Staging with sentinel lymph node biopsy in melanoma

Staging with sentinel lymph node biopsy (1)

• do not offer imaging or sentinel lymph node biopsy (SLNB) to people who have stage IA melanoma
• do not offer imaging before SLNB unless lymph node or distant metastases are suspected
• consider SLNB for people who have melanoma with a Breslow thickness of 0.8 mm to 1.0 mm and at least one of the following features:
  • ulceration
  • lymphovascular invasion
  • a mitotic index of 2 or more
• consider SLNB for people who have melanoma with a Breslow thickness greater than 1.0 mm
• for women who are pregnant, discuss the option of delaying SLNB until after the pregnancy is completed
• consider staging with whole-body and brain contrast-enhanced (CE)-CT for people with stage IIB melanoma
• offer staging with whole-body and brain CE-CT to people with stage IIC to IV melanoma
• consider staging with brain MRI, instead of brain CE-CT, if locally available and after discussion and agreement with the specialist skin cancer multidisciplinary team
• offer staging with whole body and brain MRI, instead of CE-CT, to:
  • children and young adults (from birth to 24 years) with stage IIB to IV melanoma
  • women with stage IIB to IV melanoma who are pregnant
• consider staging with brain MRI, instead of brain CE-CT, for people with stage IIIC to IV melanoma and one of the following risk factors:
  • a mitotic index of 5 or more
  • primary melanoma located on the scalp
• consider a repeat staging scan before starting adjuvant treatment, unless imaging done within the past 8 weeks is available

The NICE committee stated that:

• evidence showed that sentinel lymph node biopsy (SLNB) should be done (or ruled out) before imaging for most people because imaging does not accurately detect lymph node metastases during staging. The committee agreed that imaging should only be offered before SLNB if lymph node or distant metastases are suspected

Notes (2):

• sentinel node biopsy (SNB) is the most accurate staging tool for melanoma patients
  • the procedure is indicated especially for intermediate thickness melanoma (pT2/3). SNB can be of value in thin melanoma (>0.75 mm in thickness), with adverse prognostic factors, and in thick melanomas (pT4), although T4 patients are already at high risk of disease progression

Reference:

• NICE (July 2022). Melanoma: assessment and management
• Madu MF, Wouters MW, van Akkooi AC. Sentinel node biopsy in melanoma: Current controversies addressed. Eur J Surg Oncol. 2017 Mar;43(3):517-533