Management of the Hand Tumors. (2024)

INTRODUCTION

When people recognize a mass on their bodies, they fear that itmight be a malignant tumor. However, soft tissue, skin, and bone tumorsof the hand are commonly benign tumors. Most of the studies concerninghand tumors are retrospective and comprise a small series. Hence, tumorsof the hand are poorly documented.

The incidence, variety, prognosis, diagnosis, and treatment optionsof hand tumors are clearly different when compared to other tumors ofthe body. Tumors occurring in hand account for 10%-15% of all skin andsoft-tissue malignancies.[1]

Tumors of the hand are usually benign in nature, and therefore,treatment is usually nonessential. Indications for the surgicaltreatment are cosmetic concern and potential for malignancy. Sincemalignant hand tumors are seen very rarely, suspicious findings shouldbe assessed thoroughly, and the diagnosis should be established aswell.[2,3]

Ganglions are the most common benign soft-tissue tumor of the handand account for 50%-70% of all hand tumors.[4]

Hand tumors may originate from the skin, soft tissue, or bone andare divided into two groups such as tumor-like lesions and real tumors.Working with experienced radiologists and pathologists is essential forestablishing a definitive diagnosis.[3,5,6]

Majority of the patients present with a painless mass on the hand.However, masses with a history of rapid growth and painful enlargementshould be investigated in detail since they might indicate malignanttransformation.

It is imperative to restore the function of the hand, if theproperties of the tumor require wide excision. On the other hand,cosmetic outcomes should also be considered.

MATERIAL AND METHODS

Five hundred and twenty eight hand tumor cases from 1996 to 2016operated at our institution were analyzed retrospectively. Theinstitutional review board approval was not required.

Patients were classified according to their age and gender,anatomic location and the histopathologic features of their tumor, andtreatment modality. Tumors localized distal to the distal wrist creasewere included in the study. Bone tumors and tumors located elsewhere inthe upper extremity were excluded from the study.

Malignant tumors were also evaluated according to surgical margins,reconstructive techniques, rate of recurrence, metastatic spread, andsurvival rate.

Benign tumors were reported as glomus tumor, epidermal cyst,giant-cell tumors of the tendon sheath, pyogenic granuloma, neurinoma,schwannoma, lipoma, cystic hygroma, hemangioma, arteriovenousmalformation, fibroma, fibrolipoma, ganglion cyst, infantile digitalmyofibroblastoma, dermatofibroma, and verruca vulgaris; whereas themalignant tumors were identified as squamous cell carcinoma (SCC), basalcell carcinoma (BCC), malignant melanoma, fibrohistiocytic malignanttumor, and synovial sarcoma.

Since BCC, fibrohistiocytic malignant tumor, and synovial sarcomacases accounted only for 11.2% of all tumors, they were grouped togetheras "other" for statistical analysis. Data regarding surgicalexcision margins were analyzed with the help of the current guideline ofthe British Association of Dermatologists for the management of SCC andmalignant melanoma.[7,8]

RESULTS

Five hundred and twenty eight patients were evaluated for theirage, gender, anatomic localization of the tumor, tumor histopathology,and treatment modality [Tables 1-4]. Seventy-two tumors were malignant,and 456 tumors were benign.

The malignant tumor incidence was found to be higher in males, andthe benign tumor incidence was higher in females. About 44.3% ofpatients with malignant tumor had a history of skin cancer, and 25.2% ofbenign tumor patients had a history of soft-tissue and skin lesions.

88.8% of the malignant tumors were either SCC or malignantmelanoma. The remaining 11.2% were BCCs, soft-tissue sarcomas, andfibrohistiocytic malignant tumor.

Our study revealed that the most common benign tumor of the handwas pyogenic granuloma (108 patients-23.7%), followed by ganglion cysts(84 patients-18.4%), giant-cell tumors of the tendon sheath (68patients-14.9%), other hand tumors (60 patients-13%), hemangioma (35patients-7.7%), neurinoma and schwannoma (28 patients-6.1%), fibroma andfibrolipoma (23 patients-5%), epidermal cysts (14 patients-3.1%), glomustumors (10 patients-2.2%), and arteriovenous malformations (7patients-1.5%) [Figure 1 and Table 3].

