Lymph Node Ratio Provides Prognostic Information in Addition to American Joint Committee on Cancer N Stage in Patients With Melanoma, Even If Quality of Surgery Is Standardized

Economic Evaluation of Inguinal Versus Ilio-inguinal Lymphadenectomy for Patients with Stage III Metastatic Melanoma to Groin Lymph Nodes: Evidence from the EAGLE FM Randomized Trial

PURPOSE

We compared health outcomes and costs of inguinal lymphadenectomy (IL) versus ilio-inguinal lymphadenectomy (I-IL) for removal of metastatic melanoma to lymph nodes of the groin in adults with stage III melanoma.

METHODS

A within-trial cost-utility analysis was performed alongside an international randomized trial (EAGLE-FM) with 36 months follow-up from a health system perspective. Healthcare costs were measured by using trial records, and effectiveness measured in quality-adjusted life years (QALYs). Deterministic sensitivity analyses assessed the impact of changes in costs or quality of life on overall results. Statistical bootstrapping was employed to estimate confidence intervals around the cost-utility ratio.

RESULTS

Among 98 trial participants (IL n = 50, I-IL n = 48), with no pelvic or distant disease clinically or on PET/CT imaging, the mean life years saved for those randomized to IL showed a small but nonsignificant increase of 0.05 years compared with those in the I-IL group (2.56 vs. 2.51 years, 95% confidence interval [CI] -0.78 to 0.87). The mean difference in QALYs gained showed a small but nonsignificant increase of 0.04 QALYs (1.95 vs. 1.91, 95% CI -0.49 to 0.57). The mean hospital stay among IL patients was 6.16 days, 1.24 days shorter than I-IL patients (7.40 days) at 36 months follow-up. Mean per-patient healthcare costs of IL surgery were AU$6938 lower than for I-IL surgery ($26,555 vs. $33,493, 95% CI -$24,360 to $10,484). Inguinal lymphadenectomy was slightly more effective and slightly less expensive) over I-IL; a finding supported by 81% of bootstrapped estimates and upheld across sensitivity analyses.

CONCLUSIONS

Our study indicates that less extensive IL surgery might be the preferred surgical strategy for metastatic melanoma to the groin when PET/CT imaging shows no pelvic disease. This surgery is likely to improve quality-adjusted survival and may reduce healthcare costs; however, the differences noted in EAGLE-FM were limited by a small sample size and were not statistically significant.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02166788; anzctr.org.au ACTRN12614000721606.

Eugene Nicholas Myers' Lecture on Head and Neck Cancer, 2020: The Surgeon as a Prognostic Factor in Head and Neck Cancer Patients Undergoing Surgery

This paper is a transcript of the 29 th Eugene N. Myers, MD International Lecture on Head and Neck Cancer presented at the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) in 2020. By the end of the 19 th century, the survival rate in treated patients was 10%. With the improvements in surgical techniques, currently, about two thirds of patients survive for > 5 years. Teamwork and progress in surgical reconstruction have led to advancements in ablative surgery; the associated adjuvant treatments have further improved the prognosis in the last 30 years. However, prospective trials are lacking; most of the accumulated knowledge is based on retrospective series and some real-world data analyses. Current knowledge on prognostic factors plays a central role in an efficient treatment decision-making process. Although the influence of most tumor- and patient-related prognostic factors in head and neck cancer cannot be changed by medical interventions, some environmental factors-including treatment, decision-making, and quality-can be modified. Ideally, treatment strategy decisions should be taken in dedicated multidisciplinary team meetings. However, evidence suggests that surgeons and hospital volume and specialization play major roles in patient survival after initial or salvage head and neck cancer treatment. The metrics of surgical quality assurance (surgical margins and nodal yield) in neck dissection have a significant impact on survival in head and neck cancer patients and can be influenced by the surgeon's expertise. Strategies proposed to improve surgical quality include continuous performance measurement, feedback, and dissemination of best practice measures.

Lymph node ratio-based nomogram for prognosis evaluation and treatment optimization of non-metastatic oral cavity squamous cell carcinoma

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LNR is an independent prognostic factor over N stage in OCSCC.

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LNR-based nomogram surpasses AJCC TNM staging in predicting outcome of OCSCC.

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LNR-based nomogram is valid in guiding post-operative radiotherapy in OCSCC.

Background

Lymph node ratio (LNR) has been increasingly reported as a prognostic factor in oral cavity squamous cell carcinoma (OCSCC). This study aimed to develop and validate a prognostic nomogram integrating LNR and to further assess its role in guiding adjuvant therapy for OCSCC.

Methods

A total of 8703 OCSCC patients treated primarily with surgery in the Surveillance, Epidemiology and End Results (SEER) database were retrieved and randomly divided into training and validation cohorts. The nomogram was created based on the factors identified by Cox model. The value of PORT and chemotherapy was respectively evaluated in each prognostic group according to nomogram-deduced individualized score.

Results

The final nomogram included tumor site, grade, T stage, number of positive lymph nodes and LNR. Calibration plots demonstrated a good match between predicted and observed rates of overall survival (OS). The concordance indexes for training and validation cohorts were 0.720 (95% confidence interval (CI): 0.708, 0.732) and 0.711 (95% CI: 0.687, 0.735), both significantly higher than did TNM stage (p< 0.001). According to individualized nomogram score, patients were stratified into three subgroups with significantly distinct outcome. PORT presented survival benefit among medium- and high-risk groups whereas a near-detrimental effect in low-risk group. Chemotherapy was found to be beneficial only in high-risk group.

Conclusion

This LNR-incorporated nomogram surpassed the conventional TNM stage in predicting prognosis of patients with non-metastatic OCSCC and identified sub-settings that could gain survival benefit from adjuvant thearpy.

