Efficacy of an elective regional lymph node dissection of 1 to 4 mm thick melanomas for patients 60 years of age and younger

OBJECTIVE

A prospective multi-institutional randomized surgical trial involving 740 stage I and II melanoma patients was conducted by the Intergroup Melanoma Surgical Program to determine whether elective (immediate) lymph node dissection (ELND) for intermediate-thickness melanoma (1-4 mm) improves survival rates compared with clinical observation of the lymph nodes. A second objective was to define subgroups of melanoma patients who would have a higher survival with ELND.

METHODS

The eligible patients were stratified according to tumor thickness, anatomic site, and ulceration, and then were prerandomized to either ELND or nodal observation. Femoral, axillary, or modified neck dissections were performed using standardized surgical guidelines.

RESULTS

The median follow-up was 7.4 years. A multifactorial (Cox regression) analysis showed that the following factors independently influenced survival: tumor ulceration, trunk site, tumor thickness, and patient age. Surgical treatment results were first compared based on randomized intent. Overall 5-year survival was not significantly different for patients who received ELND or nodal observation. However, the 552 patients 60 years of age or younger (75% of total group) with ELND has a significantly better 5-year survival. Among these patients, 5-year survival was better with ELND versus nodal observation for the 335 patients with tumors 1 to 2 mm thick, the 403 patients without tumor ulceration, and the 284 patients with tumors 1 to 2 mm thick and no ulceration. In contrast, patients older than 60 years of age who had ELND actually had a lower survival trend than those who had nodal observation. When survival rates were compared based on treatment actually received (i.e., including crossover patients), the patients with significantly improved 5-year survival rates after ELND included those with tumors 1 to 2 mm thick, those without tumor ulceration, and those 60 years of age or younger with tumors 1 to 2 mm thick or without ulceration.

CONCLUSION

This is the first randomized study to prove the value of surgical treatment for clinically occult regional metastases. Patients 60 years or age or younger with intermediate-thickness melanomas, especially with nonulcerative melanoma and those with tumors 1 to 2 mm thick, may benefit from ELND. However, because some patients still are developing distant disease, these results should be considered an interim analysis.

The technique of sentinel node biopsy

Fifty-five consecutive patients with localized melanoma and clinically definable regional nodal basin who had undergone sentinel node biopsy were reviewed. The technique described by Morton et al was applied with the following modifications: (1) injection of a larger amount of isosulfan blue dye initially, i.e. 3 ml, on the side of the primary lesion facing the nodal group; (2) elevation of the primary site, for 5 min; (3) incision over the regional nodal group and exposure of the nodes with sharp dissection; (4) identification of either the blue-stained node(s) or adjacent colored lymphatics first and demonstration of their continuity. The sentinel node was identified in 51/55 (93%); specifically 33/36 (92%) in the axilla, 17/18 (93%) in the groin, and 1/1 in the supraclavicular area. It was positive in 12/51 (24%). Morton's technique of sentinel node biopsy is reproducible and can provide correct identification of the sentinel node in over 90% of the patients without the aid of radiolabelled materials.

Complications and outcome of external hemipelvectomy in the management of pelvic tumors

BACKGROUND

Although the technique of external hemipelvectomy has been adequately described, little is known about its complications and late results.

DESIGN

Retrospective review of 68 external hemipelvectomies performed at our Institute between 1973 and 1994.

MATERIALS AND METHODS

Eleven patients had bone tumor; 39 patients, soft-tissue sarcoma; seven patients, melanoma; 10 patients, squamous cell carcinoma; and one patient, giant neurofibroma. In 48 (71%) patients, the intent was curative. In 17 cases, the hemipelvectomy was extended.

RESULTS

Postoperative complications occurred in 36 (53%) patients, including flap necrosis in 11 (16%), wound infection in 24 (35%), and other complications in 12 (18%). Four (6%) patients died postoperatively. The average hospital stay after curative versus palliative resection was 39 versus 24 days. Only three (5%) patients were able to use a prosthesis, whereas 55 (81%) used crutches, six (9%) remained wheelchair bound, and four patients (6%) spent most of the time in bed. Local recurrence occurred in 35% of the patients. The estimated 5-year survival for curatively resected patients was 21%.

CONCLUSIONS

External hemipelvectomy is a procedure with considerable morbidity and is indicated for only a minority of far-advanced tumors. It offers a chance of palliation and possibly cure when lesser surgical options have been exhausted.

Local recurrence and survival in soft-tissue sarcomas

BACKGROUND

There is a continuous interest in the literature concerning the management and survival after treatment of local recurrence in sarcomas because it is one of the most common types of recurrence.

