Letter to British Medical Journal

Assistant Professor Dixon had a short comment on sentinel node biopsy published in the British Medical Journal on May 10 2008. It reads as follows:

Let's get back to basics in managing melanoma

I find the debate about sentinel node biopsy puzzling.¹ Clinicians are getting bogged down with this question while the fundamentals of managing cutaneous melanoma are being neglected. A recent Australian study² showed that doctors perform poorly in key aspects of managing this aggressive tumour.

Only a third of doctors excised cutaneous melanoma with the margins recommended by the Australian guidelines - a third used larger margins and, more worrying, a third used narrower margins. Most doctors failed to check the skin at follow-up, and they often diagnosed suspicious lesions by biopsy not local excision. Australian surgeons are slow to acquire dermoscopic skills that improve early diagnosis of melanoma. A patient with a thin melanoma is more likely to develop another cutaneous primary than metastatic disease. Yet dermoscopy and skin checks are often neglected.

If surgeons used time spent doing the sentinel lymph node biopsy in routinely examining the skin at follow, there would be a tangible gain for our patients. In contrast, a procedure with a 10% incidence of complications³ which does not improve five year survival, ⁴ is hardly a tangible gain.

Let us get back to the basics. Let’s offer our patients skin checks for life, ensure dermoscopy is a routine part of this examination, and excise suspicious lesions rather than biopsy them to gain histology. Most importantly, let’s give our patients with invasive melanoma a minimum 10 mm margin of normal skin rather than skimp.

1.         Thomas JM. Sentinel lymph node biopsy in malignant melanoma. BMJ 2008;336:902-3.

2.         Kelly JW, Henderson MA, Thursfield VJ, Slavin J, Ainslie J, Giles GG. The management of primary cutaneous melanoma in Victoria in 1996 and 2000. Med J Aust 2007;187:511-4.

3.         Morton DL, Cochran AJ, Thompson JF, Elashoff R, Essner R, Glass EC, Mozzillo N, Nieweg OE, Roses DF, Hoekstra HJ, Karakousis CP, Reintgen DS, Coventry BJ, Wang HJ. Sentinel node biopsy for early-stage melanoma: accuracy and morbidity in MSLT-I, an international multicenter trial. Ann Surg 2005;242:302-11; discussion 311-3.

 4.        Morton DL, Thompson JF, Cochran AJ, Mozzillo N, Elashoff R, Essner R, Nieweg OE, Roses DF, Hoekstra HJ, Karakousis CP, Reintgen DS, Coventry BJ, Glass EC, Wang HJ. Sentinel-node biopsy or nodal observation in melanoma. N Engl J Med 2006;355:1307-17.

The letter reminds us that at the end of the day, only two things improve long term survival in melanoma management.

1. We have to try to find the melanoma early
2. We need to excise it with an appropriate margin.

We have to work hard to get these fundamentals correct. Anything else is at the fringe. Certainly anything that studies show makes no difference to survival must be regarded as a very minor consideration.