 4) the time intervals between the two surgical sessions, 5) the need or not for reciprocity between the clinically measured and the histologically established postoperatively resection field, and a number of others. The likelihood that the key to successful treatment/no recurrence of cutaneous melanoma lies in one or more of the above points is high. We present and analyze two patients with histopathologically established intermediate-thickness cutaneous melanomas, treated : 1) one of them: with a two-stage approach according to the generally accepted AJCC/EJC recommendations, and the other with 2) a single-stage procedure/ one step melanoma surgery (OSMS) with a resection margin of surgical security of 2 cm and no detection/removal of the so-called draining lymph node (at his request). The first patient developed progression and lethality within 2 years, and the second patient remained progression-free 6 years later. Conclusions based on these observations, although speculative, could be as follows: Strict adherence to the guidelines does not insure patients against progression and lethality (patient 1), but an individualized/ personalised/modified approach, as well as deviations from the official recommendations of the generally accepted guidelines (AJCC/EJC) - could ensure (sometimes) the absence of such (progression) (patient 2). In practice, the reason for the successful treatment of cutaneous melanomas and the lack of progression, could also be due to (or associated with) the differences in the therapeutic approaches applied by clinicians. These could be seen as a good starting point for deeper analysis. The reason for the lack of progression could probably be sought in the fusion of the surgical sessions or in the application of the one step melanoma surgery (OSMS). In practice, the total resection field in one-stage and two-stage melanoma surgery is the same, but in the one-step melanoma surgery (OSMS) approach it is achieved within only one surgical session. This fusion of surgical sessions provides a number of advantages for patients that are currently not well studied from a scientific/prognostic point of view. Another key, even strange point, is the non-performance of a sentinel/draining lymph node. According to common beliefs, detection and removal of the draining lymph node is advisable, but it has more diagnostic, clarifying rather than a therapeutic value. The lack of its localization and removal in the described patient could also be related/associated with the lack of progression (although unlikely): and this fact is evident not only in the data presented in this publication, but also in other cases described in the scientific literature. And would probably benefit from further careful analysis. The lack of progression in intermediate-thickness melanomas in certain patients could be related to the following 2 interesting, concurrent, and currently unclear events: 1) the consolidation of the 2-in-1 surgical sessions (i.e., in the application of a one-step model of surgical behaviour / OSMS/ one step melanoma surgery), and 2) the failure (probably) to perform a sentinel lymph node ditection and removal. Whether this is a sporadic finding-or whether there is a definite correlation-would need to be verified by observing a larger number of patients at different clinical centers. The likelihood that other factors influence the presence or absence of this progression remains quite possible.