Critical appraisal:Spillane AJ, Cheung BL, Winstanley J, Thompson JF 2011

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Critical Appraisal

Article being appraised

Spillane AJ, Cheung BL, Winstanley J, Thompson JF. 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. Ann Surg 2011 Jan;253(1):109-15 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21119509.


Applicable clinical question

Key Facts

Study Design

cohort study

Study aims:

To investigate whether lymph node ration (LNR) gives additional prognostic information to American Joint Committee on Cancer (AJCC) N stage in a melanoma treatment centre where regional lymph node dissection (RLND) techniques are standardized

Number of Patients:

1514

Axilla= 703 Groin= 528 Neck= 283
Reported outcome(s):

Survival
Prognostic factors for survival

Results of outcome(s):

Remarkable similarity between the survival curves for the groupings, ie, N Stage 1 and LNR A, N Stage 2 and LNR B, and N Stage 3 and LNR C. This gives the impression that the 2 groupings may be representing the same patients. AJCC stage N1 patients comprise 90.9% LNR A, 9.1% LNR B and 0% LNR C. AJCC stage N2 (excluding N2c) comprise 41% LNR A, 52% LNR B and 7% LNR C. AJCC stage N3 patients comprise of 10.8% LNR A, 28.9% LNR B, and 60.2% LNR C.

Univariate analyses: important factors predicting survival for combined study population and individual RLND groups. Significant factors on multivariate analysis: LNR, primary melanoma Breslow thickness (but only when assessing AJCC Stage T0–T3 vs T4), ulceration, AJCC N Stage, age less than 50 years/50 years and more, and lymph node basin. As axillary dissection is virtually always done as a standard operation with very little variation compared to groin and neck dissections, separate multivariate analysis was completed on subgroup patients. 530 patients with axillary node involvement, the significant factors on the multivariate analysis were LNR, primary melanoma Breslow thickness, AJCC Stage T0–T3 versus T4, and N Stage.

Substaging of AJCC stage N3 patients can be achieved by using LNR groups. The 5-year survival rates range from 47% for N3 patients who are LNR A to 20% for N3 patients who are LNR C.

Includes an economic evaluation

no

Evidence ratings

Level of evidence

III-2

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
Yes
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: 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, Winstanley J, Thompson JF. 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. Ann Surg 2011 Jan;253(1):109-15 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21119509.
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