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Lee TS, Li I, Peric B, Saw RPM, Duprat JP, Bertolli E, Spillane JB, van Leeuwen BL, Moncrieff M, Sommariva A, Allan CP, de Wilt JHW, Jones RP, Geh JLC, Howle JR, Spillane AJ. Leg Lymphoedema After Inguinal and Ilio-Inguinal Lymphadenectomy for Melanoma: Results from a Prospective, Randomised Trial. Ann Surg Oncol 2024; 31:4061-4070. [PMID: 38494565 PMCID: PMC11076360 DOI: 10.1245/s10434-024-15149-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/14/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND The Evaluation of Groin Lymphadenectomy Extent for Melanoma (EAGLE FM) study sought to address the question of whether to perform inguinal (IL) or ilio-inguinal lymphadenectomy (I-IL) for patients with inguinal nodal metastatic melanoma who have no clinical or imaging evidence of pelvic disease. Primary outcome measure was disease-free survival at 5 years, and secondary endpoints included lymphoedema. METHODS EAGLE FM was designed to recruit 634 patients but closed with 88 patients randomised because of slow recruitment and changes in melanoma management. Lymphoedema assessments occurred preoperatively and at 6, 12, 18, and 24 months postoperatively. Lymphoedema was defined as Inter-Limb Volume Difference (ILVD) > 10%, Lymphoedema Index (L-Dex®) > 10 or change of L-Dex® > 10 from baseline. RESULTS Prevalence of leg lymphoedema between the two groups was similar but numerically higher for I-IL at all time points in the first 24 months of follow-up; highest at 6 months (45.9% IL [CI 29.9-62.0%], 54.1% I-IL [CI 38.0-70.1%]) and lowest at 18 months (18.8% IL [CI 5.2-32.3%], 41.4% I-IL [CI 23.5-59.3%]). Median ILVD at 24 months for those affected by lymphoedema was 14.5% (IQR 10.6-18.7%) and L-Dex® was 12.6 (IQR 9.0-17.2). There was not enough statistical evidence to support associations between lymphoedema and extent of surgery, radiotherapy, or wound infection. CONCLUSIONS Despite a trend for patients who had I-IL to have greater lymphoedema prevalence than IL in the first 24 months after surgery, our study's small sample did not have the statistical evidence to support an overall difference between the surgical groups.
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Affiliation(s)
- T S Lee
- Melanoma Institute Australia, Wollstonecraft, Sydney, Australia.
- Royal North Shore Hospital, Sydney, Australia.
- University of Sydney, Sydney, Australia.
| | - I Li
- Melanoma Institute Australia, Wollstonecraft, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - B Peric
- Medical Faculty, Institute of Oncology Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| | - R P M Saw
- Melanoma Institute Australia, Wollstonecraft, Sydney, Australia
- University of Sydney, Sydney, Australia
- Royal Prince Alfred Hospital, Sydney, Australia
- Mater Misericordiae Hospital, North Sydney, Australia
| | - J P Duprat
- AC Camargo Cancer Center, São Paulo, Brazil
| | - E Bertolli
- AC Camargo Cancer Center, São Paulo, Brazil
| | - J B Spillane
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - B L van Leeuwen
- Surgical Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - M Moncrieff
- Norfolk & Norwich University Hospital, Plastic and Reconstructive Surgery, Norwich, UK
| | - A Sommariva
- Veneto Institute of Oncology IOV-IRCCS, Surgical Oncology, Padua, Italy
| | - C P Allan
- Faculty of Medicine, Mater Clinic School, University of Queensland, Brisbane, Australia
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R Pritchard- Jones
- Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, Knowsley, UK
| | - J L C Geh
- Department of Plastic and Reconstructive Surgery, St Thomas' Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - J R Howle
- University of Sydney, Sydney, Australia
- Westmead Hospital, Sydney, Australia
| | - A J Spillane
- Melanoma Institute Australia, Wollstonecraft, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
- Mater Misericordiae Hospital, North Sydney, Australia
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Lee TS, Spillane AJ. ASO Author Reflections: Lymphoedema Related to Inguinal and Ilioinguinal Lymphadenectomy for Melanoma. Ann Surg Oncol 2024; 31:4071-4072. [PMID: 38536583 PMCID: PMC11076325 DOI: 10.1245/s10434-024-15216-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/07/2024] [Indexed: 05/09/2024]
Affiliation(s)
- T S Lee
- Melanoma Institute Australia, Sydney, Australia.
- Royal North Shore Hospital, Sydney, Australia.
- University of Sydney, Sydney, Australia.
| | - A J Spillane
- Melanoma Institute Australia, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
- Mater Misericordiae Hospital, North Sydney, Australia
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Lee TS, Li I, Peric B, Saw RPM, Duprat JP, Bertolli E, Spillane JB, van Leeuwen BL, Moncrieff M, Sommariva A, Allan C, de Wilt JHW, Pritchard-Jones R, Geh JLC, Howle JR, Spillane AJ. ASO Visual Abstract: Leg Lymphoedema After Inguinal and Ilio-Inguinal Lymphadenectomy for Melanoma: Results from a Prospective Randomized Trial. Ann Surg Oncol 2024:10.1245/s10434-024-15262-4. [PMID: 38637445 DOI: 10.1245/s10434-024-15262-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Affiliation(s)
- T S Lee
- Melanoma Institute Australia, Sydney, Australia.
- Royal North Shore Hospital, Sydney, Australia.
- University of Sydney, Sydney, Australia.
| | - I Li
- Melanoma Institute Australia, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - B Peric
- Institute of Oncology Ljubljana, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - R P M Saw
- Melanoma Institute Australia, Sydney, Australia
- University of Sydney, Sydney, Australia
- Royal Prince Alfred Hospital, Sydney, Australia
- Mater Misericordiae Hospital, North Sydney, Australia
| | - J P Duprat
- AC Camargo Cancer Center, São Paulo, Brazil
| | - E Bertolli
- AC Camargo Cancer Center, São Paulo, Brazil
| | - J B Spillane
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - B L van Leeuwen
- Surgical Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - M Moncrieff
- Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - A Sommariva
- Veneto Institute of Oncology IOV-IRCCS, Surgical Oncology, Padua, Italy
| | - C Allan
- Mater Clinic School, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R Pritchard-Jones
- Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, Knowsley, UK
| | - J L C Geh
- Department of Plastic and Reconstructive Surgery, Guy's and St. Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - J R Howle
- University of Sydney, Sydney, Australia
- Westmead Hospital, Sydney, Australia
| | - A J Spillane
- Melanoma Institute Australia, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
- Mater Misericordiae Hospital, North Sydney, Australia
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Rawson RV, Adhikari C, Bierman C, Lo SN, Shklovskaya E, Rozeman EA, Menzies AM, van Akkooi ACJ, Shannon KF, Gonzalez M, Guminski AD, Tetzlaff MT, Stretch JR, Eriksson H, van Thienen JV, Wouters MW, Haanen JBAG, Klop WMC, Zuur CL, van Houdt WJ, Nieweg OE, Ch'ng S, Rizos H, Saw RPM, Spillane AJ, Wilmott JS, Blank CU, Long GV, van de Wiel BA, Scolyer RA. Pathological response and tumour bed histopathological features correlate with survival following neoadjuvant immunotherapy in stage III melanoma. Ann Oncol 2021; 32:766-777. [PMID: 33744385 DOI: 10.1016/j.annonc.2021.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Guidelines for pathological evaluation of neoadjuvant specimens and pathological response categories have been developed by the International Neoadjuvant Melanoma Consortium (INMC). As part of the Optimal Neo-adjuvant Combination Scheme of Ipilimumab and Nivolumab (OpACIN-neo) clinical trial of neoadjuvant combination anti-programmed cell death protein 1/anti-cytotoxic T-lymphocyte-associated protein 4 immunotherapy for stage III melanoma, we sought to determine interobserver reproducibility of INMC histopathological assessment principles, identify specific tumour bed histopathological features of immunotherapeutic response that correlated with recurrence and relapse-free survival (RFS) and evaluate proposed INMC pathological response categories for predicting recurrence and RFS. PATIENTS AND METHODS Clinicopathological characteristics of lymph node dissection specimens of 83 patients enrolled in the OpACIN-neo clinical trial were evaluated. Two methods of assessing histological features of immunotherapeutic response were evaluated: the previously described immune-related pathologic response (irPR) score and our novel immunotherapeutic response score (ITRS). For a subset of cases (n = 29), cellular composition of the tumour bed was analysed by flow cytometry. RESULTS There was strong interobserver reproducibility in assessment of pathological response (κ = 0.879) and percentage residual viable melanoma (intraclass correlation coefficient = 0.965). The immunotherapeutic response subtype with high fibrosis had the strongest association with lack of recurrence (P = 0.008) and prolonged RFS (P = 0.019). Amongst patients with criteria for pathological non-response (pNR, >50% viable tumour), all who recurred had ≥70% viable melanoma. Higher ITRS and irPR scores correlated with lack of recurrence in the entire cohort (P = 0.002 and P ≤ 0.0001). The number of B lymphocytes was significantly increased in patients with a high fibrosis subtype of treatment response (P = 0.046). CONCLUSIONS There is strong reproducibility for assessment of pathological response using INMC criteria. Immunotherapeutic response of fibrosis subtype correlated with improved RFS, and may represent a biomarker. Potential B-cell contribution to fibrosis development warrants further study. Reclassification of pNR to a threshold of ≥70% viable melanoma and incorporating additional criteria of <10% fibrosis subtype of response may identify those at highest risk of recurrence, but requires validation.
