Background
In melanoma patients with nodal macrometastases, the distinction between good and poor prognosis is based on the presence of primary melanoma ulceration or metastatic involvement of 4 or ...more lymph nodes in the 7th edition of the American Joint Committee on Cancer (AJCC) classification. We hypothesized that biomarkers would increase the accurateness of staging in these patients. The aim was to assess and compare the prognostic impact of biomarkers S-100B and LDH and to determine the best timing of their measurement in stage IIIB–C melanoma.
Methods
A total of 119 patients underwent therapeutic lymph node dissection (TLND) for nodal macrometastases with serum S-100B and LDH level measurements preoperatively. In 75 of them, S-100B and LDH were also measured on postoperative days 1 and 2. S-100B and LDH levels on days 0, 1, and 2 were compared for their association with disease-free survival (DFS) and disease-specific survival (DSS).
Results
At a median follow-up of 17 (range 1–89) months, S-100B levels at all time points were associated with DFS. In multivariable analysis, preoperative S-100B and S-100B measured on day 2 showed the strongest association with DFS (hazard ratio HR 2.55,
P
= 0.007 and HR 3.80,
P
= 0.01). For DSS, the preoperative S-100B level was the strongest independent predictor (HR 2.81,
P
= 0.01). LDH measurements showed a significant association with DSS in univariate analysis only when measured preoperatively (HR 2.46,
P
= 0.01). In multivariable analysis, LDH measurement was not associated with melanoma prognosis.
Conclusions
The S-100B level measured preoperatively is, in contrast to LDH, one of the most important independent predictors of melanoma prognosis in patients undergoing TLND for nodal macrometastases.
Abstract Background Intralymphatic metastases (ILM) originate from tumor cell emboli entrapped in dermal lymphatics between primary tumor and regional lymph node basin. Because of this origin, ...sentinel lymph node biopsy (SLNB) might increase ILM by restricting lymph flow. Methods Pubmed, Embase, Cochrane and Medline were searched for articles on ILM between 1980 and September 2014. ILM Incidences were calculated after wide local excision (WLE), excision with elective lymph node dissection (ELND) or therapeutic lymph node dissection (TLND), WLE with SLNB with or without completion lymph node dissection (CLND) and delayed lymph node dissection (DLND) for patients developing nodal metastasis during follow-up. Results In 36 studies, 14,729 patients underwent WLE, 1,682 patients WLE/ELND, 362 patients WLE/DLND and 11,201 patients WLE/SLNB. On meta-analysis, ILM occurrence was 3.4% (95% CI 2.8-4.2%). ILM occurred most frequently in the WLE/DLND group (5.5%, 95% CI 3.5-8.7%), followed by WLE/ELND (4.7%, 95% CI 3.1-7.0%), WLE/SLNB (4.5%, 95% CI 3.5-5.7%) and WLE alone (1.9%, 95% CI 1.4-2.7%). 1,330 SLNB+ patients were identified and 5,783 SLNB- patients. For these groups, on meta-analysis, ILM recurrence was 13.2% (95% CI 10.8-16.2%) and 3.4% (95% CI 2.5-4.5%), respectively (p=0.01). Conclusion In this review SLNB is associated with an increase of ILM with an incidence of 1.9% for WLE vs. 3.4% for SNLB-. Selection bias in this review cannot be excluded. However, ILM occur four times more frequently after SLNB+ than SLNB- procedures and more often after SLNB+/CLND than WLE/DLND or WLE/ELND. ILM should therefore be viewed as a bio-marker of aggressive primary disease.
The potential benefit of surgery of the primary tumour in patients with asymptomatic metastatic colorectal cancer is debated. This EURECCA international comparison analyses treatment strategies and ...overall survival in the Netherlands and Norway in patients with incurable metastatic colorectal cancer.
National cohorts (2007–2013) from the Netherlands and Norway including all patients with synchronous metastatic colorectal cancer were compared on treatment strategy and overall survival. Using country as an instrumental variable, we assessed the effect of different treatment strategies on mortality in the first year.
Of 21,196 patients (16,144 Dutch and 5052 Norwegian), 38.6% Dutch and 51.5% (p < 0.001) Norwegian patients underwent resection of the primary tumour. In the Netherlands, 58.2% received chemotherapy compared with 21.4% in Norway. Radiotherapy was given in 9.5% of Dutch patients and 7.2% of Norwegian patients. Using the Netherlands as reference, the adjusted HR for overall survival was 0.96 (95% CI 0.93–0.99; p = 0.024). Instrumental variable analysis showed an adjusted OR of 1.00 (95% CI 0.99–1.02; p = 0.741).
