Hospital-Based Study of Compliance with NCCN Guidelines and Predictive Factors of Sentinel Lymph Node Biopsy in the Setting of Thin Melanoma Using the National Cancer Database

Abstract

Thin melanoma is the most common form of melanoma in the United States. The National Comprehensive Cancer Network (NCCN) has guidelines for sentinel lymph node biopsy (SLNB) which recommend “discuss and consider” SLNB for invasion >0.75 mm and “discuss and offer” SLNB for invasion >0.75 mm with suspicious features. This study looked at compliance with NCCN guidelines and factors that are predictive of a positive SLNB. This is a retrospective study of patients diagnosed with thin melanoma 2012–2013 using the National Cancer Database. A total of 26,456 patients met study qualifications. Univariate analysis showed that 76 per cent of patients meeting criteria underwent SLNB. Patients recommended to “discuss and consider” received SLNB 53 per cent of the time and those not recommended for SLNB received SLNB 20 per cent of the time. On multivariate analysis, depth was not predictive for positive SLNB whereas mitoses and ulceration were. Other factors predictive of positive SLNB were nodular cell type, lymphovascular invasion, and Clark's level greater than or equal to IV. Patients with thin melanoma that meet NCCN guidelines for SLNB undergo this procedure in good compliance but those who do not meet criteria continue to receive SLNB. Positive predictive factors for positive SLNB include mitoses, ulceration, Clark's level, and primary site.

Validation of a clinicopathological and gene expression profile model for sentinel lymph node metastasis in primary cutaneous melanoma*

“…In the development cohort, the prevalence of nodal metastasis was 17%, 29 whereas our validation cohort had a prevalence of 27%. This lower pre-test probability of nodal metastasis in the USA 23,24,[34][35][36][37] can be attributed to more defensive diagnostics in the USA 23,38,39 and differences in histopathological SLN examination between the USA and Europe. 40 Furthermore, patients with minimal tumour burden in the SLN were excluded from the main analysis in the US development cohort, as both pathological evaluation of the SLN and patient prognosis can be considered to be ambiguous.…”

Guidance of Sentinel Lymph Node Biopsy Decisions In Patients With T1–T2 Melanoma Using Gene Expression Profiling

“…Most guidelines suggest considering SLNB for melanomas with pathologic stage T1b and above, as well as T1a melanomas with high-risk features. However, this threshold is not absolute, and physicians weigh many factors, including patient preference, to make decisions pursing SLNB, thus not all eligible patients undergo the procedure [33,34]. Additional information on risk of SLN positivity and clinical outcomes could help in SLNB decision-making.…”

Sentinel lymph node biopsy guideline concordance in melanoma: Analysis of the National Cancer Database

“…Despite the utility of SLNB in certain patients with clinically node‐negative melanoma, there has been mixed adherence with national consensus guidelines 6–8 . Overutilization of SLNB may lead to unnecessary postoperative morbidity and increased medical expenditures 9 .…”

“…Underutilization may lead to the incomplete acquisition of prognostic and staging information 10–12 . Various patient and facility factors have been shown to be associated with SLNB adherence 6–8 . Additionally, facility type has also been implicated in the lack of guideline‐concordance among other cancers, but this has not been explored in melanoma 13–15 …”