Glomus tumor was found to occur four times, and cystic hygroma wasfound to occur 3.75 times more frequently in females than males. Inaddition, arteriovenous malformations, giant-cell tumors of the tendonsheath, and lipomas were found to be more frequent in females than malesas well. On the other hand, epidermal cysts, fibromas, fibrolipomas,neurinomas, schwannomas, and pyogenic granulomas were found to occurmore frequently in males [Table 3].

AVM 2%Giant cell tumors of the tendon 15%Epidermal cyst 3%Fibrom, fibrolipom 5%Glomus tumor 2%Hemanjiom 8%Ganglion cyst 18%Lipoma 17%Neuroma, schwannoma 6%Pyogenic granuloma 24%Others 13%Figure 1: Distribution of all benign hand tumorsNote: Table made from pie chart.

The most common malignant tumor of the hand was SCC (65.2%). Thesecond most common malignant tumor was malignant melanoma (23.6%). Theremaining malignant tumors were sarcomas, BCCs, and fibrohistiocyticmalignant tumors. All of the malignant hand tumors were more frequentlyseen in males (57%) than in females (43%). The age range was 5-81 years(median age, 63 years) in males and 35-92 years (median age, 60.3 years)in females [Table 1].

Treatment

Treatment of benign tumors usually provides both functional andesthetically satisfactory results [Figures 2 and 3]. However, inmalignant tumors, the surgeon's primary goal should be tumorexcision with a safe margin, while preserving or restoring function asmuch as possible.

In this sense excision of benign tumors followed by primary closureis usually sufficient; nevertheless, the management of malignant tumorsmay require variable treatment modalities [Figures 4 and 5].

The 72 malignant tumors were grouped as follows: SCC (47 patients),malignant melanoma (17 patients), sarcoma (four patients), BCC (threepatients), and fibrohistiocytic malignant tumor (one patient). Thetreatment modality varied according to the type and invasion degree ofthe tumor.

Twenty of 47 patients with SCC underwent digital amputation,whereas five patients underwent ray amputation. Fourteen patientsunderwent tumor excision followed by skin graft adaptation, and theremaining eight patients required reconstruction with a flap after tumorexcision.

Fifteen of 17 malignant melanoma cases underwent either excision ordigital amputation. Two patients required reconstruction with a skingraft after tumor excision [Table 4].

Three of four patients with sarcoma were treated with digitalamputation, whereas one patient underwent ray amputation [Figure 5]. Allthree patients with BCC were treated with excision followed byreconstruction with a skin graft. One patient with fibrohistiocyticmalignant tumor underwent digital amputation.

Thirty-one of 47 SCC patients had a tumor diameter <2 cm. Twopatients presented with a palpable lymph node underwent elective lymphnode dissection (ELND), and the pathological examination of the lymphnodes revealed metastasis in both patients.

Sentinel lymph node biopsy (SLNB) results of eight of 16 patientswith SCC with a tumor diameter of more than 2 cm were positive, and theyall underwent ELND. The pathological examination of the lymph nodesshowed metastasis in eight patients [Table 5].

Five of 17 malignant melanoma patients had a lesion with Breslowthickness <1 mm with a negative sentinel lymph node. Four patientshad a Breslow thickness between 1 and 4 mm. Since two of them presentedwith a palpable lymph node, they underwent directly ELND, and thepathological examination of the nodes showed metastasis in bothpatients. The remaining two patients showed no sentinel lymph nodeinvolvement.

Eight of 17 malignant melanoma patients with Breslow thickness>4 mm underwent ELND, and all of the patients were found to havenodal involvement [Table 6].

DISCUSSION

According to our study, the most common benign tumor of the handwas found to be pyogenic granuloma. Pyogenic granulomas are pedicled andfriable lesions that are usually localized on the fingertip and easilybleed when traumatized [Figure 6]. One hundred and eight pyogenicgranuloma cases have been diagnosed in the current study (26% of allbenign tumors), and most of them were localized on the 3rd phalanx.Treatment for all the pyogenic granulomas was excision followed byprimary closure. Alternative treatments for pyogenic granulomas are asfollows: silver nitrate, electrocauterization, laser applications, andplucking. However, the best treatment modality is excision.[5,9,10]Amelanotic melanoma and SCC should be considered for the differentialdiagnosis.[9]

According to some other studies, the most common benign tumor ofthe hand is a ganglion cyst.[4,11] The etiology of ganglion cysts areuncertain; however, mucoid degeneration of colloid tissue is thought toplay a role.[12] Angelides[11] reported that ganglion cysts arelocalized 60%-70% on the dorsum of the hand and 18%-20% on the volarsurface of the hand.

