Surveillance after surgical treatment of melanoma: Futility of routine chest radiography

Brown, Russell E.; Stromberg, Arnold J.; Hagendoorn, Lee J.; Hulsewede, Deborah Y.; Ross, Merrick I.; Noyes, R. Dirk; Goydos, James S.; Urist, Marshall M.; Edwards, Michael J.; Scoggins, Charles R.; McMasters, Kelly M.; Martin, Robert C.G.

doi:10.1016/j.surg.2010.07.042

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Volume 148, Issue 4 , Pages 711-717, October 2010

Surveillance after surgical treatment of melanoma: Futility of routine chest radiography

Presented at the 67th Annual Meeting of the Central Surgical Association, Chicago, Illinois, March 10–13, 2010.

Russell E. Brown, MD
- Division of Surgical Oncology, Department of Surgery, University of Louisville, James Graham Brown Cancer Center and Center for Advanced Surgical Technologies (CAST) of Norton Hospital Louisville, Louisville, KY
Arnold J. Stromberg, PhD
- Department of Statistics, University of Kentucky, Lexington, KY
Lee J. Hagendoorn, MBA
- Advertek Inc., Louisville, KY
Deborah Y. Hulsewede, CCRC, CCRP
- Division of Surgical Oncology, Department of Surgery, University of Louisville, James Graham Brown Cancer Center and Center for Advanced Surgical Technologies (CAST) of Norton Hospital Louisville, Louisville, KY
Merrick I. Ross, MD
- Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX
R. Dirk Noyes, MD
- Department of Surgery, LDS Hospital, Salt Lake City, UT
James S. Goydos, MD
- Cancer Institute of New Jersey, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ
Marshall M. Urist, MD
- Department of Surgery, University of Alabama, Birmingham, AL
Michael J. Edwards, MD
- Department of Surgery, University of Cincinnati, Cincinnati, OH
Charles R. Scoggins, MD, MBA
- Division of Surgical Oncology, Department of Surgery, University of Louisville, James Graham Brown Cancer Center and Center for Advanced Surgical Technologies (CAST) of Norton Hospital Louisville, Louisville, KY
Kelly M. McMasters, MD, PhD
- Division of Surgical Oncology, Department of Surgery, University of Louisville, James Graham Brown Cancer Center and Center for Advanced Surgical Technologies (CAST) of Norton Hospital Louisville, Louisville, KY
Robert C.G. Martin II, MD, PhD
- Division of Surgical Oncology, Department of Surgery, University of Louisville, James Graham Brown Cancer Center and Center for Advanced Surgical Technologies (CAST) of Norton Hospital Louisville, Louisville, KY
- Reprint requests: Robert C. G. Martin II, MD, PhD, Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway, Louisville, KY 40202.

Accepted 15 July 2010. published online 30 August 2010.

Background

Current recommendations by the National Comprehensive Cancer Network and other groups suggest that follow-up of cutaneous melanoma may include chest radiography (CXR) at 6- to 12-month intervals. The aim of this study was to determine the clinical efficacy of routine CXR for recurrence surveillance in melanoma.

Methods

Post hoc analysis was performed on data from a prospective, randomized, multi-institutional study on melanoma ≥1.0 mm in Breslow thickness. All patients underwent excision of the primary melanoma and sentinel node biopsy with completion lymphadenectomy for positive sentinel nodes. Yearly CXR and clinical assessments were obtained during follow-up. Results of routine CXR were compared with clinical disease states over the course of the study.

Results

A total of 1,235 patients were included in the analysis over a median follow-up of 74 months (range, 12–138). Overall, 210 patients (17.0%) had a recurrence, most commonly local or in-transit. Review of CXR results showed that 4,218 CXR were obtained in 1,235 patients either before, or in the absence of, initial recurrence. To date, 88% (n = 3,722) CXR are associated with no evidence of recurrence. Of CXR associated with recurrence, only 7.7% (n = 38) of surveillance CXR were read as “abnormal.” Overall, 99% (n = 4,180) of CXR were read as either “normal” or found to be falsely positive (read as “abnormal,” but without evidence of recurrence on investigation). Only 0.9% (n = 38) of all CXR obtained were true positives (“abnormal” CXR, with confirmed first known recurrence). Among these 38 patients with true positive CXR, 35 revealed widely disseminated disease (multiorgan or bilateral pulmonary metastases); only 3 (0.2%) had isolated pulmonary metastases amenable to resection. Sensitivity and specificity for surveillance CXR in detecting initial recurrence were 7.7% and 96.5%, respectively.

Conclusion

The routine use of surveillance CXR provides no clinically useful information in the follow-up of patients with melanoma. CXR does not detect recurrence at levels sufficient to justify its routine use and, therefore, cannot be recommended as part of the standard surveillance regimen for these patients.