173 O - Management of clinically positive axillary or inguinal lymph nodes in patients with malignant melanoma-A decision analysis

Abstract

Background Currently no consensus exisits concerning the management of melanoma patients with palpatory positive axillary or inguinal lymph nodes. Some authors recommend immediate lymph node dissection whenever regional lymph nodes are palpatory positve, others additionally recommend follow up by sonography or fine needle aspiration (FNA) to evaluate the clinical findings. Objective The objective of this research was to determine the utility of different management strategies for this patients. Methods Decision analysis was used to evaluate a utility value, which represents the appropriateness of the given outcomes of four management strategies for the diagnostic workup and treatment of melanoma patients with palpatory positive axillary or inguinal lymph nodes: (1) lymph node dissection (2) lymph node sonography (3) a sequence of lymph node sonography and FNA and (4) FNA. To calculate path propabilities, the required data were obtained from the literature. Sensitivity analyses were performed on all key variables. Results At our baseline estimates, lymph node sonography followed by FNA in case of ambiguous sonographic findings was superior to the other management strategies. Fixing all other variables at their baseline, sensitivity analysis revealed that if the prevalance of metastatic disease given positive palpatory findings exceeds 97% the immediate dissection of lymph nodes without performing further tests would be the most favourable strategy. Conclusion From the perspective of appropriateness of diagnosis and treatment, sonography followed by FNA in case of ambiguous sonographic findings is the most preferable management strategy of melanoma patients with clinically positive axillary or inguinal lymph nodes. Currently no consensus exisits concerning the management of melanoma patients with palpatory positive axillary or inguinal lymph nodes. Some authors recommend immediate lymph node dissection whenever regional lymph nodes are palpatory positve, others additionally recommend follow up by sonography or fine needle aspiration (FNA) to evaluate the clinical findings. The objective of this research was to determine the utility of different management strategies for this patients. Decision analysis was used to evaluate a utility value, which represents the appropriateness of the given outcomes of four management strategies for the diagnostic workup and treatment of melanoma patients with palpatory positive axillary or inguinal lymph nodes: (1) lymph node dissection (2) lymph node sonography (3) a sequence of lymph node sonography and FNA and (4) FNA. To calculate path propabilities, the required data were obtained from the literature. Sensitivity analyses were performed on all key variables. At our baseline estimates, lymph node sonography followed by FNA in case of ambiguous sonographic findings was superior to the other management strategies. Fixing all other variables at their baseline, sensitivity analysis revealed that if the prevalance of metastatic disease given positive palpatory findings exceeds 97% the immediate dissection of lymph nodes without performing further tests would be the most favourable strategy. From the perspective of appropriateness of diagnosis and treatment, sonography followed by FNA in case of ambiguous sonographic findings is the most preferable management strategy of melanoma patients with clinically positive axillary or inguinal lymph nodes.