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| |  Sentinel Node Biopsy Encouraged in Melanoma Treatment Guidelines: Presented at NCCN By Ed Susman HOLLYWOOD, Fla -- March 17, 2009 -- New guidelines for treating patients with stage IB or IIA melanoma urge doctors to perform sentinel-node biopsies when possible to more accurately tailor treatment, according to a presentation here at the National Comprehensive Cancer Network (NCCN) 14th Annual Conference: Clinical Practice Guidelines & Quality Cancer Care. "The status of the sentinel node is the most powerful predictor of outcome in patients with melanomas 1.2 to 3.5 mm thick," explained guideline presenter Daniel G. Coit, MD, Memorial-Sloan Kettering Cancer Center, New York, New York. Determination of the sentinel node is used as a staging factor, he said in his presentation on March 14. If the sentinel node is positive, more aggressive treatment for melanoma is warranted, he noted. If the sentinel node biopsy shows that the nodal system appears free of cancer cells in stage IB, IIA disease, the guidelines suggest that doctors can proceed by simple observation or by entering the patients into a clinical trial, Dr. Coit said. Dr. Coit said that observation, clinical trial participation, or treatment with interferon alfa is an acceptable option for patients with sentinel-node-negative biopsies and stage IIB or IIC disease. Because of the staging value associated with sentinel-node biopsy, the guideline authors modified the principles of biopsy that accompany the treatment pathways. "Excisional biopsy -- elliptical, punch, or saucerisation -- with 1 to 3 mm margins is preferred," Dr. Coit said. "Wider margins should be avoided to permit accurate subsequent lymphatic mapping." On the other hand, he said that shave biopsies "may compromise pathological diagnosis and complete assessment of Breslow thickness." If clinical suspicion that the lesion is melanoma is low, a shave biopsy may be acceptable, he noted. New changes to what is required from the pathology report were also included in the latest guidelines. "We are including the mitotic rate as part of the pathology report," Dr. Coit said. But the reliance on the Clark level of the lesion has been de-emphasised. The mitotic rate indicates the doubling times of cells that eventually grow and invade into adjacent lymphatic and blood vessels, and thus may be a predictor of a poor prognosis. The Clark level of invasion measures the depth of penetration of a melanoma into the skin according to anatomic layer. However, the predictive value of the Clark level measurement has been controversial. "The Clark level is just about to fall off the map," as far as its necessity for treatment decisions, Dr. Coit said.
[Presentation title: NCCN Melanoma Guidelines Update.]
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