Prognostic value of different lymph node staging methods for node-positive cardia gastric cancer: a register-based retrospective cohort study

OBJECTIVE

To investigate the prognostic efficacy of lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) in node-positive cardia gastric adenocarcinoma (CGA).

DESIGN

A registry-based retrospective cohort study.

SETTING

Patients diagnosed with node-positive CGA in the Surveillance, Epidemiology, and End Results database from 2010 to 2015.

PARTICIPANTS

A total of 1038 patients were enrolled and randomly assigned (7:3) to the training set (n=723) or validating set (n=315).

PRIMARY OUTCOME MEASURE

Cancer-specific survival (CSS).

RESULTS

The baseline characteristics of the training and validation sets were similar. Based on the optimal cut-off values, LNR was classified into low (<0.09), medium (0.09~0.33) and high (>0.33) groups; LODDS was also classified into low (<-2.09), medium (-2.09~-0.65) and high (>-0.65) groups. CSS was significantly different across LNR and LODDS subgroups. The Harrell concordance index of the N stage was lower than that of the LNR or LODDS. The Akaike information criterion of the N stage was higher than that of the LNR or LODDS. Independent predictors included race, T stage, M stage and LNR (or LODDS), and they were incorporated into nomograms for 1-year, 2-year and 5-year CSS prediction. Calibration plots showed satisfactory results for internal and external validity of the nomogram.

CONCLUSIONS

LNR and LODDS staging methods have better prognostic efficacy than the traditional N staging method in CGA with node metastasis. Moreover, the two values are promising substitutes for N staging in nomogram development when other independent prognostic factors are incorporated.

Contemporary management of locoregionally advanced melanoma in Australia and New Zealand and the role of adjuvant systemic therapy

Australia and New Zealand have the highest incidence and mortality rates for melanoma in the world. Local surgery is still the standard treatment of primary cutaneous melanoma, and it is therefore important that surgeons understand the optimal care pathways for patients with melanoma. Accurate staging is critical to ensure a reliable assessment of prognosis and to guide treatment selection. Sentinel node biopsy (SNB) plays an important role in staging and the provision of reliable prognostic estimates for patients with cutaneous melanoma. Patients with stage III melanoma have a substantial risk of disease recurrence following surgery, leading to poor long-term outcomes. Systemic immunotherapies and targeted therapies, known to be effective for stage IV melanoma, have now also been shown to be effective as adjuvant post-surgical treatments for resected stage III melanoma. These patients should be made aware of this and preferably managed in an integrated multidisciplinary model of care, involving the surgeon, medical oncologists and radiation oncologists. This review considers the impact of a recent update to the American Joint Committee on Cancer (AJCC) staging system, the role of SNB for patients with high-risk primary melanoma and recent advances in adjuvant systemic therapies for high-risk patients.

Proposed Quality Performance Indicators (QPI's) for axillary lymphadenectomy in metastatic cutaneous melanoma

INTRODUCTION

Axillary lymph node clearance (ALNC) continues to play a central role in the management of melanoma. However, what defines an adequate lymphadenectomy remains unclear. We aimed to propose Quality Performance Indicators (QPIs) for ALNC and to determine if the number of lymph nodes (LNs) removed impacts survival.

METHODS

We reviewed patients who underwent ALNC for melanoma at the Waitemata District Health Board and Melanoma Unit between February 2005 and October 2019, performed by two surgeons with standardized technique and surveillance.

RESULTS

105 patients with stage III melanoma were included, of which 73 had clinically evident disease and 32 had clinically occult disease. The mean total number of LNs excised was 29 (SD 10.90, range 10-76). On multivariate analysis, lymph node ratio (HR 4.48, 95% CI 1.55-12.93, p = 0.006), extracapsular spread (HR 2.53, 95% CI 1.06-6.05, p = 0.036) and distant recurrence (HR 11.24, 95% CI 3.79-33.31, p < 0.001) were significant predictors of mortality. The number of LNs removed did not predict survival outcomes, while the lymph node ratio did significantly predict survival outcomes. The regional recurrence rate was 3.8%.

DISCUSSION

We propose that QPIs for ALNC in melanoma include a 90th percentile LN yield of greater than 15, a mean LN yield of 20, a regional recurrence rate of less than 10%, and an overall complication rate of less than 50%.

CONCLUSION

The establishment of QPIs can help ensure that surgical oncology patients receive the highest quality of care.

Web-based nomograms for predicting the prognosis of adolescent and young adult skin melanoma, a large population-based real-world analysis

Background

Invasive cutaneous melanoma is one of the most common malignant diseases among adolescents and young adults (aged 15–40 years) in the United States. We aimed to develop web-based nomograms to precisely predict overall survival and cancer-specific survival in this group of patients with cutaneous melanoma.

Methods

We analyzed the overall and caner-specific death events in 19,887 patients who underwent surgical resection of cutaneous melanoma from Surveillance, Epidemiology and End Results database and developed web-based clinic-pathologic prediction models for overall survival and cancer specific survival based on Cox regression. C-statistics of Harrell and time-dependent Receiver Operating Characteristic Curve (ROC) were used to evaluate the prognostic accuracy of nomograms.

Results

Multivariate Cox regression model analysis suggested that age, sex, race, tumor location, Clark level, ulceration, thickness, and N stage were independently associated with both overall survival and cancer-specific survival in adolescent and young adult patients with cutaneous melanoma. The nomograms performed excellently in predicting overall survival and cancer-specific survival with C-index being 0.875 (95% CI: 0.847–0.903) and 0.901 (95% CI: 0.876–0.925), respectively. Time-dependent ROC verified that the prognostic accuracy of nomograms was better than that of American Joint Committee on Cancer staging system and other prognostic factors.

