Critical appraisal:Spillane AJ, Cheung BL, Stretch JR, Scolyer RA, Shannon KF, Quinn MJ, et al 2009

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Critical Appraisal

Article being appraised

Spillane AJ, Cheung BL, Stretch JR, Scolyer RA, Shannon KF, Quinn MJ, et al. Proposed quality standards for regional lymph node dissections in patients with melanoma. Ann Surg 2009 Mar;249(3):473-80 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19247037.


Applicable clinical question

Key Facts

Study Design

case series

Study aims:

The experience of the Sydney Melanoma Unit (SMU) is documented to offer quality assurance (QA) standards and an acceptable range for lymph node yield for regional lymph node dissection (RLND) in melanoma patients.

Number of Patients:

2141

2363 consecutive RLND procedures. 1023 axillary dissections, 716 groin dissections, 163 neck dissections of between 1 and 3 levels, and 367 neck dissections of 4 or 5 levels.
Reported outcome(s):

Number of lymph nodes removed

Results of outcome(s):

1023 axillary dissections included 863 carried out by SMU surgeons. Number of lymph nodes retrieved: 1- 83. Mean: 21.9, median: 21, and 10 or more in 90% of cases. SMU surgeons mean number of lymph nodes resected: 19.7 to 27. Non-SMU: 17.8, median: 17, and 8 or more nodes resected in 90% of cases. Difference in mean number of lymph nodes resected between SMU and non-SMU surgeons was statistically significant (P < 10-7).

716 inguinal and ilio-inguinal dissections included 595 performed by SMU surgeons. Number of lymph nodes resected: 1-54. Mean: 14.5, median: 13, and 7 or more lymph nodes resected in 90% of cases. SMU surgeons mean number of lymph nodes resected: 11 to 17.9 (excluding Surgeon 7 who only had one case on the database). 121 by non-SMU, mean: 12.0, median: 11, and 5 or more lymph nodes resected in 90% of cases. Difference in mean number of lymph nodes resected between SMU and non-SMU surgeons was statistically significant (P = 0.0005).
The subset analysis of 66 groin dissections included 37 cases who had inguinal dissection with a mean of 11.9 nodes removed (range 6–21) and 29 ilio-inguinal dissections who had a mean of 17.1 nodes removed (range 9–54). The overall mean for this 66 patient subset was 14.8, which is very similar to the mean of the overall groin dissection group noted above. There was a mean of 1.7 positive nodes per case (range 0–15).

163 CD <=3 dissections comprise 140 performed by SMU surgeons. Number of lymph nodes resected: 1 to 52. Mean: 19.5, median 18.5, and 6 or more lymph nodes were resected in 90% of cases. Comparison between the individual SMU surgeons indicated the mean number of lymph nodes resected: 12.4 to 36. 23 by non-SMU surgeons. Mean number of nodes resected by non-SMU surgeons: 16.4, median of 14, and 6.6 or more lymph nodes were resected in 90% of cases. Difference in mean number of lymph nodes resected between SMU and non-SMU surgeons not statistically significant (P = 0.24).

The 367 CD >=4 dissections comprise 347 performed by SMU surgeons. Lymph nodes retrieved: 5 to 103. Mean number resected 38.9, median 36 and in 90% of cases, 20 or more lymph nodes were resected. SMU surgeons mean resected: 19.5 to 46. 20 by non-SMU surgeons. Mean number of nodes resected by non-SMU: 36.3, median 35 and in 90% of cases 19.7 or more lymph nodes were resected. Difference in mean number of lymph nodes resected between SMU and non-SMU surgeons was not statistically significant (P = 0.49).

Trend towards an increase in the number of lymph nodes excised over time for inguinal and ilio-inguinal dissections carried out by SMU surgeons. This mostly likely reflects the increasing number of ilio-inguinal dissections carried out

Includes an economic evaluation

no

Evidence ratings

Level of evidence

IV

Risk of bias
High risk of bias Comments: No discussion of patient follow-up

Risk of bias assessment: case series

Subject selection:
Selected group (e.g. multi-institution study)
Were the outcome measures blind to pre/post-intervention?
No, but objective measures used
Follow-up complete and all patients included in the analysis?
No or not described


Relevance of evidence
1 Additional comments: Please replace this text and briefly describe the reasons for your rating
Result of appraisal

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Completed by

Jackie Buck


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Article
Spillane AJ, Cheung BL, Stretch JR, Scolyer RA, Shannon KF, Quinn MJ, et al. Proposed quality standards for regional lymph node dissections in patients with melanoma. Ann Surg 2009 Mar;249(3):473-80 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19247037.
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