Should all thick melanomas (Breslow thickness > 4mm) have a sentinel lymph node biopsy? When is a sentinel lymph node biopsy not recommended?

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VernonSondakMD (Physician - Surgery - Surgical Oncology (Verified) ) - 07 / 12 / 2012

Personally, I don’t think the ASCO/SSO guidelines went far enough when it comes to thick melanomas. In my opinion, because of the high risk of finding positive nodes (for most melanoma types, at least 30% of patients in this thickness category have or develop positive nodes), sentinel node biopsy should almost always be recommended, unless the patient is too frail or sick to safely have the procedure or not likely to live long enough to benefit from the knowledge it will provide. But there is a good reason why the ASCO/SSO guidelines are less strongly in favor of sentinel node biopsy in these patients: it’s because many patients with thick melanomas already have cancer cells in other parts of their body even if the lymph nodes are clean. This decreases the overall benefit of the procedure, but as the panel said, the sentinel node biopsy procedure “may be recommended for staging purposes and to facilitate regional disease control.” That means (a) you are still better off having a thick melanoma with negative nodes than a thick melanoma with positive nodes (“staging”), and (b) for the 30% or so with tumor already in the lymph nodes, having a complete lymph node dissection improves the chances of preventing the nodal disease from growing out of control right in that region.
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