Treatment strategies varied significantly between the Netherlands and Norway, with more surgery and less radiotherapy in Norway. Adjusted overall survival was better in Norway for all patients and patients <75 years, but not for patients ≥75 years. Instrumental variable analysis showed no benefit in one-year mortality for a treatment strategy with a higher proportion of surgery and a lower proportion of radiotherapy. Our findings emphasise the need for further research to select patients with incurable metastatic colorectal cancer for different treatment options.
Abstract Aims Ilio-inguinal lymph node dissection for stage III melanoma is often complicated by wound healing disturbances. A retrospective study was performed to investigate the wound healing ...disturbances after therapeutic ilio-inguinal lymph node dissection. Patients and methods Between 1989 and 2007, 139 consecutive patients, 73 females (53%) and 66 males (47%), median age 55 (range 20–86) years underwent a therapeutic ilio-inguinal lymph node dissection. Data were recorded on early complications: haematoma, wound infection, wound necrosis and seroma. Univariate and multivariate logistic regression analyses were used to evaluate the influence of a wide range of variables on postoperative complications. Results Seventy-two patients had one or more early wound complications (49.7%). These complications comprised haematoma ( n = 3, 2.1%), wound infection ( n = 30, 20.7%), wound necrosis ( n = 25, 17.5%) and seroma ( n = 31, 21.8%). Wound infections were significantly more common in patients with a body mass index (BMI) of >25 ( p = 0.019). Wound necrosis developed significantly more often if the Bohler Braun splint was not used postoperatively ( p = 0.002). The occurrence of one or more early complications was significantly associated with the non-use of a Bohler Braun splint ( p = 0.026) and age of >55 years ( p = 0.015). Conclusions High BMI was significantly correlated with the occurrence of wound infections. Bed with of the hip and knee in flexion using a Bohler splint improved wound healing after therapeutic ilio-inguinal lymph node dissection.
Completion lymph node dissection (CLND) in sentinel node (SN)-positive melanoma patients is accompanied with morbidity, while about 80% yield no additional metastases in non-sentinel nodes (NSNs). A ...prediction tool for NSN involvement could be of assistance in patient selection for CLND. This study investigated which parameters predict NSN-positivity, and whether the biomarker S-100B improves the accuracy of a prediction model.
Recorded clinicopathologic factors were tested for their association with NSN-positivity in 110 SN-positive patients who underwent CLND. A prediction model was developed with multivariable logistic regression, incorporating all predictive factors. Five models were compared for their predictive power by calculating the Area Under the Curve (AUC). A weighted risk score, ‘S-100B Non-Sentinel Node Risk Score’ (SN-SNORS), was derived for the model with the highest AUC. Besides, a nomogram was developed as visual representation.
NSN-positivity was present in 24 (21.8%) patients. Sex, ulceration, number of harvested SNs, number of positive SNs, and S-100B value were independently associated with NSN-positivity. The AUC for the model including all these factors was 0.78 (95%CI 0.69–0.88). SN-SNORS was the sum of scores for the five parameters. Scores of ≤9.5, 10–11.5, and ≥12 were associated with low (0%), intermediate (21.0%) and high (43.2%) risk of NSN involvement.
A prediction tool based on five parameters, including the biomarker S-100B, showed accurate risk stratification for NSN-involvement in SN-positive melanoma patients. If validated in future studies, this tool could help to identify patients with low risk for NSN-involvement.
Background The reported 54 mm median intervention diameter for endovascular aneurysm repair (EVAR) in the Vascular Quality Initiative and European data from the Pharmaceutical Aneurysm Stabilisation ...Trial (PHAST) implies that in real life the majority of abdominal aortic aneurysm (AAA) repairs occur at diameters smaller than the consensus intervention threshold of 55 mm. This study explores the potential consequences of this practice. Methods The differences between real life AAA repair and consensus based intervention threshold were explored in reported data from vascular quality initiatives and PHAST. The subsequent consequences of advancement of endovascular aneurysm repair (EVAR) were estimated using a multistate model based on life tables for the EVAR Medicare population. Results There appears an approximate 5 mm difference in AAA diameter between real life practice and consensus intervention threshold. Assuming a 2.5 mm annual growth rate, this results in an approximately 2 year advancement of AAA repair. According to the model used, early repair reduces overall small aneurysm patient mortality by 2.3%, it results in 21.9% more EVAR procedures, more EVAR related deaths, and 42.3% and 36.8% more open and endovascular re-interventions, respectively. Cost–benefit estimates imply 482 fewer AAA related deaths, but 140 extra EVAR related deaths for a population of more than 30,000 AAA patients, and a 300 million USD increase in health costs for the 8 year observation period in the Medicare population. Conclusions In the real life situation a large proportion of EVAR procedures appear to occur before reaching the consensus threshold. Although this reduces mortality, it comes at a cost of approximately 1 million USD per prevented rupture related death.
