BOB in Ped Surg 2023 - IPSO Winner - Steven Scoville, MD

Pediatric melanoma has approximately 500 new cases diagnosed annually in children less than or equal to 18 years old

Childhood melanoma is associated with delayed diagnosis and more frequently has nodal involvement compared to adults

Management of pediatric melanoma is based on adult studies despite differences in disease mechanisms

Tumors less than 8 millimeters thick are largely managed with wide local excision

Tumors greater than or equal to 8 millimeters or less than 8 millimeters with high risk features without metastatic involvement typically undergo wide local excision with sentinel lymph node biopsies

Two adult trials (Decog SLT and MSLT2) showed no significant difference in outcomes for patients with positive sentinel lymph node biopsies followed with ultrasound observation versus completion lymph node dissections

There is no pediatric data to support ultrasound observation versus completion lymph node dissection

Study included 252 patients less than or equal to 18 years old diagnosed with cutaneous melanoma between 2010 and 2020 from 14 institutions

Breslow depth ranged from 2 millimeters to 20 millimeters with a median of 2.55 millimeters

Of 227 patients who underwent wide local excision with sentinel lymph node biopsies, 115 had positive sentinel lymph node biopsies (approximately 51%)

Patients who underwent completion lymph node dissection were significantly older and more likely to receive adjuvant therapy

There was no significant difference in recurrence or death from disease between ultrasound observation and completion lymph node dissection groups

Positive sentinel lymph node biopsies had significantly higher rate of disease recurrence at 18% compared to 3% for negative sentinel lymph node biopsy group

Only 21% of those who underwent completion lymph node dissection had additional positive nodal disease

Rate of recurrence was not significantly different between completion lymph node dissection patients with or without additional nodal burden

Recurrence was associated with positive nodal disease, deeper Breslow depth, greater use of adjuvant therapy, and higher rate of death

Pediatric melanoma presents as advanced disease with nearly 50% positive sentinel lymph node biopsy rate

Management of nodal disease had no significant impact on disease outcomes with respect to recurrence or death from disease

Before the Decog and MSLT2 trials, there was a much higher rate of completion lymph node dissection in children, and after those trials the rate has gone down but is still higher than in adults

For most children with positive sentinel lymph nodes, observation is appropriate without moving forward with completion lymph node dissection

Not all patients with positive sentinel lymph nodes receive adjuvant therapy; decision depends on genetic makeup of melanoma and overall risk factors including tumor size

If a lymph node becomes clinically positive during ultrasound surveillance, the likely approach would be to move forward with systemic therapy rather than completion lymph node dissection