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Regional Nodal Metastatic Disease Is the Strongest Predictor of Survival in Patients with Thin Vertical Growth Phase Melanomas: A Case for SLN Staging Biopsy in These Patients

¹ Department of Surgery, Hospital of the University of Pennsylvania, 4th Floor Silverstein Building, 3400 Spruce Street, Philadelphia, PA 19104, USA
² Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA
³ Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
⁴ Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
⁵ Department of Medicine, Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
⁶ Pigmented Lesion Group and Melanoma Program, Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA, USA
⁷ Veterans Administration Hospital, Philadelphia, PA, USA

Correspondence: Address correspondence and reprint requests to: Francis R. Spitz, MD; E-mail: francis.spitz{at}uphs.upenn.edu

Background: The benefit of sentinel lymph node (SLN) biopsy for patients with thin ( 1.0 mm) melanomas, even for prognostic value, is controversial. This may partly result from the relatively small number and short follow-up of SLN-positive patients in this group. Previously, we have shown that clinical regional nodal metastatic disease (RNMD) serves as a good surrogate for SLN positivity. Here, we use RNMD as a validated surrogate for SLN positivity and examine its prognostic value in a large pre-SLN group of patients with thin vertical growth phase (VGP) lesions who would today commonly be offered SLN biopsy in our practice.

Methods: Between 1972 and 1991, 472 patients with thin VGP melanomas with at least 10 years’ follow-up were eligible for the study. Kaplan-Meier survival curves were computed for patients with and without RNMD. A multivariate Cox model and classification tree analysis were used to evaluate clinical and histopathologic predictors of survival.

Results: Sixty-seven patients (14.2%) developed recurrence, 53.7% of whom developed RNMD. Forty-five patients (9.5%) experienced melanoma-related deaths (MRD). The most statistically significant predictor of MRD was RNMD (hazard ratio [HR] 13.5, P < .0001). Thickness (HR 10.5, P = .004), axial location (HR 4.6, P = .001), and age >60 years (HR 2.7, P = .005) additionally were independently associated with an increased risk of MRD. RNMD patients demonstrated a 44.4% 10-year disease-specific mortality.

Conclusions: RNMD was the most statistically significant factor associated with MRD in patients with thin VGP lesions. This supports the prognostic use of SLN biopsy in this group, recognizing that additional factors, including thickness, axial location, and older age were independently associated with a worse survival outcome.

Key Words: Thin melanomas • Regional nodal disease • SLN biopsy • Predictors of survival

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