Role of radiologic imaging at the time of initial diagnosis of stage T1b‐T3b melanoma

Abstract

BACKGROUND. In patients with T1b‐T3b cutaneous melanoma the utility of radiologic imaging at the time of diagnosis is unclear. Whether initial imaging led to a change in stage or treatment plan was investigated. METHODS. The melanoma database was searched for patients with T1b‐T3b primary lesions, clinically N0, and asymptomatic for metastatic disease. Radiologic studies conducted before wide local excision ± sentinel lymph node biopsy as well as all further imaging and investigations were analyzed. Outcome measures included upstaging, change in initial surgical management, true‐positive, false‐positive, true‐negative, and false‐negative rates of each imaging modality. RESULTS. In all, 344 preoperative imaging studies (chest x‐ray [CXR], computed tomography [CT], positron emission tomography [PET]/CT) were performed on 158 patients, resulting in 49 findings suspicious for metastatic melanoma and 134 findings suggestive of nonmelanoma pathology. Only 1 of 344 (0.3%) studies, a PET/CT, correlated with confirmed metastatic melanoma. The false‐positive rates were CXR 5 of 7 (71.4%), chest CT 21 of 24 (87.5%), abdomen/pelvis CT 10 of 11 (90.9%), head CT 2 of 2 (100.0%), PET/CT 3 of 5 (60.0%). No patient was upstaged or had a change in initial surgical management based on preoperative imaging. The cost of all initial imaging and imaging to follow‐up abnormal findings was estimated as $555,308 for the 158 patients studied. CONCLUSIONS. Imaging at the time of initial diagnosis of T1b‐T3b, clinically N0, M0 melanoma was of low yield with a high false‐positive rate, and did not lead to upstaging or change in initial surgical management. These findings suggest that imaging of asymptomatic patients at the time of diagnosis may not be warranted. Cancer 2007. © 2007 American Cancer Society.

Malignant Melanoma S3‐Guideline “Diagnosis, Therapy and Follow‐up of Melanoma”

“…In a current meta-analysis, Xing et al suggest a 5-year recurrence rate of 5 % in low-risk patients [104]. Recurrence of lymph node or distant metastases has been observed in 5-11 % of patients with stage IIA or IIB disease within approximately 0.5 to 1 year after primary diagnosis [105,130]. PET/CT findings in these patients were almost always negative during initial staging [105,130].…”

“…Systematic search of the literature de-novo: [102][103][104][105] Strength of consensus: 83 % H.-P. Schlemmer…”

“…Based on current data, a general recommendation for imaging procedures cannot be issued at these tumor stages. Published data, primarily based on studies with inhomogenous patient groups [102,105], has shown that additional CT imaging is not indicated in the absence of symptoms. A particular problem is the not clearly quantifiable rate of false negative and false positive findings.…”

“…A total of 6 642 patient were included in a meta-analysis by Bafounta et al [113] comprising 12 trials that assessed the validity of sonography, compared to mere palpation, in the evaluation of lymph node invasion in melanoma patients. Use of sonography resulted in a higher differentiation (odds ratio of 1 755 [95 % CI 726-4 238] versus 21 [95][96][97][98][99][100][101][102][103][104][105][106][107][108][109][110][111]; p = 0.0001) not only at initial staging, but also during follow-up. These findings have been confirmed in subsequent studies.…”

“…In the course of initial staging up to stage IIB, the sensitivity of PET and PET/CT for the detection of clinically occult locoregional lymph node metastases is low and clearly inferior to sentinel lymph node scintigraphy with subsequent lymph node dissection [104,105,130,132,[134][135][136][137][138][139]. PET or PET/CT with fluorodeoxyglucose (FDG) should not be performed for the detection and/or localization of locoregional lymph node metastasis.…”