DESIGN

We retrospectively reviewed 93 patients treated for local recurrence from soft-tissue sarcoma.

METHODS

We evaluated prognostic parameters (grade, tumor size, location) and the effect of treatment on survival.

RESULTS

Resection of all the gross tumor at first visit to our Institute for local recurrence was accomplished in 88 patients (95%). Of the 59 patients with extremity tumors, six (10%) required an amputation. At a mean follow-up of 66 months, further local recurrence was noted in 27%. The estimated 5-year survival rate was 100% for patients with grade I tumors (n = 16), 77% for grade II (n = 31), and 45% for grade III tumors (n = 46) (p = 0.0002). This value was 78% for tumors < or = 5 cm and 57% for those > 5 cm (p = 0.03).

CONCLUSIONS

Local recurrence is resectable and limb preservation is possible in the majority of patients. The overall 5-year survival rate was 65%. Survival after treatment of local recurrence is determined mainly by the grade and secondarily by the size of the tumor as for primary sarcomas.

Positive deep nodes in the groin and survival in malignant melanoma

A review of 48 consecutive patients with positive deep nodes in the groin and positive inguinal nodes from malignant melanoma was carried out. The deep nodes were enlarged (>2 cm) in 60% of the patients. The estimated 5-year survival rate following dissection of the deep nodes was 34%, 31% for those with palpable nodes (n=40) and 50% for those with non-palpable (n=8) inguinal nodes (P=0.13). The overall 10-year survival rate was 25%. Involvement of the deep (iliac or obturator) nodes in malignant melanoma does not indicate systemic dissemination for all patients, as an appreciable percentage attains long-term survival after a thorough dissection of these nodes.

Major vessel resection during limb-preserving surgery for soft tissue sarcomas

There is uncertainty in the literature as to whether major vessel involvement in extremity soft tissue sarcomas constitutes an indication for amputation. This retrospective review includes 21 patients who underwent major vessel resection in the context of limb preservation for soft tissue sarcomas. Resected vessels were the common iliac in one, external iliac and common femoral in six, common and superficial femoral in five, superficial femoral in six, distal superficial and popliteal in two, and subclavian vessels in one. Wound infection occurred postoperatively in five patients (24%). One Gore-tex and one vein graft became exposed, but the wounds healed by secondary intention with routine wound care. Three patients (14%) manifested local recurrence, of which one required an amputation. The estimated 5-year survival rate is 63%. Involvement of major vessel(s) by soft tissue sarcomas of the extremities is not in itself an indication for amputation, as with en bloc resection of major vessels the local recurrence and 5-year survival rates parallel those of patients with soft tissue sarcomas not requiring major vessel resection.

Resectability and survival in retroperitoneal sarcomas

BACKGROUND

Retroperitoneal sarcomas historically have presented difficulties in their management due to a high rate of unresectability, which affects the survival of these patients.

METHODS

We retrospectively reviewed the charts of 87 consecutive patients with retroperitoneal sarcomas treated in the period 1977-1994.

RESULTS

The resectability rate was 100% for the primary tumors (n = 55) and 87% for the locally recurrent tumors (n = 32). The 5-year survival rate was 63% (66% for the primary tumors and 57% for those with local recurrence). The 10-year survival rate was 46% (57% for primary tumors and 26% for those referred with locally recurrent tumor). The overall local recurrence rate was 31% (25% for the primary tumors and 41% for those referred with local recurrence); it was 56% after local excision and 15% after wide resection (p = 0.0003). The 10-year disease-free survival of patients with local excision (n = 25) was 7%, and that of patients with wide resection (n = 54) 59% (p = 0.0001).

CONCLUSIONS

The overall resectability rate of retroperitoneal sarcomas was 95%. Wide resection produced a significantly higher survival rate compared with that of local excision. The survival rate for the primary tumors, varying significantly with the histologic grade, approached the rate reported for primary soft-tissue sarcomas of the extremity.

Radical scapulectomy with limb salvage for shoulder girdle soft tissue sarcoma

Limb-sparing surgical procedures, such as the Tikhoff-Linberg resection, have gradually replaced the forequarter amputation as the surgical treatment of choice for soft tissue tumours in and around the shoulder girdle. Although the Tikhoff-Linberg procedure provides limb salvage, it leaves a significant functional and cosmetic deficit in many patients. Scapular resections combined with radical excision of the soft tissues allows wide margins of resection, limited excision of uninvolved bone and excellent physical rehabilitation in treating soft tissue tumours of the shoulder girdle. The case of a young woman with Stage IVA malignant fibrous histiocytoma of the left shoulder girdle who underwent a radical scapulectomy with limb salvage and adequate surgical margins, while preserving a functional and cosmetically acceptable extremity, is reported. A historical review of scapular resections is also presented.

