Sentinel Lymph Node Biopsy and Management of Regional Lymph Nodes in Melanoma: American Society of Clinical Oncology and Society of Surgical Oncology Clinical Practice Guideline Update

Abstract

Purpose

To update the American Society of Clinical Oncology (ASCO)-Society of Surgical Oncology (SSO) guideline for sentinel lymph node (SLN) biopsy in melanoma.

Methods

An ASCO-SSO panel was formed, and a systematic review of the literature was conducted regarding SLN biopsy and completion lymph node dissection (CLND) after a positive sentinel node in patients with melanoma.

Results

Nine new observational studies, two systematic reviews and an updated randomized controlled trial (RCT) of SLN biopsy, as well as two randomized controlled trials of CLND after positive SLN biopsy, were included.

Recommendations

Routine SLN biopsy is not recommended for patients with thin melanomas that are T1a (non-ulcerated lesions < 0.8 mm in Breslow thickness). SLN biopsy may be considered for thin melanomas that are T1b (0.8 to 1.0 mm Breslow thickness or <0.8 mm Breslow thickness with ulceration) after a thorough discussion with the patient of the potential benefits and risk of harms associated with the procedure. SLN biopsy is recommended for patients with intermediate-thickness melanomas (T2 or T3; Breslow thickness of >1.0 to 4.0 mm). SLN biopsy may be recommended for patients with thick melanomas (T4; > 4.0 mm in Breslow thickness), after a discussion of the potential benefits and risks of harm. In the case of a positive SLN biopsy, CLND or careful observation are options for patients with low-risk micrometastatic disease, with due consideration of clinicopathological factors. For higher risk patients, careful observation may be considered only after a thorough discussion with patients about the potential risks and benefits of foregoing CLND. Important qualifying statements outlining relevant clinicopathological factors, and details of the reference patient populations are included within the guideline.

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Acknowledgement

The Expert Panel thanks Jeffrey Kirshner, MD, Geoffrey Gibney, MD, and Jean Rene Clemenceau, MD, and the Clinical Practice Guidelines Committee for their thoughtful reviews and insightful comments on this guideline.

Disclosures

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or www.ascopubs.org/jco/site/ifc. Sandra L. Wong: no relationship to disclose. Mark B. Faries: Consulting or Advisory Role: Immune Design, Delcath Systems, Novartis, Castle Biosciences. Erin B. Kennedy: No relationship to disclose. Sanjiv S. Agarwala: Travel, Accommodations, Expenses: MSD, Bristol-Myers Squibb. Timothy J. Akhurst: Employment: Intellerad (I), Stock or Other Ownership: Perkin Elmer (I). Charlotte Ariyan: Employment: Pfizer (I), Stock or Other Ownership: Pfizer (I). Charles M. Balch: Honoraria: Merck, Merck Sharp & Dohme, Consulting or Advisory Role: Merck, Travel, Accommodations, Expenses: Merck, Merck Sharp & Dohme. Barry S. Berman: Consulting or Advisory Role: Bristol-Myers Squibb, Bayer, Genentech, Alexion Pharmaceuticals, Axess Oncology. Alistair Cochran: No relationship to disclose. Keith A. Delman: No relationship to disclose. Mark Gorman: No relationship to disclose. John M. Kirkwood: Consulting or Advisory Role: Bristol-Myers Squibb, Novartis, Genentech/Roche, EMD Serono, Array BioPharma, Merck. Research Funding: Prometheus (Inst), Merck (Inst). Marc D. Moncrieff: No relationship to disclose. Jonathan S. Zager: Honoraria: Amgen, Consulting or Advisory Role: Amgen, Castle Biosciences, Delcath Systems, Speakers’ Bureau: Amgen, Research Funding: Amgen (Inst), Castle Biosciences (Inst), Delcath Systems (Inst), Provectus (Inst). Travel, Accommodations, Expenses: Amgen. Gary H. Lyman: Consulting or Advisory Role: Halozyme, G1 Therapeutics, Coherus Biosciences. Research Funding: Amgen (Inst)

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Corresponding author

Correspondence to Erin B. Kennedy MHSc.

Additional information

Gary H. Lyman and Sandra L. Wong were Expert Panel co-chairs.

Editor’s note

ASCO Clinical Practice Guideline Committee Approved: July 20, 2017

This Society of Surgical Oncology (SSO) and American Society of Clinical Oncology (ASCO) Clinical Practice Guideline provides recommendations, with comprehensive review and analyses of the relevant literature for each recommendation. Additional information, including a Data Supplement with additional evidence tables and a Methodology Supplement are available at https://link.springer.com/journal/10434 and www.asco.org/melanoma-guidelines. In addition, slide sets, clinical tools and resources, and links to patient information are available at www.cancer.net, www.asco.org/melanoma-guidelines and www.asco.org/guidelineswiki.

Published online ahead of print at https://link.springer.com/journal/10434 and www.jco.org.

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Wong, S.L., Faries, M.B., Kennedy, E.B. et al. Sentinel Lymph Node Biopsy and Management of Regional Lymph Nodes in Melanoma: American Society of Clinical Oncology and Society of Surgical Oncology Clinical Practice Guideline Update. Ann Surg Oncol 25, 356–377 (2018). https://doi.org/10.1245/s10434-017-6267-7

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Keywords

  • American Society Of Clinical Oncology (ASCO)
  • Completion Lymph Node Dissection (CLND)
  • Intermediate Thickness Melanomas
  • Thin Melanomas
  • Breslow Thickness