Background
Older patients with breast cancer are often not treated in accordance with guidelines. With the emergence of endocrine therapy, omission of surgery can be considered in some patients. The ...aim of this population‐based study was to investigate time trends in surgical treatment between 1995 and 2011, and to evaluate the effects of omitting surgery on overall and relative survival in older patients with resectable breast cancer.
Methods
Patients aged 75 years and older with stage I–III breast cancer diagnosed between 1995 and 2011 were selected from the Netherlands Cancer Registry. Time trends of all treatment modalities were evaluated using linear regression models. Changes in overall survival were calculated by Cox regression. Relative survival was calculated using the Ederer II method.
Results
Overall, 26 292 patients were included. The proportion of patients receiving surgical treatment decreased significantly, from 90·8 per cent in 1995 to 69·9 per cent in 2011 (P < 0·001). Multivariable analysis showed that overall survival did not change over time (hazard ratio 1·00 (95 per cent confidence interval (c.i.) 0·99 to 1·00) per year); nor did relative survival (relative excess risk 1·00 (0·98 to 1·02) per year).
Conclusion
Omission of surgery has become more common in older patients with breast cancer during the past 15 years in the Netherlands, but this has not altered overall or relative survival.
Primary endocrine therapy was effective
Decreased cancer specific survival in older colorectal patients is mainly due to mortality in the first year, emphasizing the importance of the first postoperative year. This study aims to gain an ...overview and time trends of short-term mortality in octogenarians (≥80 years) with colorectal cancer across four North European countries.
Patients of 80 years or older, operated for colorectal cancer (stage I-III) between 2005 and 2014, were included. Population-based cohorts from Belgium, Denmark, the Netherlands, and Sweden were collected. Separately for colon- and rectal cancer, 30-day, 90-day, one-year, and excess one-year mortality were calculated. Also, short-term mortality over three time periods (2005–2008, 2009–2011, 2012–2014) was analyzed.
In total, 35,158 colon cancer patients and 10,144 rectal cancer patients were included. For colon cancer, 90-day mortality rate was highest in Denmark (15%) and lowest in Sweden (8%). For rectal cancer, 90-day mortality rate was highest in Belgium (11%) and lowest in Sweden (7%). One-year excess mortality rate of colon cancer patients decreased from 2005 to 2008 to 2012–2014 for all countries (Belgium: 17%–11%, Denmark: 21%–15%, the Netherlands: 18%–10%, and Sweden: 10%–8%). For rectal cancer, from 2005 to 2008 to 2012–2014 one-year excess mortality rate decreased in the Netherlands from 16% to 7% and Sweden: 8%–2%).
Short-term mortality rates were high in octogenarians operated for colorectal cancer. Short-term mortality rates differ across four North European countries, but decreased over time for both colon and rectal cancer patients in all countries.
Background
Combined whole-body FDG-PET and CT provide the most comprehensive staging of melanoma patients with palpable lymph node metastases (LNM). The aim of this study is to analyze survival of ...FDG-PET and CT negative or positive melanoma patients and to assess which factors have independent prognostic impact on survival of these patients.
Methods
Patients with palpable and histologically or cytologically proven LNM of melanoma, referred to participating hospitals for examination with FDG-PET and CT, were selected from a previous study. Melanoma-specific survival (MSS) and disease-free period (DFP) were analyzed for FDG-PET and CT positive and negative patients using the Kaplan–Meier method. Cox-regression analysis was performed to analyze which patient or melanoma characteristics had significant impact on MSS or DFP.
Results
For all 252 patients 5-year MSS was 38.2 %. For FDG-PET and CT negative and positive patients 5-year MSS was 47.6 and 16.9 %, respectively. Disease-free period for FDG-PET and CT negative patients was 46.0 % after 5 years. Gender, a positive FDG-PET and CT, LNM in axilla compared to head or neck, and presence of extranodal growth were independent factors for worse MSS in all patients. Positive FDG-PET and CT was the most important prognostic factor for MSS with a hazard ratio of 2.54 (95 % CI, 1.55–4.17,
P
< 0.001).
Conclusions
Staging melanoma patients with palpable LNM is more accurate when whole-body FDG-PET and CT is added to the diagnostic workup. Hence, FDG-PET and CT, preferably combined, are indicated in the staging of clinical stage III melanoma patients.
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