Different Natural Course of Disease in Patients With Melanoma

Abstract

along with adjuvant systemic therapy treated all the nodal areas at risk, including the internal mammary node. However, the extent of the nodal fields is controversial. We await the outcome of the Selective Use of Post Mastectomy Radiotherapy trial with interest. Second, Russell et al cite a number of primarily adjuvant systemic therapy studies to suggest that the risk of local recurrence in the modern systemic therapy era may be less than has been previously reported. Many of these studies report only the first site of failure, not the total frequency of locoregional failure. Furthermore, some locoregional recurrences are subclinical and others are misclassified as systemic failures—internal mammary nodal recurrence classified as “sternal metastasis,” for instance. The bottom line, however, is the impact on survival, something easily and accurately measured. Third, nodal ratio is certainly an alternative and interesting way to define subgroups. All cut points are, to some degree, arbitrary. Although the risk of locoregional relapse will likely increase with the extent of nodal involvement (measured as either the number or fraction involved), so will the risk of systemic relapse. Thus, the impact of PMRT on survival is related to competing risks and may not exactly parallel the risk of locoregional relapse. Indeed, the magnitude of the benefit of PMRT on survival is similar in the patients with one to three versus four or more positive axillary nodes. Finally, in our editorial, we stated that “comprehensive PMRT is appropriate for the great majority of node-positive patients undergoing mastectomy,” but “some selection based on other clinical and biologic factors may be important and appropriate” as well. However,