title: Outcome of thick (> 4 mm) node-negative melanomas.
abstract: BACKGROUND
  Patients with thick melanomas > 4 mm deep are at great risk for regional and distant metastatic disease. Historically, the appropriate management of thick melanomas has remained unclear and there is no consensus in the literature. Many have taken the nihilistic view that surgical intervention to excise regional nodal basins is not justified in light of the poor overall prognosis and risk of occult distant disease.
  
  
  OBJECTIVE
  To review the outcome of patients with thick node negative melanoma treated at a multidisciplinary academic center
  
  
  METHODS
  We retrospectively reviewed a database of melanoma patients to identify patients with thick melanomas, > 4 mm, who were either clinically or sentinel node biopsy negative, staged T4N0, stage IIb or IIc. The charts of these patients were reviewed and updated, with a median follow-up of 4 years.
  
  
  RESULTS
  We identified 23 patients who fit these criteria. Of these, 18 (78%) remain alive with a median follow-up of 4 years. Five patients died of metastatic disease. Of the 18 surviving patients, 14 remained with no evidence of disease after initial resection of their primary lesions. The majority of the recurrences were non-nodal.
  
  
  CONCLUSIONS
  The overall survival of patients in our study remains above 75% at median follow-up of 4 years, even with thick initial index tumor depths. Most of the failures were due to hematogenous spread with lymphatic sparing. Tumor biology that may inhibit lymphatic spread could be a target of future investigation.
authors.affiliation: Department of Surgery C & Surgical Oncology, Sheba Medical Center, Tel Hashomer, Israel. dougbz@gmail.com
authors.forename: Douglas B
authors.initials: DB
authors.lastname: Zippel
authors.forename: Roni
authors.initials: R
authors.lastname: Shapira
authors.forename: Irena
authors.initials: I
authors.lastname: Kuchuk
authors.forename: David
authors.initials: D
authors.lastname: Goitein
authors.forename: Eyal
authors.initials: E
authors.lastname: Winkler
authors.forename: Moshe Z
authors.initials: MZ
authors.lastname: Papa
authors.forename: Jacob
authors.initials: J
authors.lastname: Schachter
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008297:Male; D008545:Melanoma / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D008875:Middle Aged; D009367:Neoplasm Staging; D012189:Retrospective Studies; D021701:Sentinel Lymph Node Biopsy; D012878:Skin Neoplasms / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D015996:Survival Rate; D016896:Treatment Outcome; D055815:Young Adult