title: Thick primary melanoma has a heterogeneous tumor biology: an institutional series.
abstract: BACKGROUND
  Thick melanomas (TM) ≥4 mm have a high risk for nodal and distant metastases. Optimal surgical management, prognostic significance of sentinel node biopsy (SLNB), and benefits of interferon (IFN) for these patients are unclear. As a continuum of increasing tumor thickness is placed into a single TM group, differences in biologic and clinical behavior may be lost. The purpose of this study was to better characterize the diverse biology in TM, including the value of increasing thickness and nodal status information, potentially identifying high risk TM subgroups that may warrant more aggressive treatment/follow up.
  
  
  METHODS
  155 consecutive TM patients treated at a single institution between 1971 and 2007 were retrospectively reviewed. Patient, disease and treatment features were analyzed with respect to disease-free (DFS) and overall survival (OS).
  
  
  RESULTS
  Median patient age was 66 years and 68% of patients were men. The trunk was the most common TM location (35%), followed by the head and neck (29%) and lower extremities (20%). Median thickness was 6 mm and 61% were ulcerated. 6% patients had stage IV disease, 12% had clinical nodal metastases. Clinically negative lymph node basins were treated by observation (22 patients--15.4%), elective lymph node dissection (ELND) (24 patients--17.6%) or SLNB (91 patients--67%). 75% of ELND's and 53% of SLNB's were positive. Completion node dissection was performed in 38 SLNB+ patients and 22% had additional positive nodes. 17% of the study patients received IFN. At median follow up of 26 months, 5 year DFS and OS were 42% and 43.6%. For SLNB positive vs negative, median DFS were 22 vs 111 months (p = 0.006) and median OS were 41 vs 111 months (p = 0.006). When stratified by tumor thickness ≤ vs > 6 mm, 5 year DFS was 58.3% vs 20% (p < 0.0001) and OS was 62% vs 20% (P < 0.0001). IFN had no impact on DFS or OS (p = 0.98 and 0.8 respectively).
  
  
  CONCLUSIONS
  Within the high risk group of patients with TM, cases with tumor thickness > 6 mm or a positive SLNB had a significantly worse DFS and OS (p < .0001, <.0001 and .006, .006).
authors.affiliation: Department of Surgery, McGill University, Montreal, QC H3A1A1, Canada. ari.meguerditchian@mcgill.ca
authors.forename: Ari-Nareg
authors.initials: AN
authors.lastname: Meguerditchian
authors.forename: Kobby
authors.initials: K
authors.lastname: Asubonteng
authors.forename: Calvin
authors.initials: C
authors.lastname: Young
authors.forename: Bethany
authors.initials: B
authors.lastname: Lema
authors.forename: Gregory
authors.initials: G
authors.lastname: Wilding
authors.forename: John M
authors.initials: JM
authors.lastname: Kane
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008197:Lymph Node Excision; D008297:Male; D008545:Melanoma / Q000401:mortality / Q000473:pathology* / Q000601:surgery; D008875:Middle Aged; D012189:Retrospective Studies; D021701:Sentinel Lymph Node Biopsy