Conclusions

These user-friendly nomograms can precisely predict overall survival and cancer-specific survival in cutaneous melanoma patients treated with surgical resection, which may help to make individualized postoperative follow-up and therapeutic schemes.

Number of Excised Lymph Nodes Has No Impact on Relapse and Survival in Patients With Stage III Melanoma

BACKGROUND

Even though both the involvement of regional lymph nodes and the number of metastatic lymph nodes are regarded as major determinants of survival in cutaneous melanoma, the extent of node dissection has been analyzed as an independent prognostic indicator in only a few studies. This study aims to determine how the extent of lymph node excision (EN) might predict the disease relapse and survival in melanoma.

METHODS

A total of 317 patients with stage III melanoma were included in the study and reviewed retrospectively. The patients were divided into 2 groups based on the number of the excised lymph nodes: EN1 for fewer than 10 and EN2 for 10 or more lymph nodes removed.

RESULTS

The median number of positive nodes was 1 (range, 1-32). The largest group was N1 (52.4%), which was followed by N2 (29.6%) and N3 (18%). The median number of EN was 13 (range, 1-73). The patients were allocated to EN1 and EN2 as follows: 31.9% and 68.1%, respectively. The rates of EN2 patients were 62.2%, 72.2%, and 78.2% in N1, N2, and N3, respectively. For all patients, the estimated 5- and 10-year relapse-free survival rates were 41% and 39%, respectively; and the estimated 5- and 10-year overall survival rates were 51% and 42%, respectively. Extension of lymph node excision was found to be not prognostic for relapse and survival (P = 0.55 and P = 0.88, respectively).

CONCLUSIONS

Extension of lymph node excision has no impact on relapse and survival of stage III cutaneous melanomas.

Lymph node ratio (LNR) as a complementary staging system to TNM staging in salivary gland cancer

Purpose

The role of lymph node ratio (LNR, ratio of metastatic to examined nodes) in the staging of multiple human malignancies has been reported. We aim to evaluate its value in salivary gland cancer (SGC).

Methods

Records of SGC patients from Surveillance, Epidemiology, and End Results database (SEER, training set, N = 4262) and Fudan University Shanghai Cancer Center (FUSCC, validating set, N = 154) were analyzed for the prognostic value of LNR. Kaplan–Meier survival estimates, the Log-rank χ² test and Cox proportional hazards model were used for univariate and multivariate analysis. Optimal LNR cutoff points were identified by X-tile.

Results

Optimal LNR cutoff points classified patients into four risk groups, R0, R1 (≤ 0.17), R2 (0.17–0.56) and R3 (> 0.56), corresponding to 5-year cause-specific survival in SEER patients of 88.6%, 57.2%, 53.1% and 39.7%, disease-free survival in FUSCC patients of 69.2%, 63.3%, 34.6% and 0%, and disease-specific survival in FUSCC patients of 92.3%, 90.0%, 71.4% and 0%, respectively. Compared with TNM staging, TNM + R staging showed smaller AIC values and higher C-index values in the Cox regression model in both patient sets.

Conclusions

LNR classification should be considered as a complementary system to TNM staging and LNR classification based clinical trials deserve further research.

Electronic supplementary material

The online version of this article (10.1007/s00405-019-05597-0) contains supplementary material, which is available to authorized users.

Lymph node ratio has impact on relapse and outcome in patients with stage III melanoma

BACKGROUND

Even though both the involvement of regional lymph nodes and the number of metastatic lymph nodes are regarded as major determinants of survival in cutaneous melanoma, the extent of node dissection has been analyzed as an independent prognostic indicator in only a few studies. This study aims to determine how the lymph node ratio (NR) (ratio of positive nodes to total nodes removed) might predict the disease relapse and survival in node-positive melanoma.

MATERIALS AND METHODS

A total of 317 patients with stage III primary melanoma were included in the study and reviewed retrospectively. All patients had nodal staging (N) by radical lymph node dissection. Patients were divided into three groups based on NR1 ≤ 10%, NR2 10-25%, and NR3 > 25%.

RESULTS

The median age was 50 years (range 16-86) and men were predominant (59.3%). The majority of the patients had thicker Breslow depth (> 2 mm) (83.3%), higher mitotic rate (> 2/mm2) (64.1%) and ulcerated lesions (69.4%). The median number of positive nodes was 1 (range 1-32). The largest group was N1 (52.4%), which was followed by N2 (29.6%) and N3 (18%). The ratios of patients were 37.5%, 35.3%, and 27.1% in NR1, NR2, and NR3, respectively. The median number of excised lymph nodes was 13 (range 1-73). For all patients the estimated 5-and 10-year relapse-free survival (RFS) rates were 41% and 39%, respectively; and the estimated 5-and 10-year overall survival (OS) rates were 51% and 42%, respectively. Nodular histopathology, ulcerated lesions, higher mitotic rates, and higher node substages were the independent variables that were inversely correlated with survival for all patients; and NR was one of the significant prognostic factors and strongest predictors of relapse and survival (p = 0.03 and p = 0.01, respectively).

CONCLUSION

Our results suggest that, apart from the conventional nodal status, NR is an independent prognostic factor-regarding both RFS and OS in stage III cutaneous melanoma.

Pre-operative ctDNA predicts survival in high-risk stage III cutaneous melanoma patients

BACKGROUND

The outcomes of patients with stage III cutaneous melanoma who undergo complete surgical resection can be highly variable, and estimation of individual risk of disease recurrence and mortality remains imprecise. With recent demonstrations of effective adjuvant targeted and immune checkpoint inhibitor therapy, more precise stratification of patients for costly and potentially toxic adjuvant therapy is needed. We report the utility of pre-operative circulating tumour DNA (ctDNA) in patients with high-risk stage III melanoma.