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Affiliation(s)
- R V Rawson
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Departments of Tissue Pathology and Diagnostic Oncology, Sydney, Australia; Department of Melanoma Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia; NSW Health Pathology, Sydney, Australia
| | - C Adhikari
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Departments of Tissue Pathology and Diagnostic Oncology, Sydney, Australia; Department of Melanoma Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia; NSW Health Pathology, Sydney, Australia
| | - C Bierman
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - S N Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
| | - E Shklovskaya
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - E A Rozeman
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - A M Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Royal North Shore Hospital, Sydney, Australia; Mater Hospital, Sydney, Australia
| | | | - K F Shannon
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Departments of Tissue Pathology and Diagnostic Oncology, Sydney, Australia; Department of Melanoma Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia
| | - M Gonzalez
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia
| | - A D Guminski
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Royal North Shore Hospital, Sydney, Australia; Mater Hospital, Sydney, Australia
| | - M T Tetzlaff
- Department of Pathology, Dermatopathology and Oral Pathology Unit, The University of California, San Francisco, San Francisco, USA; Department of Dermatology, Dermatopathology and Oral Pathology Unit, The University of California, San Francisco, San Francisco, USA
| | - J R Stretch
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Departments of Tissue Pathology and Diagnostic Oncology, Sydney, Australia; Department of Melanoma Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia; Mater Hospital, Sydney, Australia
| | - H Eriksson
- Theme Cancer, Skin Cancer Center/Department of Oncology, Karolinska University Hospital, Stockholm, Sweden; Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - J V van Thienen
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - M W Wouters
- The Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - J B A G Haanen
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - W M C Klop
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - C L Zuur
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - W J van Houdt
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - O E Nieweg
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Departments of Tissue Pathology and Diagnostic Oncology, Sydney, Australia; Department of Melanoma Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia; Mater Hospital, Sydney, Australia
| | - S Ch'ng
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Departments of Tissue Pathology and Diagnostic Oncology, Sydney, Australia; Department of Melanoma Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia; Mater Hospital, Sydney, Australia
| | - H Rizos
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - R P M Saw
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Departments of Tissue Pathology and Diagnostic Oncology, Sydney, Australia; Department of Melanoma Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia; Mater Hospital, Sydney, Australia
| | - A J Spillane
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Royal North Shore Hospital, Sydney, Australia; Mater Hospital, Sydney, Australia
| | - J S Wilmott
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - C U Blank
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - G V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Royal North Shore Hospital, Sydney, Australia; Mater Hospital, Sydney, Australia
| | - B A van de Wiel
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - R A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Departments of Tissue Pathology and Diagnostic Oncology, Sydney, Australia; Department of Melanoma Surgical Oncology, Royal Prince Alfred Hospital, Sydney, Australia; NSW Health Pathology, Sydney, Australia.
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Tetzlaff MT, Adhikari C, Lo S, Rawson RV, Amaria RN, Menzies AM, Wilmott JS, Ferguson PM, Ross MI, Spillane AJ, Vu KA, Ma J, Ning J, Haydu LE, Saw RPM, Wargo JA, Tawbi HA, Gershenwald JE, Long GV, Davies MA, Scolyer RA. Histopathological features of complete pathological response predict recurrence-free survival following neoadjuvant targeted therapy for metastatic melanoma. Ann Oncol 2020; 31:1569-1579. [PMID: 32739408 DOI: 10.1016/j.annonc.2020.07.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/02/2020] [Accepted: 07/23/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Recent clinical trials demonstrated the safety and efficacy of neoadjuvant dabrafenib and trametinib (DT) among patients with surgically resectable clinical stage III BRAFV600E/K mutant melanoma. Although patients achieving a complete pathological response (pCR) exhibited superior recurrence-free survival (RFS) versus those who did not, 30% of pCR patients relapsed. We sought to identify whether histopathological features of the pathological response further delineated risk of relapse. METHODS Surgical resection specimens from DT-treated patients in two phase 2 clinical trials were reviewed. Histopathological features, including relative amounts of viable tumour, necrosis, melanosis, and fibrosis (hyalinized or immature/proliferative) were assessed for associations with patient outcomes. RESULTS Fifty-nine patients underwent surgical resection following neoadjuvant DT. Patients achieving pCR (49%) had longer RFS compared with patients who did not (P = 0.005). Patients whose treated tumour showed any hyalinized fibrosis had longer RFS versus those without (P = 0.014), whereas necrosis (P = 0.012) and/or immature/proliferative fibrosis (P = 0.026) correlated with shorter RFS. Multivariable analyses showed absence of pCR or presence of immature fibrosis independently predicted shorter RFS. Among pCR patients, mature/hyalinized-type fibrosis correlated with improved RFS (P = 0.035). CONCLUSIONS The extent and composition of the pathological response following neoadjuvant DT in BRAFV600E/K mutant melanoma correlates with RFS, including pCR patients. These findings support the need for detailed histological analysis of specimens collected after neoadjuvant therapy.
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Affiliation(s)
- M T Tetzlaff
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA.
| | - C Adhikari
- Melanoma Institute of Australia, The University of Sydney, Sydney, Australia
| | - S Lo
- Melanoma Institute of Australia, The University of Sydney, Sydney, Australia
| | - R V Rawson
- Melanoma Institute of Australia, The University of Sydney, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, Australia; New South Wales Health Pathology, Sydney, Australia
| | - R N Amaria
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - A M Menzies
- Melanoma Institute of Australia, The University of Sydney, Sydney, Australia; Royal North Shore and Mater Hospitals, Sydney, Australia
| | - J S Wilmott
- Melanoma Institute of Australia, The University of Sydney, Sydney, Australia
| | - P M Ferguson
- Melanoma Institute of Australia, The University of Sydney, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, Australia; New South Wales Health Pathology, Sydney, Australia
| | - M I Ross
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - A J Spillane
- Melanoma Institute of Australia, The University of Sydney, Sydney, Australia; Royal North Shore and Mater Hospitals, Sydney, Australia
| | - K A Vu
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - J Ma
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - J Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - L E Haydu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - R P M Saw
- Melanoma Institute of Australia, The University of Sydney, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, Australia
| | - J A Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - H A Tawbi
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - J E Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - G V Long
- Melanoma Institute of Australia, The University of Sydney, Sydney, Australia; Royal North Shore and Mater Hospitals, Sydney, Australia
| | - M A Davies
- Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Systems Biology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - R A Scolyer
- Melanoma Institute of Australia, The University of Sydney, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, Australia; New South Wales Health Pathology, Sydney, Australia.
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Versluis JM, Rozeman EA, Menzies AM, Reijers ILM, Krijgsman O, Hoefsmit EP, van de Wiel BA, Sikorska K, Bierman C, Dimitriadis P, Gonzalez M, Broeks A, Kerkhoven RM, Spillane AJ, Haanen JBAG, van Houdt WJ, Saw RPM, Eriksson H, van Akkooi ACJ, Scolyer RA, Schumacher TN, Long GV, Blank CU. L3 Update of the OpACIN and OpACIN-neo trials: 36-months and 24-months relapse-free survival after (neo)adjuvant ipilimumab plus nivolumab in macroscopic stage III melanoma patients. J Immunother Cancer 2020. [DOI: 10.1136/jitc-2020-itoc7.