title: Metastatic melanoma cells in the sentinel node cannot be ignored.
abstract: BACKGROUND
  How to best risk-stratify patients with metastatic melanoma in the sentinel node (SN) is controversial. Not all node-positive disease is equivalent in terms of disease-free or overall survival, and some have suggested that submicrometastatic disease, characterized by <0.1 mm tumor burden, can represent a distinct classification not associated with a chance for recurrence or death. We hypothesize that all patients with metastatic melanoma cells in the sentinel node have potentially life-threatening disease.
  
  
  METHODS
  This is a retrospective review of an IRB-approved, prospectively maintained melanoma database of >1,100 patients. All invasive melanoma patients who had an SN biopsy and at least 1 year of followup were included. Patients with metastatic melanoma in the SN were divided into groups according to diameter of SN tumor burden: node-negative, <0.1 mm (submicrometastatic), 0.1 to 1.0 mm, and >1.0 mm. Statistical methods included the Jonckheere-Terpstra method, Fisher's exact tests, and Kaplan-Meier method.
  
  
  RESULTS
  From July 1, 1998 to July 1, 2007, 578 patients with invasive melanoma underwent SN procedure. Median followup was 2.2 years. There was a statistically significant difference in the proportion of patients who experienced a recurrence between the node-negative group (11%) and the <0.1 mm group (24%) (p = 0.049). Patients in the submicrometastatic group have a statistically significant (p = 0.048) earlier recurrence than those in the node-negative group.
  
  
  CONCLUSIONS
  These results suggest that patients with submicrometastatic SN disease should not be treated as node-negative, as it appears to represent a more biologically aggressive melanoma, associated with a substantially faster time to recurrence. We cannot agree with recent proposals that patients with very small tumor burden in the SN can be treated as node-negative and be spared completion node dissection.
authors.affiliation: Department of Surgery, Division of Surgical Oncology and Endocrine Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7213, USA. david_ollila@med.unc.edu
authors.forename: David W
authors.initials: DW
authors.lastname: Ollila
authors.forename: Jean H
authors.initials: JH
authors.lastname: Ashburn
authors.forename: Keith D
authors.initials: KD
authors.lastname: Amos
authors.forename: Jen Jen
authors.initials: JJ
authors.lastname: Yeh
authors.forename: Jill S
authors.initials: JS
authors.lastname: Frank
authors.forename: Allison M
authors.initials: AM
authors.lastname: Deal
authors.forename: Patricia
authors.initials: P
authors.lastname: Long
authors.forename: Nancy D
authors.initials: ND
authors.lastname: Thomas
authors.forename: Michael O
authors.initials: MO
authors.lastname: Meyers
mesh_terms: D006801:Humans; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology*; D008207:Lymphatic Metastasis; D008545:Melanoma / Q000473:pathology*; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D021701:Sentinel Lymph Node Biopsy; D012878:Skin Neoplasms / Q000473:pathology*