PATIENTS AND METHODS

ctDNA was analysed in blood specimens that were collected pre-operatively from 174 patients with stage III melanoma undergoing complete lymph node (LN) dissection. Cox regression analyses were used to evaluate the prognostic significance of ctDNA for distant metastasis recurrence-free survival and melanoma-specific survival (MSS).

RESULTS

The detection of ctDNA in the discovery and validation cohort was 34% and 33%, respectively, and was associated with larger nodal melanoma deposit, higher number of melanoma involved LNs, more advanced stage and high lactate dehydrogenase (LDH) levels. Detectable ctDNA was significantly associated with worse MSS in the discovery [hazard ratio (HR) 2.11 P < 0.01] and validation cohort (HR 2.29, P = 0.04) and remained significant in a multivariable analysis (HR 1.85, P = 0.04). ctDNA further sub-stratified patients with AJCC stage III substage, with increasing significance observed in more advanced stage melanoma.

CONCLUSION

Pre-operative ctDNA predicts MSS in high-risk stage III melanoma patients undergoing complete LN dissection, independent of stage III substage. This biomarker may have an important role in determining prognosis and stratifying patients for adjuvant treatment.

Lymph node ratio as a prognostic factor in melanoma: results from European Organization for Research and Treatment of Cancer 18871, 18952, and 18991 studies

The aim of this study was to assess the prognostic importance of lymph node ratio (LNR) in stage III melanoma after complete lymph nodal dissections. From European Organization for Research and Treatment of Cancer randomized trials 18871, 18952, and 18991, 2358 patients had full information on positive and examined lymph nodes (LNs) and were included. Cox proportional hazards models stratified by trial were used to assess the prognostic impact of LNR adjusted for confounders on melanoma-specific survival. Optimal cutoff values for LNR were calculated for each LN dissection site (axillary, inguinal, and neck). LNR (≥ vs. <35%: hazard ratio=1.44, 95% confidence interval: 1.23-1.69) and number of positive LNs appeared to be of independent strong prognostic importance. Dissection sites impacted the optimal LNR cutoff: 35% for axillary, 40% for inguinal, and 50% for neck dissections. Combining these into one 'high versus low LNR' resulted in a highly significant multivariately adjusted hazard ratio of 1.48 (95% confidence interval: 1.26-1.74). In subgroup analyses, LNR was only significant in advanced disease (American Joint Committee on Cancer stage N2b, N3; IIIC). LNR was most significant for inguinal dissections, followed by axillary dissections, but seemed less useful in neck dissections. LNR is an independent significant prognostic factor in stage III melanoma patients. Our study showed higher than previously reported cutoffs that differed per dissection site. However, because of conflicting results compared with other studies and apparent limited prognostic impact confined to subgroups, the practical use of LNR seems limited.

Re-examining the role of adjuvant radiation therapy

Previously important roles for adjuvant radiotherapy (RT) in melanoma patients included improved regional control after resection of high-risk nodal disease, to reduce local recurrence for desmoplastic, and other subtypes of melanoma with neurotropism, reducing in-brain relapse of brain metastases after surgery and other situations on a case-by-case basis. This review evaluates the integration of adjuvant RT into clinical practice at this time of rapidly evolving knowledge and improving outcomes from effective systemic therapy.

Lymph Node Ratio Is Less Prognostic in Melanoma When Minimum Node Retrieval Thresholds Are Not Met

BACKGROUND

Lymph node ratio (LNR), positive nodes divided by nodes examined, has been proposed for prognostication in melanoma to mitigate problems with low node counts. However, it is unclear if LNR offers superior prognostication over total counts of positive nodes and nodes examined. Additionally, the prognostic value of LNR may change if a threshold number of nodes are examined. We evaluated whether LNR is more prognostic than positive nodes and nodes examined, and whether the prognostic value of LNR changes with minimum thresholds.

METHODS

Using the National Cancer Data Base Participant User File, we identified 74,692 incident cases with nodal dissection during 2000-2006. We compared LNR versus counts of examined and positive nodes based on Harrell's C, a measure of predictive ability. We then stratified by total nodes examined: greater versus fewer than ten for axillary lymph node dissection (ALND) and greater versus fewer than five for inguinal lymph node dissection (ILND).

RESULTS

Overall, LNR had a Harrell's C of 0.628 (95 % confidence interval [CI] 0.625-0.631). Examined and positive nodes were not significantly different from this, with a Harrell's C of 0.625 (95 % CI 0.621-0.630). In ALND, LNR had a Harrell's C of 0.626 (95 % CI 0.610-0.643) with ≥10 nodes versus 0.554 (95 % CI 0.551-0.558) < 10 nodes. In ILND, LNR had a Harrell's C of 0.679 (95 % CI 0.664-0.694) with ≥5 nodes versus C of 0.601 (95 % CI 0.595-0.606) < 5 nodes.

CONCLUSIONS

LNR provides no prognostic superiority versus counts of examined and positive nodes. Moreover, the prognostic value of LNR diminishes when minimum node retrieval thresholds are not met.

Lymph-Node Ratio in Patients with Cutaneous Melanoma: A Multi-Institution Prognostic Study

BACKGROUND

Lymph node ratio (LNR)-the number of metastatic lymph nodes (LNs) over the number of excised LNs after lymphadenectomy-is a prognostic factor for many solid tumors, but controversies still exist for skin melanoma. We investigated the prognostic relevance of LNR in melanoma patients and formulated a proposal for considering the LNR in the current American Joint Committee on Cancer (AJCC) N staging system.

