1. 2017/2018 Sentinel Lymph Node Biopsy in Malignant Melanoma
M Rice, V Valeanu, I Delikonstantinou, E Wilson, A Orlando

2. SLNB Surgical Protocol
1 Pre-op lymphoscintigraphy with radio colloid
2 Dermal injection with patent blue
3 WLE of MM scar
4 Gamma probe guided SLNB (>95% accuracy when performed with dermal injection)

3. Why Perform SLNB? A Staging Procedure
Key prognostic indicator in Melanoma and determinant of access to adjuvant therapy
NICE (2015): indicate SLNB in Stage 1B with Breslow >1.0mm
AJCC 8th edition : 0.8mm Breslow or ulcerating lesion
Melanoma Focus Group 2019: pT1b, particularly when: a. Lymphovascular invasion b. Mitotic rate ≥2/mm2
1. Staging procedure for malignant melanoma + to detect lymph node micrometastasis, avoiding extensive dissection
2. 1 out of 10 patients die within 10 years if SLNB NEG, compared to 3 out of 10 in SLNB POS
However, 3 out of 100 SLNB neg will subsequently develop recurrence in same group of LNs

4. Aims Continue Annual Audit of SLNB @ NBT
Measure Surgical Outcomes of NBT
Compare practice against NICE guidance
Retrospective review from July 2017 —> June 2018 using notes and ICE
Evaluate and compare our practice against recommended guidelines from NICE and the Melanoma Focus Group
To measure surgical outcomes of SLNB in NBT
Retrospective review (notes and ICE) from June 2016 to July 2017
Compare current practice to NICE
Re-audit in the future
Cycle 1
July 2014 – June 2016
Cycle 2
July 2016 – June 2017
Cycle 3
July 2017 – June 2018

5. Methods Retrospective review of Medical Records: Demographics Timings
Histopathology reports
Outcomes
Patients coding for Melanoma identified from Business Intelligence Services
Electronic notes, Discharge Summaries and ICE reports reviewed
Compare to previous data and guidelines

6. Results: Case Load Increase in patients seen since last year – 10%99 90 85 50
Steady increasing trend in patients referred for consideration of SLNB
10% more cases seen this year, resulted in a 14% increase in SLNB procedures
Increase in patients seen since last year – 10%
Increase in SLNB procedures since last year – 14%

7. Results: Gender Distribution
99 Patient identified in 2017 – 2018
Male to Female: 1.41 / 1
Gender Distribution
Male
52.2%
Female
47.8%
patients
patients
Female
41%
Male
59%
Male
69.1%
Female
30.9%
Gender Distribution
99 Patients referred over the course of June – July 2017/18
Gender distribution again demonstrates a slight preponderance towards males
90 patients

8. Results: Age Distribution
Average: 64 yrs
Median: 60 yrs
Average: 59.7 yrs (prev 58.7)
Median: 60 yrs
Age Distribution
Similar spread compared to 2016 / 17

9. Results: Melanoma Referral Geography
Referral by Geography 21 15 18

10. Results: Diagnosis of Primary Lesion n %
Excision biopsy 68
84.0
Unknown 6
7.4
Shave biopsy 5
6.2
Punch biopsy 1
1.2
Incisional biopsy
0.0
Mainly GPs 4/5
Reflection education n %
Excision biopsy 87
88%
Incisional biopsy 6 6%
Unknown 3 3%
Shave biopsy
The excision biopsy should include the whole tumour with a clinical margin of 2 mm of normal skin, and a cuff of fat.
This allows confirmation of the diagnosis by examination of the entire lesion, such that subsequent definitive treatment can be based on Breslow thickness.
Diagnostic shave biopsies should not be performed as they may lead to incorrect diagnosis due to sampling error, and make accurate pathological staging of the lesion impossible (Level III). For the same reasons partial removal of naevi for diagnosis must be avoided and partial removal of a melanocytic naevus may result in a clinical and pathological picture very like melanoma (pseudomelanoma). This gives rise to needless anxiety and is avoidable.
Incisional or punch biopsy is occasionally acceptable, for example in the differential diagnosis of lentigo maligna (LM) on the face or of acral melanoma, but there is no place for either incisional or punch biopsy outside the skin cancer MDT (Level III).
3 GPs

11. Histology report to SLNB
Results: Time Targets
Time Difference
Referral to OPD clinic
16.45
20.95
14.5
(0-49)
Histology report to SLNB
51.45
60.89
83.1
(22-158)
OPD clinic to SLNB -
42.34
73.7
(20-185)
Referral to SLNB
64.15
87.3
(20-172)
SWAG Network Skin Cancer SSG Meeting Sept
SWAG_Skin_SSG_Draft_Notes_ pdf

12. Results: Breslow Thickness
Average BT
= 2.54 (2.18)
SLNB -VE
= 2.43 (2.04)
SLNB +VE
= 2.72 (2.17)
2 results unknown BT
NICE Guidelines “Melanoma: assessment and management:
1.5.1 Do not offer imaging or SLNB to people who have stage 1A melanoma or those who have stage 1B melanoma with a Breslow thickness of 1mm or less.