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BackgroundBefore adjuvant checkpoint inhibition the 5-year overall survival (OS) rate was poor (<50%) in high-risk stage III melanoma patients. Adjuvant CTLA-4 (ipilimumab, IPI) and PD-1 (nivolumab, NIVO, or pembrolizumab) blockade have been shown to improve relapse-free survival (RFS) and OS (latter only for IPI so far). Due to a broader immune activation neoadjuvant therapy with checkpoint inhibitors might be more effective than adjuvant, as suggested in preclinical experiments. The OpACIN trial compared neoadjuvant versus adjuvant IPI plus NIVO, while the subsequent OpACIN-neo trial tested three different dosing schedules of neoadjuvant IPI plus NIVO without adjuvant therapy. High pathologic response rates of 74–78% were induced by neoadjuvant IPI plus NIVO. Here, we present the 36- and 24-months RFS of the OpACIN and OpACIN-neo trial, respectively.Materials and MethodsThe phase 1b OpACIN trial included 20 stage IIIB/IIIC melanoma patients, which were randomized to receive IPI 3 mg/kg plus NIVO 1 mg/kg either adjuvant 4 cycles or split 2 cycles neoadjuvant and 2 adjuvant. In the phase 2 OpACIN-neo trial, 86 patients were randomized to 2 cycles neoadjuvant treatment, either in arm A: 2x IPI 3 mg/kg plus NIVO 1 mg/kg q3w (n=30), arm B: 2x IPI 1 mg/kg plus NIVO 3 mg/kg q3w (n=30), or arm C: 2x IPI 3 mg/kg q3w followed immediately by 2x NIVO 3 mg/kg q3w (n=26). Pathologic response was defined as <50% viable tumor cells and in both trials centrally reviewed by a blinded pathologist. RFS rates were estimated using the Kaplan-Meier method.ResultsOnly 1 of 71 (1.4%) patients with a pathologic response on neoadjuvant therapy had relapsed, versus 16 of 23 patients (69.6%) without a pathologic response, after a median follow-up of 36 months for the OpACIN and 24 months for the OpACIN-neo trial. In the OpACIN trial, the estimated 3-year RFS rate for the neoadjuvant arm was 80% (95% CI: 59%-100%) versus 60% (95% CI: 36%-100%) for the adjuvant arm. Median RFS was not reached for any of the arms within the OpACIN-neo trial. Estimated 24-months RFS rate was 84% for all patients (95% CI: 76%-92%); 90% for arm A (95% CI: 80%-100%), 78% for arm B (95% CI: 63%-96%) and 83% for arm C (95% CI: 70%-100%). Baseline interferon-γ gene expression score and tumor mutational burden predict response.ConclusionsOpACIN for the first time showed a potential benefit of neoadjuvant IPI plus NIVO versus adjuvant immunotherapy, whereas the OpACIN-neo trial confirmed the high pathologic response rates that can be achieved by neoadjuvant IPI plus NIVO. Both trials show that pathologic response can function as a surrogate markers for RFS.Clinical trial informationNCT02437279, NCT02977052Disclosure InformationJ.M. Versluis: None. E.A. Rozeman: None. A.M. Menzies: F. Consultant/Advisory Board; Modest; BMS, MSD, Novartis, Roche, Pierre-Fabre. I.L.M. Reijers: None. O. Krijgsman: B. Research Grant (principal investigator, collaborator or consultant and pending grants as well as grants already received); Modest; BMS. E.P. Hoefsmit: None. B.A. van de Wiel: None. K. Sikorska: None. C. Bierman: None. P. Dimitriadis: None. M. Gonzalez: None. A. Broeks: None. R.M. Kerkhoven: None. A.J. Spillane: None. J.B.A.G. Haanen: B. Research Grant (principal investigator, collaborator or consultant and pending grants as well as grants already received); Modest; BMS, MSD, Neon Therapeutics, Novartis. F. Consultant/Advisory Board; Modest; BMS, MSD, Novartis, Pfizer, AZ/MedImmune, Rocher/Genentech, Ipsen, Bayer, Immunocore, SeattleGenetics, Neon Therapeutics, Celsius Therapeutics, Gadet, GSK. W.J. van Houdt: None. R.P.M. Saw: None. H. Eriksson: None. A.C.J. van Akkooi: B. Research Grant (principal investigator, collaborator or consultant and pending grants as well as grants already received); Modest; Amgen, BMS, Novartis. F. Consultant/Advisory Board; Modest; Amgen, BMS, Novartis, MSD Merck, Merck-Pfizer, 4SC. R.A. Scolyer: F. Consultant/Advisory Board; Modest; MSD, Neracare, Myriad, Novartis. T.N. Schumacher: B. Research Grant (principal investigator, collaborator or consultant and pending grants as well as grants already received); Modest; MSD, BMS, Merck. E. Ownership Interest (stock, stock options, patent or other intellectual property); Modest; AIMM Therapeutics, Allogene Therapeutics, Amgen, Merus, Neogene Therapeutics, Neon Therapeutics. F. Consultant/Advisory Board; Modest; Adaptive Biotechnologies, AIMM Therapeutics, Allogene Therapeutics, Amgen, Merus, Neon Therapeutics, Scenic Biotech. Other; Modest; Third Rock Ventures. G.V. Long: F. Consultant/Advisory Board; Modest; Aduro, Amgen, BMS, Mass-Array, Pierre-Fabre, Novartis, Merck MSD, Roche. C.U. Blank: B. Research Grant (principal investigator, collaborator or consultant and pending grants as well as grants already received); Modest; BMS, Novartis, NanoString. E. Ownership Interest (stock, stock options, patent or other intellectual property); Modest; Uniti Cars, Neon Therapeutics, Forty Seven. F. Consultant/Advisory Board; Modest; BMS, MSD, Roche, Novartis, GSK, AZ, Pfizer, Lilly, GenMab, Pierre-Fabre.
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Tetzlaff MT, Messina JL, Stein JE, Xu X, Amaria RN, Blank CU, van de Wiel BA, Ferguson PM, Rawson RV, Ross MI, Spillane AJ, Gershenwald JE, Saw RPM, van Akkooi ACJ, van Houdt WJ, Mitchell TC, Menzies AM, Long GV, Wargo JA, Davies MA, Prieto VG, Taube JM, Scolyer RA. Pathological assessment of resection specimens after neoadjuvant therapy for metastatic melanoma. Ann Oncol 2019; 29:1861-1868. [PMID: 29945191 DOI: 10.1093/annonc/mdy226] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Clinical trials have recently evaluated safety and efficacy of neoadjuvant therapy among patients with surgically resectable regional melanoma metastases. To capture informative prognostic data connected to pathological response in such trials, it is critical to standardize pathologic assessment and reporting of tumor response after this treatment. Methods The International Neoadjuvant Melanoma Consortium meetings in 2016 and 2017 assembled pathologists from academic centers to develop consensus guidelines for pathologic examination and reporting of surgical specimens from AJCC (8th edition) stage IIIB/C/D or oligometastatic stage IV melanoma patients treated with neoadjuvant-targeted or immune therapy. Patterns of pathologic response are provided context to inform these guidelines. Results Based on our collective experience and guided by efforts in well-established neoadjuvant settings like breast cancer, procedures directing handling of pre- and post-neoadjuvant therapy-treated melanoma specimens are provided to facilitate comparison of findings across different trials and centers. Definitions of pathologic response are provided together with guidelines for reporting and quantifying the extent of pathologic response. Finally, the spectrum of histopathologic responses observed following neoadjuvant-targeted and immune-checkpoint therapy is described and illustrated. Conclusions Standardizing pathologic evaluation of resected melanoma metastases following neoadjuvant-targeted or immune-checkpoint therapy allows more robust stratification of patient outcomes. This includes recognizing the spectrum of histopathologic response patterns to neoadjuvant therapy and a standard approach to grading pathologic responses. Such an approach will facilitate comparison of results across clinical trials and inform ongoing correlative studies into the mechanisms of response and resistance to agents applied in the neoadjuvant setting.
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Affiliation(s)
- M T Tetzlaff
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA.
| | - J L Messina
- Departments of Anatomic Pathology and Cutaneous Oncology, Moffitt Cancer Center, Tampa, USA
| | - J E Stein
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - X Xu
- Department of Pathology and Laboratory Medicine, The Hospital of the University of Pennsylvania, Philadelphia, USA
| | - R N Amaria
- Melanoma Medical Oncology Department, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - C U Blank
- The Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - P M Ferguson
- Melanoma Institute of Australia, The University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
| | - R V Rawson
- Melanoma Institute of Australia, The University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
| | - M I Ross
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - A J Spillane
- Melanoma Institute of Australia, The University of Sydney, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - J E Gershenwald
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - R P M Saw
- Melanoma Institute of Australia, The University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
| | | | - W J van Houdt
- The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - T C Mitchell
- Department of Medicine, The Hospital of the University of Pennsylvania, Philadelphia, USA
| | - A M Menzies
- Melanoma Institute of Australia, The University of Sydney, Royal North Shore and Mater Hospitals, Sydney, Australia
| | - G V Long
- Melanoma Institute of Australia, The University of Sydney, Royal North Shore Hospital, Sydney, Australia
| | - J A Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - M A Davies
- Department of Translational and Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA; Melanoma Medical Oncology Department, The University of Texas MD Anderson Cancer Center, Houston, USA; Department of Systems Biology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - V G Prieto
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA; Dermatology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - J M Taube
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - R A Scolyer
- Melanoma Institute of Australia, The University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
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8
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Lee JH, Saw RP, Thompson JF, Lo S, Spillane AJ, Shannon KF, Stretch JR, Howle J, Menzies AM, Carlino MS, Kefford RF, Long GV, Scolyer RA, Rizos H. Pre-operative ctDNA predicts survival in high-risk stage III cutaneous melanoma patients. Ann Oncol 2019; 30:815-822. [PMID: 30860590 PMCID: PMC6551453 DOI: 10.1093/annonc/mdz075] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The outcomes of patients with stage III cutaneous melanoma who undergo complete surgical resection can be highly variable, and estimation of individual risk of disease recurrence and mortality remains imprecise. With recent demonstrations of effective adjuvant targeted and immune checkpoint inhibitor therapy, more precise stratification of patients for costly and potentially toxic adjuvant therapy is needed. We report the utility of pre-operative circulating tumour DNA (ctDNA) in patients with high-risk stage III melanoma. PATIENTS AND METHODS ctDNA was analysed in blood specimens that were collected pre-operatively from 174 patients with stage III melanoma undergoing complete lymph node (LN) dissection. Cox regression analyses were used to evaluate the prognostic significance of ctDNA for distant metastasis recurrence-free survival and melanoma-specific survival (MSS). RESULTS The detection of ctDNA in the discovery and validation cohort was 34% and 33%, respectively, and was associated with larger nodal melanoma deposit, higher number of melanoma involved LNs, more advanced stage and high lactate dehydrogenase (LDH) levels. Detectable ctDNA was significantly associated with worse MSS in the discovery [hazard ratio (HR) 2.11 P < 0.01] and validation cohort (HR 2.29, P = 0.04) and remained significant in a multivariable analysis (HR 1.85, P = 0.04). ctDNA further sub-stratified patients with AJCC stage III substage, with increasing significance observed in more advanced stage melanoma. CONCLUSION Pre-operative ctDNA predicts MSS in high-risk stage III melanoma patients undergoing complete LN dissection, independent of stage III substage. This biomarker may have an important role in determining prognosis and stratifying patients for adjuvant treatment.