Ganglion cysts mostly occur in women, usually in the 3rd and 4thdecades. In this study, ganglion cysts were the second most commonbenign tumor of the hand, accounting for 18% of all benign hand tumors.Seventy-eight percentages of the patients were females, and 22% weremales. Ganglion cysts were mostly localized on the dorsal surface of theleft wrist.

Pardini et al.[13] recommended that asymptomatic intraosseousganglion cysts should be followed, and excision is considered only if itis associated with pain and restriction of movement. Uriburu andLevy[14] recommended excision for all ganglion cysts. The rate ofrecurrence would be lower if ganglion cysts are excised accurately andcarefully.

Ganglion cysts may also be treated with compression, aspiration,and injection of steroids or sclerosing agents; however, the rate ofrecurrence is expected to be higher. Since volar ganglion cysts areusually located very close to the radial artery, the radial artery maybe injured during dissection.[4,11]

Although BCC is the most common malignant skin tumor, it occurs inhand in only 10% of cases.[15] In this study, we observed a lowerincidence (3.2%) of this tumor. Sun exposure and particular syndromesare among the predisposing factors. Subtypes include nodular (the mostcommon), sclerosing, pigmented, and superficial types. Small (<2 cm)or low.grade lesions require surgical margins of 4 mm and large (>2cm) or high-grade BCC s require margins of 6 mm to prevent localrecurrence.[16-18] To maximize tissue preservation, some authorsadvocate the usage of Mohs micrographic surgery.[19] Following excision,the 5-year recurrence rate was 3%-10% for primary tumors and more than17% for recurrent BCC cases.[20,21]

SCC makes up approximately 20% of all skin cancers and nearly 75%of all malignant skin lesions occurring in hand.[22,23] In this study,the SCC incidence was 65.3%. Since dorsum of the hand is exposed tosunlight more often than the other areas are, SCC lesions tend to occurin this region [Figure 7]. Risk factors include fair skin, cumulativeover-exposure to ultraviolet radiation, advanced age, and chronicallydamaged skin. Mostly, the treatment of choice is surgical excision. Therisk for metastasis and recurrence for squamous cell cancer of the handare greater than that of other locations.[24,25] 95% of low-risk lesionsare excised successfully with 4-mm margins.[7,26] High-risk lesionsrequire a margin of 6 mm for adequate resection. Digital amputation isessential if the tumor had invaded phalanges. After excision of an SCClesion, the defect closure may be performed by either primary closure,local flaps, skin grafts, or distant flaps. Current evidence does notrecommend the routine use of SLNB for low-risk lesions since they haveshown a low rate of lymph node metastasis. However, SLNB may be usefulfor high-risk SCC lesions without a palpable lymph node.[27] Lesions<2 cm in diameter have a local recurrence rate of 7.4% and 9.1% ofmetastasis rate; tumors larger than 2 cm in diameter have 15.2% of localrecurrence rate and 30.3% of metastasis rate.[28] If there is noclinically or radiologically positive lymph node involvement, smalllesions do not require lymph node dissection. In this study, there wereonly two patients with palpable lymph node, who had tumors with adiameter <2 cm. On the other hand, all patients with a SCC lesion>2 cm in diameter underwent SLNB. Eight of them had a positivesentinel lymph node, and therefore, they underwent ELND and thepathological examination showed metastasis in all patients.

Malignant melanoma (MM) is an aggressive, cutaneous malignancy forwhich early detection and intervention are essential for prognosis andsurvival. MM in the hand region is seen rarely, accounting for only 3%of all hand tumors.[29]

The nodal staging information was invaluable to define theprognosis for patients, to determine the need for therapeutic lymph nodedissection, to identify patients for adjuvant therapy with interferonalpha-2b, and to stratify hom*ogeneous patient populations for entry intoclinical trials of new adjuvant therapies.[30]

