Kelly M. McMasters

Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma

PURPOSEnTo revise the staging system for cutaneous melanoma under the auspices of the American Joint Committee on Cancer (AJCC).nnnMATERIALS AND METHODSnThe prognostic factors analysis described in the companion publication (this issue), as well as evidence from the published literature, was used to assemble the tumor-node-metastasis criteria and stage grouping for the melanoma staging system.nnnRESULTSnMajor changes include (1) melanoma thickness and ulceration but not level of invasion to be used in the T category (except for T1 melanomas); (2) the number of metastatic lymph nodes rather than their gross dimensions and the delineation of clinically occult (ie, microscopic) versus clinically apparent (ie, macroscopic) nodal metastases to be used in the N category; (3) the site of distant metastases and the presence of elevated serum lactic dehydrogenase to be used in the M category; (4) an upstaging of all patients with stage I, II, and III disease when a primary melanoma is ulcerated; (5) a merging of satellite metastases around a primary melanoma and in-transit metastases into a single staging entity that is grouped into stage III disease; and (6) a new convention for defining clinical and pathologic staging so as to take into account the staging information gained from intraoperative lymphatic mapping and sentinel node biopsy.nnnCONCLUSIONnThis revision will become official with publication of the sixth edition of the AJCC Cancer Staging Manual in the year 2002.

Prognostic Factors Analysis of 17,600 Melanoma Patients: Validation of the American Joint Committee on Cancer Melanoma Staging System

PURPOSEnThe American Joint Committee on Cancer (AJCC) recently proposed major revisions of the tumor-node-metastases (TNM) categories and stage groupings for cutaneous melanoma. Thirteen cancer centers and cancer cooperative groups contributed staging and survival data from a total of 30,450 melanoma patients from their databases in order to validate this staging proposal.nnnPATIENTS AND METHODSnThere were 17,600 melanoma patients with complete clinical, pathologic, and follow-up information. Factors predicting melanoma-specific survival rates were analyzed using the Cox proportional hazards regression model. Follow-up survival data for 5 years or longer were available for 73% of the patients.nnnRESULTSnThis analysis demonstrated that (1) in the T category, tumor thickness and ulceration were the most powerful predictors of survival, and the level of invasion had a significant impact only within the subgroup of thin (< or = 1 mm) melanomas; (2) in the N category, the following three independent factors were identified: the number of metastatic nodes, whether nodal metastases were clinically occult or clinically apparent, and the presence or absence of primary tumor ulceration; and (3) in the M category, nonvisceral metastases was associated with a better survival compared with visceral metastases. A marked diversity in the natural history of pathologic stage III melanoma was demonstrated by five-fold differences in 5-year survival rates for defined subgroups. This analysis also demonstrated that large and complex data sets could be used effectively to examine prognosis and survival outcome in melanoma patients.nnnCONCLUSIONnThe results of this evidence-based methodology were incorporated into the AJCC melanoma staging as described in the companion publication.

Use of adjuvant chemotherapy in young women with node-negative ER+ breast cancer: Refining the use of recurrence score—A decision analysis

11547 Background: Current guidelines recommend young women with early ER+ breast cancer with intermediate recurrence scores (RS) receive “consideration” for adjuvant chemotherapy. To guide clinical decision making in this setting, a formal decision analysis was performed to identify the RS at which the benefit of chemotherapy outweighs its risks of adverse events and reduced health- related quality of life. Methods: A decision tree was constructed around the choice of adjuvant chemotherapy with hormone therapy vs. hormone therapy alone for a 40-year old patient with a LN-, ER+ tumor (TreeAge Pro). The probability of long-term adverse events resulting from chemotherapy was estimated from clinical trial data. Standard gamble utilities for the terminal states of relapse after 10 years were obtained from the literature and direct estimation. The probability of relapse was estimated using Adjuvant! Online; a sensitivity analysis was performed over a range of RS from 18–30. The threshold probability of relapse ...

Prolonged survival after radiofrequency ablation of synchronous colorectal liver metastases

3763 Background: Synchronous liver metastasis (SLM), commonly defined as liver metastasis occurring within 12 months of the colon primary, represents 13-25% of the 90,000 newly diagnosed colorectal liver metastases. SLM have historically been found to have a worse overall survival when compared to metachronous lesions. The primary reason for this worse overall survival has been related to a majority of patients having unresectable disease because of multiple bilobar tumors or comorbid conditions. We hypothesized that patients with synchronous liver metastases would benefit from an aggressive ablation and resection to the same degree as patients with metachronous metastases.nnnMETHODSnReview of our prospective database revealed 64 pts with unresectable colorectal liver metastases treated since 1998. The vast majority of patients underwent RFA as an open procedure. Survival was determined by the Kaplan-Meier.nnnRESULTSnSixty-four pts underwent treatment for 200 liver metastases (38 resected, 162 RFA; mean 3.1 tumors/pt). Median age was 63 years (range 17-88). Median follow-up was 22 mo. The median size of the largest metastasis was 3 cm (range 1-10 cm). RFA was performed for 9 pts known to have minimal extrahepatic (EH) disease preoperatively, and 6 who were found to have EH disease at operation. Synchronous metastases were present in 38 pts. Eighteen pts (28%) experienced postoperative complications, usually minor and self-limited. Thirty-day mortality was 1.6%. Repeat RFA was performed in 11 pts for liver recurrence. Median disease-free and overall survival rates for the entire group were 12 and 31 mo, respectively. Median overall survival rates were 26 and 36 mo, respectively, for pts with or without EH metastasis (P=0.14). There were no differences in survival for pts with synchronous vs. metachronous liver metastases, or for pts who underwent RFA alone vs. RFA + resection.nnnCONCLUSIONSnRFA is as effective for patients with synchronous metastases as it is for those with metachronous metastases. Patients without EH disease appear to benefit the most, although further study is necessary to determine the potential benefit for patients with limited EH disease. No significant financial relationships to disclose.