Skip to main content

Risk of Overusing Sentinel Node Biopsy in Patients With Thin Melanoma

Publication: Journal of Clinical Oncology

Accompanying Article

Free access

To the Editor:

Moncrieff et al1 recently reported on results of sentinel node (SN) biopsy in a retrospective study of 3,607 patients with pT1b or pT2a melanoma, who underwent SN biopsy between 2005 and 2020 at nine cancer centers while also assessing the prognostic value of tumor deposit maximum dimension in patients with SN micrometastases. SN biopsy was positive in 408 patients (11.3%). These patients would be classified with stage IIIA disease according to the eighth edition of American Joint Committee on Cancer (AJCC).2 Survival analysis among SN-positive patients identified a SN tumor deposit maximum dimension of 0.3 mm as the optimal cut point for stratifying survival. Five-year disease-specific survival rates were 80.3% and 94.1% for patients with SN metastatic tumor deposits ≥ 0.3 mm and < 0.3 mm, respectively (hazard ratio, 1.26 [1.11 to 1.44]; P < .0001). The authors propose that indications for offering adjuvant systemic therapy in patients with AJCC IIIA melanoma should use this cutoff rather than the > 1 mm cutoff currently suggested in many guidelines.1 The newly identified high-risk (≥ 0.3 mm) subgroup comprised 271 (66.4%) patients of the stage IIIA cohort, whereas only 142 (34.8%) patients had SN tumor deposits > 1 mm in maximum dimension.1
However, there is a risk of overuse of SN biopsy in patients with T1b melanoma and overuse of adjuvant therapy in stage IIIA patients. In addition, it would be appreciated if the authors could elaborate on some specific aspects.
In the reported cohort of pT1b/pT2a melanomas, 27.7% (1,000 of 3,607) of the patients had pT1b thin melanoma (Table 1), of whom 7.5% (n = 75) had positive SN biopsy.1 However, the definition of pT1b disease has changed to also now include a large subset of patients with melanoma 0.8 to 1.0 mm Breslow thickness without ulceration.2 In a recent series (2017-2021) from Naples-Italy, where patients were offered SN biopsy taking largely into account the new definition of T1b melanomas (0.8 to 1.0 mm without or with ulceration or < 0.8 mm with ulceration), there were as many patients receiving SN biopsy for T1b melanoma than for a T2a melanoma, and the SN biopsy positivity rate was as low as 2.3% in patients with T1b melanoma.3 SN biopsy adds potential morbidity, more extensive surgery and anesthesia, and significant cost compared with a simple wide local excision. Thus, more elective use of SN biopsy in the population of T1b melanoma is warranted.3-5
The percentage of SN-positive patients with tumor deposit > 1 mm in maximum dimension (34.8%) also looks high. In a large series by Maurichi et al,6 only 19.4% of patients with thin melanomas and positive SN biopsy had a tumor deposit > 1 mm in maximum dimension.
From the AJCC database, the five-year disease-specific survival rate of the new stage IIIA cohort was 93%.2 Comparatively, the five-year disease-specific survival rate of 80.3% for patients with SN metastatic tumor deposits ≥ 0.3 mm (66.4% of the IIIA cohort) in the reported series is rather low and probably does not integrate advances in systemic therapy for relapsed/metastatic patients.1
Finally, the authors propose that indications for offering adjuvant systemic therapy in patients with AJCC IIIA melanoma should use the new cutoff of SN tumor deposits ≥ 0.3 mm in maximum dimension rather than the traditional > 1 mm cutoff.1 However, inclusion in adjuvant trials of AJCC IIIA patients with nonulcerated melanoma required that SN metastasis exceeds 1 mm.7,8 So, novel trials would be needed on the basis of the proposed new cutoff of ≥ 0.3 mm. Moreover, even for patients with AJCC eighth edition IIIA melanoma and tumor deposit > 1 mm, the benefit from adjuvant therapy was low compared with the other AJCC III subgroups.7,8 The benefit-to-toxicity ratio is not yet fully established and expanding the group further might not be desirable at present time.9

Author'S Disclosures of Potential Conflicts of Interest

Risk of Overusing Sentinel Node Biopsy in Patients With Thin Melanoma

The following represents disclosure information provided by the author of this manuscript. All relationships are considered compensated unless otherwise noted. 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 or
Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).
No potential conflicts of interest were reported.


Moncrieff MD, Lo SN, Scolyer RA, et al: Clinical outcomes and risk stratification of early-stage melanoma micrometastases from an international multicenter study: Implications for the management of American Joint Committee on Cancer IIIA disease. J Clin Oncol 40:3940-3951, 2022
Gershenwald JE, Scolyer RA, Hess KR, et al: Melanoma staging: Evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin 67:472-492, 2017
Brancaccio G, Pellerone S, Scharf C, et al: Sentinel node biopsy in thin melanoma: A retrospective descriptive cohort study. J Eur Acad Dermatol Venereol 2022;36:e795-e796
Weitemeyer MB, Helvind NM, Brinck AM, et al: More sentinel lymph node biopsies for thin melanomas after transition to AJCC 8th edition do not increase positivity rate: A Danish population-based study of 7148 patients. J Surg Oncol 125:498-508, 2022
Herb JN, Ollila DW, Stitzenberg KB, et al: Use and costs of sentinel lymph node biopsy in non-ulcerated T1b melanoma: Analysis of a population-based registry. Ann Surg Oncol 28:3470-3478, 2021
Maurichi A, Miceli R, Eriksson H, et al: Reply to E. Hindié. J Clin Oncol 38:3238-3240, 2020
Hauschild A, Dummer R, Schadendorf D, et al: Longer follow-up confirms relapse-free survival benefit with adjuvant dabrafenib plus trametinib in patients with resected BRAF V600-mutant stage III melanoma. J Clin Oncol 36:3441-3449, 2018
Eggermont AMM, Blank CU, Mandalà M, et al: Adjuvant pembrolizumab versus placebo in resected stage III melanoma (EORTC 1325-MG/KEYNOTE-054): Distant metastasis-free survival results from a double-blind, randomised, controlled, phase 3 trial. Lancet Oncol 22:643-654, 2021
Eggermont AMM, Suciu S, Robert C: Adjuvant therapy in stage IIIA melanoma—Authors' reply. Lancet Oncol 22:e300, 2021

Information & Authors


Published In

Journal of Clinical Oncology
Pages: 1325 - 1326
PubMed: 36455165


Published online: December 01, 2022
Published in print: February 20, 2023


Request permissions for this article.



Elif Hindié, MD, PhD, Bordeaux University Hospital, Bordeaux, France


Corresponding author: Elif Hindié, MD, PhD, Department of Nuclear Medicine, CHU Bordeaux, Hôpital Haut-Lévêque, Ave Magellan, 33604 Pessac, France; e-mail: [email protected].

Metrics & Citations




Article Citation

Download Citation

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.


Download article citation data for:
Elif Hindié
Journal of Clinical Oncology 2023 41:6, 1325-1326

View Options

View options


View PDF







Share article link