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Affiliation(s)
- J H Lee
- Faculty of Medicine and Health Sciences, Macquarie University, Macquarie Park, NSW; Melanoma Institute Australia, Wollstonecraft, NSW
| | - R P Saw
- Melanoma Institute Australia, Wollstonecraft, NSW; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Camperdown, NSW; Sydney Medical School, The University of Sydney, Camperdown, NSW
| | - J F Thompson
- Melanoma Institute Australia, Wollstonecraft, NSW; Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Camperdown, NSW; Sydney Medical School, The University of Sydney, Camperdown, NSW
| | - S Lo
- Melanoma Institute Australia, Wollstonecraft, NSW; Sydney Medical School, The University of Sydney, Camperdown, NSW
| | - A J Spillane
- Melanoma Institute Australia, Wollstonecraft, NSW; Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW
| | - K F Shannon
- Melanoma Institute Australia, Wollstonecraft, NSW; Chris O'Brien Lifehouse, Camperdown, NSW
| | - J R Stretch
- Melanoma Institute Australia, Wollstonecraft, NSW
| | - J Howle
- Crown Princess Mary Cancer Centre, Westmead and Blacktown hospitals, Wentworthville, NSW
| | - A M Menzies
- Melanoma Institute Australia, Wollstonecraft, NSW; Sydney Medical School, The University of Sydney, Camperdown, NSW; Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW
| | - M S Carlino
- Melanoma Institute Australia, Wollstonecraft, NSW; Sydney Medical School, The University of Sydney, Camperdown, NSW; Crown Princess Mary Cancer Centre, Westmead and Blacktown hospitals, Wentworthville, NSW
| | - R F Kefford
- Faculty of Medicine and Health Sciences, Macquarie University, Macquarie Park, NSW; Melanoma Institute Australia, Wollstonecraft, NSW; Crown Princess Mary Cancer Centre, Westmead and Blacktown hospitals, Wentworthville, NSW
| | - G V Long
- Melanoma Institute Australia, Wollstonecraft, NSW; Sydney Medical School, The University of Sydney, Camperdown, NSW; Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW
| | - R A Scolyer
- Melanoma Institute Australia, Wollstonecraft, NSW; Sydney Medical School, The University of Sydney, Camperdown, NSW; Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - H Rizos
- Faculty of Medicine and Health Sciences, Macquarie University, Macquarie Park, NSW; Melanoma Institute Australia, Wollstonecraft, NSW.
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9
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Flitcroft KL, Brennan ME, Costa DSJ, Spillane AJ. Regional variation in immediate breast reconstruction in Australia. BJS Open 2017; 1:114-121. [PMID: 29951613 PMCID: PMC5989981 DOI: 10.1002/bjs5.19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/24/2017] [Indexed: 11/09/2022] Open
Abstract
Background Breast reconstruction following mastectomy has proven benefits and is the standard of care in many high‐income countries. This audit documented regional variation in immediate breast reconstruction rates across Australia. Methods The Breast Surgeons of Australia and New Zealand (BreastSurgANZ) Quality Audit database and geospatial software were used to model the distribution of breast reconstructions performed on women having mastectomy in Australia in 2013. Geospatial mapping identified the distribution of these procedures in relation to the Greater Capital City Statistical Areas (GCCSAs) of the five largest states. Data were analysed using χ2 tests of independence and an independent‐samples t test. Results Of 3786 patients having a mastectomy, 692 underwent breast reconstruction of which 679 (98·1 per cent) were immediate reconstructions. Rates of reconstruction differed significantly between jurisdictions (χ2 = 164·90), and were significantly higher in GCCSAs (χ2 = 144·60) and private hospitals (χ2 = 50·72) (all P < 0·001). Immediate breast reconstruction was not reported for 43·8 per cent of hospitals where mastectomy was conducted by members of BreastSurgANZ, including 29·8 per cent of hospitals within GCCSAs. A wider age range of women appeared to have had immediate reconstructions at hospitals within GCCSAs, although the difference in mean age between regions was not significant. Immediate breast reconstruction was considerably less likely to be performed in women who lived in areas of lower to mid socioeconomic status. Conclusion Variations in the rate of immediate breast reconstruction may not be purely resource‐driven.
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Affiliation(s)
- K L Flitcroft
- Breast and Surgical Oncology at the Poche Centre University of Sydney Sydney Australia.,Northern Clinical School University of Sydney Sydney Australia
| | - M E Brennan
- Breast and Surgical Oncology at the Poche Centre University of Sydney Sydney Australia.,Northern Clinical School University of Sydney Sydney Australia
| | - D S J Costa
- Pain Management Research Unit University of Sydney at Royal North Shore Hospital St Leonards, New South Wales Australia
| | - A J Spillane
- Breast and Surgical Oncology at the Poche Centre University of Sydney Sydney Australia.,Northern Clinical School University of Sydney Sydney Australia.,Surgical Oncology, Breast and Endocrine Surgery Department, Mater Hospital Sydney Australia.,Surgical Oncology, Breast and Endocrine Surgery Department, Royal North Shore Hospital St Leonards, New South Wales Australia
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10
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Martin RCW, Shannon KF, Quinn MJ, Saw RPM, Spillane AJ, Stretch JR, Colman MH, Gao K, Thompson JF. The management of cervical lymph nodes in patients with cutaneous melanoma. Ann Surg Oncol 2012; 19:3926-32. [PMID: 22669449 DOI: 10.1245/s10434-012-2374-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aim of this study was to review the management of cervical lymph nodes in patients with cutaneous melanoma and to analyze factors influencing prognosis. METHODS This was a retrospective cohort study of patients who had cervical node surgery at the Sydney Melanoma Unit from 1990 to 2004. RESULTS Of 716 patients who met the study criteria, 339 had a sentinel node biopsy (SNB) and 396 had a neck dissection. Locoregional recurrence occurred in 27.6 % of those undergoing therapeutic neck dissection and 60 % eventually developed distant metastases. Radiotherapy was given as adjuvant treatment in 110 of the patients who had a therapeutic neck dissection (41 %), but this was not associated with improved regional control (p = .322). Multivariate analysis showed that nodal positivity (p < .001) and primary tumor ulceration (p = < .027) were the most important predictors of locoregional recurrence and that primary tumor Breslow thickness (p = .009) and node positivity (p = .046) were the most important factors predicting survival. SNB-positive patients who underwent immediate completion lymphadenectomy had a 5-year survival advantage over those who had a therapeutic neck dissection for macroscopic disease (54 % vs 47 %, p = .028). CONCLUSIONS Nodal status was the most important factor predicting disease-free and overall survival in patients with melanoma of the head and neck. Adjuvant radiotherapy was not associated with better locoregional control in the non-randomized cohorts of patients in this study.
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Affiliation(s)
- R C W Martin
- Melanoma Institute Australia (Formerly the Sydney Melanoma Unit), North Sydney, NSW, Australia
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11
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Uren RF, Howman-Giles R, Chung DKV, Spillane AJ, Noushi F, Gillett D, Gluch L, Mak C, West R, Briody J, Carmalt H. SPECT/CT scans allow precise anatomical location of sentinel lymph nodes in breast cancer and redefine lymphatic drainage from the breast to the axilla. Breast 2011; 21:480-6. [PMID: 22153573 DOI: 10.1016/j.breast.2011.11.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 11/09/2011] [Accepted: 11/16/2011] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Historical studies of lymphatic drainage of the breast have suggested that the lymphatic drainage of the breast was to lymph nodes lying in the antero-pectoral group of nodes in the axilla just lateral to the pectoral muscles. The purpose of this study was to confirm this is not correct. METHODS The hybrid imaging method of SPECT/CT allows the exact anatomical position of the sentinel lymph node (SLN) in the axilla to be documented during pre-operative lymphoscintigraphy (LS) in patients with breast cancer. We have done this in a series of 741 patients. The Level I axillary nodes were defined as anterior, mid or posterior. This was related to the anatomical location of the primary cancer in the breast. RESULTS A SLN was found in the axilla in 97.8% of our patients. Just under 50% of SLNs located in the axilla were not in the anterior group and lay in the mid or posterior group of Level I axillary nodes. There was a SLN in a single node field in 460 patients (63%), two node fields in 261(36%), three node fields in 6 and four node fields in 1 patient. CONCLUSION Axillary lymphatic drainage from the breast is not exclusively to the anterior (or antero-pectoral) group of Level I nodes. SYNOPSIS SPECT/CT lymphoscintigraphy shows that the breast does not always drain to the anterior group of Level I lymph nodes in the axilla but may drain to the mid axilla and/or posterior group in about 50% of patients with breast cancer regardless of the location of the cancer in the breast. These data redefine lymph drainage from the breast to axillary lymph nodes.
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Affiliation(s)
- R F Uren
- Nuclear Medicine and Diagnostic Ultrasound, RPAH Medical Centre, Sydney, NSW, Australia.
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Abstract
Purpose. To report the phenomenon of infected retroperitoneal sarcoma (RPS). Method. Two case reports. Results. Both patients died soon after laparotomy. Discussion. Infected RPS is identified as an entity not clearly documented in the literature. It should probably be added to the list of poor prognostic factors when planning the management of patients with RPS.
