To develop more evidence-based guidelines for the frequency of patient follow-up after treatment of localized (American Joint Committee on Cancer AJCC stage I or II) melanoma.
We used data from ...Melanoma Institute Australia on an inception cohort of 3,081 consecutive patients first diagnosed with stage I or II melanoma between January 1985 and December 2009. Kaplan-Meier curves and Cox models were used to characterize the time course and predictors for recurrence and new primaries. We modeled the delay in diagnosis of recurrence or new primary as well as the number of monitoring visits required using two monitoring schedules: first, according to 2008 Australian and New Zealand guidelines and, second, with fewer visits, especially for those at lowest risk of recurrence.
For every 1,000 patients beginning follow-up, 229 developed recurrence and 61 developed new primary within 10 years. There was only a small difference in modeled delay in diagnosis (extra 44.9 and 9.6 patients per 1,000 for recurrence and new primary, respectively, with delay greater than 2 months) using a schedule that requires far fewer visits (3,000 fewer visits per 1,000 patients) than recommended by current guidelines. AJCC substage was the most important predictor of recurrence, whereas age and date of primary diagnosis were important predictors of developing new primary.
By providing less intensive monitoring, more efficient follow-up strategies are possible. Fewer visits with a more focused approach may address the needs of patients and clinicians to detect recurrent or new melanoma.
Background
This study compares well-being, recurrences, and deaths of early-stage cutaneous melanoma patients in follow-up, as recommended in the Dutch guideline, with that of patients in a ...stage-adjusted reduced follow-up schedule, 3 years after diagnosis, as well as costs.
Methods
Overall, 180 eligible pathological American Joint Committee on Cancer (AJCC) stage IB–IIC, sentinel node staged, melanoma patients (response rate = 87%, 48% male, median age 57 years), randomized into a conventional (CSG,
n
= 93) or experimental (ESG,
n
= 87) follow-up schedule group, completed patient-reported outcome measures (PROMs) at diagnosis (T1): State-Trait Anxiety Inventory–State version (STAI-S), Cancer Worry Scale (CWS), Impact of Event Scale (IES), and RAND-36 (Mental and Physical Component scales PCS/MCS). Three years later (T3), 110 patients (CSG,
n
= 56; ESG,
n
= 54) completed PROMs, while 42 declined (23%).
Results
Repeated measures analyses of variance (ANOVAs) showed a significant group effect on the IES (
p
= 0.001) in favor of the ESG, and on the RAND-36 PCS (
p
= 0.02) favoring the CSG. Mean IES and CWS scores decreased significantly over time, while those on the RAND-36 MCS and PCS increased. Effect sizes were small. Twenty-five patients developed a recurrence or second primary melanoma, of whom 13 patients died within 3 years. Cox proportional hazards models showed no differences between groups in recurrence-free survival (hazard ratio HR 0.71 0.32–1.58;
p
= 0.400) and disease-free survival (HR 1.24 0.42–3.71;
p
= 0.690). Costs per patient after 3 years (computed for 77.3% of patients) were 39% lower in the ESG.
Conclusion
These results seemingly support the notion that a stage-adjusted reduced follow-up schedule forms an appropriate, safe, and cost-effective alternative for pathological AJCC stage IB–IIC melanoma patients to the follow-up regimen as advised in the current melanoma guideline.
The value of follow-up surveillance for patients with cutaneous melanoma remains uncertain. In this prospective study the frequency of detection of first melanoma recurrence (FMR) by patient or ...doctor was analyzed to assist in the future design of evidence-based follow-up guidelines.
Patients who had a recurrence of a previously treated American Joint Committee on Cancer (AJCC) stage I-III primary melanoma (PM) were interviewed to ascertain how their PM and FMR were detected. Factors predicting the detection of PM and FMR were analyzed.
The study group comprised 211 patients. In 168 patients, information on detection of their PM was available; 102 PMs (61%) were detected by the patient and 18 (11%) by their partner. Higher AJCC stage, visible location for the patient, and female sex were independent predictive factors for patient-detected PM (P = .03, .002, and .02 respectively). The FMR type was local in 28 (13%), in transit in 35 (17%), in regional lymph nodes in 97 (46%), and distant in 51 (24%). Seventy-three percent of all FMRs were detected by the patient. The presence of a symptom was the only independent predictor of a patient-detected FMR (P < .0001). There was no statistically significant survival difference between the patient-detected and doctor-detected FMRs.