Malignant melanoma of the gallbladder: report of a case and review of the literature

A case of primary melanoma of the gallbladder is presented and review of the literature. Eighteen cases have been previously reported. The diagnosis is usually not made preoperatively. Metastatic melanoma to the gallbladder as an isolated site is also rare.

Resectability of retroperitoneal sarcomas: a matter of surgical technique?

The management of retroperitoneal sarcomas has been hampered by the difficulty in complete resection, the resectability rate in the literature being about 53%. In a review of the last 88 consecutive patients with retroperitoneal sarcomas the resectability rate was 95%. At a mean follow-up of 48 months, the local recurrence rate was 17% following wide resection and 59% following local excision (P = 0.0002). For patients with minimum follow-up of 5 years, the local recurrence rate was 39% for those with primary tumours and 57% for those referred with local recurrence. Local recurrence diminished the rate of long-term survival. The 5- and 10-year survival rates for the primary retroperitoneal sarcomas (n = 55) were 66% and 57% and for those referred with locally recurrent sarcoma (n = 33) 57% and 26%, respectively. The 5-year survival rate varied significantly with the grade of the tumour, from 88% for Grade I to 44% for Grade III tumours (P = 0.006). In conclusion, with modern surgical techniques the resectability rate of retroperitoneal sarcomas is about 95%, and the survival rate of the primary tumours approximates that of the primary soft tissue sarcomas of the extremities.

[Surgical therapy of soft tissue sarcomas II. Sarcomas of the extremities and their surgical resection]

In the past, the rate of amputation for soft tissue sarcomas of the extremities was 40-50%. In recent years this rate has declined to about 50%. The improved rate of limb salvage with improved rates of local control, compared to those of the past, has been due to the development of surgical techniques allowing often satisfactory resection with limb preservation and to the use of adjuvant radiation in the presence of inadequate surgical margins. Below, the surgical techniques of limb preservation, as well as those or the major amputations are described.

Retroperitoneal sarcomas and their management

BACKGROUND

Retroperitoneal sarcomas historically have presented difficulties in their management due to a high rate of unresectability.

OBJECTIVE

To determine prognostic parameters, resectability, and survival of these patients in a more recent period.

DESIGN

Retrospective review, with a mean follow-up of 47 months.

SETTING

Tertiary care cancer institute.

PATIENTS

The charts of 90 consecutive patients with retroperitoneal sarcomas treated in the period from 1977 to 1995. No patient referred with a localized retroperitoneal sarcoma was excluded from this review.

RESULTS

The resectability rate was 100% for the primary tumors (n = 57) and 88% for the tumors initially presenting as local recurrence (n = 33). The 5-year survival rate was 63% (66% for patients with primary tumors and 57% for those with local recurrence). The 10-year survival rate was 46% (57% for patients with primary tumors and 26% for those referred with local recurrence). The local recurrence rate was 25% for primary tumors and 39% for tumors initially presented as local recurrence (overall rate, 30%); it was 56% after local excision and 16% after wide or radical resection (P < .001). The 5- and 10-year survival rates were 72% and 61%, respectively, for those with wide resection and 55% and 23%, respectively, for those with local excision (P = .01).

CONCLUSIONS

With modern surgical techniques, the overall resectability rate of retroperitoneal sarcomas is 96%. The ensuing survival, affected significantly by the histologic grade, approaches that for the extremity sarcomas.

[Surgical therapy of soft tissue sarcoma. I. General principles and resections of the trunk]

Resection, preferably wide resection is the primary treatment modality for localized (primary or locally recurrent) soft tissue sarcomas. Sarcomas of the chest or abdominal wall usually do not present great difficulty in their resection. When a mesh is used in the abdominal wall care should be exercised that there will be no direct contact between bowel loops and the mesh by using tissue interposition since otherwise the rate of bowel fistulization due to erosion by the mesh is considerable. Although the average rate of resectability in published reports in the United States for retroperitoneal sarcomas is 53%, with the incisions and techniques described below this rate is 95%.

