Adjuvant Therapy for Stage III Melanoma Without Immediate Completion Lymph Node Dissection

INTRODUCTION

For patients with stage III melanoma with occult lymph node metastasis, the use of adjuvant therapy is increasing, and completion lymph node dissection (CLND) is decreasing. We sought to evaluate the use of modern adjuvant therapy and outcomes for patients with stage III melanoma who did not undergo CLND.

METHODS

Patients with a positive SLNB from 2015 to 2020 who did not undergo CLND were evaluated retrospectively. Nodal recurrence, recurrence-free survival (RFS), distant metastasis-free survival (DMFS), and melanoma-specific survival were evaluated.

RESULTS

Among 90 patients, 56 (62%) received adjuvant therapy and 34 (38%) underwent observation alone. Patients who received adjuvant therapy were younger (mean age: 53 vs. 65, p < 0.001) and had higher overall stage (Stage IIIb/c 75% vs. 54%, p = 0.041). Disease recurred in 12 of 34 patients (35%) in the observation group and 11 of 56 patients (20%) in the adjuvant therapy group. The most common first site of recurrence was distant recurrence alone (5/34 patients) in the observation group and nodal recurrence alone (8/90 patients) in the adjuvant therapy group. Despite more adverse nodal features in the adjuvant therapy group, 24-month nodal recurrence rate and RFS were not significantly different between the adjuvant and observation cohorts (nodal recurrence rate: 26% vs. 20%, p = 0.68; RFS: 75% vs. 61%, p = 0.39). Among patients with stage IIIb/c disease, adjuvant therapy was associated with a significantly improved 24-month DMFS (86% vs. 59%, p = 0.04).

CONCLUSIONS

In this early report, modern adjuvant therapy in patients who forego CLND is associated with longer DMFS among patients with stage IIIb/c disease.

Performance of a prognostic 31-gene expression profile in an independent cohort of 523 cutaneous melanoma patients

BACKGROUND

The heterogeneous behavior of patients with melanoma makes prognostication challenging. To address this, a gene expression profile (GEP) test to predict metastatic risk was previously developed. This study evaluates the GEP's prognostic accuracy in an independent cohort of cutaneous melanoma patients.

METHODS

This multi-center study analyzed primary melanoma tumors from 523 patients, using the GEP to classify patients as Class 1 (low risk) and Class 2 (high risk). Molecular classification was correlated to clinical outcome and assessed along with AJCC v7 staging criteria. Primary endpoints were recurrence-free (RFS) and distant metastasis-free (DMFS) survival.

RESULTS

The 5-year RFS rates for Class 1 and Class 2 were 88% and 52%, respectively, and DMFS rates were 93% versus 60%, respectively (P < 0.001). The GEP was a significant predictor of RFS and DMFS in univariate analysis (hazard ratio [HR] = 5.4 and 6.6, respectively, P < 0.001 for each), along with Breslow thickness, ulceration, mitotic rate, and sentinel lymph node (SLN) status (P < 0.001 for each). GEP, tumor thickness and SLN status were significant predictors of RFS and DMFS in a multivariate model that also included ulceration and mitotic rate (RFS HR = 2.1, 1.2, and 2.5, respectively, P < 0.001 for each; and DMFS HR = 2.7, 1.3 and 3.0, respectively, P < 0.01 for each).

CONCLUSIONS

The GEP test is an objective predictor of metastatic risk and provides additional independent prognostic information to traditional staging to help estimate an individual's risk for recurrence. The assay identified 70% of stage I and II patients who ultimately developed distant metastasis. Its role in consideration of patients for adjuvant therapy should be examined prospectively.

Rationale, development, and clinical outcomes of a multidisciplinary amiodarone clinic

OBJECTIVES

To review the rationale and development of a multidisciplinary amiodarone clinic, and document the clinical outcomes resulting from its implementation.

METHODS

A clinic was established to provide an ambulatory setting in which patients receiving amiodarone could be followed according to published guidelines by a multidisciplinary team of cardiovascular health care specialists. Patients receiving amiodarone were referred to the clinic by their primary physicians. A data base containing each patient's medical history, current drug therapy, and baseline laboratory values was developed during the initial visit. Liver function tests, thyroid function tests, and chest radiographs were performed every 6 months, and pulmonary function tests were scheduled on an annual basis. Dosage adjustments were performed in select patients.

