The Value of Performing Frozen Section on Sentinel Lymph Node Biopsy in Patients with Melanoma
Anup Patel, MD, MBA, Marc Walker, MD, MBA, James Clune, MD, Ajul Shah, MD, Calvin Young, MD, Deepak Narayan, MD, Stephan Ariyan, MD, MBA.
Yale University School of Medicine, New Haven, CT, USA.
Studies have demonstrated sentinel lymph node biopsy (SLNB) as a valid and relatively minimally invasive technique for evaluating regional lymph nodes in patients with melanoma.1 Yet, controversy exists over the benefit of performing frozen section (FS) on the SLNB given its potential false-negative rate.2 In current fiscal climate, this study evaluates the cost of performing FS on SLNB in patients with melanoma.
A retrospective review of all patients undergoing completion axillary lymphadenectomy (CAL) for cutaneous melanoma from 2011-2012 was conducted. Exclusion criteria included patients undergoing bilateral axillary SLNB, extra-axillary SLNB during the same operation, and referral for completion lymphadenectomy. Therefore, two options below for the management of melanoma with SLNB exist.
Option 1 (No FS): In the first operation, the patient undergoes resection of melanoma using permanent section (PS) for SLNB. If the SLNB is positive, then delayed lymphadenectomy is performed.
Option 2 (FS Used): In the first operation, the patient undergoes resection of melanoma using FS for SLNB. If the SLNB is positive on FS, then immediate lymphadenectomy is performed. False-negative FS undergo delayed lymphadenectomy.
The cost of each operation including anesthesia fees was obtained from 2012 Connecticut Medicare Reimbursement Rates. The median operative time for negative SLNB on PS and FS was equivalent given FS nodal evaluation is performed during resurfacing of the melanoma.3 A sensitivity analysis was performed on the false-negative rate for sentinel node.
The median operative time for 140 minutes for negative SLNB (PS and FS), 202 minutes for positive SLNB on FS, and 235 minutes for delayed lymphadenectomy (positive SLNB on PS and false-negative on FS). With a true-positive rate of 80% on PS, false-negative rate of 2% on FS, and epidemiologic date from 2011 Cancer Statistics, Option 2 employing FS generates national cost-savings of $9 million dollars. Sensitivity analysis demonstrated for option 1 to cost less than option 2 the false-negative rate of SLNB must be 10%.
FS on SLNB provides cost-savings of approximately 20% of Medicare’s annual budget for melanoma. It can reduce secondary operations that have associated surgical risk. Furthermore, an extra operation requires from time off of work that has financial implications that are significant.
Morton DL, Cochran AJ, Thompson JF, et al.: Sentinel node biopsy for early-stage melanoma: Accuracy and morbidity in MSLT-I, an international multicenter trial. Ann Surg 2005;242: 302 – 311.
Bagaria SP, Faries MB, Morton DL. Sentinel node biopsy in melanoma: technical considerations of the procedure as performed at the John Wayne Cancer Institute. J Surg Oncol 2010;101:669-76.
Ariyan S, Ariyan C, Farber LR, Fischer DS, Flynn SD, Truini C. Reliability of identification of 655 sentinel lymph nodes in 263 consecutive patients with malignant melanoma. J Am Coll Surg 2004;198:924-32.
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