COMMENTARY

McMaster EBM: Today, Lymph Node-Positive Melanoma Treatment

This transcript has been edited for clarity.

Hello and welcome. I'm Dr George Lundberg and this is At Large at Medscape.

Anyone who practices medicine has a problem keeping up with a rapidly changing information landscape. What to read? What to trust?

Fortunately, free, trustworthy sources are available to help the reader sort it out. One such source is McMaster University in Hamilton, Ontario, which has been a focal point for evidence-based medicine (EBM) for decades, ever since that initiative was spearheaded there by the American, Dr David Sackett.

The open-access McMaster DynaMed Plus[1] includes a searchable collection of the best evidence from 500 top-rated medical journals and is presented in a format easy to read, comprehend, and upon which to clinically act. The database is continually updated and provides links for abstracts, ratings, and topics, and helpfully indicates whether the full-text link is or is not behind a paywall. I recommend that you get on their regular email list for Evidence Alerts.

Today we focus on malignant melanoma.[2] About 95,000 Americans are diagnosed with cutaneous melanoma each year. About 88,000 are cured; some 7000 die of the disease.

Surgery remains the principal treatment. Melanomas can spread by direct extension or by blood but typically metastasize via lymphatic channels. After primary excision, the surgeon usually locates and excises the sentinel node (SLN). If no cancer is found in the SLN, active surgical treatment is complete. If metastatic disease is found (SLN-positive), what should be done then?

From the McMaster-curated database[2]:

Angeles and colleagues from Dartmouth performed a systematic review and meta-analysis to evaluate the survival and recurrence rates of SLN-positive melanoma in patients who underwent a completion lymph node dissection (CLND) compared with those who did not.

Fifteen cohort studies and two randomized clinical trials (including a total of about 10,000 patients) that assessed the survival and recurrence outcomes of CLND versus observation were determined to be of high enough quality by the Cochrane risk-of-bias tool and the Newcastle-Ottawa Scale to be included. The relative risk for death was 0.85 (CI, 0.71-1.02) and for recurrence was 0.91 (CI, 0.79-1.05). No statistical difference.

Conclusion: Patients with SLN-positive melanoma do not receive significant benefit from CLND. I believe the data and would act upon them.

That's my opinion. I'm Dr George Lundberg, at large at Medscape.

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