Sentinel lymph node biopsy is unreliable in predicting melanoma mortality for both younger and older patients

Abstract

BackgroundMelanoma disease patterns vary with patient age.AimTo evaluate sentinel lymph node biopsy (SLNB) in managing melanoma at differing patient ages.MethodsOnline prediction tools were applied to compare SLNB positivity (SLNB+) and survival risk at patient ages 20–80. Tübingen melanoma data were used to determine variations in the hazard ratio of SLNB+ for mortality at different patient ages.ResultsRegardless of tumour thickness, predicted SLNB+ rates were markedly higher than mortality rates for 20‐year‐old patients. For 80‐year‐old patients, it is the opposite.DiscussionIf 1000 20‐year‐olds with a 0.4 mm thickness non‐ulcerated melanoma underwent SLNB, 100 would likely be positive. If all 100 were to be offered adjuvant drug therapy (ADT), fewer than three more melanoma deaths in those 1000 patients would be avoided. In total, 97 patients would have received medication they may never have needed. If 1000 80‐year‐olds with a 3 mm thickness non‐ulcerated melanoma underwent SLNB, only 40 would likely be positive. In total, 274 patients would be predicted to die of melanoma, 245 being SLNB negative and 29 SLNB+. ADT linked to SLNB+ could deny treatment to 89% of these high‐risk patients.LimitationsThe authors relied on published risk data.ConclusionSLNB has poor specificity at predicting mortality in young melanoma patients and poor sensitivity in older patients. SLNB is not indicated in managing cutaneous melanoma for patients under 40 or over 60 years of age. Many such patients could be managed with wide local excision alone in their clinician's office‐based practice. For all cutaneous melanoma patients at all ages, linking ADT to BAUSSS biomarker, (an algorithm of Breslow thickness, age, ulceration, subtype, sex and Site) rather than SLNB+ is likely more appropriate. BAUSSS provides a more accurate melanoma‐specific mortality risk assessment for patients without burdening them with added surgery, hospitalization, costs or morbidity risk.

Primary Cutaneous Melanoma—Management in 2024

“…Our recent research has found that the benefit of SLNB is a particularly poor prognostic indicator for patients under 40 and over 60 years of age [ 57 ].…”

“…It is estimated that only 30 of the 1000 patients would die from their melanoma [ 60 ]. The HR specific to this age group demonstrates that there will be two melanoma-specific deaths in this clinical scenario in SLNB- patients for every death in a SLNB+ patient [ 57 ]. A total of 1000 patients would receive added surgery and 120 patients would be potentially treated with ADT to hopefully prolong life for 10 patients.…”

“…We have previously identified the extent to which the prognosis of melanomas is worse as patients are older [ 57 ]. This raises the question of how to manage the skin of melanoma patients after their 5 or 10 years of follow-up.…”

A Narrative Review of Current Knowledge on Cutaneous Melanoma

“…Similarly, sentinel node biopsy has low sensitivity for predicting mortality in individuals over 60 years old. Therefore, regarding the two groups, management can be achieved without SLN biopsy via wide local excision [90].…”

Age matters: Rethinking SLNB's reliability in melanoma mortality prediction

“…The research presented in this article by Dixon et al 1 tackles a critical issue in the management of melanoma, a type of skin cancer known for its aggressive nature and potential for rapid progression. Melanoma's behaviour and prognosis are notoriously variable, influenced significantly by patient age, among other factors.…”