Clinical management of melanocytic tumours of uncertain malignant potential (MelTUMPs), including melanocytomas: A systematic review and meta‐analysis

Abstract

Little guidance is currently available for managing patients with melanocytic tumours of uncertain or low malignant potential (MelTUMPs, including melanocytomas), in particular the optimal excision margins and whether to offer sentinel node biopsy (SNB). The objective of this review was to evaluate excision margins and the prognostic utility of SNB by systematic review of the literature and meta‐analysis. PRISMA guidelines were followed. Medline, EMBASE and Cochrane databases were searched to October 2021 for studies of patients with MelTUMPs reporting excision margins and/or SNB‐positivity. Meta‐analysis was performed on the SNB‐positivity rate using a random effects model, followed by sensitivity analyses on subgroups. 111 primary studies reported excision margins and/or SNB data for 1962 patients. Follow‐up was available for 1649 patients: 1561 (94.7%) were alive without disease at last review, 53 (3.2%) had developed further disease, 29 (1.8%) had died of metastatic disease (melanoma) and six (0.4%) died of unrelated causes. SNB was performed in 837 patients. The pooled positivity rate on meta‐analysis was 32% (95% CI: 23–44%). Clinical outcome could be correlated with excision margin in only 171 patients (60% of those with known follow up) and was therefore not analysed further. Evidence indicating the ideal excision margins for MelTUMPs was lacking. SNB had a high positivity rate despite very low rates of recurrence or melanoma‐related death. Consequently, SNB should not be offered routinely for MelTUMPs (including melanocytomas), due to its lack of prognostic utility for this tumour type (high certainty of evidence).

Melanoma is not just one disease, but many

“…While it is arguably a small subgroup of melanocytic tumours, clinical and histological features of MelTUMPs are often worrisome triggering diagnostic procedures including lymph node surgery and modern adjuvant therapy for which there is very little evidence and documented benefit as confirmed by research in this special issue. 7 Not recommending certain procedures and treatments remains one of the most challenging situations in medicine, particularly when diagnoses come with a significant degree of uncertainty. Most physicians and patients feel better potentially doing a little bit too much than a little bit too little.…”

“…One of these grey zones are melanocytic tumours of uncertain malignant potential (MelTUMPs). While it is arguably a small subgroup of melanocytic tumours, clinical and histological features of MelTUMPs are often worrisome triggering diagnostic procedures including lymph node surgery and modern adjuvant therapy for which there is very little evidence and documented benefit as confirmed by research in this special issue 7 …”

Primum non nocere: MelTUMP

“…A recently published systematic review by Varey et al 2 aimed to address some of these questions. Key messages from this article are: 5–10 mm excision margins for the primary tumour appear to be an appropriate balance between surgery‐associated morbidity and adequacy of treatment for MelTUMPs.…”