Tumour mitotic rate—a poor predictor of sentinel lymph
node status in cutaneous melanoma: should we select
using staging criteria?
Aidan M. Rose
David A. Munnoch
Received: 28 December 2011 / Accepted: 28 February 2012 / Published online: 4 April 2012
Background Selection for sentinel lymph node biopsy
(SLNB) in cutaneous melanoma is currently based on
histopathological variables specified in prognostic staging
criteria. In 2009, these criteria were updated replacing
Clark level with the tumour mitotic rate (TMR) when
defining thin T1 tumours. This study aimed to determine
the histopathological variables independently predictive of
sentinel lymph node involvement and discusses which
variables should influence our selection for SLNB.
Methods One hundred and fifty-three patients with primary
invasive localized cutaneous melanoma who underwent
SLNB between 2003 and 2007 were reviewed from a pro-
spectively collected database. We performed a multivariate
binary logistic regression analysis to ascertain which varia-
bles independently predict sentinel status.
Results SLNB positivity rate was 17.3%. No patient with a
thin T1 tumour was SLNB positive. Breslow thickness was
the only independent predictor of sentinel lymph node
(SLN) status to reach significance (x
, 10.555; p, 0.001).
TMR and ulceration were not independent predictors of
sentinel node status (x
,0.988;p, 0.320 and x
p, 0.149, respectively).
Conclusion Breslow thickness is the only variable that is
consistently reported as an independent predictor of SLN
status. The use of TMR and ulceration in staging criteria
is intended to establish prognosis, not select for SLNB.
Given the important implications of a positive SLNB on
surgical management, accurate selection is imperative.
Selection based solely on Breslow thickness, rather than
staging criteria, may be valid. However, there is an
urgent need for a well-designed large multi-centre anal-
ysis to validate this. Until then, we continue to select for
SLNB within a multidisciplinary team accounting for
Level of Evidence: Level II, Prognostic/Risk Study.
Sentinel node biopsy
Sentinel lymph node (SLN) status is the most important
prognostic factor for both disease-free and overall survival
in stage I and II melanoma [1, 2]. A number of histopatho-
logical variables, most notably Breslow thickness and ulcer-
ation, are also proven strong determinants of prognosis.
Poor melanoma-specific survival in those with cellular pro-
liferation, reflected by a high tumour mitotic rate (TMR),
was first reported by Allen and Spitz in 1953 . Since then,
a number of reports, including two large studies from the
Sydney Melanoma Unit [4, 5] renewed interest in the TMR
as a prognostic factor. Azzola et al. analysed 3,661 patients,
concluding that TMR was the second most powerful pre-
dictor of survival, behind Breslow thickness . These
results were replicated in a recent analysis of 13,296 patients
by Thompson et al. . In light of this, the AJCC Melanoma
Presentations 4th International Symposium on Cancer Metastasis and
Lymphovascular System: Basis for Rational Therapy. Intercontinental
New York Barclay Hotel, New York, NY. 12–14th May 2011.
British Association of Plastic Reconstructive and Aesthetic Surgeons,
Summer Meeting. Oxford. 6–8th July 2011.
A. M. Rose (*)
D. A. Munnoch
Department of Plastic and Reconstructive Surgery, NHS Tayside,
Dundee DD19SY, UK
Eur J Plast Surg (2012) 35:741–746