Does staging computered tomography change management in thick malignant melanoma?

Histological confirmation and assessment of Breslow thickness are essential before embarking on the management plan in Malignant Melanoma (MM). Computerised Tomography (CT) is used in staging of MM in the UK according to BAD/BAPS (British Association of Dermatologists/British Association of Plastic Surgeons). Currently UK guidelines for the management of cutaneous melanoma at intermediate or high risk of recurrent disease (American Joint Cancer Committee) AJCC IIB disease or worse (Breslow 2.01-4.0mm with ulceration or Breslow >4mm) should have the following staging investigations: chest X-ray; liver ultrasonography or computed tomographic (CT) scan with intravenous contrast enhancement of chest, abdomen and pelvis; liver function tests; lactate dehydrogenase and full blood count. It has been the practice at our unit to perform a CT head and neck also as part of our staging. The aim of this study was to determine whether CT staging changed clinical management at the initial presentation scan and follow up scans. Also we aimed to see whether there was a benefit in performing CT head and neck in staging.

A retrospective case note review was performed to see whether CT staging actually changed patient clinical management on 132 cases of AJCC IIB melanoma or worse over the past six years at our unit. Clinical management changes were divided into two groups: Initial presentation CT staging and follow up CT staging. In addition numbers of metastases to body regions were recorded.

A total of 488 CT scans were performed on 132 patients (3.7 scans per patient). Initial presentation CT staging scans picked up 1/132 (0.7%) patient with an occult metastases that changed their clinical management. Of the 356 follow up CT staging scans imaging (11/127) 8.6% of patients had metastases detected and clinical management changed. All of these patients exhibited symptoms and signs of clinical metastatic disease. Head metastases are at least as common as other regions such as the chest & abdomen and more common than in the pelvis. Neck CT did not change management.

CT staging for cutaneous melanoma is not indicated unless there are signs or symptoms of metastatic disease. If there are symptoms and signs of metastatic disease than patients should be staged and we advocate that staging of AJCC IIB/C should include imaging of the head in addition to chest, abdomen and pelvis.