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Affiliation(s)
- A J Spillane
- Melanoma and Sarcoma Unit Royal Marsden Hospital Fulham Road London SW3 6JJ UK
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13
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Noushi F, Spillane AJ, Uren RF, Gebski V. Internal mammary lymph node metastasis in breast cancer: predictive models to assist with prognostic influence. Breast 2011; 20:278-83. [PMID: 21310616 DOI: 10.1016/j.breast.2010.12.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 10/12/2010] [Accepted: 12/23/2010] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Metastatic breast cancer in the internal mammary nodes (IMN) indicates a poor prognosis. Several recent epidemiological surveys have determined a reduction in survival for patients with medial compared to lateral sector tumors attributing this to a higher rate of unrecognized IMN metastasis and hence these patients are undertreated with adjuvant therapy.(1-6) AIM Through mathematical modeling based on large datasets we aim to quantify the impact on survival of IMN metastases at different tumor and axillary stages. METHODS Mathematical models were created to estimate the survival of patients with and without IMN metastasis. It was assumed that the different rate of survival between medial and lateral sector breast cancers was a result of the differential rate of unrecognized IMN metastases with resultant under-staging and under treatment. We applied these models on a retrospective database analysis from the Surveillance, Epidemiology and End-Results (SEER) registries from 1994 to 2003. RESULTS The 10-year odds of death (OOD) from breast cancer for patients with medial compared with lateral sector tumors ranged from 1.2 to 1.5 depending on stage. The predicted odds of breast cancer death for patients with unrecognized IMN metastases ranged from 2.4 to 20, with the highest OOD in the groups with small tumors and no axillary node metastasis. CONCLUSIONS Through modeling we have been able to predict and quantify the significantly worse survival outcomes for patients with undiagnosed IMN metastasis.
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Affiliation(s)
- F Noushi
- Department of Surgical Oncology, Mater and Royal North Shore Hospital, University of Sydney, Lindfield, NSW 2071, Sydney, Australia.
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14
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Spillane AJ, Brennan ME. Accuracy of sentinel lymph node biopsy in large and multifocal/multicentric breast carcinoma--a systematic review. Eur J Surg Oncol 2011; 37:371-85. [PMID: 21292433 DOI: 10.1016/j.ejso.2011.01.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 12/31/2010] [Accepted: 01/10/2011] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND While sentinel lymph node biopsy (SLNB) is established in the management of small unifocal breast cancer its role in management of multifocal (MF), multicentric (MC) and larger tumors is still evolving. METHODS Medline was searched; studies meeting pre-determined criteria were included. Data were extracted and entered into evidence tables. RESULTS Twenty six studies met inclusion criteria and reported data on accuracy; no randomized trials were identified. For MF cancers (n = 314 cases), success rate for identification of an SLN was 86-94%, SLN positivity rate 42-59%, false negative rate (FNR) 0-33% and overall accuracy 78-100%. For MC (n = 294 cases): success rate 92-100%, SLN positivity rate 25-61%, FNR 4-8% and accuracy 96-100%. For 'multiple breast cancer' (studies combining MF/MC cases; n = 996 cases): success rate 92-100%, SLN positivity rate 12-63%, FNR 0-25%, and accuracy 82-100%. For larger tumors (n = 1912 cases): success rate 86-100%, SLN positivity rate 49-77%, FNR 3-18% and accuracy 85-98%. For MC/MF and larger cancers overall non-SLN positivity rates were up to 82%; axillary recurrence rates were low but seldom reported. CONCLUSION There are no randomized trials evaluating the safety of SLNB in MF/MC and larger breast cancers. Based on limited evidence, success rate and FNR appear to be similar to those for small unifocal cancers, however node positivity rates are higher and rates of non-SLN positivity are very high. Awareness of these issues is essential when recommending SLNB based axillary management for these higher-risk tumors.
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Affiliation(s)
- A J Spillane
- Breast and Surgical Oncology at The Poche Centre, 40 Rocklands Rd, North Sydney, NSW 2060, Australia.
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Brennan ME, Spillane AJ. Abstract P1-01-03: Accuracy of Sentinel Lymph Node Biopsy in Large and Multifocal/Multicentric Breast Carcinoma — Systematic Review. Cancer Res 2010. [DOI: 10.1158/0008-5472.sabcs10-p1-01-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Sentinel lymph node biopsy (SLNB) is well established for management of small unifocal breast cancers. As confidence in SLNB increases, use of SLN-based management has increased and it is now often used for axillary staging in cases of multifocal (MF) and multicentric (MC) breast cancer and larger tumors although its role in the management of these tumors is controversial.
The aim of this study is to systematically review the evidence for SLNB in axillary staging for newly diagnosed invasive breast cancer that is MF/MC or greater than 30mm in diameter. Studies reporting accuracy of SLNB in these situations are reviewed and implications for patient management are discussed.
Methods: Medline was searched, identifying 3,461 studies of SLNB in breast cancer. Of these, 57 abstracts met the eligibility criteria which were: (a) original studies that reported (b) outcomes of SLNB in invasive breast cancer and (c) outcomes separately for a population of women with tumors that were either MF/MC or diameter 30mm or greater. Following review of full text articles, 36 studies were excluded as they did not meet criteria; two more studies were added after review of reference lists. Results: 23 studies met inclusion criteria and reported 20,687 cases of SLNB. This included data on accuracy for 1,541 MF, 369 MC, and 1,646 larger tumors. All included studies were case series; no randomized controlled trials were identified. Injection for lymphatic mapping was variably performed in site and technique and was variably reported. For MF cancers (n=976; 8 studies), success rate for identification of a SLN was 86-100%, SLN positivity rate 42-59%, false negative rate (FNR)
6-33%(with 4 of the 7 case series reporting false negative rates over 21%). The overall accuracy for MF tumors was 75-97%. For MC cancers (n=262; 4 studies): success rate for identification of a SLN 92-96%, SLN positivity rate 50-61%, FNR 0-8% and accuracy 96-100%. For ‘multiple breast cancer’ (n=688; 8 studies combining MF/MC cases): success rate for identification of a SLN 93-100%, SLN positivity rate 11-63%, FNR
6-13%, and accuracy 93-98%. For larger tumors (n=1646; 9 studies): success rate for identification of a SLN 86-100%, SLN positivity rate 42-59%, FNR 3-16.2% and accuracy 88-97.7%. For MF/MC and larger cancers overall non-SLN positivity rates were up to 82%; axillary recurrence rates were low but not often reported.
Conclusion: Although the evidence suggests that success rate and FNR of SLNB in MF/MC and larger tumors are similar to small unifocal cancers, node positivity rates are higher in these breast cancers and this translates to higher rates of understaging in real terms. High rates of non-SLN positivity for these tumors compared to rates for lower risk tumors mean that omitting ALND in the case of a positive SLNB risks leaving disease in the axilla more often than previously accepted. Thus the evidence supports the use of ALND in the majority of cases when the SLNB is positive. Women must be made aware that the high likelihood of positive axillary lymph nodes in MF/MC and larger breast tumors. Relying on SLNB-based management means accepting a higher risk of understaging and/or under treatment than when using SLNB based management for lower risk tumors.
Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-03.
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Affiliation(s)
- ME Brennan
- The Poche Centre, North Sydney, NSW, Australia; University of Sydney, NSW, Australia; The Mater Hospital, North Sydney, NSW, Australia; Royal North Shore Hospital, St Leonards, NSW, Australia
| | - AJ Spillane
- The Poche Centre, North Sydney, NSW, Australia; University of Sydney, NSW, Australia; The Mater Hospital, North Sydney, NSW, Australia; Royal North Shore Hospital, St Leonards, NSW, Australia
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Spillane AJ. BS02�SENTINEL NODE BIOPSY FOR LOCALLY RECURRENT BREAST CANCER. ANZ J Surg 2009. [DOI: 10.1111/j.1445-2197.2009.04913_2.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Spillane AJ, Noushi F, Cooper R, Uren RF. The anatomically correct incidence of internal mammary node drainage on lymphoscintigraphy. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-1024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Abstract #1024
Background: The documented rate of IMN drainage on lymphoscintigraphy ranges from <2% to 38% depending on the technique utilized and the radio-isotope used. The relevance of IMN drainage is debated. Surgeons and oncologists who work in an environment where IMN drainage is rare have no practical perspective of how it may impact on individual patient management decisions. Those who work in an environment where up to 38% of cases drain to the IMN are familiar with the impact on management. A recently published anatomical model of breast lymphatic drainage1 correlates well with the findings on lymphoscintigraphy using a peritumoral injection technique but not with superficial injections.
 Methods: Two separate nuclear medicine facilities' prospective data bases were used to document their IMN drainage rates on lymphoscintigraphy over 15 years and 7 years respectively. Lymphoscintigraphy was done using a technique of peritumoral injection with antimony sulfide colloid. Review of the literature was done to identify the parameters indicating success at demonstrating IMN drainage and the rates of positivity of IMN.
 Results: The 2 facilities identified axillary sentinel nodes in 95.5% and 93.6% of cases respectively. Facility U had a 34% IMN drainage rate. It varied between 28% and 48 % over the 15 year period (first 9 years 316 cases at a rate of 40%; later 6 years 1438 cases at 33%). Facility C had an overall IMN drainage rate of 29%. The initial drainage rate of 19% fluctuated to 36% over the 7 year period (first 4 years 186 cases at 25%; later 3 years 421 cases at 31%). The increasing IMN drainage rate at Facility C was associated with increasing case volume and modifications in technique, quality of collimators and gamma cameras. Literature review shows rates of IMN drainage vary widely but not exceed of 38%. Transpectoral IMN biopsy positivity rates range from 13 – 25% and are not related to the rate of IMN drainage at the facility.
