Sentinel Lymph Node Biopsy for Thin Melanoma - Winship Cancer ...

Sentinel Lymph Node Biopsy 

for Thin Melanoma: 

Can We Put the Genie Back in 

the Bottle 

Daniel G. Coit MD, FACS 

Memorial Sloan-Kettering Cancer Center 

New York, NY

SLNB in thin melanoma 

Concepts 

• Probability vs threshold 

– Probability: MD defined 

– Threshold: Patient defined 

• Clinical utility 

– Cost/benefit analysis 

– Multifactorial

SLNB for thin melanoma 

Thin melanoma 

Number of patients presenting to MSKCC for primary 

treatment of melanoma by thickness, 1997-2003 

1800 

1600 

1400 

1200 

1000 

800 

600 

400 

200 

0 

1654 

55% of all patients 

649 

411 

294 

< 1 mm 1-2 mm 2-4 mm > 4mm 

Thickness MSKCC, 2004


Nodal relapse in thin melanoma 

Institution U Penn JWCI 

Period 1996-2004 1971-2005 

Patients 882 1732 

Median 

follow-up 

Nodal 

relapse 

16.4 years 13.2 years 

31 (3.5%) 50 (2.9%) 

Independent 

predictors 

of nodal 

relapse 

Ulceration P=0.002 

Mitotic rate > 0 P=0.003 

VGP present P=0.009 

Male gender P=0.01 

Male gender P


Nodal relapse in thin melanoma 

Nodal relapse by Breslow thickness 

Nodal relapse nomogram 

Faries MB, Arch Surg 2010; 145(2):137-42

SLNB in melanoma 


• Meta-analysis of 3651 patients with thin melanoma 

undergoing SLNB, from 34 studies. 

• Positive SLN found in 5% of patients. 

• 14 studies reported results of CLND in 1135 

patients 

– One patient had a positive NSLN 

• 14 studies reported recurrence and survival 

– 6/8 patients with recurrence had melanomas ≥ 0.75 mm 

– 8 studies reported no melanoma related deaths 

Warycha MA, Cancer 2009; 115:869-79



• 223 patients with thin melanoma 

(< 1 mm ) underwent WE with 

SLNB at MSKCC. 

• Patient and tumor related data 

were analyzed for predictors of 

SLNB positivity. 

• Prognostic significance of 

positive SLN was analyzed. 

Wong S, Ann Surg Oncol; 2006, 13(3):1-8



Factors predictive of (+) SLN 

Clinicopathologic characteristic 

p-value 

Age (continuous) 0.74 

Gender 0.89 

Site of primary (extremity, trunk, head and neck) 0.37 

Thickness (continuous) 0.74 

Clark level (II, III, IV) 0.26 

Ulceration 0.33 

Regression 0.16 

Tumor infiltrating lymphocytes (brisk, minimal, none/unk) 0.40 

Mitotic rate (high, low, unknown) 0.07 

Number of involved nodal basins (single, multiple) 0.62 




(+) SLN biopsy N (%) 

< 1.0 mm thickness (n=223) 8/223 (3.6%) 

< 0.75 mm thickness (n=73) 0/73 (0%) 

0.75 – 1.0 mm thickness (n=150) 8/150 (5.3%) 

Clark level II/III (n=70) 0/70 (0%) 

Clark level IV (n=150) 8/150 (5.3%) 

0.75 – 1.0 mm thickness AND Clark level IV (n=114) 8/114 (7%) 

All patients with + SLN underwent completion 

lymphadenectomy; no patient had disease beyond the SLN 



Thin melanoma – probability of + SLN 

Author Year N + SLN % Survival 

Statius Muller 2001 104 7 6.7% NA 

Rousseau 2003 388 16 4.1% NA 

Borgognoni 2004 114 2 1.8% NA 

Stitzenberg 2004 146 6 4.1% NA 

Puleo 2005 409 20 4.9% NA 

Kesmodel 2005 181 9 5.0% NA 

Kruper 2006 251 13 5.2% NA 

Thompson 2006 187 9 4.8% NA 

Ranieri 2006 184 12 6.5% P=0.01 on UVA (one death) 

Cascinelli 2006 145 6 4.1% NA 

Nowecki 2006 260 17 6.5% NA 

Wong 2006 223 8 3.6% P=NS on UVA 

Wright 2008 631 31 5.0% P



Author Year + SLN



Author Year N Clark Ulcer MR VGP Regres TIL Gender Age 

Bedrosian 2000 71 Y 

Bleicher 2003 272 N N N N N N 

Jacobs 2003 63 N 

Olah 2003 89 N N N Y 

Oliveira 2003 77 N Y Y Y 

Sondak 2004 42 Y Y 

Stitzenberg 2004 146 N N N N N 

Kesmodel 2005 181 N N Y N N 

Puleo 2005 409 N N 

Ranieri 2006 184 Y N Y N N N 

Hershko 2006 64 N N N 

Wong 2006 223 N N N N N N N 

Taylor 2007 135 Y 

Cecchi 2008 59 N 

Wright 2008 631 Y N Y Y 

Yonick 2011 147 N Y N N N N N N 

Murali 2012 432 N N N N N N 

Studies identifying factor 2/12 2/12 4/8 2/6 1/7 1/4 1/7 2/10


Thin melanoma - outcome after SLNB 



Thin melanoma - outcome after SLNB 

Melanoma-specific survival according to the nodal status after wide local excision and sentinel 

