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Sentinel Lymph Node Biopsy for melanoma- what is new?


Sasi Attili

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It is now virtually routine in most centers around the world to consider SLN biopsy for all patients with melanoma's of stage 1b and above.

Current evidence suggests that this is only a prognostic exercise and has no influence on long-term outcome for patients. However, patients still do end up having SLN biopsy and lymphadenectomy (when SLN +ve), depending on the individual surgeon's enthusiasm regarding the procedure and the ability to sway the patient either way through 'informed consent'!. I am however, not sure how many surgeons practicing SLN truly understand the evidence base behind it and are able to convey the same in understandable words, to their patients. I personally would not want to go through a SLN procedure, just for the sake of being given a number!

I was however quite pleased to see a recent journal article (see below) that has looked into the prognostic value of SLN in melanoma and confirmed the prognostic value, particularly in thick lesions. The article in the Dermatol Surg. is a meta-analysis of all the studies so far and has suggested that in thin melanoma's (<1mm), the value of SLN is debatable, especially because these tumours have an excellent prognosis anyway and having a +ve SLN, would not alter prognosis a great deal. But the prognostic value of SLN procedure is better in thicker lesions.

I use the [url="http://www.melanomaprognosis.org/"]AJCC Melanoma Prognosis PredictionTool[/url] when discussing SLN with patients. Though this is straightforward, it ignores a few variables, that have actually been included in [url="http://www.lifemath.net/cancer/melanoma/outcome/index.php"]this tool by lifemath.net.[/url] However, the results with both tools are not vastly different.

The [url="http://nomograms.mskcc.org/Melanoma/PositiveSentinelNode.aspx"]Melanoma nomogram[/url] is an excellent tool I use to predict the probability of SLN positivity- very useful for patients to decide on whether it is worth going for the procedure.

Would be interested to know if anyone is aware of any other superior/ more up-to-date tools.




[size=4][font=arial,helvetica,sans-serif][url="http://www.ncbi.nlm.nih.gov/pubmed/24299573#"][color=#000080]Dermatol Surg.[/color][/url][color=#000080] 2013 Dec;39(12):1800-12. doi: 10.1111/dsu.12351. Epub 2013 Nov 10.
[b]Prognostic Value of Sentinel Lymph Node Biopsy Compared with that of Breslow Thickness: Implications for Informed Consent in Patients with Invasive Melanoma.[/b][/color]

[url="http://www.ncbi.nlm.nih.gov/pubmed?term=Freeman%20SR%5BAuthor%5D&cauthor=true&cauthor_uid=24299573"][color=#000080]Freeman SR[/color][/url][color=#000080], [/color][url="http://www.ncbi.nlm.nih.gov/pubmed?term=Gibbs%20BB%5BAuthor%5D&cauthor=true&cauthor_uid=24299573"][color=#000080]Gibbs BB[/color][/url][color=#000080], [/color][url="http://www.ncbi.nlm.nih.gov/pubmed?term=Brodland%20DG%5BAuthor%5D&cauthor=true&cauthor_uid=24299573"][color=#000080]Brodland DG[/color][/url][color=#000080], [/color][url="http://www.ncbi.nlm.nih.gov/pubmed?term=Zitelli%20JA%5BAuthor%5D&cauthor=true&cauthor_uid=24299573"][color=#000080]Zitelli JA[/color][/url][color=#000080].

[b] Source[/b]

Shadyside Medical Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

[b] Abstract[/b]


[b] BACKGROUND:[/b]

Sentinel lymph node (SLN) status is reportedly a powerful prognosticator of survival. Breslow thickness alone provides significantprognostic information.
[b] OBJECTIVE:[/b]

To assess overall survival (OS) according to tumor depth based on SLN status.
[b] MATERIALS AND METHODS:[/b]

MEDLINE, EMBASE, and the Cochrane Central Database were searched for studies. Included studies evaluated overall survival according to SLNB results and were stratified according to Breslow thickness. Meta-analysis was performed if appropriate in each category for which three or more studies reported risk estimates and variability measurement.
[b] RESULTS:[/b]

Twenty-nine articles met inclusion criteria. Six met the criteria for meta-analysis. In individuals with thin melanoma (<1 mm), SLN-negative status conferred no survival advantage (sign test, p > .99). Few studies were available for intermediate depths, and most reported worse survival in SLN-positive patients, although the difference was not statistically significant (p > .05). For thick melanoma (>4 mm), SLN positivity was related to worse prognosis (sign test, p = .004). Based on the pooled results of six studies of patients with tumors 4 mm thick or thicker, SLN-positive patients had a greater likelihood of dying (hazard ratio = 2.42, 95% confidence interval = 2.00-2.92).[/color][/font][/size]

[color=#000080][size=4][font=arial,helvetica,sans-serif][b] CONCLUSIONS:[/b]

Sentinel lymph node biopsy may not provide more-accurate prognostic information than Breslow thickness for most melanomas.
© 2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.
[/font][/size][/color]
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Robledo F. Rocha

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I don’t feel sentinel lymph node biopsy is a good approach for patients with melanoma, even though this is a routine practice in oncology centers which I have professional contact. Personal and reflective literature data permit me to advocate that sentinel lymph node biopsy does not render either predictive or prognostic information. A negative node does not compulsorily mean that melanoma spreading has not taken place in distant sites. A positive node does not necessarily reserve an unfavorable outcome when compared with another patient who got a melanoma with greater thickness but negative node. Seventh edition of the AJCC Cancer Staging Manual, launched in 2010, analyzes sentinel nodal staging in T1b melanoma with these words:

[indent=1]“[i]In the sixth edition of the AJCC [/i][i]Staging Manual [/i][i]it was recommended that sentinel node staging be considered in patients presenting with T1bN0M0 or thicker melanomas, based upon the secondary features of either tumor ulceration or Clark’s level IV depth of invasion, which were associated with an approximately 10% yield of occult nodal metastases. The use of mitotic rate for the purpose of classifying thin melanomas as T1b in the seventh edition was based on a survival analysis. The AJCC Melanoma Staging Database did not contain sufficient data for precisely estimating risk for occult nodal micrometastases in this population. However, preliminary evidence from several other large studies would suggest that T1b melanomas (as defined in the new system) of[/i][i] ≥[/i][i]0.76mm in thickness are associated with an approximately 10% risk of occult nodal metastases. Conversely, T1a melanomas with <1 mitoses/mm[sup]2[/sup], or T1b melanomas <0.5mm in thickness have a very low risk of nodal micrometastases. These data may be helpful when discussing the indications for sentinel lymph node biopsy for staging with individual patients with T1b melanoma.”[/i][/indent]
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