 Conclusion: Recent anatomical models of breast lymphatic drainage1 correlate well with both facilities' patterns of IMN drainage. These facilities results and the available literature suggests that the true rate of IMN drainage is around 35%. Technical modifications resulted in Facility C converging on this parameter. High quality lymphatic mapping with peritumoral injections is the best known demonstrator of breast lymphatic anatomy. An institution finding lower rates of IMN drainage reflects technical issues and not the true anatomy of the breast. The remarkably constant rate of positive lymph nodes irrespective of the IMN drainage rate is supportive of the above conclusions. There is compelling contemporary evidence that IMN positivity is a strong predictor of worse prognosis and this information is important information when making adjuvant therapy decisions.
 1. Suami H, Pan WR, Mann GB, et al: The lymphatic anatomy of the breast and its implications for sentinel lymph node biopsy: a human cadaver study. Ann Surg Oncol 15:863-71, 2008.
Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1024.
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Affiliation(s)
- AJ Spillane
- 1 Surgical Oncology, University of Sydney, North Sydney, NSW, Australia
| | - F Noushi
- 1 Surgical Oncology, University of Sydney, North Sydney, NSW, Australia
| | - R Cooper
- 2 Nuclear Medicine, Mater Hospital, North Sydney, NSW, Australia
| | - RF Uren
- 3 Nuclear Medicine and Ultrasound, University of Sydney, Newtown, NSW, Australia
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Spillane AJ, Brennan ME. Minimal access breast surgery: a single breast incision for breast conservation surgery and sentinel lymph node biopsy. Eur J Surg Oncol 2008; 35:380-6. [PMID: 18757165 DOI: 10.1016/j.ejso.2008.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Revised: 07/16/2008] [Accepted: 07/18/2008] [Indexed: 11/19/2022] Open
Abstract
AIMS Minimal access breast surgery (MABS) is a procedure that completes breast conservation surgery (BCS) and sentinel node biopsy (SNB) through a single incision. It allows access to axillary sentinel nodes via the breast incision and also provides access to the internal mammary nodes (IMN) as well as other nodal sites when needed. The aims of this study are to describe the MABS approach and to evaluate its safety and efficacy in cases undergoing BCS and SNB (axillary or IMN) for treatment of breast cancer. METHODS The surgical technique for MABS is described. One hundred and three consecutive clinically lymph node negative patients undergoing BCS and SNB (axillary or IMN) were considered for MABS. Cases were classified according to the location of sentinel nodes dissected (axillary, internal mammary or other), the location of the tumour and whether MABS was used. The success of MABS was calculated based on the number of cases where BCS and SNB were completed through a single breast incision. Number of lymph nodes (LN) retrieved, rate of LN positivity, aesthetics and complications were documented. RESULTS Eighty-six percent of cases of BCS with axillary-only SNB were completed with MABS. For cases of BCS with axillary and IMN SNB, MABS was successful for BCS and IMN SNB in 97% of cases and for BCS and SNB from both nodal regions in 63%. There was only one case, a woman with breast prostheses, who required three separate incisions. When axillary-only SNB cases were completed with MABS, an average of 2.9 axillary LN per case with a 29% axillary LN positivity rate was seen. When axillary and IMN SNB were completed with MABS for both regions, an average of 3.0 axillary LN per case were retrieved with an axillary LN positivity rate of 65%. When separate axillary and breast incisions were made, 2.7 LN per case were removed with an axillary LN positivity rate of 30%. Aesthetics were excellent and there were no complications associated with reaching the nodes through the breast incision. CONCLUSION MABS is a feasible option for the majority of women undergoing BCS and SNB and it does not compromise the success of SNB.
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Affiliation(s)
- A J Spillane
- The University of Sydney, Northern Clinical School, Sydney, NSW, Australia.
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Soni NK, Carmalt HL, Gillett DJ, Spillane AJ. Evaluation of a breast cancer nomogram for prediction of non-sentinel lymph node positivity. Eur J Surg Oncol 2005; 31:958-64. [PMID: 15979270 DOI: 10.1016/j.ejso.2005.04.011] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2005] [Accepted: 04/22/2005] [Indexed: 02/06/2023] Open
Abstract
AIMS This study evaluates the breast cancer nomogram (BCN), an online tool developed by Memorial Sloan-Kettering Cancer Center to determine the rate of non-SLN positivity, in an independent cohort of SLN positive patients. MATERIAL AND METHODS Available data between 02/2000 and 06/2004 in two prospective databases, 749 cases had successful SLN biopsy including 149 axillary-SLN metastases study cases. These cases had accurately graded tumours up to 9 cm in size and CAD with a minimum total 10 nodes removed. Histopathological assessment of nodes included hematoxylin and eosin staining and/or immunohistochemistry. Computerized BCN was used to estimate probability of non-SLN positivity and compared with actual probability after grouping into deciles. RESULTS The trend of actual probability in various decile groups was comparable to the predicted probability. An area under the receiver operating characteristic curve was 0.75 as compared to 0.76 in the original study. CONCLUSION Although this study is small, the results are encouraging and suggest the nomogram is a useful tool to estimate the likelihood of positive axillary non-SLN. However, variations in pathological assessment between centres are the major impediment to widespread application of BCN. If SLN positive patients decline the standard recommendation of CAD or entry into clinical trials evaluating the significance of CAD then the BCN could help in decision making.
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Affiliation(s)
- N K Soni
- Breast Surgery, Sydney Breast Cancer Institute, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Hong J, Choy E, Chog E, Soni N, Carmalt H, Gillett D, Spillane AJ. Extra-axillary sentinel node biopsy in the management of early breast cancer. Eur J Surg Oncol 2005; 31:942-8. [PMID: 16229984 DOI: 10.1016/j.ejso.2005.08.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2005] [Accepted: 08/04/2005] [Indexed: 11/23/2022] Open
Abstract
AIM To document of our experience with EAS SNB and evaluate its impact on the staging, management and the associated morbidities of patients with early breast cancer. METHOD A review of two prospective breast cancer databases identifying all SNB procedures performed at two affiliated breast units from 1998 to 2003. RESULTS A series of 979 patients underwent lymphatic mapping. Sentinel nodes were successfully identified in 903 patients. There were 142 cases in which lymphoscintigraphy identified EAS. In 17 cases extraaxillary sentinel nodes were identified with lymphoscintigraphy but could not be removed. There were 138 cases where internal mammary nodes (IMN) were removed. Of those IMN removed 25 were positive for metastases and in six of these cases only the IMN was positive. Of the 21 cases where other EAS were identified there was one case in which a supraclavicular sentinel node was positive. Twenty-five of the 26 positive sentinel nodes in EAS were macrometastases and one was a micrometastasis. No significant morbidity resulted from biopsy of EAS SNB. During IMN SNB there were eight pleural breeches, which did not result in pneumothoraces, and one case in which bleeding was difficult to control. CONCLUSION EAS SNB is technically feasible in the majority of cases. Minimal morbidity occurs after an initial learning phase. IMN SNB was shown to have significant impact on the staging and management in 18% of patients when IMNs were identified with lymphoscintigraphy. The impact of other extraaxillary lymph nodes is more difficult to assess due to small numbers. As there is little morbidity and valuable information is gained in a significant percentage of cases we strongly advocate EAS SNB.
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Affiliation(s)
- J Hong
- Sydney Cancer Centre, Breast Unit, Royal Prince Hospital, Sydney, NSW, Australia
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Abstract
BACKGROUND Retroperitoneal sarcoma (RPS) is considered a disease with poor prognosis partly because of the difficulty with diagnosis at an early stage. This review assesses the current best practice principles for RPS and finds evidence suggesting a better outlook for appropriately managed cases. Recommendations are made for improving diagnostic certainty before laparotomy and inappropriate transperitoneal biopsy occur. METHODS A critical review of the English language literature was conducted using MEDLINE software and searching the terms 'retroperitoneal sarcoma' alone or in combination with 'prognosis', 'surgery' and 'adjuvant therapy'. CONCLUSIONS Retroperitoneal sarcoma is a rare disease but when appropriately managed the disease-free survival can be improved and may even approach that of extremity soft tissue sarcoma. One of the greatest barriers to improving outcome is the misinterpretation of clinical signs and an over-reliance on ultrasound diagnosis in pelvic presentations, or misinterpretation of clinical signs and/or computer tomography (CT) scans in abdominal masses. Physicians referring patients with a retroperitoneal mass should consider more frequently the less common differential diagnoses of an abdominopelvic mass including retroperitoneal sarcoma. This is especially true in circumstances where there is a circumscribed, predominantly solid tumour, with clinical or radiological signs of vascular or rectal displacement, ureteric obstruction and/or classic renal rotational displacement. The more frequent use of CT scans with intravenous and oral contrast with referral prior to inappropriate transperitoneal biopsy is recommended. In atypical cases where preoperative biopsy is necessary, extraperitoneal routes are preferable. Complete en bloc surgical excision at the first laparotomy is the treatment of choice in RPS. Macroscopic clearance may necessitate resection of adjacent viscera, neurovascular structures or abdominopelvic walls but, if achieved, may lead to long-term survival depending on individual tumour biology.
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Affiliation(s)
- A J Spillane
- Sydney Cancer Centre, Royal Prince Alfred Hospital, New South Wales, Australia.
