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Mitotic Rate and Younger Age Are Predictors of Sentinel Lymph Node Positivity: Lessons Learned From the Generation of a Probabilistic Model

From the Departments of Surgery (VKS, MSS, ACG, AEC, AMY, TMJ), Biostatistics (JMGT, YW, JM), Pathology (LL), Dermatology (LL, TMJ), and Otolaryngology (TMJ), University of Michigan Health System, Ann Arbor, Michigan.

Correspondence: Address correspondence and reprint requests to: Vernon K. Sondak, MD, Room 3306, Cancer Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0932; Fax: 734-647-9647; E-mail: vsondak{at}umich.edu

Background: Sentinel lymph node (SLN) biopsy allows surgeons to identify patients with subclinical nodal involvement who may benefit from lymphadenectomy and, possibly, adjuvant therapy. Several factors have been variably, and sometimes discordantly, reported to have predictive value for SLN metastasis to best select which patients require SLN biopsy.

Methods: We reviewed 419 patients who underwent SLN biopsy for melanoma from a prospectively collected melanoma database. To derive a probabilistic model for the occurrence of a positive SLN, a multivariate logistic model was fit by using a stepwise variable selection method. The accuracy of each model was evaluated by using receiver operator characteristic curves.

Results: On univariate analysis, the number of mitoses per square millimeter, increasing Breslow depth, decreasing age, ulceration, and melanoma on the trunk showed a significant relationship to a positive SLN. Multivariate analysis revealed that once age, mitotic rate, and Breslow thickness were included, no other factor, including ulceration, was significantly associated with a positive SLN. The data suggest that younger patients with tumors <1 mm may still have a substantial risk for a positive SLN, especially if the mitotic rate is high.

Conclusions: In addition to Breslow depth, mitoses per square millimeter and younger age were factors identified as independent predictors of a positive SLN. This model may identify patients with thin melanoma at sufficient risk for metastases to justify SLN biopsy.

Key Words: Melanoma • Sentinel lymph node • Mitotic rate • Ulceration

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