Treating Melanoma in Primary Care

There is quite a lot of confusion and concern about when melanoma patients should be offered sentinel lymph node biopsy and excision. Research is continuing in this space, and two recent publications provide useful, new information for primary care doctors in Australia.

The latest Australian clinical practice guidelines are provided as an online wiki and are updated regularly. Click here to read the guidelines.

A paper was recently published in the Australasian Journal of Dermatology by Gyorki et al, answering the question: ‘When is a sentinel lymph node (SLN) biopsy indicated?’ You can read the full paper here: Gyorki et al, 2017, Australasian Journal of Dermatology.

They reach the conclusion that ‘SLN biopsy should be considered for all patients with melanoma greater than 1mm in thickness and for patients with melanoma greater than 0.75mm with other high-risk pathological features to provide optimal staging and prognostic information and to maximise management options for patients who are node positive.’

So this means no SLN biopsy for in situ melanoma, but we should consider it for all invasive melanoma >1mm thick or >0.75mm thick if there are other risk features on pathology. SLN biopsy is a specialist procedure, so you need to refer to your melanoma unit. SLN biopsy provides additional prognostic information and may assist entry to drug trials.

What about SLN excision if the nodes are positive on biopsy? A paper by Faries et al reports on a randomised controlled trial that compared SLN excision with no excision but observation by ultrasound in people with positive SLN. You can read the full paper here: Faries et al, 2017, The New England Journal of Medicine.

They found that excision did not lead to improved survival but it did improve local disease control. This indicates that SLN excision is not a useful intervention.

Professor David Wilkinson

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