Annals of Surgical Oncology

, Volume 24, Issue 4, pp 952–959 | Cite as

Thin Melanoma with Nodal Involvement: Analysis of Demographic, Pathologic, and Treatment Factors with Regard to Prognosis

  • Giorgos Karakousis
  • Phyllis A. Gimotty
  • Edmund K. Bartlett
  • Myung-Shin Sim
  • Madalyn G. Neuwirth
  • Douglas Fraker
  • Brian J. Czerniecki
  • Mark B. Faries



Although only a small proportion of thin melanomas result in lymph node metastasis, the abundance of these lesions results in a relatively large absolute number of patients with a diagnosis of nodal metastases, determined by either sentinel lymph node (SLN) biopsy or clinical nodal recurrence (CNR).


Independent cohorts with thin melanoma and either SLN metastasis or CNR were identified at two melanoma referral centers. At both centers, SLN metastasis patients were included. At center 1, the CNR cohort included patients with initial negative clinical nodal evaluation followed by CNR. At center 2, the CNR cohort was restricted to those presenting in the era before the use of SLN biopsy. Uni- and multivariable analyses of melanoma-specific survival (MSS) were performed.


At center 1, 427 CNR patients were compared with 91 SLN+ patients. The 5- and 10-year survival rates in the SLN group were respectively 88 and 84 % compared with 72 and 49 % in the CNR group (p < 0.0001). The multivariate analysis showed age older than 50 years (hazard ratio [HR] 1.5; 95 % confidence interval [CI] 1.2–1.9), present ulceration (HR 1.9; 95 % CI 1.2–2.9), unknown ulceration (HR 1.6; 95 % CI 1.3–2.1), truncal site (HR 1.6; 95 % CI 1.2–2.2), and CNR (HR 3.3; 95 % CI 1.8–6.0) to be associated significantly with decreased MSS (p < 0.01 for each). The center 2 cohort demonstrated remarkably similar findings, with a 5-year MSS of 88 % in the SLN (n = 29) group and 76 % in the CNR group (n = 39, p = 0.09).


Patients with nodal metastases from thin melanomas have a substantial risk of melanoma death. This risk is lower among patients whose disease is discovered by SLN biopsy rather than CNR.