METHODS

Retrospective data of 2,526 melanoma patients with LN metastasis from nine Italian institutions were collected in a multicenter database. The prognostic value of the LNR (categorized as A, ≤0.1; B, 0.11-0.25; and C, >0.25) was assessed by multivariable survival analysis.

RESULTS

LNR was a significant independent prognostic factor for melanoma-specific survival (LNR B vs. A: hazard ratio [HR] 1.47, 95 % CI 1.16-1.87, p = 0.002; LNR C vs. A: HR 1.84, 95 % CI 1.29-2.61, p = 0.001). The LNR had prognostic value in patients with AJCC N1a (one positive LN after sentinel LN biopsy [SLNB], HR 2.33, 95 % CI 1.49-3.63, p < 0.001) and N2a (two to three positive LNs after SLNB, HR 1.62, 95 % CI 1.09-2.40, p = 0.016) substages, but not in those with N1b (one clinically positive LN, p = 0.765), N2b (two to three clinically positive LNs, p = 0.165), and N3 (≥ four positive LNs, p = 0.084) substages.

CONCLUSION

The LNR is a prognostic factor in melanoma patients with one (AJCC N1a) and two to three (AJCC N2a) positive LNs after SLNB. This easy-to-obtain parameter should be considered for the staging of melanoma patients with LN metastasis, along with the number of positive LNs.

Prognostic factors in patients with penile carcinoma and inguinal lymph node metastasis

OBJECTIVES

To identify prognostic factors in patients with penile carcinoma and confirmed lymph node metastasis.

METHODS

Patients were selected from a historical series of patients with penile carcinoma. An experienced pathologist reviewed all cases. Information regarding the total number of lymph nodes excised, the number of positive lymph nodes and the presence of extranodal extension were used. Lymph node ratio was categorized as <0.15 and >0.15.

RESULTS

The 5-year recurrence-free survival and disease-specific survival rates were 55.3% and 64.1%, respectively. Lymphovascular invasion, lymph node ratio and pN status influenced survival rates in univariate analysis. Lymphovascular invasion and lymph node ratio remained as independent predictors of disease-specific survival and recurrence-free survival in the multivariate analysis. A risk stratification of death and tumor recurrence was observed when patients were grouped into three categories: absence of risk factors; the presence of one risk factor; and the presence of two or more risk factors.

CONCLUSIONS

The presence of one or more of the following parameters is correlated with a significantly higher risk of death and tumor recurrence in patients with penile carcinoma and inguinal lymph node metastasis: extranodal extension, lymph node ratio >0.15 and lymphovascular invasion.

Management of regional lymph nodes in the elderly melanoma patient: patient selection, accuracy and prognostic implications

BACKGROUND

Among older melanoma patients, lymphatic mapping failure, lower rates of SLN positivity and poor prognosis are reported reasons for omission of sentinel lymph node biopsy (SLNB). We investigated reasons for non-compliance with guidelines, sensitivity and prognostic significance of SLNB and completion lymphadenectomy (CLND) for elderly melanoma patients.

METHODS

Retrospective review of patients ≥65 years with ≥1 mm thick melanoma treated at a single Institution. Wilcoxon, chi-square and Fisher's exact tests were used for analysis as appropriate. Univariable and multivariable Cox regressions were used to analyze time-to-event variables.

RESULTS

72 of 358 patients (20%) did not undergo SLNB. Reasons for omission included selective neck dissection in 26 (7%), patient refusal in 11 (3%), physician recommendation in 15 (4%) and significant comorbidities in 8 (2%). Of the 286 patients undergoing SLNB, only 5 (1.7%) had lymphatic mapping failures. 76 patients (26.6%) were SLN-positive. The sensitivity of SLNB was 90.5%, the negative predictive value was 96.3% and the false negative rate was 3.8%. Sixty-seven (88%) SLN-positive patients underwent CLND and 10 (15%) had positive non-SLNs. Reasons for omission of CLND included patient refusal in 3 (4%), surgeon recommendation in 5 (7%) and postoperative complication in 1 (1%). SLN and non-SLN status were independently associated with disease-free survival. SLN status was independently associated with melanoma-specific survival.

CONCLUSIONS

SLNB was successful in 98.7% of elderly patients with high sensitivity and a low false negative rate. Only 2% of our elderly patients appeared too frail for SLNB. Age alone should not be a contraindication to SLNB and CLND for melanoma.

The number of excised lymph nodes is associated with survival of melanoma patients with lymph node metastasis

BACKGROUND

Although the number of excised LNs has been associated with patient prognosis in many solid tumors, this association has not been widely investigated in cutaneous melanoma. This study aims to evaluate the association between the number of excised regional lymph nodes (LNs) and melanoma-specific survival.

PATIENT AND METHODS

Clinico-pathological data from 2507 patients with LN metastasis treated at nine Italian centers were retrospectively collected.

RESULTS

The number of excised LNs correlated with younger age (P < 0.001), male sex (P < 0.001), neck LN field (P < 0.001), LN micrometastasis (P < 0.001) and number of positive LNs (P < 0.001). The number of excised LNs was an independent prognostic factor (HR = 0.85; P = 0.002) after adjustment for other staging features. Upon subgroup analysis, the number of excised LNs had a significant prognostic value in patients bearing 1.01-2.00 mm (HR = 0.79; P = 0.032) and 2.01-4.00 mm (HR = 0.71; P < 0.001) thick melanomas, primary tumors showing ulceration (HR = 0.86; P = 0.033) and Clark level V of invasion (HR = 0.86; P = 0.010), LN micrometastasis (HR = 0.83; P = 0.014) and two to three positive LNs (HR = 0.71; P = 0.001). Finally, this study investigated the influence of the number of excised LNs on patient staging: only when ≥11 nodes were excised the AJCC N stage could stratify prognosis (P < 0.001). Considering the number of excised LNs for each lymphatic field, at least 14, 11, 10 and 12 LNs were needed to stage patients according to the AJCC N stage after a lymphadenectomy of the neck, axilla, inguinal and ilioinguinal LN fields, respectively.

