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33. Snore (non-Sentinel Node Risk score): a system for accurately stratifying risk of non-sentinel node positivity in cutaneous melanoma patients with positive sentinel lymph nodes
ABSTRACTS
(HR ¼ 1.2, 95% CI 1.1–1.3). SLN positivity in Clark level III tumours (HR ¼ 8.0, 95%CI 1.8–36.0) and anatomic location in head/neck region in Clark level IV tumours (HR ¼ 23.7, 95% CI 2.0–277, compared to limbs) were the only independent predictors of poorer disease-free survival. Conclusions: Patients with thicker tumours (>0.5 mm) and other adverse prognostic factors (e.g., ulceration, elevated mitotic rate, lymphovascular invasion) have a greater risk of occult nodal metastasis and are more likely to benefit from SLN biopsy. 33. SNORE (NON-SENTINEL NODE RISK SCORE): A SYSTEM FOR ACCURATELY STRATIFYING RISK OF NON-SENTINEL NODE POSITIVITY IN CUTANEOUS MELANOMA PATIENTS WITH POSITIVE SENTINEL LYMPH NODES Rajmohan Murali1,2,3, Chitra Desilva2, John Thompson2,3, Richard Scolyer1,2,3 1 Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, 2Melanoma Institute Australia, and 3University of Sydney, Sydney, NSW, Australia Background: Completion lymph node dissection (CLND) is usually offered to all sentinel lymph node (SLN)-positive melanoma patients. However, metastatic melanoma is not present in 80% of CLND specimens, and these patients are needlessly subjected to the operative risks and morbidities associated with CLND. In this study, we attempted to refine the criteria for selection of SLN-positive patients for CLND. Methods: In SLN-positive patients managed at a single melanoma centre, the ability of clinical, primary tumour and SLN tumour features to predict NSLN positivity was investigated using logistic regression models. A weighted score (non-Sentinel Node scORE) was derived from the models, and the efficacy of SNORE at stratifying risk of NSLN involvement was studied. Results: There were 409 SLN-positive patients. Factors independently predictive of NSLN positivity included: regression, proportion of harvested SLNs involved by melanoma (%PosSLN), sex (trend), and SLN tumour burden indices [maximum size of largest deposit (MaxSize), % cross-sectional area of SLN occupied by tumour, tumour-penetrative depth, intranodal location of tumour) and perinodal lymphatic invasion (PLI). The final SNORE system included: sex, regression, %PosSLN, MaxSize, and PLI. SNOREs of 0, 1–3, 4–5, 6–7 and 8 were associated with very low (0%), low (5–10%), intermediate (15–20%), high (40–50%) and very high (70–80%) risk of NSLN involvement. Conclusions: A weighted score (SNORE) based on clinico-pathological characteristics accurately stratifies the risk of NSLN involvement. If validated in future studies of large numbers of SLN-positive melanoma patients, SNORE will better inform patients and their treating physicians with regard to prognosis and aid in management decisions. 34. ASSOCIATION OF HISTOLOGICAL FEATURES OF METASTATIC MELANOMA IN SENTINEL LYMPH NODES WITH LYMPH NODE RECURRENCE, DISTANT METASTASIS AND SURVIVAL Rajmohan Murali1,2,3, Chitra Desilva2, John Thompson2,3, Richard Scolyer1,2,3 1 Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, 2Melanoma Institute Australia, and 3University of Sydney, Sydney, NSW, Australia
S99
Background: Studies which have found that histological features of metastatic melanoma in SLN were predictive of survival, have differed considerably in their design and results. We investigated in detail the influence of SLN tumour, clinical and primary tumour parameters on clinical outcomes in a large cohort of patients treated in a single centre. Methods: In SLN-positive melanoma patients, the association of clinical, primary tumour and SLN tumour features [maximum size (MaxSize), % cross-sectional area of SLN occupied by tumour (%CS), tumour-penetrative depth (TPD), intranodal location of tumour, extranodal spread (ENS) and perinodal lymphatic invasion (PLI)] with lymph node recurrence (LNR), disease-free (DFS), distant metastasis-free (DMFS) and melanoma-specific (MSS) survival was analysed. Results: There were 409 SLN-positive patients. Age >50 years, presence of lymphovascular invasion in primary tumour and completion lymph node dissection (CLND) status were independent predictors of LNR. Primary tumour features (presence of ulceration and satellites) and presence of ENS in SLN were independent predictors of DFS, DMFS and MSS. In addition, poorer DFS was independently associated with primary tumour site (trunk vs limbs), SLN tumour features (MaxSize >2 mm, presence of PLI) and positive CLND; other factors independently predictive of DMFS were male sex, primary tumour features (absence of TILs) and SLN tumour MaxSize >10 mm; and age 50 years, presence of PLI in SLN were additional independent predictors of MSS. Conclusions: The use of clinical, primary tumour and SLN tumour characteristics shown to be independent predictors of clinical outcomes in melanoma patients will assist in accurate prediction of prognosis and optimise clinical management. 