We were expecting the new year to bring us big paradigm shifts in the nodal management of melanoma considering this year’s published failure of conventional completion node dissection (CLND) to prove a survival advantage worthy of its morbidity. ASCO and SSO have come together to offer-up the newest consensus guidelines on the subject, and we’re underwhelmed. In terms of sentinel lymph node dissection (SLND), they recommend: no for thickness <0.8 mm, +/- for 0.8-1 mm, yes for >1-4 mm, and (nihilistically) probably not for >4 mm since they have just as much chance to fail distantly as regionally (except plot twist: a positive SLND can now buy them life-prolonging adjuvant therapy). Where we’re really left unsatisfied is their recs for CLND after positive SLND: +/- for low-risk patients (read: eligible for MSLT-II), a strong probably yes for high-risk patients (would have been excluded from MSLT-II due to ECE, >3 +SLN, immunosuppression, etc), and yes for clinically involved nodes. In summary, it’s mostly up to you, but it's not a bad strategy to do as much and no more than will get your patients systemic therapy.


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