Approximately 50% of Mohs surgery cases on invasive melanoma in which the NCCN guidelines recommended to “discuss and offer SLNB” actually underwent SLNB.
Clinical Pearls
This study evaluated the rate of performance of Sentinel-Lymph Node Biopsy (SLNB) for invasive melanomas treated Mohs surgery on the basis of NCCN recommendations
Approximately 50% of Mohs surgery cases on invasive melanoma in which the NCCN guidelines recommended to “discuss and offer SLNB” actually underwent SLNB. Similarly, 38.5% of cases in which the NCCN guidelines recommended to “discuss and consider SLNB” underwent SLNB.
Weaknesses of the study include the fact that NCCN states its consensus-based guidelines are not standard of care, and thus, the decision to pursue SLNB must be made in the context of each patient’s clinical picture. The authors also do not address the impact of the shared decision-making process on SLNB rates in patients with invasive melanoma treated with Mohs surgery.
Discussion:
Sentinel lymph node biopsy is often recommended for patients with cutaneous melanoma based on tumor T stage according to the National Comprehensive Cancer Network (NCCN) guidelines. In the past, this procedure has been completed by surgeons at the same time as treatment via wide local excision. However, the use of Mohs surgery to treat invasive melanoma requires the use of a provider from a different specialty to perform SLNB. This study aimed to determine the rate of SLNB performed for invasive melanomas using the NCCN guidelines as a reference.
The study cohort included 7096 cases of invasive cutaneous melanomas treated with Mohs surgery. Out of all the cases which the NCCN guidelines recommended to “discuss and offer SLNB”, 48.2% involved patients undergoing SLNB. Additionally, of all cases in which the NCCN guidelines recommended to “discuss and consider SLNB”, 38.5% involved patients undergoing SLNB. Overall, this study concluded that less than half of invasive melanoma cases treated with Mohs surgery follow the NCCN guidelines for performing SLNB.
While this study provides very insightful and unique data regarding the real-world management of melanoma, there are several weaknesses which may be addressed. Firstly, the authors do not acknowledge the shared decision-making process and its likely impact on whether patients will undergo SLNB. Additionally, the NCCN states that its consensus-based guidelines are not standard of care, and thus, the necessity of SLNB will vary largely depend on each patient’s unique clinical situation. There is also room for bias and evidence suggesting bias in the process of determining what recommendations requested for review by the NCCN are truly reviewed and cited. Finally, it is important to keep in mind that the NCCN guidelines on the management of melanoma are based on consensus-based voting from 32 largely, tertiary cancer centers. While the extensive experience of this group will provide exceptional direction for physicians at similar institutions, the experience and resources of those at smaller institutions or in community settings may differ. Furthermore, of the 32 authors contributing to the NCCN guidelines on the management of melanoma, there are only two dermatologists, of which one is a fellowship-trained Mohs surgeon. Thus, the viewpoints of dermatologists may not be fully represented in the creation of these guidelines.
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