13. Results: Primary MM Site
2016/17 26 4
PUT SOME %
Leg / Thigh = lower limb except foot
Back = shoulder and back
Upper limb
Trunk
Foot
With percentages and maybe a body outline 18

14. Results: WLE Margins 27 69 1 Breslow Thickness (mm)
1 cm 11 23 27
1.5cm 7
2 cm
106 43 69
2.5 cm 6 2 1
3 cm 3
3 WLE margins unknown
GUIDELINES ARE FOLLOWED
Breslow Thickness (mm)
Recommended Margin (cm)
In-situ
0.5
<1.0 1
1.01 – 2.0
1 – 2
2.01 – 4.0 2
>4
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Melanoma, version National Comprehensive Cancer Network; Fort Washington, PA:
NICE Melanoma: assessment and management (NG14) . July

15. Results: Sentinel Node Basins
2.9%
7.6%
54.8%
Basin %
Axilla 65
47.1 49
50.5 57
54.8
Groin 55
39.9 31
31.9 36
34.6
Parotid 4
2.9 2
2.1
Neck 14
10.1 7
7.3 8
7.6
Other
0.0
8.2 3
TOTAL
138 97
104
34.6%

16. Results: Sentinel Node Basins
Number of Basins % 1
121
87.7 63
78.7 89 86 2 17
12.3 13
16.3 15 14
3 or more
0.0 4
5.00

17. Results: Sentinel Node Biopsy Status
SLNB Status %
Negative 97
72.4 62
77.5 69
71.1
Positive 37
27.6 19
22.5 28
28.9
CLND = 22 Performed*
7 declined
1 died
We performed 97 SLNB procedures in total which is 14% more than last year.
69 (71.1%) returned with negative findings.
According to MSTL1 80% of Intermediate MM should be SLNB negative
We are at 71.1% however this included more advanced thick melanoma >4mm Breslow thickness
We also performed 22 completion dissections although we offered 30 in total. 7 declined surgery opting for CT interval scans and 1 patient passed away.
CLND = 14 Performed
4 declined
* 22 Dissections performed – 2 on different sites of same patient

18. Results: Complications
2016/17 SLNB Complication :
14 cases (17.2%)
2016/17 CLND Complications :
4/11 (36%)
Complications
SLNB
Dissection
Infection 9 3
Bleeding
Infected Seroma 5 1
Haematoma
2017/18 SLNB Complication :
14 cases (13.7%)
2017/18 CLND Complications :
8/22 (36%)
Complications
SLNB
Dissection
Infection 2
Seroma 7
Infected Seroma 4 3
Bleeding 1
Apnoea
Pneumothorax
Hypoglossal injury
Public Health England Surveillance of surgical site infections in NHS hospitals in England 2017:
Cumulative SSI incidence April 2016 to March %
Enterobacteriaceae SSI incidence is slowly rising to 29%
Staph aereus and MRSA continue to decrease
NICE Surgical site infections report 2017:
nasal decontamination of Staph Aureus
both Chlorhexidine and Povidine Iodine (water and alcohol-based solutions) recommended
Intra-operative antimicrobials
Antibiotics sutures
1. nasal decontamination of Staph Aureus key but still undergoing review
2. both Chlorhexidine and Povidine Iodine (water and alcohol-based solutions) recommended
3. Intra-operative gentamicin-collagen sponges MAY reduce infection but concern over resistance so needs further evaluation
4. No evidence for triclosan-coated sutures outside of abdominal surgery

19. Results: Complications
SLNB complications most often occurred in the Groin: 64% - Seroma or Infected Seroma
Completion Dissection complications were most common following Groin Dissection: % - Seroma or Infected Seroma

20. Conclusions Increase in Overall Case Load (99 vs 85 patients)
Most referrals are from Dermatology and from Gloucester / Cheltenham region
Less Shave Biopsies performed (3% vs 6.6%)
Problem with meeting service time target – reduced surgical capacity for a period, higher number of metastatic cases requiring more complex procedures, reduced surgical team for a period
14% increase in SLNB procedures performed (97 vs 81)
36.4% increase in number of lymph node dissections undertaken (22 vs 14)
SLNB Complication rate decreased for 2nd consecutive cycle (13.7% vs 17.2%)
Dissection Complication rate remained the same (36%) – however zero mortality, no major complications, and several unusual complications unlikely to recur

21. Recommendations
Focus on improving hit rate regarding service time targets – increased surgical capacity and back to a full team.
Be aware of steadily increasing case load year-on-year and account of this in planning future provision
Thank you slide

22. Many Thanks