RESULTS

Since November 1996, 60 patients have been referred to the amiodarone clinic. Mean length of follow-up before and after referral was 16.3+/-25.5 and 9.2+/-5.5 months, respectively. Laboratory tests were performed according to accepted guidelines in 14 (23%) patients before referral compared with 54 (90%) patients after enrollment (p<0.001). Previously unrecognized adverse events were detected in 21 (35%) patients, including pulmonary fibrosis, QT prolongation, liver enzyme elevation, hypothyroidism, hyperthyroidism, and asthma exacerbation. Amiodarone was discontinued in six patients, four of whom had suspected pulmonary toxicity. The dose of amiodarone was adjusted in 29 (48.4%) patients.

CONCLUSION

Many patients receiving amiodarone are not being followed according to published recommendations. Implementation of a specialized, multidisciplinary amiodarone clinic improves outcomes by monitoring for early detection of drug-related toxicities and by facilitating proper dosage modifications.

Influence of feelings of burden on the caregiver's perception of the patient's functional status

We studied the correlation between the caregiver's feelings of burden and the cognitive, behavioral and functional impairment of demented patients. We attempted to show the influence of caregiver's feelings of burden on their perception of the patients' functional status and to establish the predictors of feelings of burden. Twenty-five probable Alzheimer disease patients (NINCDS-ADRDA criteria) were assessed on cognitive measures and functional status (DAFS). The caregiver's index of burden (CIB), obtained from an adapted version of the Zarit Burden Interview, was correlated with the caregiver's report on the patient's instrumental activities of daily living (IADL) and physical self-maintenance functions (ADL); total and partial DAFS scores, and patient's cognitive and behavioral problems rated with the Functional Dementia Scale (FDS). The CIB correlated with the caregiver's report on the patient's behavioral disturbances (r = 0.71, p < 0.001) and physical self-maintenance activities (r = 0.62, p < 0.001), but not with cognitive impairment, IADL and the DAFS. The patients showed better functional performance in the direct assessment than in that reported by their caregivers (mainly in shopping, feeding, dressing, and ambulation). Thus, burden may foster a growing intolerance of the caregiver, inducing an underestimation of the patient's actual functional competence. The caregiver's report on the patient's behavioral problems was the best predictor of feelings of burden (P = 19,9, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

An iterative thresholding algorithm for image segmentation

A thresholding technique is developed for segmenting digital images with bimodal reflectance distributions under nonuniform illumination. The algorithm works in a raster format, thus making it an attractive segmentation tool in situations requiring fast data throughput. The theoretical base of the algorithm is a recursive Taylor expansion of a continuously varying threshold tracking function.

Sampling considerations for multilevel crossing analysis

This paper examines the amplitude fluctuations of band-limited functions with bounded zeroth absolute moments, and the problems associated with estimating the level crossing profiles of these functions. Level crossings have received increased attention as features for pattern recognition because of their capability to provide information related to both amplitude and frequency behavior. A detailed analysis of the average rate of change of band-limited functions is presented, including a derivation of the least upper bound on functions for which the zeroth absolute moments of the functions are bounded. The average rate of change of a function over an interval in which one endpoint of the interval is an extremum of the function is similarly bounded and used to establish a sampling rate which guarantees that between successive samples of a band-limited function with bounded zeroth absolute moment the function itself does not deviate from the amplitude interval defined by the samples by more than some predefined amplitude change. Based on these results, a theorem is developed which defines the sampling rate required to ensure that, in the estimation of level crossing profiles, no more than 2m (m >> 1) level crossings of m levels are missed per extremum of the sampled function. It is shown that the sampling rate defined by this theorem reduces to the well-known Nyquist rate for the special case of zero crossing analysis.

Optimal solution of linear inequalities with applications to pattern recognition

An algorithm for the optimal solution of consistent and inconsistent linear inequalities is presented, where the optimality criterion is the maximization of the number of constraints satisfied. In the terminology of pattern recognition, the algorithm finds a linear decision function which minimizes the number of patterns misclassified. The algorithm is developed as a nonenumerative search procedure based on several new results established in this paper. Bounds on the search are also developed and the method is experimentally evaluated and shown to be computationally superior to other techniques for finding minimum-error solutions.

Equivalence and reduction of expansive tree grammars

The equivalence of nonterminals of an expansive tree grammar is considered. Algorithms are presented for constructing sets of equivalent nonterminals for an expansive tree grammar, for reducing the grammar, and for determining whether two grammars generate the same language.

Reversal learning and forgetting in bird and fish

Pigeons and goldfish were trained in red-green discrimination in daily sessions, with the rewarded color changed every 2 days. Improvement in the performance of the pigeons could be traced to decrements in retention from each day to the next. The goldfish showed no improvement and no decrements in retention. The results suggest that progressive improvement in habit reversal is a product of proactive interference, and that the absence of improvement in the fish is due, not to the lack of some higher-order process which operates to produce improvement in higher vertebrates, but to a difference in learning-retention mechanisms.