SLNB indications in MM include a Breslow thickness >1.0 mm or<1.0 mm with a Clark level IV or V.[31] Sentinel lymph nodeinvolvement was found to be 10.1% for a Breslow thickness of 1.01-2 mm,whereas the rate was 53.7% for the lesions with a Breslow thickness>4 mm showing that there is a direct relationship between nodalinvolvement and Breslow thickness.[32] However, SLNB is not free ofcomplications. Complications such as seroma, hematoma, and infection areseen frequently. Sensory morbidity occurs mostly in the axilla (e.g.,pain, mobility limitation, or discomfort). SLNB performed in the neckregion is associated with the highest rate of identificationfailure.[33]

Cryotherapy and laser therapy may also be utilized to treat MM, butthey have higher recurrence rates even in in situ melanoma cases.Topical treatment with interferon-alpha and imiquimod showed promisingresults but needs further studies.[34] Thus, surgical excision remainsthe recommended treatment for melanoma cases.

When the localizations of MM and SCC lesions were compared, MMlesions were found to be mostly located in the palmar surface of thehand, whereas most of the SCC cases were usually located on the dorsumof the hand. SCC lesions were located mostly between the distal portionof the dorsal wrist crease and metacarpophalangeal joints, where the sunexposure is at a maximum level compared to other regions in the hand.Most of the actinic keratosis lesions are also located in this region.The rarity of soft-tissue sarcomas of the hand is an obstacle to conductlarge prospective randomized studies and to develop specificstandardized treatment protocols. Surgery remains the only option forcure. Even amputation may be necessary when clear margins cannot beobtained by other surgical approaches. In case the pathology result isuncertain or the frozen section is unreliable, additional tissue shouldbe sent for analysis, and the definitive reconstruction should bedelayed.[35]

We have analyzed 528 hand tumors treated over the past 20 years.Seventy-two (13.6%) of these tumors were malignant, and 456 (86.4%) werebenign. Butler et al.[36] reported 437 cases of hand tumors, of which24% were malignant. Pack[37] reported 389 cases and 59% of cases showedmalignant change. The latter studies show that the incidence ofmalignancy in the hand varies widely.

CONCLUSIONS

A careful history and physical examination performed by aspecialist can narrow down the possibilities regarding the type oftumor. The vast majority of hand tumors tend to be benign. In contrastto skin cancers, in general, those occurring on the hand frequently havea worse prognosis, with a greater propensity for recurrence, metastaticspread, and functional deficit in addition to need for amputation andcomplex soft-tissue reconstruction. For all malignant hand tumors, earlydetection and intervention are essential for prognosis and survival.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

(1.) Martinez JC, Otley CC. The management of melanoma andnonmelanoma skin cancer: A review for the primary care physician. MayoClin Proc 2001;76:1253-65.

(2.) Ingari JV, Faillace JJ. Benign tumors of fibrous tissue andadipose tissue in the hand. Hand Clin 2004;20:243-8, v.

(3.) Posch JL. Tumors of the hand. J Bone Joint Surg Am 1956;38-A:517-39.

(4.) Athanasian EA. Bone and Soft Tissue Tumors. Green'sOperative Hand Surgery. 5th ed. Pennsylvania: Elsevier ChurchillLivingstone; 2005. p. 2211-63.

(5.) Plate AM, Lee SJ, Steiner G, Posner MA. Tumorlike lesions andbenign tumors of the hand and wrist. J Am Acad Orthop Surg2003;11:129-41.

(6.) Unni KK, Dahlin DC. Dahlin's Bone Tumors. 5th ed.Philadelphia: Lippincott-Raven; 1996.

(7.) Motley R, Kersey P, Lawrence C; British Association ofDermatologists, British Association of Plastic Surgeons, Royal Collegeof Radiologists, Faculty of Clinical Oncology, et al. Multiprofessionalguidelines for the management of the patient with primary cutaneoussquamous cell carcinoma. Br J Dermatol 2002;146:18-25.

(8.) Marsden JR, Newton-Bishop JA, Burrows L, Cook M, Corrie PG,Cox NH, et al. Revised U.K. Guidelines for the management of cutaneousmelanoma 2010. Br J Dermatol 2010;163:238-56.

(9.) Fleegler EJ. Green Athanasian, Skin Tumors. 5th ed.Pennsylvania: Elsevier Churchill Livingstone; 2005. p. 2191-209.

(10.) Fleegler EJ, Zeinowicz RJ. Tumors of the perionychium. HandClin 1990;6:113-33.

(11.) Angelides AC. Ganglions of the Hand and the Wrist. OperativeHand Surgery. 4th ed., Vol. 2. New York: Churchill-Livingstone; 1999. p.2171-83.

