title: Management of regional lymph nodes in the elderly melanoma patient: patient selection, accuracy and prognostic implications.
abstract: BACKGROUND
  Among older melanoma patients, lymphatic mapping failure, lower rates of SLN positivity and poor prognosis are reported reasons for omission of sentinel lymph node biopsy (SLNB). We investigated reasons for non-compliance with guidelines, sensitivity and prognostic significance of SLNB and completion lymphadenectomy (CLND) for elderly melanoma patients.
  
  
  METHODS
  Retrospective review of patients ≥65 years with ≥1 mm thick melanoma treated at a single Institution. Wilcoxon, chi-square and Fisher's exact tests were used for analysis as appropriate. Univariable and multivariable Cox regressions were used to analyze time-to-event variables.
  
  
  RESULTS
  72 of 358 patients (20%) did not undergo SLNB. Reasons for omission included selective neck dissection in 26 (7%), patient refusal in 11 (3%), physician recommendation in 15 (4%) and significant comorbidities in 8 (2%). Of the 286 patients undergoing SLNB, only 5 (1.7%) had lymphatic mapping failures. 76 patients (26.6%) were SLN-positive. The sensitivity of SLNB was 90.5%, the negative predictive value was 96.3% and the false negative rate was 3.8%. Sixty-seven (88%) SLN-positive patients underwent CLND and 10 (15%) had positive non-SLNs. Reasons for omission of CLND included patient refusal in 3 (4%), surgeon recommendation in 5 (7%) and postoperative complication in 1 (1%). SLN and non-SLN status were independently associated with disease-free survival. SLN status was independently associated with melanoma-specific survival.
  
  
  CONCLUSIONS
  SLNB was successful in 98.7% of elderly patients with high sensitivity and a low false negative rate. Only 2% of our elderly patients appeared too frail for SLNB. Age alone should not be a contraindication to SLNB and CLND for melanoma.
authors.affiliation: Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: T E
authors.initials: TE
authors.lastname: Grotz
authors.affiliation: Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: C A
authors.initials: CA
authors.lastname: Puig
authors.affiliation: Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: S
authors.initials: S
authors.lastname: Perkins
authors.affiliation: Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: K
authors.initials: K
authors.lastname: Ballman
authors.affiliation: Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA. Electronic address: hieken.tina@mayo.edu.
authors.forename: T J
authors.initials: TJ
authors.lastname: Hieken
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D018572:Disease-Free Survival; D005260:Female; D006258:Head and Neck Neoplasms / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods; D008198:Lymph Nodes / Q000473:pathology*; D008297:Male; D008545:Melanoma / Q000473:pathology / Q000601:surgery*; D015999:Multivariate Analysis; D037981:Neck Dissection / Q000379:methods*; D018579:Patient Selection; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*; D012878:Skin Neoplasms / Q000473:pathology / Q000601:surgery*
keywords: Elderly; Guidelines; Lymph node dissection; Melanoma; Patient selection; Sentinel lymph node biopsy