A number of technological advancements have come together to allow more conservative surgery for the melanoma patient and, at the same time, provide a mechanism for more accurate staging. These advances involve the refinement of a nuclear medicine study, lymphoscintigraphy, to identify which basins are at risk for metastatic disease, the use of intraoperative lymphatic mapping, and sentinel lymph node biopsy to identify which node in the basin is most at risk for disease, and finally the development of more sensitive assays for detection of occult metastases. These assays are based on immunohistochemical staining and molecular biology techniques. The advances in the staging of the melanoma patient could not have happened without the advances intraoperatively, as it would be too time-consuming and too expensive to perform a technique like the reverse tran-scriptase-polymerase chain reaction (RT-PCR) on the 20-25 nodes from a complete regional node dissection. The fact that the lymphatic mapping techniques can identify the one or two sentinel lymph nodes that are most likely to contain the metastases makes the application of the more sensitive assays for occult metastases practical.

The staging of the melanoma patient is becoming more important with the recent publication of a multicenter, prospective, randomized trial that shows a benefit for the adjuvant treatment of T4 or Stage III melanoma patients with interferon-a [1]. Adjuvant therapy should be applied early when tumor burden is minimal and in a selective fashion so that only those patients with a proven benefit are exposed to the toxicities and expense of the adjuvant therapies. The accurate staging of the melanoma patient will identify the subgroup of patients who have the most to benefit from interferon-a.

Focused on nodal status as the dominant prognostic factor for early-stage melanoma, investigators at the Moffitt Cancer Center initiated a line of research in an attempt to combine lymphatic mapping and more sensitive assays for occult metastases to better stage patients with this disease.

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