CONCLUSIONS

The number of excised LNs can be considered for risk stratification of patients with regional LN metastasis from cutaneous melanoma. We demonstrated that a minimum number of LNs is required for the correct staging of patients. Further research is needed to evaluate the effectiveness of the minimum number of LNs to be dissected.

Contemporary controversies and perspectives in the staging and treatment of patients with lymph node metastasis from melanoma, especially with regards positive sentinel lymph node biopsy

The management of melanoma lymph node metastasis particularly when detected by sentinel lymph node biopsy (SLNB) is still controversial. Results of the only randomized trial conducted to assess the therapeutic value of SLNB, the Multicenter Selective Lymphadenectomy Trial (MSLT-1), have not conclusively proven the effectiveness of this procedure but are interpreted by the authors and guidelines as indicating SLNB is standard of care. After surgery, interferon alpha had a small survival benefit and radiotherapy has limited effectiveness for patient at high-risk of regional recurrence. New drugs, including immune modulating agents and targeted therapies, already shown to be effective in patients with distant metastasis, are being evaluated in the adjuvant setting. In this regard, ensuring high quality of surgery through the identification of reliable quality assurance indicators and improving the homogeneity of prognostic stratification of patients entered onto clinical trials is paramount. Here, we review the controversial issues regarding the staging and treatment of melanoma patients with lymph node metastasis, present a summary of important and potentially practice changing ongoing research and provide a commentary on what it all means at this point in time.

Melanoma patients with an unknown primary tumor site have a better outcome than those with a known primary following therapeutic lymph node dissection for macroscopic (clinically palpable) nodal disease

BACKGROUND

Several reports in the literature suggest a difference in outcome between melanoma patients with macroscopic (clinically palpable) nodal disease from an unknown primary (MUP) and a known primary (MKP). The purpose of this study was to compare the outcomes for MUP and MKP patients after therapeutic lymph node dissection (TLND) for macroscopic nodal disease.

METHODS

From a large, prospective, single-institution database, the details of melanoma patients who first presented with macroscopic nodal disease and underwent TLND between 1971 and 2010 were extracted and analyzed.

RESULTS

There were 287 MUP patients and 264 MKP patients who fulfilled the study selection criteria. MUP patients had better disease-free, distant metastasis-free, and melanoma-specific survival after their TLND than MKP patients (all p < 0.001). Extranodal melanoma extension, >3 positive lymph nodes, and administration of adjuvant radiotherapy were all independent predictors of reduced disease-free and melanoma-specific survival (all p < 0.05). MUP patients also had a better prognosis than MKP patients whose primary melanoma had regression (p = 0.001).

CONCLUSIONS

The occurrence and improved outcome of MUP patients may be due to immune-induced total regression of the primary tumor and better immunologic prevention or control of distant metastatic disease. Alternatively, in some MUP patients, melanoma may not be metastatic but may originate de novo from nevus cells in lymph nodes, with the more favorable prognosis attributable to their primary nodal origin and complete surgical resection.

Nomograms to predict recurrence and survival in stage IIIB and IIIC melanoma after therapeutic lymphadenectomy

BACKGROUND

Current staging algorithms in melanoma patients undergoing therapeutic lymph node dissection (LND) fail to accurately distinguish long-term survivors from those at risk of rapid relapse. Our goal was to establish and validate nomograms for predicting both recurrence and survival after LND.

METHODS

A prospective cohort of stage IIIB and IIIC melanoma patients was ascertained from a tertiary hospital in Brisbane, Australia. Failure-time multivariate analysis identified key factors that, in adjusted combinations, generated nomograms to predict 2-year recurrence and 5-year melanoma-specific survival. The predictive value of these nomograms was further validated in a patient cohort from Rotterdam, The Netherlands.

RESULTS

In 494 Australian patients, number of positive lymph nodes, extra-capsular extension and nodular histopathological subtype were the main independent predictors of 2-year recurrence while age, number of positive nodes and extra-capsular extension were the independent predictors of survival. Predictive value was confirmed in The Netherlands cohort of 331 patients. The nomograms were able to classify patients according to their 2-year recurrence and 5-year survival rates even within each stage III sub-class.

CONCLUSIONS

Models that include extra-capsular extension predict outcomes in patients with clinically involved lymph nodes. This tool may help tailor treatment and monitoring of this group of patients.

Lymph node ratio for postoperative staging of laryngeal squamous cell carcinoma with lymph node metastasis

BACKGROUND

Lymph node metastasis has a significant impact on laryngeal cancer prognosis. The role of lymph node ratio (LNR, ratio of metastatic to examined nodes) in the staging of laryngeal cancer was not reported.

PATIENTS AND METHODS

Records of laryngeal cancer patients with lymph node involvement from Surveillance, Epidemiology, and End Results database (SEER, training set, N = 1963) and Fudan University Shanghai Cancer Center (FDSCC, validating set, N = 27) were analyzed for the prognostic value of LNR. Kaplan-Meier survival estimates, the Log-rank χ² test and Cox proportional hazards model were used for univariate and multivariate analysis. Optimal LNR cutoff points were identified by X-tile.

