Critical appraisal:Mu E, Lange JR, Strouse JJ 2012

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Critical Appraisal

Article being appraised

Mu E, Lange JR, Strouse JJ. Comparison of the use and results of sentinel lymph node biopsy in children and young adults with melanoma. Cancer 2012 May 15;118(10):2700-7 Available from:

Applicable clinical question

Key Facts

Study Design

cohort study

Study aims:

To compare the factors associated with SLN biopsy use and metastases in pediatric and young adult patients
with melanoma

Number of Patients:


717 cases of melanoma in patients aged <20 years at diagnosis and 1368 cases in patients ages 20 to 24 years
Reported outcome(s):

Factors associated with a positive SLNB
Thickness Subset Analyses (according to thickness and ulceration)

Results of outcome(s):

SLN metastasis= 25% of children and 14% of young adults had SLN metastases. Pediatric characteristics associated with SLN metastases= increasing thickness, ulceration (62%), and nodular histology (43%). Children who had melanoma thickness between 1.01 mm and 2.00 mm had SLN metastases more often than young adults (24% vs 4%) in univariate analysis. Overall, children were more likely than young adults to have SLN metastases for all analyzed characteristics (ulceration, histology, thickness, sex, and primary site). Adjusted analysis indicated ulceration, thickness, and an interaction between age <20 years and thickness from 1.01 mm to 2.00 mm independently contributed to the probability of having SLN metastases; whereas histology, sex, and primary site did not. Patients with melanomas that were >1 mm thick had an OR of 4.9 (95% CI, 2.5-9.6) of having SLN metastases compared with those who had melanomas that were 1 mm thick in adjusted analyses. There was no significant interaction between age and ulceration (OR, 0.85; 95% CI, 0.24- 2.9). Socioeconomic status variables not associated with SLN biopsy or metastases.

Thickness Subset Analyses (according to thickness and ulceration): Tumor thickness < .001 mm and had no ulceration= 21% of pediatric patients and 20% of young adult patients underwent SLN biopsy (P = .8). 5.1% of children (3 of 59) and 5.3% of young adults (7 of 132) had SLN metastases (P =.9).
Non- ulcerated melanoma 1.01 mm to 2.00 mm in thickness= 88% of pediatric patients and 76% of young adult patients underwent SLN biopsy (P = .12). 24% of children (14 of 58) and 4% of young adults (3 of 79) had SLN metastases (P < .001)

Survival differed significantly between those with and without SLN metastases in both pediatric and young adult melanoma patients who underwent SLN biopsy (P < .001). Survival between lymph node-positive adults and lymph node-positive children (5- year survival rate 87% [95% CI, 68%-95%] vs 89% [95% CI, 74%-96%], respectively) (P = .07). Positive SLNB was associated with poorer prognosis in children (P = .003) and young adults (P = .001). Of those patients who had SLN metastases, 4 of 64 children and 4 of 54 young adults died. Of those patients who had negative SLN biopsies, 1 of 182 children and 3 of 322 young adults died.

Includes an economic evaluation


Evidence ratings

Level of evidence


Risk of bias
Moderate risk of bias Comments: Please replace this text and include any additional comments in regards to your quality rating

Risk of bias assessment: cohort study

Subject selection
"New technology" group
Selected group
Comparison group
Selected group
Comparability of groups on demographic characteristics and clinical features
Not comparable but adjusted analysis used
Measurement of outcomes
Outcome measures blind to technology used
No, but objective measures used
Same method of measurement used across comparison groups
Completeness of follow-up
Was follow-up complete and were all patients included in the analysis?
Yes (follow-up >95%) or survival analysis using all patients

Relevance of evidence
1 Additional comments: Survival, prognostic factors
Result of appraisal

Jutta's tick icon.png Included

Completed by

Jackie Buck

Jutta's tick icon.png This appraisal has been completed.

Mu E, Lange JR, Strouse JJ. Comparison of the use and results of sentinel lymph node biopsy in children and young adults with melanoma. Cancer 2012 May 15;118(10):2700-7 Available from:
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Form:Critical appraisal

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