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What risk factors indicate that a sentinel lymph node biopsy should be considered for a thin melanoma (Breslow thickness < 1mm)?
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VernonSondakMD (Physician - Surgery - Surgical Oncology (Verified) ) - 07 / 12 / 2012
Again using the “beyond a reasonable doubt” criterion, the ASCO/SSO Guidelines panel appropriately concluded that sentinel node biopsy should not be used for ALL thin melanoma patients. That is because many of the patients with very thin melanomas have little or no chance of having melanoma develop or be detected in their nodes. But they did say “it may be considered in selected patients with high-risk features when staging benefits outweigh risks of the procedure.” This is how almost all melanoma surgeons today use sentinel node biopsy for thin melanoma – selectively for higher-risk cases. However, the Guidelines panel was operating under those strict rules of evidence, and because of that they were not able to specifically define what “high risk features” surgeons and patients should consider, and that is probably the single greatest deficiency of these guidelines.
In my opinion, and this is based on my years of experience but also a recent review of our experience with 271 thin melanoma patients undergoing sentinel node biopsy at Moffitt Cancer Center over the past 5 years, there is a thickness cutoff that needs to be considered even lower than 1 mm: we feel that sentinel node biopsy is NOT necessary or appropriate for the overwhelming majority of patients whose melanoma is <0.76 mm in thickness. However, for patients with melanomas between 0.76 and 1.00 mm in thickness, we believe that many of those patients will be appropriate candidates for the procedure, but even there a lot of thought needs to go into the decision. It’s also worth emphasizing how important the pathology report is in making a final recommendation about whether or not to undergo a sentinel node biopsy. Patients should be sure to discuss their pathology report in detail with the doctor who makes the original diagnosis (usually a dermatologist or family doctor), and ask if they should be evaluated by a surgeon or surgical oncologist for consideration of a sentinel node biopsy. If all the pathologic features required to make an informed decision have not been reported, and sometimes even if they are, we found that getting a second pathology opinion by a dermatopathologists who specializes in melanoma was extremely helpful and sometimes dramatically changed our recommendation. But again, the ASCO/SSO guidelines should reassure patients that sentinel node biopsy is often but by no means always appropriate – and a thoughtful discussion of the pros and cons of the procedure is important in every case.
In my opinion, and this is based on my years of experience but also a recent review of our experience with 271 thin melanoma patients undergoing sentinel node biopsy at Moffitt Cancer Center over the past 5 years, there is a thickness cutoff that needs to be considered even lower than 1 mm: we feel that sentinel node biopsy is NOT necessary or appropriate for the overwhelming majority of patients whose melanoma is <0.76 mm in thickness. However, for patients with melanomas between 0.76 and 1.00 mm in thickness, we believe that many of those patients will be appropriate candidates for the procedure, but even there a lot of thought needs to go into the decision. It’s also worth emphasizing how important the pathology report is in making a final recommendation about whether or not to undergo a sentinel node biopsy. Patients should be sure to discuss their pathology report in detail with the doctor who makes the original diagnosis (usually a dermatologist or family doctor), and ask if they should be evaluated by a surgeon or surgical oncologist for consideration of a sentinel node biopsy. If all the pathologic features required to make an informed decision have not been reported, and sometimes even if they are, we found that getting a second pathology opinion by a dermatopathologists who specializes in melanoma was extremely helpful and sometimes dramatically changed our recommendation. But again, the ASCO/SSO guidelines should reassure patients that sentinel node biopsy is often but by no means always appropriate – and a thoughtful discussion of the pros and cons of the procedure is important in every case.
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