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Staging Workup, Sentinel Node Biopsy, and Follow-up Tests for Melanoma Update of Current Concepts

Timothy M. Johnson, MD; Carol R. Bradford, MD; Stephen B. Gruber, MD, PhD; Vernon K. Sondak, MD; Jennifer L. Schwartz, MD
Arch Dermatol. 2004;140(1):107-113. doi:10.1001/archderm.140.1.107.
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Objectives  To clarify and update workup and follow-up strategies based on fundamental principles and current data, and to discuss new and current concepts regarding sentinel lymph node biopsy (SLNB), particularly in relation to the staging workup.

Data Sources  Studies conducted from 1995 to 2003 were identified by PubMed search. Additional searches included workup for reference lists of retrieved articles when applicable, and PubMed-related articles.

Study Selection  Contemporary studies with good design, conclusions based on sound methods, and results pertaining to staging workup, SLNB, and follow-up tests were critically reviewed.

Data Extraction  Data and conclusions based on the above studies were incorporated into a review.

Data Synthesis  Routine tests have marginal to no efficacy and are not cost-efficient for detecting occult disease in asymptomatic patients with localized melanoma. The only staging test that has relatively high sensitivity and specificity and provides tissue diagnosis is SLNB; moreover, SLNB has revolutionized our understanding of lymphatic pathways. The concepts of interval nodes and unexpected lymphatic drainage pathways have been addressed by several recent reports. There are no data that demonstrate any significant difference in overall survival for detection of asymptomatic vs symptomatic stage IV melanoma.

Conclusions  An initial workup is useful for staging and prognosis to identify occult disease, with potential outcome benefit if treated early; and, by detecting distant occult disease (stage IV), to obviate the need for an extensive surgical procedure and thereby avoid associated increased morbidity. The foundation for the workup and follow-up remains thorough history taking and a physical examination, combined with a low index of suspicion for symptom-directed tests.

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Figure 1.

Patient with newly diagnosed metastatic melanoma to the left inguinal lymph node basin, asymptomatic but with multiple significant comorbidities. A positron emission tomography scan, obtained prior to therapeutic lymphadenectomy, demonstrated widespread metastatic disease. The patient opted for hospice care.

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Figure 2.

A healthy 68-year-old woman presented with a melanoma 5.5 mm in depth at the deep margins, greater than 3 cm in diameter, and with ulceration on the left side of her back. A, Dynamic lymphoscintigraphy scan demonstrates multiple lymphatic drainage pathways in the axilla bilaterally, more prominent in the right than in the left side (posterior view). B, This 18-minute anterior view reveals bilateral sentinel lymph nodes. One of 4 sentinel lymph nodes in the right axilla were positive and 2 of 2 in the the left axilla were negative. A chest radiograph and measurement results for serum lactate dehydrogenase concentration ordered at another institution were normal. There was unusual drainage with metastasis from a primary lesion on the left side of the back to the right axilla.

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Figure 3.

Melanoma, 1.43 mm in depth, on the right dorsal foot of a 35-year-old man. Preoperative lymphoscintogram demonstrates 2 lymphatic channels to both the popliteal (interval node) and inguinal basins. Four sentinel lymph node biopsy specimens from the popliteal basin and groin were negative. This case highlights the finding of interval nodes.

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