LAUSR

patients with a positive SLN biopsy who had CLND were labelled ‘disease-free’ and those who had therapeutic dissection after detection of clinical nodes were labelled ‘diseased’. Thus, this secondary outcome of ‘local disease control’ should be viewed cautiously and is considered by many to be not clinically significant. Indeed, a recent systematic review reported no statistical difference in morbidity following CLND after a positive SLN biopsy compared with a therapeutic lymphadenectomy for palpable disease. The case that CLND after a positive SLN biopsy provides further useful prognostic information is also questioned, and it is hard to justify such a morbid procedure solely for staging purposes when in > 80% of cases, no further metastatic nodes are found. The challenge is to identify those few patients with non-SLN involvement who may benefit from immediate CLND; attempts to grade this risk can be helpful in making an informed decision. We believe, in light of these data from multiple studies, that there should be an immediate move away from CLND after a positive SLN biopsy in favour of clinical and noninvasive radiological surveillance. The use of adjuvant systemic immunotherapy after a positive SLN biopsy should be increased, both in routine clinical practice and in further clinical trials, and existing guidelines should be updated to reflect the evidence. We do not believe that CLND should be an entry requirement in future adjuvant clinical trials, and the search for a better biomarker will continue to help stratify risk. SLN status is not a helpful stand-alone marker of prognosis and often adds little to Breslow thickness. SLN biopsy is still important, however, as SLN positivity will allow entry into clinical trials of adjuvant therapies, and these must be supported as it remains critically important to collect robust evidence on which to base clinical practice.