(12.) Shapiro PS, Seitz WH Jr. Non-neoplastic tumors of the handand upper extremity. Hand Clin 1995;11:133-60.

(13.) Pardini AG, Freitas AD, Gusmao NS. The natural history ofwrist ganglion. IFSSH 1998; Abstract vol. 89.

(14.) Uriburu IJ, Levy VD. Intraosseous ganglia of the scaphoid andlunate bones: Report of 15 cases in 13 patients. J Hand Surg Am1999;24:508-15.

(15.) Sobanko JF, Dagum AB, Davis IC, Kriegel DA. Soft tissuetumors of the hand 1. Benign. Dermatol Surg 2007;33:651-67.

(16.) Dessoukey MW, Omar MF, Abdel-Dayem H. Eruptivekeratoacanthomas associated with immunosuppressive therapy in a patientwith systemic lupus erythematosus. J Am Acad Dermatol 1997;37:478-80.

(17.) Williamson GS, Jackson R. Treatment of squamous cellcarcinoma of the skin by electrodesiccation and curettage. Can Med AssocJ 1964;90:408-13.

(18.) Motley R, Kersey P, Lawrence C; British Association ofDermatologists, British Association of Plastic Surgeons.Multiprofessional guidelines for the management of the patient withprimary cutaneous squamous cell carcinoma. Br J Plast Surg2003;56:85-91.

(19.) Schwartz RA, Blaszczyk M, Jablonska S. Generalized eruptivekeratoacanthoma of grzybowski: Follow-up of the original description and50-year retrospect. Dermatology 2002;205:348-52.

(20.) Goldstein AM, Bale SJ, Peck GL, DiGiovanna JJ. Sun exposureand basal cell carcinomas in the nevoid basal cell carcinoma syndrome. JAm Acad Dermatol 1993;29:34-41.

(21.) Kuijpers DI, Thissen MR, Neumann MH. Basal cell carcinoma:Treatment options and prognosis, a scientific approach to a commonmalignancy. Am J Clin Dermatol 2002;3:247-59.

(22.) Chakrabarti I, Watson JD, Dorrance H. Skin tumours of thehand. A 10-year review. J Hand Surg Br 1993;18:484-6.

(23.) Bean DJ, Rees RS, O'Leary JP, Lynch JB. Carcinoma of thehand: A 20-year experience. South Med J 1984;77:998-1000.

(24.) Ariyan S. Benign and malignant soft tissue tumors of thehand. In: McCarthy JG, May JW, Littler JW, editors. Plastic Surgery. TheHand. Part 2. Vol. 8. Philadelphia: W.B. Saunders; 1990. p. 5483-509.

(25.) Schiavon M, Mazzoleni F, Chiarelli A, Matano P. Squamous cellcarcinoma of the hand: Fifty-five case reports. J Hand Surg Am1988;13:401-4.

(26.) Brodland DG, Zitelli JA. Surgical margins for excision ofprimary cutaneous squamous cell carcinoma. J Am Acad Dermatol1992;27:241-8.

(27.) Henderson MM, Neumeister MW, Bueno RA Jr. Hand tumors: I.Skin and soft-tissue tumors of the hand. Plast Reconstr Surg2014;133:154e-64e.

(28.) Rowe DE, Carroll RJ, Day CL Jr. Prognostic factors for localrecurrence, metastasis, and survival rates in squamous cell carcinoma ofthe skin, ear, and lip. Implications for treatment modality selection. JAm Acad Dermatol 1992;26:976-90.

(29.) Sobanko JF, Dagum AB, Davis IC, Kriegel DA. Soft tissuetumors of the hand 2. Malignant. Dermatol Surg 2007;33:771-85.

(30.) Manca G, Facchetti F, Pizzocaro C, Biasca F, Farfa*glia R,Simoncini E, et al. Nodal staging in localized melanoma. The experienceof the brescia melanoma unit. Br J Plast Surg 2003;56:534-9.

(31.) Netscher DT, Leong M, Orengo I, Yang D, Berg C, Krishnan B,et al. Cutaneous malignancies: Melanoma and nonmelanoma types. PlastReconstr Surg 2011;127:37e-56e.