lymph node biopsy in patients with thin primary cutaneous melanoma 

631 patients with melanomas ≤1 mm 

thick underwent WE/SLNB at JWCI 

Negative SLN - 600 

Positive SLN - 31 (5%) 

Median f/u 57 months 

Wright, BE, Arch Surg 2008;143:892


NCCN guidelines


NCCN guidelines for SLNB 

Thickness 

(mm) 

Mitotic rate Ulceration Adverse factors* 

1.0-4.0 Offer Offer Offer Offer Offer Offer 

> 4.0 Offer Offer Offer Offer Offer Offer 

* Adverse features include + margin, LVI, Clark IV


Cost of SLNB in thin melanoma 

• 120 patients with thin melanoma undergo SLNB 

• Six patients (5%) will have a positive SLN 

– All will be offered CLND; none will have a + NSLN 

– All will be considered for adjuvant therapy 

– All will be considered for baseline/follow-up imaging 

– All will be followed closely for recurrence 

• Of the six patients with a positive SLN 

– One (15%) will die and five (85%) will survive



• If the incremental charge rendered for SLNB 

alone is $10,000, then, excluding charges 

associated with CLND, adjuvant therapy and 

more intensive followup for those patients with 

a positive SLN, the cost to identify one excess 

unpreventable death from melanoma = 

$10,000 x 120 = $1,200,000



Among the six patients with a positive SLN 

ALL WILL WORRY!!


Concepts – clinical utility of SLNB 

Intrinsic value for patient 

Direct clinical care 

Impact on recurrence 

Impact on survival 

Stratify for clinical trials 

Financial cost 

Of SLNB procedure 

If SLN positive: 

Imaging 

Frequent follow-up 

Adjuvant therapy 

Morbidity 

SLNB 

CLND 

Psychological stress 

Variable predictive value 

Insurability 

Pro 

Con


Summary 

• The probability of a positive SLN in patients 

with thin melanoma is around 5%. 

• The most reliable predictor of a positive SLN in 

patients with thin melanoma is primary tumor 

thickness. 

– ≤ 0.75 mm 2.5% 

– 0.76-1.0 mm 7% 

• There is no consensus as to what other risk 

factors predict a positive SLN in thin melanoma.


Summary 

• A positive SLN in patients with thin melanoma 

is prognostically significant: 

– A positive SLN is associated with a 12-25% 

worse survival. 

– The survival difference may not be apparent 

for five years or more. 

• The financial cost of identifying one 

unpreventable death by performing SLNB on 

all patients with thin melanoma is prohibitive.


Summary 

• We have a rudimentary understanding of the 

probability of a positive SLN in patients with 

thin melanoma. 

• There is no consensus on a firm threshold of 

probability below which SLNB should not be 

performed. 

• While a discussion of SLNB should be 

encouraged in all patients with melanoma, it 

should include recommendations on who 

should not undergo the procedure.


Question 1 

• A 56 year old man presents to you for treatment 

of a changing mole on his back. Shave biopsy 

revealed a melanoma measuring 0.6 mm, Clark 

IV, non-ulcerated, with a mitotic rate of 2/mm 2 , 

and a positive margin (in situ melanoma seen at 

the periphery). The probability of a positive 

SLN is: 

a) 1% 

b) 3% 

c) 5% 

d) 7% 

e) 10%


Question 2 

• This patient was found to have a micrometastasis 

in 1/2 sentinel nodes (0.5 mm in subcapsular 

sinus, without extracapsular extension). He 

went on to completion LND with no further 

melanoma seen in 10 nodes examined. His 

probability of survival at 8 years is: 

a) 95% 

b) 80% 

c) 50% 

d) 30% 

e) 10%


Question 3 

• If you had this man’s melanoma, and were 

found to have micrometastatic disease in 1/2 

sentinel nodes, what would you choose to do 

a) Cross sectional imaging 

b) Completion LND 

c) Adjuvant interferon 

d) a) and b) 

e) a) and c) 

f) b) and c) 

g) a) and b) and c) 

h) None of the above


Question 4 

• Independent of how it is determined, your 

personal threshold of probability of finding a 

positive sentinel node that would persuade you to 

undergo SLNB is: 

a) 1% 

b) 3% 

c) 5% 

d) 7% 

e) 10%

Sentinel Lymph Node Biopsy for Thin Melanoma - Winship Cancer ...

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