35. FACTORS PREDICTIVE OF CLINICAL OUTCOMES IN PATIENTS WITH THIN CUTANEOUS MELANOMA Rajmohan Murali1,2,3, Lauren Haydu1, Georgina Long2,3, John Thompson2,3, Richard Scolyer1,2,3 1 Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, 2Melanoma Institute Australia, and 3University of Sydney, Sydney, NSW, Australia Background: Although the outlook for patients with thin (1 mm) melanomas is generally good, a minority of patients will suffer adverse clinical outcomes (distant metastasis and death). The aim of this study was to identify clinico-pathological factors predictive of poorer clinical outcomes in a large number of patients with thin melanomas, by comparing patients with distant metastases with those who did not experience any tumour recurrence. Methods: Patients with thin melanoma (1 mm thick) were identified in the Melanoma Institute Australia database. From this group, all patients who experienced distant metastasis, and 1000 random patients who experienced no recurrences were identified. The association of clinico-pathological features with the development of brain metastasis, distant metastasis-free survival (DMFS) and melanoma-specific survival (MSS) was analysed. Results: Of 5628 patients with thin melanoma, 174 experienced distant metastasis. Factors significantly associated with development of brain metastasis included: Breslow thickness 0.51– 0.76 mm (OR ¼ 3.8, 95%CI ¼ 1.1–13.7) and 0.76–1.00 mm (OR ¼ 5.2, 95%CI ¼ 1.5–18.6), compared with 0.01–0.50 mm; ulceration (OR ¼ 4.4, 95%CI ¼ 1.8–10.7); anatomical location in trunk vs other sites (OR ¼ 2.4, 95%CI ¼ 1.2–4.7); and mitoses 1/mm2 (OR ¼ 2.5, 95%CI ¼ 1.2–5.5). Factors independently
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.
(HR ¼ 1.2, 95% CI 1.1–1.3). SLN positivity in Clark level III tumours (HR ¼ 8.0, 95%CI 1.8–36.0) and anatomic location in head/neck region in Clark level IV tumours (HR ¼ 23.7, 95% CI 2.0–277, compared to limbs) were the only independent predictors of poorer disease-free survival. Conclusions: Patients with thicker tumours (>0.5 mm) and other adverse prognostic factors (e.g., ulceration, elevated mitotic rate, lymphovascular invasion) have a greater risk of occult nodal metastasis and are more likely to benefit from SLN biopsy. 33. SNORE (NON-SENTINEL NODE RISK SCORE): A SYSTEM FOR ACCURATELY STRATIFYING RISK OF NON-SENTINEL NODE POSITIVITY IN CUTANEOUS MELANOMA PATIENTS WITH POSITIVE SENTINEL LYMPH NODES Rajmohan Murali1,2,3, Chitra Desilva2, John Thompson2,3, Richard Scolyer1,2,3 1 Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, 2Melanoma Institute Australia, and 3University of Sydney, Sydney, NSW, Australia Background: Completion lymph node dissection (CLND) is usually offered to all sentinel lymph node (SLN)-positive melanoma patients. However, metastatic melanoma is not present in 80% of CLND specimens, and these patients are needlessly subjected to the operative risks and morbidities associated with CLND. In this study, we attempted to refine the criteria for selection of SLN-positive patients for CLND. Methods: In SLN-positive patients managed at a single melanoma centre, the ability of clinical, primary tumour and SLN tumour features to predict NSLN positivity was investigated using logistic regression models. A weighted score (non-Sentinel Node scORE) was derived from the models, and the efficacy of SNORE at stratifying risk of NSLN involvement was studied. Results: There were 409 SLN-positive patients. Factors independently predictive of NSLN positivity included: regression, proportion of harvested SLNs involved by melanoma (%PosSLN), sex (trend), and SLN tumour burden indices [maximum size of largest deposit (MaxSize), % cross-sectional area of SLN occupied by tumour, tumour-penetrative depth, intranodal location of tumour) and perinodal lymphatic invasion (PLI). The final SNORE system included: sex, regression, %PosSLN, MaxSize, and PLI. SNOREs of 0, 1–3, 4–5, 6–7 and 8 were associated with very low (0%), low (5–10%), intermediate (15–20%), high (40–50%) and very high (70–80%) risk of NSLN involvement. Conclusions: A weighted score (SNORE) based on clinico-pathological characteristics accurately stratifies the risk of NSLN involvement. If validated in future studies of large numbers of SLN-positive melanoma patients, SNORE will better inform patients and their treating physicians with regard to prognosis and aid in management decisions. 