Sentinel lymph node biopsy in melanoma: Which hot nodes should be harvested and is blue dye really necessary?

The '10% rule' has become widely accepted by surgeons performing sentinel lymph node biopsy (SLNB) for melanoma. The purpose of this study was to compare the '10% rule' with alternative node harvesting criteria. In particular, we were interested to see whether the use of blue dye had any impact on the sensitivity of the test and whether it is necessary to remove all hot nodes.

We reviewed 537 SLNBs performed for primary melanoma from 2009-2015. SLNB was offered to all patients with 1-4 mm Breslow thickness melanoma and sentinel nodes were harvested according to the '10% rule'.

One hundred sixteen patients (22%) had at least one positive sentinel node and there were 45 positive nodal basins from which more than one sentinel node had been harvested. Excluding blue dye and sampling only hot nodes would have enabled a 5% reduction in nodes harvested, without any compromise in the sensitivity of the test. However, applying harvesting criteria whereby not all hot nodes are taken was associated with a loss of sensitivity, with positive sentinel nodes being missed and patients understaged.

Our data do not support the continued use of blue dye in SLNB for melanoma, as it does not improve the sensitivity of the test. This series adds to growing evidence, suggesting that the '10% rule' with the inclusion of blue nodes should be reconsidered and that radiocolloid tracer alone is sufficient for sentinel node localisation.