International Journal of Clinical Oncology

, Volume 24, Issue 6, pp 721–726 | Cite as

Lymph node ratio has impact on relapse and outcome in patients with stage III melanoma

  • Faruk TasEmail author
  • Kayhan Erturk
Original Article



Even though both the involvement of regional lymph nodes and the number of metastatic lymph nodes are regarded as major determinants of survival in cutaneous melanoma, the extent of node dissection has been analyzed as an independent prognostic indicator in only a few studies. This study aims to determine how the lymph node ratio (NR) (ratio of positive nodes to total nodes removed) might predict the disease relapse and survival in node-positive melanoma.

Materials and methods

A total of 317 patients with stage III primary melanoma were included in the study and reviewed retrospectively. All patients had nodal staging (N) by radical lymph node dissection. Patients were divided into three groups based on NR1 ≤ 10%, NR2 10–25%, and NR3 > 25%.


The median age was 50 years (range 16–86) and men were predominant (59.3%). The majority of the patients had thicker Breslow depth (> 2 mm) (83.3%), higher mitotic rate (> 2/mm2) (64.1%) and ulcerated lesions (69.4%). The median number of positive nodes was 1 (range 1–32). The largest group was N1 (52.4%), which was followed by N2 (29.6%) and N3 (18%). The ratios of patients were 37.5%, 35.3%, and 27.1% in NR1, NR2, and NR3, respectively. The median number of excised lymph nodes was 13 (range 1–73). For all patients the estimated 5-and 10-year relapse-free survival (RFS) rates were 41% and 39%, respectively; and the estimated 5-and 10-year overall survival (OS) rates were 51% and 42%, respectively. Nodular histopathology, ulcerated lesions, higher mitotic rates, and higher node substages were the independent variables that were inversely correlated with survival for all patients; and NR was one of the significant prognostic factors and strongest predictors of relapse and survival (p = 0.03 and p = 0.01, respectively).


Our results suggest that, apart from the conventional nodal status, NR is an independent prognostic factor-regarding both RFS and OS in stage III cutaneous melanoma.


Melanoma stage III N-ratio Prognostic factor Survival 




Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Informed consent

Informed consent was obtained from all individual participants included in the study. The study was reviewed and approved by our local ethical committee.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.


  1. 1.
    Siegel RL, Miller KD, Jemal A (2017) Cancer statistics, 2017. CA Cancer J Clin 67:7–30CrossRefGoogle Scholar
  2. 2.
    Balch CM, Soong SJ, Gershenwald JE et al (2001) Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer Melanoma Staging System. J Clin Oncol 19:3622–3634CrossRefGoogle Scholar
  3. 3.
    Gershenwald JE, Scolyer RA, Hess KR et al (2017) Melanoma of the skin. In: Amin MB et al (eds) AJCC cancer staging manual. Springer, Cham, pp 563–85CrossRefGoogle Scholar
  4. 4.
    NCCN Guidelines (2018) Cutaneous melanoma, NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Version 1.2019, November 1, 2018Google Scholar
  5. 5.
    Galliot-Repkat C, Cailliod R, Trost O et al (2006) The prognostic impact of the extent of lymph node dissection in patients with stage III melanoma. Eur J Surg Oncol 32:790–794CrossRefGoogle Scholar
  6. 6.
    Spillane AJ, Winstanley J, Thompson JF (2009) Lymph node ratio in melanoma: a marker of variation in surgical quality? Cancer 115:2384–2387CrossRefGoogle Scholar
  7. 7.
    Rossi CR, Mocellin S, Pasquali S et al (2008) N-ratio: a novel independent prognostic factor for patients with stage-III cutaneous melanoma. Ann Surg Oncol 15:310–315CrossRefGoogle Scholar
  8. 8.
    Berger AC, Fierro M, Kairys JC et al (2012) Lymph node ratio is an important and independent prognostic factor for patients with stage III melanoma. J Surg Oncol 105:15–20CrossRefGoogle Scholar
  9. 9.
    Spillane AJ, Cheung BL, Winstanley J et al (2011) Lymph node ratio provides prognostic information in addition to American Joint Committee on Cancer N stage in patients with melanoma, even if quality of surgery is standardized. Ann Surg 253:109–115CrossRefGoogle Scholar
  10. 10.
    Xing Y, Badgwell BD, Ross MI et al (2009) Lymph node ratio predicts disease-specific survival in melanoma patients. Cancer 115:2505–2513CrossRefGoogle Scholar
  11. 11.
    Kunisaki C, Makino H, Akiyama H et al (2008) Clinical significance of the metastatic lymph-node ratio in early gastric cancer. J Gastrointest Surg 12:542–549CrossRefGoogle Scholar
  12. 12.
    Wright JL, Lin DW, Porter MP (2008) The association between extent of lymphadenectomy and survival among patients with lymph node metastases undergoing radical cystectomy. Cancer 112:2401–2408CrossRefGoogle Scholar

Copyright information

© Japan Society of Clinical Oncology 2019

Authors and Affiliations

  1. 1.Department of Medical Oncology, Institute of OncologyUniversity of IstanbulIstanbulTurkey

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