Introducing controversies in dermatology: sentinel lymph node biopsy for cutaneous melanoma - a useful technique or a waste of time?
Authors: David J. Eedy
Journal: British Journal of Dermatology (2004)

In my introductory Editorial I promised that I would introduce controversial topics to the British Journal of Dermatology (BJD).1 Unlike anatomy or biochemistry, most of clinical medicine, including dermatology, is an inexact science, where there will always be room for differences of opinion. Honest exploration of these differences should enliven and enrich us as doctors, as well as give a strong stimulus in the search for the truth. To assess truth we must be abreast of what is already known and then use our critical faculties to discern all that is best in dermatology, and ultimately all that is best for our patients. If we are to grow as physicians, we need continually to modify, improve, devise and think; in short, to stretch the mental elasticity of receptive and progressive minds. Most doctors do not effectively appraise original articles and most are probably incapable of doing so.2 Most depend on, and accept the judgement of, the editorial team and its peer reviewers until one of the more astute readers critically appraises the evidence and points out that a particular study or technique is scientific nonsense.2 Challenging tenets by allowing commentary on controversial issues by those who have made a detailed appraisal of such subjects may open the door of enlightenment for us all. By introducing a section on controversies in dermatology to the BJD, I hope to continue to spark the curiosity of readers, and to inspire them to examine the facts for and against established principles in dermatology, with open-mindedness, unbiased by whimsical personal preferences. By doing so, we may all more thoroughly reflect about the so-called truths, and attempt to eschew the common facility of reaching conclusions from superficial observations and being misled by uncritically accepting them, regardless of the eminence of their origin. We must continuously judge between the excellent and the inferior, the sound and the unsound, the true and the half true.3 The first controversy I wish to explore is the increasing trend to introduce the use of sentinel lymph node biopsy in the treatment of cutaneous malignant melanoma. My interest in this controversy was triggered well over a year ago, while attending an American Academy of Dermatology meeting, when my attention was drawn to a monograph by Medalie and Ackerman. Drs Medalie and Ackerman argued passionately against sentinel lymph node biopsy and stated ‘that there is no justification, whatsoever, for the procedure, scientifically or practically, and for that reason it should be abandoned, without delay, now’.4-6 As a result, I invited Dr Ackerman to take up the challenge of writing points against sentinel lymph node biopsy, while I would seek out authors to support the diametrically opposed view. It took many months to seek out experts prepared to support sentinel lymph node biopsy. Many experts who currently perform sentinel lymph node biopsy trials declined the offer and one submission was so diced with ad hominem comments, I felt obliged to disregard it. I did fortunately persuade its original advocates, Drs Morton and Cochran, to write the case for sentinel lymph node biopsy in the management of cutaneous melanoma.7 The two opposing opinions are presented in this issue of the BJD.8, 9 Reading these articles one after the other surely demonstrates that one man's myth is another man's belief! On contemplating these controversial issues in these two articles, the words of Voltaire come to mind: ‘I disapprove of what you say, but I will defend to the death your right to say it’. Read and savour this controversy as played out by the giants!