Case Vignette - The New England Journal of Medicine

A Woman with Melanoma and Sentinel-Node Metastasis

Lisa Caulley, M.D., M.P.H.

Ms. Evans is a 52-year-old woman who is sitting in your office awaiting your assessment of her recent diagnosis of melanoma.

She had initially presented to her primary care physician 6 weeks earlier with an irregular lesion on her right arm. After a punch biopsy, a superficial spreading melanoma was diagnosed. She was referred to a surgical oncologist for consultation and subsequently underwent wide local excision of the primary lesion and an axillary sentinel lymph-node biopsy.

Family history

Ms. Evans is visiting your clinic today, 2 weeks later, to review the pathological findings and to determine the next steps in care. In response to your questions, Ms. Evans reports a history of multiple sunburns as a child but no personal or family history of skin cancer. Her medical history is significant for impaired glucose tolerance, which she treats with diet and lifestyle modifications. She does not consume alcohol and is a lifelong nonsmoker.

On physical examination, the lasting effects of long-term, unprotected sun exposure are evident; you observe diffuse, mottled pigmentation, age spots, and telangiectasias. With fair skin and light eyes, Ms. Evans meets the criteria for Fitzpatrick skin type II. (Fitzpatrick skin type classifies skin according to tanning ability and susceptibility to skin cancer, ranging from type I [very light skin that always burns and never tans] to type VI [very dark skin that never burns, tans very easily, and is deeply pigmented]; skin type II is fair skin that usually burns, tans with difficulty, and is associated with a high risk of skin cancer.) The previous surgical sites are healing well, and there is no palpable lymphadenopathy. A review of the pathological findings shows that the primary lesion was 1.7 mm in thickness with no ulcerations. The sentinel lymph-node biopsy was positive in two lymph nodes, with one metastasis measuring 2 mm and the other measuring 0.5 mm.

After you have reviewed the pathology results with Ms. Evans, she expresses concern regarding the results of the sentinel lymph-node biopsy and would like you to recommend the best treatment plan for her nodal disease.

Treatment Options

Which one of the following strategies would you choose for this patient? Base your choice on the published literature, your own experience, recent guidelines, and other sources of information, as appropriate.

1. Recommend completion lymph-node dissection
2. Recommend observation of the nodes with ultrasonography

To aid in your decision making, each of these approaches is defended in a short essay by an expert in the field. Given your knowledge of the patient and the points made by the experts, which option would you choose? Make your choice, vote, and offer your comments at NEJM.org.

To read about the two options and make the poll - go to The New England Journal od Medicine