Three-quarters of FMRs were detected by patients or their partners, and it should be possible to improve this rate even further by better education. More frequent follow-up visits are thus unlikely to be valuable. Reductions in follow-up frequency may therefore be safe and economically responsible.
Anorectal melanoma is a rare neoplasm with a poor prognosis. The surgical approaches for anorectal melanoma can be categorized into local excision (procedures without lymph node removal and ...preservation of the rectum) and extensive resection (procedures with rectum and pararectal lymph node removal). The aim of this systematic review and meta-analysis was to compare the survival of patients who underwent extensive resection with that of patients who underwent local excision, stratifying patients according to tumour stage.
A literature review was performed according to PRISMA guidelines by searching MEDLINE/PubMed for manuscripts published until March 2021. Studies comparing survival outcomes in patients with anorectal melanoma who underwent local excision versus extensive resection were screened for eligibility. Meta-analysis was performed for overall survival after the different surgical approaches, stratified by tumour stage.
There were 347 studiesidentified of which 34 were included for meta-analysis with a total of 1858 patients. There was no significant difference in overall survival between the surgical approaches in patients per stage (stage I odds ratio 1.30 (95 per cent c.i. 0.62 to 2.72, P = 0.49); stage II odds ratio 1.61 (95 per cent c.i. 0.62 to 4.18, P = 0.33); stage I-III odds ratio 1.19 (95 per cent c.i. 0.83 to 1.70, P = 0.35). Subgroup analyses were conducted for the time intervals (<2000, 2001-2010 and 2011-2021) and for continent of study origin. Subgroup analysis for time interval and continent of origin also showed no statistically significant differences in overall survival.
No significant survival benefit exists for patients with anorectal melanoma treated with local excision or extensive resection, independent of tumour stage.
Objective
The aim of this study was to determine the adherence to consensus guidelines on preoperative imaging of patients with primary hyperparathyroidism (pHPT) in real local practice.
Methods
This ...was a retrospective multicenter cohort study of 411 patients undergoing parathyroidectomy for pHPT from 2007 to 2017 in three referral centers.
Results
In 286/411 patients (69%) the preoperative imaging workup adhered to guidelines (utilizing ultrasound and parathyroid scintigraphy). In patients in whom guidelines were followed 63% were discharged within one day versus 37% in whom guidelines were not followed (P < .0005). The use of a bimodality imaging workup, starting with ultrasound and parathyroid scintigraphy followed by imaging upscaling aiming for anatomical and functional concordance, was a predictor for the performance of a minimally invasive parathyroidectomy (OR 4.098, 95% CI 2.296‐7.315, P < .0005).
Conclusion
The level of compliance to preoperative imaging guidelines is suboptimal in this population. Patients in whom adherence was achieved showed a shorter length of stay. More education of physicians is required regarding the appropriate preoperative imaging workup in pHPT.
Level of evidence
2b (individual cohort study).
This study found that the level of compliance to consensus guidelines on preoperative imaging in patients with primary hyperparathyroidism in routine daily practice was suboptimal (69% adherence). Patients in whom adherence was achieved showed a shorter duration of hospitalization, and if imaging upscaling was performed aiming for positive concordance of anatomical and functional localization, adherence was associated with the performance of a minimally invasive parathyroidectomy. Based on these results, we suggest more education of physicians is required regarding the appropriate preoperative imaging workup in primary hyperparathyroidism leading ultimately to an increased appropriate adherence to consensus guidelines.
Background
We evaluated the diagnostic implications of a small-voxel reconstruction for lymph node characterization in breast cancer patients, using state-of-the-art FDG-PET/CT. We included 69 ...FDG-PET/CT scans from breast cancer patients. PET data were reconstructed using standard 4 × 4 × 4 mm
3
and small 2 × 2 × 2 mm
3
voxels. Two hundred thirty loco-regional lymph nodes were included, of which 209 nodes were visualised on PET/CT. All nodes were visually scored as benign or malignant, and SUV
max
and TB
ratio
(=SUV
max
/SUV
background
) were measured. Final diagnosis was based on histological or imaging information. We determined the accuracy, sensitivity and specificity for both reconstruction methods and calculated optimal cut-off values to distinguish benign from malignant nodes.