34. ASSOCIATION OF HISTOLOGICAL FEATURES OF METASTATIC MELANOMA IN SENTINEL LYMPH NODES WITH LYMPH NODE RECURRENCE, DISTANT METASTASIS AND SURVIVAL Rajmohan Murali1,2,3, Chitra Desilva2, John Thompson2,3, Richard Scolyer1,2,3 1 Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, 2Melanoma Institute Australia, and 3University of Sydney, Sydney, NSW, Australia
S99
Background: Studies which have found that histological features of metastatic melanoma in SLN were predictive of survival, have differed considerably in their design and results. We investigated in detail the influence of SLN tumour, clinical and primary tumour parameters on clinical outcomes in a large cohort of patients treated in a single centre. Methods: In SLN-positive melanoma patients, the association of clinical, primary tumour and SLN tumour features [maximum size (MaxSize), % cross-sectional area of SLN occupied by tumour (%CS), tumour-penetrative depth (TPD), intranodal location of tumour, extranodal spread (ENS) and perinodal lymphatic invasion (PLI)] with lymph node recurrence (LNR), disease-free (DFS), distant metastasis-free (DMFS) and melanoma-specific (MSS) survival was analysed. Results: There were 409 SLN-positive patients. Age >50 years, presence of lymphovascular invasion in primary tumour and completion lymph node dissection (CLND) status were independent predictors of LNR. Primary tumour features (presence of ulceration and satellites) and presence of ENS in SLN were independent predictors of DFS, DMFS and MSS. In addition, poorer DFS was independently associated with primary tumour site (trunk vs limbs), SLN tumour features (MaxSize >2 mm, presence of PLI) and positive CLND; other factors independently predictive of DMFS were male sex, primary tumour features (absence of TILs) and SLN tumour MaxSize >10 mm; and age 50 years, presence of PLI in SLN were additional independent predictors of MSS. Conclusions: The use of clinical, primary tumour and SLN tumour characteristics shown to be independent predictors of clinical outcomes in melanoma patients will assist in accurate prediction of prognosis and optimise clinical management. 35. FACTORS PREDICTIVE OF CLINICAL OUTCOMES IN PATIENTS WITH THIN CUTANEOUS MELANOMA Rajmohan Murali1,2,3, Lauren Haydu1, Georgina Long2,3, John Thompson2,3, Richard Scolyer1,2,3 1 Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, 2Melanoma Institute Australia, and 3University of Sydney, Sydney, NSW, Australia Background: Although the outlook for patients with thin (1 mm) melanomas is generally good, a minority of patients will suffer adverse clinical outcomes (distant metastasis and death). The aim of this study was to identify clinico-pathological factors predictive of poorer clinical outcomes in a large number of patients with thin melanomas, by comparing patients with distant metastases with those who did not experience any tumour recurrence. Methods: Patients with thin melanoma (1 mm thick) were identified in the Melanoma Institute Australia database. From this group, all patients who experienced distant metastasis, and 1000 random patients who experienced no recurrences were identified. The association of clinico-pathological features with the development of brain metastasis, distant metastasis-free survival (DMFS) and melanoma-specific survival (MSS) was analysed. Results: Of 5628 patients with thin melanoma, 174 experienced distant metastasis. Factors significantly associated with development of brain metastasis included: Breslow thickness 0.51– 0.76 mm (OR ¼ 3.8, 95%CI ¼ 1.1–13.7) and 0.76–1.00 mm (OR ¼ 5.2, 95%CI ¼ 1.5–18.6), compared with 0.01–0.50 mm; ulceration (OR ¼ 4.4, 95%CI ¼ 1.8–10.7); anatomical location in trunk vs other sites (OR ¼ 2.4, 95%CI ¼ 1.2–4.7); and mitoses 1/mm2 (OR ¼ 2.5, 95%CI ¼ 1.2–5.5). Factors independently
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.