Improving outcomes for people with skin tumours including melanoma

One systematic review based upon 12 studies found the proportion of
tumour positive sentinel nodes to be 17.8% [95% CI 16.7% to 19.0%],
and this proportion correlated strongly with Breslow thickness. The
authors recommended that SNB is inappropriate for tumours with
Breslow thickness less than 1 mm, that for Breslow thickness between
1.0 mm and 1.5 mm SNB should be considered on an individual basis
in the light of other prognostic factors and possible adjunctive
therapy, and that for Breslow thickness between 1.51 mm and 4.0
mm SNB is appropriate. The authors reported that the value of SNB
for Breslow thickness greater than 4.0 mm is questionable because of
the high risk of existing haematogenous spread.
Improving Outcomes for
People with Skin Tumours
including Melanoma
Initial investigation,
diagnosis, staging and
management
There is evidence from observational studies that the status of the
sentinel node significantly predicts disease-free survival.
Evidence from observational studies suggests that, while surgical
complications can arise from SNB, the procedure is less invasive than
a regional lymphadenectomy.
The findings of observational studies are inconsistent as to whether
patients with melanoma who undergo SNB show increased rates of
in-transit recurrence, compared with patients who receive delayed
regional lymphadenectomy after detection of clinically palpable
lymph nodes.
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Lymph node clearance
One systematic review found no statistically significant advantage in
terms of overall mortality arising from elective lymph node dissection
compared to delayed lymph node dissection at the onset of clinical
symptoms.
One RCT of elective versus delayed regional lymph node dissection
in patients with melanoma found that the routine use of immediate
node dissection had no significant impact on survival, while the status
of regional nodes significantly predicted survival.
Cryotherapy/cryosurgery
Three UK clinical guidelines produced on behalf of the British
Association of Dermatologists support the use of cryotherapy in the
treatment of a sub-set of patients with Bowen’s disease, SCC (where
good short-term cure rates are achievable) and primary BCC.
Guidance on cancer services: skin tumours including melanoma 93