  1. 1.
    Cascinelli N, Morabito A, Santinami M, MacKie RM, Belli F. Immediate or delayed dissection of regional nodes in patients with melanoma of the trunk: a randomised trial. WHO Melanoma Programme. Lancet. 1998;351:793–6.Google Scholar
  2. 2.
    Balch CM, Soong S, Ross MI, Urist MM, Karakousis CP, Temple WJ, et al. Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0 to 4.0 mm). Intergroup Melanoma Surgical Trial. Ann Surg Oncol. 2000;7:87–97.CrossRefPubMedGoogle Scholar
  3. 3.
    Gimotty PA, Guerry D, Ming ME, Elenitsas R, Xu X, Czerniecki B, et al. Thin primary cutaneous malignant melanoma: a prognostic tree for 10-year metastasis is more accurate than American Joint Committee on Cancer staging. J Clin Oncol. 2004;22:3668–76.CrossRefPubMedGoogle Scholar
  4. 4.
    Balch CM, Gershenwald JE, Soong SJ, Thompson JF, Atkins MB, Byrd DR, et al. Final version of 2009 AJCC melanoma staging and classification. J Clin Oncol. 2009;27:6199–206.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Howlader NNA, Krapcho M, Neyman N, Aminou R, Altekruse SF, Kosary CL, et al. SEER Cancer Statistics Review, 19752009 (Vintage 2009 Populations) National Cancer Institute, Bethesda, MD, 2011.
  6. 6.
    Wong SL, Balch CM, Hurley P, Agarwala SS, Akhurst TJ, Cochran A, et al. Sentinel lymph node biopsy for melanoma: American Society of Clinical Oncology and Society of Surgical Oncology joint clinical practice guideline. J Clin Oncol. 2012;30:2912–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Plitas G, Ariyan CE. Controversies in the management of regional nodes in melanoma. J Natl Compr Cancer Netw. 2012;10:414–21.Google Scholar
  8. 8.
    Ra JH, McMasters KM, Spitz FR. Should all melanoma patients undergo sentinel lymph node biopsy? Curr Opin Oncol. 2006;18:185–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Karakousis GC, Gimotty PA, Botbyl JD, Kesmodel SB, Elder DE, Elenitsas R, et al. Predictors of regional nodal disease in patients with thin melanomas. Ann Surg Oncol. 2006;13:533–41.CrossRefPubMedGoogle Scholar
  10. 10.
    Faries MB, Wanek LA, Elashoff D, Wright BE, Morton DL. Predictors of occult nodal metastasis in patients with thin melanoma. Arch Surg. 2010;145:137–42.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Warycha MA, Zakrzewski J, Ni Q, Shapiro RL, Berman RS, Pavlick AC, Polsky D, et al. Meta-analysis of sentinel lymph node positivity in thin melanoma (≤1 mm). Cancer. 2009;115:869–79.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Karakousis GC, Gimotty PA, Czerniecki BJ, Elder DE, Elenitsas R, Ming ME, et al. Regional nodal metastatic disease is the strongest predictor of survival in patients with thin vertical growth phase melanomas: a case for SLN staging biopsy in these patients. Ann Surg Oncol. 2007;14:1596–603.CrossRefPubMedGoogle Scholar
  13. 13.
    Wright BE, Scheri RP, Ye X, Faries MB, Turner RR, Essner R Morton DL. Importance of sentinel lymph node biopsy in patients with thin melanoma. Arch Surg. 2008;143:892–9; discussion 9–900.Google Scholar
  14. 14.
    Ranieri JM, Wagner JD, Wenck S, Johnson CS Coleman JJ III. The prognostic importance of sentinel lymph node biopsy in thin melanoma. Ann Surg Oncol. 2006;13:927–32.CrossRefPubMedGoogle Scholar
  15. 15.
    Bartlett EK, Gimotty PA, Sinnamon AJ, Wachtel H, Roses RE, Schuchter L, et al. Clark level risk stratifies patients with mitogenic thin melanomas for sentinel lymph node biopsy. Ann Surg Oncol. 2014;21:643–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Han D, Zager JS, Shyr Y, Chen H, Berry LD, Iyengar S, et al. Clinicopathologic predictors of sentinel lymph node metastasis in thin melanoma. J Clin Oncol. 2013;31:4387–93.CrossRefPubMedGoogle Scholar
  17. 17.
    Murali R, Haydu LE, Quinn MJ, Saw RP, Shannon K, Spillane AJ, et al. Sentinel lymph node biopsy in patients with thin primary cutaneous melanoma. Ann Surg. 2012;255:128–33.CrossRefPubMedGoogle Scholar
  18. 18.
    Wong SL, Brady MS, Busam KJ, Coit DG. Results of sentinel lymph node biopsy in patients with thin melanoma. Ann Surg Oncol. 2006;13:302–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Gajdos C, Griffith KA, Wong SL, Johnson TM, Chang AE, Cimmino VM, et al. Is there a benefit to sentinel lymph node biopsy in patients with T4 melanoma? Cancer. 2009;115:5752–60.CrossRefPubMedGoogle Scholar
  20. 20.
    Gershenwald JE, Mansfield PF, Lee JE, Ross MI. Role for lymphatic mapping and sentinel lymph node biopsy in patients with thick (≥4 mm) primary melanoma. Ann Surg Oncol. 2000;7:160–5.CrossRefPubMedGoogle Scholar
  21. 21.
    Thompson JF Shaw HM. The prognosis of patients with thick primary melanomas: is regional lymph node status relevant, and does removing positive regional nodes influence outcome? Ann Surg Oncol. 2002;9:719–22.CrossRefPubMedGoogle Scholar
  22. 22.
    Carlson GW, Murray DR, Hestley A, Staley CA, Lyles RH Cohen C. Sentinel lymph node mapping for thick (≥4 mm) melanoma: should we be doing it? Ann Surg Oncol. 2003;10:408–15.CrossRefPubMedGoogle Scholar
  23. 23.
    Morton DL, Thompson JF, Essner R, Elashoff R, Stern SL, Nieweg OE, et al. Validation of the accuracy of intraoperative lymphatic mapping and sentinel lymphadenectomy for early-stage melanoma: a multicenter trial. Multicenter Selective Lymphadenectomy Trial Group. Ann Surg. 1999;230:453–63; discussion 63–5.Google Scholar
  24. 24.
    Faries MB, Steen S, Ye X, Sim M Morton DL. Late recurrence in melanoma: clinical implications of lost dormancy. J Am Coll Surg. 2013;217:27–34.Google Scholar
  25. 25.
    Morton DL, Thompson JF, Cochran AJ, Mozzillo N, Nieweg OE, Roses DF, et al. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med. 2014; 370:599–609.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of Surgical Oncology 2016

Authors and Affiliations

  • Giorgos Karakousis
    • 1
  • Phyllis A. Gimotty
    • 1
  • Edmund K. Bartlett
    • 1
  • Myung-Shin Sim
    • 2
  • Madalyn G. Neuwirth
    • 1
  • Douglas Fraker
    • 1
  • Brian J. Czerniecki
    • 3
  • Mark B. Faries
    • 2
  1. 1.Department of SurgeryHospital of the University of PennsylvaniaPhiladelphiaUSA
  2. 2.John Wayne Cancer InstituteSanta MonicaUSA
  3. 3.Moffit Cancer CenterTampaUSA

Personalised recommendations