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Spillane AJ, Kennedy CW, Gillett DJ, Carmalt HL, Janu NC, Rickard MT, Donnellan MJ. Screen-detected breast cancer compared to symptomatic presentation: an analysis of surgical treatment and end-points of effective mammographic screening. ANZ J Surg 2001; 71:398-402. [PMID: 11450913 DOI: 10.1046/j.1440-1622.2001.02144.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Mammographic screening has been shown to reduce mortality from breast cancer and to offer more opportunity for breast conservation surgery (BCS). The minimum standards (or surrogate end-points) that need to be achieved by a screening programme if it is to reduce mortality have been derived from the Two County Study. Three surrogate end-points that can be used to gauge the quality of the screening service are that 50% of the identified infiltrating cancers should be < 15 mm; at least 30% of grade 3 cancers should be < 15 mm; and 70% of screen-detected cancers should have a negative axillary dissection. The present study assesses these end-points of effective screening in an urban population referred to The Strathfield Breast Centre (TSBC). The screening end-points and surgical treatment of one group of women referred with a BreastScreen New South Wales (NSW)-detected breast cancer (screen group) were compared to all the other, mostly symptomatic, breast cancer referrals (symptom group). The problems with the current pattern of acceptance of mammographic screening in TSBC's referral area are discussed. METHODS A prospective non-randomized study was done via analysis of the prospective database at The Strathfield Breast Centre (TSBC). RESULTS There were 224 women in the screen group and 657 women in the symptom group. The mean tumour size was 18.1 mm in the screen group and 22.1 mm in the symptom group. There were significantly more small invasive cancers (< 15 mm) in the screen group (58%) compared with the symptom group (33%; P < 0.001). In the screen group there were more low-grade tumours but 30% of grade 3 tumours were < 15 mm compared with 16% in the symptom group (P = 0.009). In patients with invasive cancers who underwent axillary dissection, there was a significant difference in axillary node negativity, being 72% in the screen group and 59% in the symptom group (P = 0.003). In the screen group 64% of women had BCS compared with 51% in the symptom group (P = 0.002). CONCLUSIONS These end-points of effective mammographic screening were met in the BreastScreen NSW group of women who were referred to TSBC despite the biases involved which could lessen the effectiveness of the screening programme. This crudely translated into a significant reduction in breast cancer mortality but selection and lead time bias has to be taken into account in evaluation of these data. There was a significantly greater chance of BCS in the screen group.
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Affiliation(s)
- A J Spillane
- Sydney Cancer Centre, Camperdown, New South Wales, Australia
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Abstract
BACKGROUND The biopsy method of choice for soft tissue sarcomas (STS) of the limb and limb girdle is controversial. There have been no randomized controlled trials that compare incision biopsy with Tru-cut biopsy. We present a large series, which includes an analysis of the effectiveness of Tru-cut core biopsy both in a tertiary referral center as well as from many referring hospitals. This is compared with the other methods of biopsy of all soft tissue tumors (STT) referred to this institution. METHODS A retrospective review of all patients who were referred to Royal Marsden Hospital NHS Trust (RMH) from 1989 to 1998. RESULTS There were 570 patients (576 lesions) identified. Overall Tru-cut biopsy differentiated benign from malignant tumors with a sensitivity of 99.4%, specificity 98.7%, positive predictive value 99.4%, and negative predictive value 98.7% with similar results for RMH and referral hospitals. Tru-cut identified both tumor subtype and grade in approximately 80% of STS. Incision biopsy had similar sensitivity and specificity for differentiating benign from malignant STT as well as subtype of STS but was less accurate for grade assessment. Tumors from patients who were referred after enucleation had a median maximum tumor diameter (MTD) of 4.9 cm, whereas median MTD of tumors diagnosed at referring hospitals by Tru-cut biopsy was 10.6 cm. (P < 0.001). CONCLUSION Tru-cut biopsy is highly sensitive and specific in the diagnosis of STT as well as subtyping and grading of STS. It is equally effective as incision biopsy in all these parameters and has a lesser morbidity. The failure to use Tru-cut biopsy is most likely because of the possibility that STS is not suspected in patients with small tumors even when they are deep to the investing fascia.
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Affiliation(s)
- I Hoeber
- Sarcoma Unit, Royal Marsden Hospital, London, UK
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Abstract
PURPOSE Synovial sarcoma (SS) is a common soft tissue sarcoma (STS) with a propensity for young adults and notable sensitivity to chemotherapy (CT). This study provides a current clinicopathologic, staging, and prognostic assessment for SS. The problems with the current American Joint Committee for Cancer (AJCC) Staging System in relation to SS are discussed. METHODS Review of a prospective database supplemented by retrospective data. RESULTS One hundred fifty patients were assessed; median age was 30 years and median follow-up was 52 months. Overall actuarial 5-year survival rate was 57%. Size trend, but not a cutoff of less than 5 cm versus > or = 5 cm, was a prognostic indicator (P <.001). The current AJCC/International Union Against Cancer Staging System differentiated prognosis less well than the recently proposed Royal Marsden Hospital Staging System. Age greater than 20 years at diagnosis implied worse prognosis. A local recurrence event was associated with a worse survival (P <.001). Therapeutic CT was administered to 55 patients. Eleven of 19 patients had an objective response to a combination of ifosfamide and doxorubicin. Four cases had complete response after CT. Twenty-one patients had pulmonary metastasectomy, with an actuarial 5-year survival rate of 23%. CONCLUSION SS tends to affect young people. In this subtype of STS, size trend is the most significant influence on stage and hence survival; however, smaller SSs have an unexpectedly poor prognosis. Adequate local control may affect survival. SS is often chemosensitive, and given its poor prognosis, multicenter trials of adjuvant therapy are warranted.
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Affiliation(s)
- A J Spillane
- Sarcoma Unit, Royal Marsden Hospital, London, United Kingdom.
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Abstract
BACKGROUND Controversy continues to surround the best practice for management of the axilla in patients with early breast cancer (EBC), particularly the clinically negative axilla. The balance between therapeutic and staging roles of axillary surgery (with the consequent morbidity of the procedures utilized) has altered. This is due to the increasing frequency of women presenting with early stage disease, the more widespread utilization of adjuvant chemoendocrine therapy and, more recently, the advent of alternative staging procedures, principally sentinel node biopsy (SNB). The aim of the present review is to critically analyse the current literature concerning the preferred management of the axilla in early breast cancer and make evidence-based recommendations on current management. METHODS A review was undertaken of the English language medical literature, using MEDLINE database software and cross-referencing major articles on the subject, focusing on the last 10 years. The following combinations of key words have been searched: breast neoplasms, axilla, axillary dissection, survival, prognosis, and sentinel node biopsy. RESULTS Despite the trend to more frequent earlier stage diagnosis, levels I and II axillary dissection remain the treatment of choice in the majority of women with EBC and a clinically negative axilla. CONCLUSIONS Sentinel node biopsy has no proven superiority over axillary dissection because no randomized controlled trials have been completed to date. Despite this, SNB will become increasingly utilized due to encouraging results from major centres responsible for its development, and patient demand. Therefore if patients are not being enrolled in clinical trials strict quality controls need to be established at a local level before SNB is allowed to replace standard treatment of the axilla. Unless this is strictly adhered to there is a significant risk of an increase in the frequency of axillary relapse and possible increased understaging and resultant inadequate treatment of patients.
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Affiliation(s)
- A J Spillane
- Breast Unit, Royal Marsden Hospital, London, UK.
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Abstract
BACKGROUND Epithelioid sarcoma is a rare high grade soft tissue sarcoma with a known propensity for locoregional recurrence. The literature is limited on other characteristics such as frequency of multifocal disease at presentation, the relationship of presenting size of the primary lesion to prognosis, and the ability of current staging systems to predict prognosis. METHODS Review of the Royal Marsden National Health Service Trust (RMH) experience of 37 cases over 21 years. RESULTS The mean age was 29 years, with male predominance (2.7:1), and distal limb locations were most common (56%). Five patients presented with multifocal local disease. Median follow-up was 88 months in the 19 patients still alive. The 5- and 10-year actuarial overall survival was 70% and 42%, respectively. Tumors deep to the investing fascia had a worse prognosis than superficial tumors. Regional metastasis events were also associated with significantly worse overall survival. Local recurrence, size of 5 cm or larger, and regional metastasis events were predictive of worse distant metastasis-free survival. Tumor size (<5 cm vs. > or =5 cm), local recurrence events, sex, and site were not significant predictors of survival. The American Joint Committee on Cancer/International Union Against Cancer staging systems and the recently proposed RMH staging system of the Royal Marsden National Health Service Trust provided poor differentiation of prognosis in epithelioid sarcoma. The 5-year actuarial local recurrence rate was 35%. The 5-year actuarial regional nodal metastasis rate was 23%. The actuarial 5-year distant metastasis rate was 40%, with pleuropulmonary metastases the most common site of metastatic disease, and 35% of pleuropulmonary metastases presented with pleural effusion. Median post-distant metastasis survival was 8 months. CONCLUSIONS Epithelioid sarcoma has unusual clinical behavior compared with other high grade soft tissue sarcoma. It has a propensity for multifocal disease at presentation, local recurrence, regional metastasis, and particularly poor prognosis after regional or distant metastatic disease. Size and stage according to the American Joint Committee on Cancer/International Union Against Cancer are unreliable predictors of prognosis.
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Affiliation(s)
- A J Spillane
- Sarcoma Unit, Royal Marsden Hospital, London, England, UK.
