Critical appraisal:Xing Y, Badgwell BD, Ross MI, Gershenwald JE, Lee JE, Mansfield PF, et al 2009
Xing Y, Badgwell BD, Ross MI, Gershenwald JE, Lee JE, Mansfield PF, et al. Lymph node ratio predicts disease-specific survival in melanoma patients. Cancer 2009 Jun 1;115(11):2505-13 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19309746.
- What is the appropriate treatment for macroscopic (i.e. detectable clinically or by ultrasound) nodal metastasis?
The objectives of this analysis were to compare various measures associated with lymph node (LN) dissection and to identify threshold values associated with disease-specific survival (DSS) outcomes in patients with melanoma.
Removed lymph nodes
LN ratio thresholds and DSS
Median of 1 positive LN removed from patients who underwent neck, axillary and inguinal LND (P < .001). Fewer negative LNs (median, 9; interquartile range [IQR], 5 to 14) and total LNs (median, 11; IQR, 7 to 16) were removed from patients who underwent inguinal LND than from patients who underwent neck and axillary LND. Median LN ratio was higher in inguinal LND patients than in neck and axillary LND patients (0.15 v 0.09 and 0.08, respectively; P<.001).
Cox multivariate analyses: increasing LN ratio was an adverse prognostic factor for DSS for all LND regions (data not shown). Total LNs removed and number of negative LNs removed were not significantly associated with DSS
LN ratio thresholds were 0.07, 0.13, and 0.18 for neck, axillary, and inguinal regions, corresponding to 15, 8, and 6 LNs removed per positive node. 5-year DSS rates: 64% vs 36% for neck LND, 70% vs 51% for axillary LND, and 70% vs 45% for inguinal LND (P < .001)
After adjustment for age, sex, year of diagnosis, SEER region, Clark level, primary tumor (T) stage, histologic subtype, and the presence/absence of primary tumor ulceration, patients who had a LN ratio less than the threshold had a 50% reduction in the risk of disease-specific death compared with patients who had a LN ratio at or above the threshold (P <.001). Specifically, the HR was 0.53 (95% CI, 0.40 to 0.71) in the neck, 0.52 (95% CI, 0.42 to 0.65) in the axillary, and 0.47 (95% CI, 0.36 to 0.61) in the inguinal LND groups for patients who met LN ratio threshold. In the axillary LND group, nodular melanoma (HR, 1.40; 95% CI, 1.02 to 1.94; P = .04) was a poor prognostic factor for DSS; Clark levels IV and V (HR, 1.56; 95% CI, 1.0 to 2.43; P = .05) and primary tumor ulceration (HR, 1.44; 95% CI, 1.07 to 1.94; P = .016) were adverse prognostic factor for DSS in the inguinal LND group.
|Moderate risk of bias||Comments: Please replace this text and include any additional comments in regards to your risk of bias rating|
Risk of bias assessment: cohort study
- Representative of eligible patients.
- Representative of eligible patients
Comparability of groups on demographic characteristics and clinical features
- Not comparable but adjusted analysis used
Measurement of outcomes
Completeness of follow-up
- Yes (follow-up >95%) or survival analysis using all patients
|1||Additional comments: Please replace this text and briefly describe the reasons for your rating|
- Xing Y, Badgwell BD, Ross MI, Gershenwald JE, Lee JE, Mansfield PF, et al. Lymph node ratio predicts disease-specific survival in melanoma patients. Cancer 2009 Jun 1;115(11):2505-13 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19309746.
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- Clinical question
Section below only relevant for Cancer Council Project Officer