(32.) Duprat JP, Silva DC, Coimbra FJ, Lima IA, Lima EN, AlmeidaOM, et al. Sentinel lymph node biopsy in cutaneous melanoma: Analysis of240 consecutive cases. Plast Reconstr Surg 2005;115:1944-51.

(33.) Wasserberg N, Tulchinsky H, Schachter J, Feinmesser M, GutmanH. Sentinel-lymph-node biopsy (SLNB) for melanoma is notcomplication-free. Eur J Surg Oncol 2004;30:851-6.

(34.) Arlette JP, Trotter MJ, Trotter T, Temple CL. Management oflentigo maligna and lentigo maligna melanoma: Seminars in surgicaloncology. J Surg Oncol 2004;86:179-86.

(35.) Labow BI, Rosen H, Greene AK, Lee WP, Upton J. Soft tissuesarcomas of the hand: Functional reconstruction and outcome analysis.Hand (N Y) 2008;3:229-36.

(36.) Butler ED, Hamill JP, Seipel RS, De Lorimier AA. Tumors ofthe hand. A ten-year survey and report of 437 cases. Am J Surg1960;100:293-302.

(37.) Pack GT. Tumor of the Hand and Feet. St. Louis: C.V. MosbyCo.; 1939. p. 33-135.

Fatih Irmak, Selami Serhat Sirvan, Isil Akgun Demir, Kamuran ZeynepSevim, Memet Yazar, Aysin Karasoy Yesilada

Department of Plastic, Reconstructive and Aesthetic Surgery,University of Health Sciences Sisli Hamidiye Etfal Training and ResearchHospital, Istanbul, Turkey

Address for correspondence: Dr. Isil Akgun Demir, Department ofPlastic, Reconstructive and Aesthetic Surgery, Saglik BilimleriUniversity, Sisli Hamidiye Etfal Training and Research Hospital,Istanbul, Turkey.

E-mail: [emailprotected]

How to cite this article: Irmak F, Sirvan SS, Demir IA, Sevim KZ,Yazar M, Yesilada AK. Management of the hand tumors. Turk J Plast Surg2018;26:103-9.

DOI: 10.4103/tjps.tjps_32_18

Table 1: Demographics of the patients with malignant tumorMean age Female 60.3 Male 63Age range Female 35-92 Male 5-81Male-to-female ratio 1:0.75History of previous skin cancer (%) 44.3Table 2: Demographics of the patients with benign tumorMean age Female 38 Male 41Age range Female 4-59 Male 8-61Male:female ratio 1.16:1.22History of previous skin lesion (%) 25.2Table 3: Distribution of the benign hand tumors Number The most Female:male of frequent ratio patients localizationArteriovenous 7 Index finger 1.33:1malformationGiant-cell tumor of 68 Middle finger 1.23:1the tendon sheathEpidermal cyst 14 Phalanx 1:1.5Fibroma/fibrolipoma 23 Phalanx 1:1.25Glomus tumor 10 Ring finger 4:1Hemangioma 35 Index finger 1.26:1Ganglion cyst 84 Left wrist 3.75:1Lipoma 19 Dorsum of hand 1.37:1Neuroma/schwannoma 28 Pulpa 1:1.25Pyogenic granuloma 108 Middle finger 0.75:1Others 60Table 4: Treatment modalities for malignant tumors Excision/digital Skin Ray Flap Total amputation graft amputationSCC 20 14 5 8 47MM 15 2 - - 17Others 4 3 1 - 8SCC: Squamous cell cancer, MM: Malignant melanomaTable 5: Lymph node management in squamous cell carcinoma patientsDiameter Number SLNB ELND Result ofof the of ELNDlesion (cm) patients<2 31 Negative in Only in two Positive 29 patients patients with a palpable lymph node>2 16 Positive in In all patients Positive in eight patients eight patientsSLNB: Sentinel lymph node biopsy, ELND: Elective lymph node dissectionTable 6: Lymph node management in malignant melanoma patientsBreslow thickness (mm) Number of patients SLNB Result of SLNB <1 5 - - 1-4 4 2 Negative >4 8 1 PositiveBreslow thickness (mm) ELND <1 2 1-4 In two patients with a palpable lymph node >4 8Breslow thickness (mm) Result of ELND <1 Negative 1-4 Positive in both patients >4 Positive in all patientsSLNB: Sentinel lymph node biopsy, ELND: Elective lymph node dissection