Results
Sixty-one benign and 169 malignant lymph nodes were included. Visual evaluation accuracy was 73% (sensitivity 67%, specificity 89%) on standard-voxel images and 77% (sensitivity 78%, specificity 74%) on small-voxel images (
p
= 0.13). Across malignant nodes visualised on PET/CT, the small-voxel score was more often correct compared with the standard-voxel score (89 vs. 76%,
p
< 0.001). In benign nodes, the standard-voxel score was more often correct (89 vs. 74%,
p
= 0.04).
Quantitative data were based on the 61 benign and 148 malignant lymph nodes visualised on PET/CT. SUVs and TB
ratio
were on average 3.0 and 1.6 times higher in malignant nodes compared to those in benign nodes (
p
< 0.001), on standard- and small-voxel PET images respectively. Small-voxel PET showed average increases in SUV
max
and TB
ratio
of typically 40% over standard-voxel PET. The optimal SUV
max
cut-off using standard-voxels was 1.8 (sensitivity 81%, specificity 95%, accuracy 85%) while for small-voxels, the optimal SUV
max
cut-off was 2.6 (sensitivity 78%, specificity 98%, accuracy 84%). Differences in accuracy were non-significant.
Conclusions
Small-voxel PET/CT improves the sensitivity of visual lymph node characterization and provides a higher detection rate of malignant lymph nodes. However, small-voxel PET/CT also introduced more false-positive results in benign nodes. Across all nodes, differences in accuracy were non-significant. Quantitatively, small-voxel images require higher cut-off values. Readers have to adapt their reference standards.
The MELFO (MELanoma FOllow-up) study is an international phase III randomized controlled trial comparing an experimental low-intensity schedule against current national guidelines.
Evidence-based ...guidelines for the follow-up of sentinel node-negative melanoma patients are lacking.
Overall, 388 adult patients diagnosed with sentinel node-negative primary melanoma patients were randomized in cancer centers in the Netherlands and United Kingdom between 2006 and 2016. The conventional schedule group (control: n=196) was reviewed as per current national guidelines. The experimental schedule group (n=192) was reviewed in a reduced-frequency schedule. Quality of life was the primary outcome measurement. Detection rates and survival outcomes were recorded. Patient satisfaction rates and compliance with allocated schedules were compared.
At 5 years, both arms expressed high satisfaction with their regimens (>97%). This study found no significant group effect on any patient-reported outcome measure scores between the follow-up protocols. In total, 75/388 (19.4%) patients recurred, with no difference in incidence found between the 2 arms (hazard ratio=0.87, 95% confidence interval: 0.54-1.39, P =0.57). Self-examination was the method of detection for 25 experimental patients and 32 control patients (75.8% vs. 76.2%; P =0.41). This study found no difference in any survival outcomes between the 2 study arms (disease-free survival: hazard ratio=1.00, 95% confidence interval: 0.49-2.07, P =0.99).
A reduced-intensity, American Joint Committee on Cancer (AJCC) stage-adjusted follow-up schedule for sentinel node-negative melanoma patients is a safe strategy, and patient self-examination is effective for recurrence detection with no evidence of diagnostic delay. Patients' acceptance is very high.
Purpose
Follow-up for breast cancer survivors consists of after care and surveillance. The benefits of routine surveillance visits remain debatable. In this study we compared the severity of ...locoregional recurrences (LRRs) and the subsequent risk of a distant metastasis (DM) between LRRs detected at routine and interval visits.
Methods
Women diagnosed with early breast cancer between 2003 and 2008 in one of the 15 participating hospitals, and who developed a LRR as first event after primary treatment, were selected from the Netherlands Cancer Registry (Cohort A). Chi-squared tests were used to compare the severity of routine- and interval-detected local recurrences (LRs) and regional recurrences (RRs), using tumor size, tumor grade, and number of positive lymph nodes. Data on the development of a subsequent DM after a LRR were available for a subset of patients (Cohort B). Cohort B was used to estimate the association between way of LRR-detection and risk of a DM.
Results
Cohort A consisted of 109 routine- and 113 interval-LRR patients. The severity of routine-detected LRs or RRs and interval-detected LRs or RRs did not significantly differ. Cohort B consisted of 66 routine- and 61 interval-LRR patients. Sixteen routine- (24%) and 17 (28%) interval-LRR patients developed a DM. After adjustment, way of LRR-detection was not significantly associated with the risk of a DM (hazard ratio: 1.22; 95% confidence interval: 0.49–3.06).
Conclusion
The current study showed that routine visits did not lead to less severe LRRs and did not decrease the risk of a subsequent DM.
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