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Affiliation(s)
- T M Hughes
- Sarcoma Unit, Royal Marsden Hospital NHS Trust, Fulham Road, London SW3 6JJ, UK
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Abstract
OBJECTIVE To illustrate the problems associated with mistaken pre-operative diagnosis following gynaecological presentation of patients with retroperitoneal tumours. DESIGN A case series of five referrals. RESULTS Non-gynaecological tumours were not suspected in each case and hence there was a failure to undertake further pre-operative investigation and referral to a specialised soft tissue sarcoma service. This resulted in four of the patients having an unnecessary laparotomy with an inappropriate transperitoneal biopsy undertaken when the retroperitoneal tumour was discovered. The mistaken diagnosis of ovarian malignancy lead to increased morbidity, compromise of potential for a long disease free interval and/or possibly lessened the chance of cure in each case. CONCLUSIONS Misinterpretation of clinical signs and an over-reliance on ultrasound diagnosis were the commonest causes of inappropriate management of these patients. Gynaecologists should consider more frequently the other, less common differential diagnoses of a pelvic mass. This is especially true in circumstances with a predominantly solid tumour, where there are clinical signs of vascular or rectal displacement, or where there is ultrasound evidence of ureteric obstruction. The more frequent utilisation of a computerised tomography scan with intravenous and oral contrast with referral before inappropriate transperitoneal biopsy are recommended as complete en bloc surgical excision at the first laparotomy is the treatment of choice in virtually all primary retroperitoneal tumours.
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Affiliation(s)
- A J Spillane
- Melanoma and Sarcoma Unit, Royal Marsden Hospital, London, UK
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Spillane AJ, Sacks NP. Which patients with early breast cancer need axillary clearance? Swiss Surg 1999; 5:205-13. [PMID: 10546518 DOI: 10.1024/1023-9332.5.5.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The role of axillary surgery in the management of early breast cancer is currently the topic of intense debate in the literature. There are strong indications that women are presenting with earlier tumours and hence the majority have negative axillary nodes making axillary dissection less beneficial both in terms of disease control and less likely to result in an alteration of management. Alternative less morbid axillary staging and non-axillary staging methods are being investigated, but sentinel node biopsy shows the most promise for reliable assessment of the axilla. This review aims to assess the current literature regarding the role of axillary surgery in breast cancer management. The reasoning why axillary dissection is still the gold standard in breast cancer management is explained and related to the other methods of axillary assessment and therapy. Suggested guidelines for current optimal management are made.
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Affiliation(s)
- A J Spillane
- Department of Academic Surgery, Royal Marsden Hospital, London
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Abstract
AIM To demonstrate the pathological variety and highlight the surgical principles involved in the management of tumours of the iliopsoas compartment (IPC). METHODS Review of four clinical cases. RESULTS Adequate surgical resection or palliation was achieved in each case. CONCLUSION Resection of IPC tumours is feasible but access to the most superior part of the muscle may be impossible. An extraperitoneal approach is advocated.
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Abstract
BACKGROUND Myxoid liposarcomas (ML) make up the major subset of liposarcomas, which in most series represent the second or third most common type of soft tissue sarcoma. The tendency for ML to metastasize to other soft tissues (STM) in preference to lung parenchyma has been previously described; however, the natural history of this tumor's behavior is poorly documented. Our intent was to analyze the natural history of ML and further quantify the incidence of STM, concentrating on their significance in terms of survival. METHODS We reviewed the experience at the Royal Marsden Hospital over a 10-year period, documenting the clinicopathological behavior of ML, including the frequency of STM. RESULTS There were 50 patients, with a median follow-up of 43 months. The actuarial 5-year soft tissue metastasis rate was 31%, and the most common sites of STM were the retroperitoneum, abdominal wall, and abdominal cavity. In those 12 patients who had STM there was a median interval of 23 months after original diagnosis to the time the first metastasis became apparent (range, 0-142 months). Median survival following first metastasis was 35 months; 6 of the 12 patients died between 6 and 50 months. Four patients who had STM remain disease free at 15 to 59 months after their first STM. Any round cell component of the ML was associated with a significantly greater chance of metastatic disease (P = .02). In this series, the overall 5-year and 7-year survival rates were 85% and 68%. Patients with STM had an 11 times greater chance of dying than those who did not. CONCLUSIONS ML usually is an indolent disease, but there is a subset of patients who develop STM and have a significantly worse prognosis. STM can occur years after the initial diagnosis and can be associated with medium-long-term survival after they occur. STM should be managed aggressively because of this.
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Affiliation(s)
- A J Spillane
- Melanoma and Sarcoma Unit, Royal Marsden Hospital, London, United Kingdom
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Abstract
Intramammary lymph nodes (IMLN) are present in up to 47% of breasts and may be involved in metastatic disease in up to 9.8 % of operable breast cancer cases. IMLN are likely to be increasingly recognized with wider acceptance of high quality screening mammography and the use of ultrasound assessment of breast disease. The aim of this study is to demonstrate how IMLN can have an impact on management of breast cancer patients by presenting a case series of three patients. We conclude that IMLN metastases from breast cancer alters the prognosis and hence the management of patients. This will need to be addressed more frequently as sentinel node biopsy is more widely utilized.
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Affiliation(s)
- A J Spillane
- Division of Surgery, Prince of Wales Hospital, Randwick, NSW 2031, Australia.
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Spillane AJ, Littlejohn D, Wong S, Robertson AO, Crowe PJ. Australia's breast surgery workload is changing: comparison of a metropolitan and a rural hospital. Aust N Z J Surg 1999; 69:178-82. [PMID: 10075355 DOI: 10.1046/j.1440-1622.1999.01518.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Breast cancer is a common disease in our community and its incidence is increasing. As a result of the improvements in community awareness and introduction of screening, patients are being diagnosed with earlier breast cancer and with a higher incidence of pre-invasive disease. Improvements in radiology, often coupled with minimally invasive diagnostic modalities, have lessened the requirement for open diagnostic biopsies and also reduced the number of operations for benign breast disease. METHODS An audit of the surgical workload at Prince of Wales/Prince Henry Hospitals and Tamworth Base Hospital was conducted to document and compare the above changes in the metropolitan and rural settings. This study was conducted between 1987 and 1996 to assess the effect of screening and improved technology over a 10-year period. RESULTS The study found that a high percentage of malignant lesions are being diagnosed by fine-needle aspiration biopsy (FNAB) with a corresponding reduction in open biopsy rate at the Prince of Wales Hospital. There is a smaller percentage of benign operations in both settings with a reduction of equal proportion. The reporting of the pathology specimens has markedly improved at both institutions. There has been a reduction in the number of patients having modified radical mastectomy and there has been a corresponding increase in breast conservation surgery especially at the Prince of Wales/Prince Henry Hospitals, although there was an unexpectedly high incidence of breast conservation surgery at Tamworth Base Hospital in 1987. In 1996 the rates of breast conservation surgery were the same in both hospitals. CONCLUSIONS There are minimal differences in the quality of surgical care being offered to patients at the Tamworth Base Hospital compared with the Prince of Wales Hospital and both institutions are within reach of the accepted best management practices available.
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Affiliation(s)
- A J Spillane
- Division of Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
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Spillane AJ, French J, Donnellan MJ. Symphysiotomy for pelvic access in difficult extirpative surgery. Aust N Z J Surg 1999; 69:237-9. [PMID: 10075371 DOI: 10.1046/j.1440-1622.1999.01537.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- A J Spillane
- Sydney Sarcoma Unit, Prince of Wales Hospital, Randwick, New South Wales, Australia.
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Abstract
BACKGROUND The development of skills in critical appraisal of the medical literature is an important aspect of surgical training. METHODS At the Prince of Wales Hospital a journal club has been conducted for more than 5 years to improve the registrars' training in this area. A questionnaire was circulated regarding the success of the journal club at achieving adequate review of the important current literature, development of critical appraisal skills by registrars and providing a convivial social gathering. RESULTS A total of 28 out of 39 current or previous journal club members responded to the questionnaire. Twenty-three of the respondents felt that the journal club provided a good to excellent review of current literature, 26 felt that the journal club facilitated development of critical appraisal skills and all 28 said that the journal club was a convivial social forum. Eight research projects developed from journal club reviews, 19 of the respondents reported that their clinical practice had changed, and 19 had been stimulated to further review a topic as a result of the journal club. Many of the respondents had specific criticisms of the journal club, and these have been used to improve the journal club format. CONCLUSIONS The present study has highlighted the strengths and weaknesses of our journal club. The journal club is a valuable component of surgical education.
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Affiliation(s)
- A J Spillane
- Department of General Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
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Abstract
BACKGROUND Gastro-oesophageal reflux (GOR) is a physiological problem in infancy that can become pathological and life-threatening in certain cases. Fundoplication has been shown previously to be effective in the control of this problem when medical therapy fails. METHODS A retrospective review of the hospital records and the Department of Paediatric Surgery database was carried out, in order to demonstrate the Prince of Wales Children Hospital's (POWCH) experience with 106 fundoplications between February 1989 and March 1993. RESULTS There was a failure rate of 7.5% and a long-term mortality rate of 7.8%. The children most at risk of mortality and morbidity are shown to be the neurologically impaired. The special problems associated with these children as compared with neurologically normal children with pathological GOR are discussed and the literature reviewed. CONCLUSION Fundoplication is shown to be a safe operation that can be life-saving in certain circumstances.
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Affiliation(s)
- A J Spillane
- Department of Surgery, Prince of Wales Children's Hospital, Randwick, New South Wales, Australia
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Spillane AJ, Ham JM, Fung CL. Metachronous colorectal and biliary carcinoma: the aetiological implications of k-ras oncogenes. Aust N Z J Surg 1996; 66:572-4. [PMID: 8712999 DOI: 10.1111/j.1445-2197.1996.tb00818.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- A J Spillane
- Gastrointestinal Surgery Unit, Prince of Wales Hospital, Randwick, New South Wales, Australia
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