RESULTS

Optimal LNR cutoff points classified patients into three risk groups R1 (≤0.09), R2 (0.09-0.20) and R3 (>0.20), corresponding to 5-year cause-specific survival and overall survival in SEER patients of 55.1%, 40.2%, 28.8% and 43.1%, 31.5%, 21.8%, 2-year disease free survival and disease specific survival in FDSCC patients of 74.1%, 62.5%, 50.0%, and 67.7%, 43.2%, 25.0%, respectively. R3 stratified more high risk patients than N3 with the same survival rate, and R classification clearly separated N2 patients to 3 risk groups and N1 patients to 2 risk groups (R1-2 and R3).

CONCLUSIONS

R classification is a significant prognostic factor of laryngeal cancer and should be used as a complementary staging system of N classification.

Limitations of lymph node ratio, evidence-based benchmarks, and the importance of a thorough lymph node dissection in melanoma

BACKGROUND

Stage III melanoma is currently stratified by number of lymph nodes (LNs) involved. However, given the variability of LN retrieval counts we hypothesize that lymph node ratio (LNR) may also provide prognostic information.

METHODS

Retrospective cohort study of 411 patients with stage III melanoma were divided into two groups based on LNR (<0.15, n = 291 and ≥0.15, n = 120).

RESULTS

In multivariate analysis N stage (N3 vs. N1, hazard ratio [HR] = 2.13, p < 0.001), extranodal extension (HR = 1.92, p = 0.002), macrometastasis (HR = 1.70, p = 0.005), non-SLN involvement (HR = 1.65, p = 0.005), risk of N2 disease exceeding 35 % (HR = 1.51, p = 0.03), and LNR ≥0.15 (HR = 1.46, p = 0.03) were associated with overall survival (OS). LNR failed to further stratify stage III melanoma; however, the number of LNs examined was an independent prognostic factor. Patients who had >8 inguinal, >15 axillary, or >20 cervical LNs examined had fewer same nodal basin recurrences (26 [8 %] vs. 20 [20 %], p = 0.0009) and for N1 patients an improved OS (3-year OS 84 % vs. 76 %, 10-year OS 53 % vs. 34 %, p = 0.06) compared with N1 patients who had fewer LNs examined.

CONCLUSIONS

LNR is an important prognostic factor in stage III melanoma; however, it was not independent over the current AJCC TNM staging system. Diligence by the surgeon and pathologist to retrieve and examine >8 inguinal, >15 axillary, or >20 cervical LNs is associated with fewer same nodal basin recurrences and improved survival and is critical to reliable prognostication.

Impact of lymph node ratio on the survival of patients with hypopharyngeal squamous cell carcinoma: a population-based analysis

Objective

To analyze the impact of the lymph node ratio (LNR, ratio of metastatic to examined nodes) on the prognosis of hypopharyngeal cancer patients.

Methods

SEER (Surveillance, Epidemiology and End Results)-registered hypopharyngeal cancer patients with lymph node metastasis were evaluated using multivariate Cox regression analysis to identify the prognostic role of the LNR. The categorical LNR was compared with the continuous LNR and pN classifications to predict cause-specific survival (CSS) and overall survival (OS) rates of hypopharyngeal cancer patients.

Results

Multivariate analysis of 916 pN+ hypopharyngeal cancer cases identified race, primary site, radiation sequence, T classification, N classification, M classification, the number of regional lymph nodes examined, the continuous LNR (Hazard ratio 2.415, 95% CI 1.707–3.416, P<0.001) and age as prognostic variables that were associated with CSS in hypopharyngeal cancer. The categorical LNR showed a higher C-index and lower Akaike information criterion (AIC) value than the continuous LNR. When patients (n = 1152) were classified into four risk groups according to LNR, R0 (LNR = 0), R1 (LNR ≤0.05), R2 (LNR 0.05–0.30) and R3 (LNR >0.30), the Cox regression model for CSS and OS using the R classification had a higher C-index value and lower AIC value than the model using the pN classification. Significant improvements in both CSS and OS were found for R2 and R3 patients with postoperative radiotherapy.

Conclusions

LNR is a significant prognostic factor for the survival of hypopharyngeal cancer patients. Using the cutoff points 0.05/0.30, the R classification was more accurate than the pN classification in predicting survival and can be used to select high risk patients for postoperative treatment.

Superficial and deep lymph node dissection for stage III cutaneous melanoma: clinical outcome and prognostic factors

Background

The aims of this retrospective analysis were to evaluate the effect of combined superficial and deep groin dissection on disease-free and melanoma-specific survival, and to identify the most important factors for predicting the involvement of deep nodes according to clinically or microscopically detected nodal metastases.

Methods

Between January 1996 and December 2005, 133 consecutive patients with groin lymph node metastases underwent superficial and deep dissection at the National Cancer Institute, Naples. Lymph node involvement was clinically evident in 84 patients and detected by sentinel node biopsy in 49 cases.

Results

The 5-year disease-free survival was significantly better for patients with superficial lymph node metastases than for patients with involvement of both superficial and deep lymph nodes (34.9% vs. 19.0%; P = 0.001). The 5-year melanoma-specific survival was also significantly better for patients with superficial node metastases only (55.6% vs. 33.3%; P = 0.001).

Conclusions

Metastasis in the deep nodes is the strongest predictor of both disease-free and melanoma-specific survival. Deep groin dissection should be considered for all patients with groin clinical nodal involvement, but might be spared in patients with a positive sentinel node. Prospective studies will clarify the issue further.

