Utility of sentinel lymph node biopsy for solitary dermal melanomas

Abstract

Background and Objectives Solitary dermal melanoma (SDM) is melanoma confined to subcutaneous and/or dermal layers in the absence of a known primary cutaneous lesion. We hypothesized that sentinel node biopsy is an effective staging strategy for this rare disease. Methods A Markov decision model was constructed to represent two management strategies for SDM: wide local excision followed by observation, and wide local excision followed by sentinel node biopsy. Utilities, likelihood of positive sentinel node biopsy, and cancer progression rates during a five year time horizon were assigned based on institutional data and a review of existing literature. Estimated costs were derived using Medicare reimbursements. Results Excision followed by sentinel node biopsy provides greater utility, yielding 3.85 discounted quality-adjusted life years (dQALY) compared to 3.66 for excision alone. The incremental cost-effectiveness ratio for sentinel node biopsy is $19,102 per dQALY. Sensitivity analyses demonstrated that observation is more cost-effective if greater than 23% of sentinel node biopsies are positive (16% reported), or if 5-year survival for observed patients is greater than 76% (69% reported). Conclusions Based on existing clinical evidence, sentinel node biopsy yields greater utility than excision alone and is cost-effective for patients presenting with solitary dermal melanoma.

Dermal melanoma: A report on prognosis, outcomes, and the utility of sentinel lymph node biopsy

“…They constructed a Markov model to compare management strategies of WE of DM with and without the use of SLNB. The authors concluded patients in the SLNB arm were more likely to remain in the disease‐free state compared to those who had a WE followed by observation alone . In the final analysis of the MSLT‐1 trial, patients with intermediate thick melanomas (1.2–3.5 mm) who were randomized to SLNB had a significant improvement in relapse‐free survival compared to those in the observation arm ( P = 0.01) .…”

“…They constructed a Markov model to compare management strategies of WE of DM with and without the use of SLNB. The authors concluded patients in the SLNB arm were more likely to remain in the disease-free state compared to those who had a WE followed by observation alone [19]. In the final analysis of the MSLT-1 trial, patients with…”

Clinical significance of tumor mitotic rate and lack of epidermal attachment in melanoma of the head and neck

“…In this study, primary dermal melanoma is defined as a melanoma (collection of atypical melanocytes that are pleomorphic, often mitotically active) within the dermis without overlying melanoma in situ from which it is arising, in the absence of evidence that this is a metastasis from another primary melanoma. Primary dermal melanoma is thought to represent about 0.4%‐0.9% of all melanomas . These tumors may be a unique subtype of melanoma, distinct from dermal metastases .…”

“…When compared with cutaneous lesions, these lesions have similar prognostic characteristics as intermediate‐thickness primary cutaneous melanomas . There is evidence that SLNB for primary dermal melanoma has utility compared to excision alone …”

“…Primary dermal melanoma is thought to represent about 0.4%-0.9% of all melanomas. 12,13 These tumors may be a unique subtype of melanoma, distinct from dermal metastases. 11,14 Although histologically similar to metastatic disease, this distinct subtype of melanoma has unexpectedly high survival, which would not be expected from metastatic melanoma of unknown primary.…”