Is patient age associated with rate of lymph node positivity in clinically localized thin melanoma?
In this cohort study of a national data set of 8772 patients undergoing curative resection of thin melanoma, older age was significantly associated with reduced risk of lymph node metastases. Patients younger than 40 years with category T1b tumors 0.50 to 0.75 mm, who would generally not be recommended sentinel lymph node biopsy, had a lymph node positivity rate of 5.6%; conversely, patients 65 years or older with T1b tumors 0.76 mm or larger, who would generally be recommended for sentinel lymph node biopsy, had a lymph node positivity rate of only 3.9%.
Current guidelines for sentinel lymph node biopsy may be overly restrictive in younger patients and overly permissive in older patients.
More than half of all new melanoma diagnoses present as clinically localized T1 melanoma, yet sentinel lymph node biopsy (SLNB) is controversial in this population given the overall low yield. Guidelines for SLNB have focused on pathologic factors, but patient factors, such as age, are not routinely considered.
To identify indicators of lymph node (LN) metastasis in thin melanoma in a large, generalizable data set and to evaluate the association between patient age and LN positivity.
Design, Setting, and Participants
A retrospective cohort study using the National Cancer Database, an oncology database representing patients from more than 1500 hospitals throughout the United States, was performed (2010-2013). Data analysis was conducted from October 1, 2016, to January 15, 2017. A total of 8772 patients with clinical stage I 0.50 to 1.0 mm thin melanoma undergoing wide excision and surgical evaluation of regional LNs were included for study.
Main Outcome and Measures
The primary outcome of interest was presence of melanoma in a biopsied regional LN. Clinicopathologic factors associated with LN positivity were characterized, using logistic regression. Age was categorized as younger than 40 years, 40 to 64 years, and 65 years or older for multivariable analysis. Classification tree analysis was performed to identify high-risk groups for LN positivity.
Among the study cohort (n = 8772), 333 patients had nodal metastases, for an overall positivity rate of 3.8% (95% CI, 3.4%-4.2%). A total of 4087 (54.0%) patients were women. Median age was 56 years (interquartile range [IQR], 46-67) in patients with negative LNs and 52 years (IQR, 41-61) in those with positive LNs (P < .001). In multivariable analysis, younger age, female sex, thickness of 0.76 mm or larger, increasing Clark level, mitoses, ulceration, and lymphovascular invasion were independently associated with LN positivity. In decision tree analysis, patient age was identified as an important risk stratifier for LN metastases, after mitoses and thickness. Patients younger than 40 years with category T1b tumors 0.50 to 0.75 mm, who would generally not be recommended for SLNB, had an LN positivity rate of 5.6% (95% CI, 3.3%-8.6%); conversely, patients 65 years or older with T1b tumors 0.76 mm or larger, who would generally be recommended for SLNB, had an LN positivity rate of only 3.9% (95% CI, 2.7%-5.3%).
Conclusions and Relevance
Patient age is an important factor in estimating lymph node positivity in thin melanoma independent of traditional pathologic factors. Age therefore should be taken into consideration when selecting patients for nodal biopsy.
Andrew J. Sinnamon, Madalyn G. Neuwirth, Pratyusha Yalamanchi, Phyllis Gimotty, David E. Elder, Xiaowei Xu, Rachel R. Kelz, Robert E. Roses, Emily Y. Chu, Michael E. Ming, Douglas L. Fraker, Giorgos C. Karakousis. Association Between Patient Age and Lymph Node Positivity in Thin Melanoma . JAMA Dermatol. 2017;153(9):866–873. doi:10.1001/jamadermatol.2017.2497