Nodal metastasis in early melanoma

http://www.sciencedirect.com/science/article/pii/S0748798312009936# ------- Background: According to current guidelines, the treatment for thin melanoma (T1a) is limited to surgical excision with a margin >1 cm. The prognostic factors in treatment planning must surely be re-evaluated, because we have encountered distant recurrence in patients with early melanoma so treated. Methods: Between January 2004 and November 2010, we observed 6 patients with lymph node metastasis from early melanoma (Breslow depth, 0.3 - 0.9 mm, not ulcerated tumor, mitosis/mm2<1). All patients were biopsied with a margin<1 cm and then re-operated to obtain a greater safety margin for cancer. No patient had received a prior sentinel lymph node biopsy. The series comprised: melanoma of the abdominal region with inguinal lymph node metastasis (n¼1); melanoma of the back with metastasis to the ipsilateral groin (n¼1); melanoma of the upper limb with ipsilateral axillary metastasis (n¼1); and lower limb melanomas with metastasis to the ipsilateral groin (n¼3). The time of occurrence of lymph node metastases was between 6 and 20 months. Diagnosis was confirmed by fine-needle aspiration cytology (FNAC). All patients underwent enlarged lymphadenectomy of the involved lymphatic stations and cancer re-staging. Results: Pathological lymph node examination consistently confirmed metastatic melanoma. All patients were referred to the oncologist for adjuvant therapy. The average duration of follow-up as of December 2012 is 51.5 months. Metastatic disease was detected in locations distant from the operated lymph nodes in 3 patients. One patient died; the remaining 4 patients are in follow-up without evidence of disease to date. Conclusions: Current guidelines for the treatment of melanoma include sentinel lymph node biopsy only in cases of primary tumor thickness 1 mm according to Breslow depth or in cases of ulcerated tumor, or even in cases of Breslow depth <1 mm with evidence of one or more mitoses/mm2. It is now accepted that in the event of a thickness <1 mm the probability of finding a positive sentinel lymph node is about 3-7%. Our experience, supported by the cases described and the literature, advocates sentinel lymph node biopsy in all patients, given the procedure’s low morbidity and important prognostic role, in addition to the possibility to reduce the incidence of lymph node metastases.