title: 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.
abstract: BACKGROUND
  The benefit of sentinel lymph node (SLN) biopsy for patients with thin (< or =1.0 mm) melanomas, even for prognostic value, is controversial. This may partly result from the relatively small number and short follow-up of SLN-positive patients in this group. Previously, we have shown that clinical regional nodal metastatic disease (RNMD) serves as a good surrogate for SLN positivity. Here, we use RNMD as a validated surrogate for SLN positivity and examine its prognostic value in a large pre-SLN group of patients with thin vertical growth phase (VGP) lesions who would today commonly be offered SLN biopsy in our practice.
  
  
  METHODS
  Between 1972 and 1991, 472 patients with thin VGP melanomas with at least 10 years' follow-up were eligible for the study. Kaplan-Meier survival curves were computed for patients with and without RNMD. A multivariate Cox model and classification tree analysis were used to evaluate clinical and histopathologic predictors of survival.
  
  
  RESULTS
  Sixty-seven patients (14.2%) developed recurrence, 53.7% of whom developed RNMD. Forty-five patients (9.5%) experienced melanoma-related deaths (MRD). The most statistically significant predictor of MRD was RNMD (hazard ratio [HR] 13.5, P < .0001). Thickness (HR 10.5, P = .004), axial location (HR 4.6, P = .001), and age >60 years (HR 2.7, P = .005) additionally were independently associated with an increased risk of MRD. RNMD patients demonstrated a 44.4% 10-year disease-specific mortality.
  
  
  CONCLUSIONS
  RNMD was the most statistically significant factor associated with MRD in patients with thin VGP lesions. This supports the prognostic use of SLN biopsy in this group, recognizing that additional factors, including thickness, axial location, and older age were independently associated with a worse survival outcome.
authors.affiliation: Department of Surgery, Hospital of the University of Pennsylvania, 4th Floor Silverstein Building, 3400 Spruce Street, Philadelphia, PA 19104, USA.
authors.forename: Giorgos C
authors.initials: GC
authors.lastname: Karakousis
authors.forename: Phyllis A
authors.initials: PA
authors.lastname: Gimotty
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Czerniecki
authors.forename: David E
authors.initials: DE
authors.lastname: Elder
authors.forename: Rosalie
authors.initials: R
authors.lastname: Elenitsas
authors.forename: Michael E
authors.initials: ME
authors.lastname: Ming
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Fraker
authors.forename: DuPont
authors.initials: D
authors.lastname: Guerry
authors.forename: Francis R
authors.initials: FR
authors.lastname: Spitz
mesh_terms: D015331:Cohort Studies; D005260:Female; D006801:Humans; D015994:Incidence; D008207:Lymphatic Metastasis; D008297:Male; D008545:Melanoma / Q000401:mortality / Q000556:secondary*; D008875:Middle Aged; D008938:Mitosis; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D011379:Prognosis; D021701:Sentinel Lymph Node Biopsy; D012878:Skin Neoplasms / Q000401:mortality / Q000473:pathology*; D015996:Survival Rate; D013997:Time Factors