N0/N1, PNL, or LNR? The effect of lymph node number on accurate survival prediction in pancreatic ductal adenocarcinoma

INTRODUCTION

We evaluated the prognostic accuracy of LN variables (N0/N1), numbers of positive lymph nodes (PLN), and lymph node ratio (LNR) in the context of the total number of examined lymph nodes (ELN).

METHODS

Patients from SEER and a single institution (MGH) were reviewed and survival analyses performed in subgroups based on numbers of ELN to calculate excess risk of death (hazard ratio, HR).

RESULTS

In SEER and MGH, higher numbers of ELN improved the overall survival for N0 patients. The prognostic significance (N0/N1) and PLN were too variable as the importance of a single PLN depended on the total number of LN dissected. LNR consistently correlated with survival once a certain number of lymph nodes were dissected (≥13 in SEER and ≥17 in the MGH dataset).

CONCLUSIONS

Better survival for N0 patients with increasing ELN likely represents improved staging. PLN have some predictive value but the ELN strongly influence their impact on survival, suggesting the need for a ratio-based classification. LNR strongly correlates with outcome provided that a certain number of lymph nodes is evaluated, suggesting that the prognostic accuracy of any LN variable depends on the total number of ELN.

Surgeons' opinions on lymphadenectomy in melanoma patients with positive sentinel nodes: a worldwide web-based survey

PURPOSE

A worldwide web-based survey was conducted among melanoma surgeons to investigate opinions about completion lymph node dissection (CLND) in patients with positive sentinel nodes (SN).

METHODS

A questionnaire was designed following input from a group of melanoma surgeons. Cognitive interviews and pilot testing were performed. Surgeons identified through a systematic-review of the SN and CLND literature were invited by email.

RESULTS

Of 337 surgeons, 193 (57.2 %) from 25 countries responded (January-July 2011). Most respondents work in melanoma (30.1 %) and surgical oncology (44.6 %) units. In patients with a positive SN, 169 (91.8 %) recommend CLND; the strength of the recommendation is mostly influenced by patient comorbidities (64.7 %) and SN tumor burden (59.2 %). Seventy-one responders enroll patients in the second Multicenter Selective-Lymphadenectomy Trial (MSLT-2), and 64 of them (76 %) suggest entering the trial to majority of patients. In cases requiring neck CLND, level 1-5 dissection is recommended by 35 % of responders, whereas 62 % base the extent of dissection on primary site and lymphatic mapping patterns. Only inguinal dissection or ilioinguinal dissection is performed by 36 and 30 % of surgeons, respectively. The remaining 34 % select either procedure according to number of positive SNs, node of Cloquet status, and lymphatic drainage patterns. Most surgeons (81 %) perform full axillary dissections in positive SN cases.

CONCLUSIONS

The majority of melanoma surgeons recommend CLND in SN-positive patients. Surgeons participating in the MSLT-2 suggest entering the trial to the majority of patients. More evidence is needed to standardize the extent of neck and groin CLND surgeries.

Proposal of new classification for stage III breast cancer on the number and ratio of metastatic lymph nodes

BACKGROUND

The objective of the retrospective study was to confirm whether the current staging system of stage III was appropriate for breast cancer.

METHODS

Four hundred fifteen patients with breast cancer in stage III were analyzed. The survival analysis was performed by Kaplan-Meier.

RESULTS

Survival time of the patients with T1N3M0 was significantly better than the patients with other subgroups of stage IIIC (T2,3,4N3M0) and similar that of patients with T4N0,1,2M0 who formed the stage IIIB group based on pN stage. Tumor size, number of positive lymph nodes and lymph node ratio (LNR) were associated with overall survival (OS). The greatest survival difference was found when 0.60 as the cutoff point of LNR for the patients with current stage IIIC (pN3). rN1 included the patients in pN3 with LNR ≤ 0.60 and rN2 included the patients in pN3 with LNR >0.60. Survival time of the patients with T1,2,3,4N3(rN1)M0 and T1N3(rN2)M0 was differently better than the patients with T2,3,4N3(rN2)M0 and similar that of patients with T4N0,1,2M0.

CONCLUSION

We suggested current staging system should be modified combining pN with rN. We presumed the patients with T1N3M0 and T2,3,4N3(rN1)M0 disease were excluded from the current stage IIIC and included in stage IIIB group.

Therapeutic surgical management of palpable melanoma groin metastases: superficial or combined superficial and deep groin lymph node dissection

Background

Management of patients with clinically detectable lymph node metastasis to the groin is by ilioinguinal or combined superficial and deep groin dissection (CGD) according to most literature, but in practice superficial groin dissection (SGD) only is still performed in some centers. The aim of this study is to evaluate the experience in CGD versus SGD patients in our center.

Methods

Between 1991 and 2009, 121 therapeutic CGD and 48 SGD were performed in 169 melanoma patients with palpable groin metastases at our institute. Median follow-up was 20 and, for survivors, 45 months.

Results

In this heterogeneous group of patients, overall (OS) and disease-free survival, local control rates, and morbidity rates were not significantly different between CGD and SGD patients. However, CGD patients had a trend towards more chronic lymphedema. Superficial lymph node ratio, the number of positive superficial lymph nodes, and the presence of deep nodes were prognostic factors for survival. CGD patients with involved deep lymph nodes (24.8%) had estimated 5-year OS of 12% compared with 40% with no involved deep lymph nodes (p = 0.001). Preoperative computed tomography (CT) scan had high negative predictive value of 91% for detection of pelvic nodal involvement.

Conclusions

This study demonstrated that survival and local control do not differ for patients with palpable groin metastases treated by CGD or SGD. Patients without pathological iliac nodes on CT might safely undergo SGD, while CGD might be reserved for patients with multiple positive nodes on SGD and/or positive deep nodes on CT scan.