Primary soft tissue sarcoma of the extremities in adults

The modern literature on adult extremity sarcoma implies that adjuvant therapy (usually irradiation) is mandatory for adequate local control, at least in patients with high-grade tumours undergoing limb-sparing procedures. In 152 primary extremity soft tissue sarcomas, wide or radical resection was employed (116 patients) including amputation in nine patients (6 per cent), or local excision followed by adjuvant postoperative radiation therapy (36). Local recurrence alone occurred in 5 per cent of patients, and in combination with distant metastases in 9 per cent. The total rate of local recurrence was 10 per cent after wide resection (with or without chemotherapy) and 25 per cent after conservative resection and radiotherapy (with or without chemotherapy). Limb sparing was possible in 94 per cent of patients. The majority (76 per cent) had surgical resection alone as local treatment with satisfactory results. Wide resection, when feasible, provides acceptable local control and may be preferable to local excision plus radiation therapy.

Various types of hemipelvectomy for soft tissue sarcomas: complications, survival and prognostic factors

Fifty-three hemipelvectomies were performed for primary or recurrent soft tissue sarcomas with fixation to the pelvis or peripelvic tissues. Resection was carried out in the absence of distant metastases in 70% of the cases. The hemipelvectomy was posterior in 66%, anterior in 6% and internal in 28%. Post-operative complications included wound edge necrosis in 19% and infection in 43% of cases. The mortality rate was 5.7%. Margins were macroscopically clear in 76% and marginal in 24% of cases. Tumours were high grade in 92%; their mean diameter was 16.5 cm. Local recurrence occurred in 19% and distant recurrence in 66% of patients. Overall survival was 39% at 2 years and 10% at 5 years. Pelvic soft tissue sarcomas have a poor prognosis. However, in the absence of other effective therapy, hemipelvectomy provides local control with acceptable morbidity in the majority of patients, with a small percentage (10%) surviving 5 years or longer.

Use of a mesh for musculoaponeurotic defects of the abdominal wall in cancer surgery and the risk of bowel fistulas

BACKGROUND

Enterocutaneous fistulas resulting from mesh reconstruction of full-thickness musculoaponeurotic abdominal defects in benign conditions is a relatively infrequent, but serious complication.

STUDY DESIGN

In the period 1977 to 1986, 26 patients with abdominal wall defects due to ablative surgery for carcinoma had repair with prosthetic material without any special effort to interpose tissue between bowel loops and the mesh. In the period 1986 to 1992, 30 patients with similar defects had tissue interposition between the bowel loops and the mesh (four patients had a free peritoneal patch). In an experimental study, 11 rabbits had an abdominal wall defect repaired with mesh alone, and 14 other rabbits had the abdominal wall defect repaired with the mesh plus a free peritoneal patch sutured underneath.

RESULTS

In the first group of patients, six (23 percent) of 26 had enterocutaneous fistulas develop, in the second group zero (zero percent) of 30 had a fistula develop (p = 0.007). In the experimental study, the first group (ten of 11 rabbits) had dense adhesions develop between bowel loops and the mesh. In the second group, none of the 14 rabbits had adhesions develop (p < 0.0001).

CONCLUSIONS

In full-thickness abdominal wall defects, omentum, muscle flap, or a peritoneal patch sewn under a mesh prevent fistula formation.

Partial and complete internal hemipelvectomy: complications and long-term follow-up

BACKGROUND

The complications and long-term follow-up results of internal hemipelvectomy are not well documented.

STUDY DESIGN

We reviewed 32 internal hemipelvectomies performed between 1976 and 1994.

RESULTS

The pathologic diagnoses were soft tissue sarcoma in 15 cases, bone tumor in 14 cases, melanoma in two cases, and carcinoma in one of the cases. In 24 cases, the intent of surgery was curative; in 22 cases, the procedure was modified. Average blood loss was 3.2 L; the procedure took on average 7.5 hours. Complications included skin flap necrosis in four cases, infection in 15 cases, and various other complications in five cases. Three mortalities (9 percent) occurred. Thirty-four percent of the patients ambulated without any assistance, 59 percent ambulated with crutches, while 7 percent remained wheel-chair bound. The survival rate after resection for cure was 45 percent at ten years compared with 29 percent at two years for palliative resections.

CONCLUSIONS

Internal hemipelvectomy is a complex procedure that is functionally and cosmetically superior to external hemipelvectomy and, when done with curative intent, results in considerable long-term survival rates.

An institutional review of sarcomas of the large and small intestine

BACKGROUND

This study was done to review the institutional experience with the treatment of sarcoma of the small or large intestine.

STUDY DESIGN

Thirty-nine patients admitted between the years 1959 and 1987, with a diagnosis of sarcoma of the small or large bowel form the basis of this review.

RESULTS

At referral, 74 percent of the patients presented with peritoneal sarcomatosis. Only six patients underwent complete resection. The overall five-year survival rate was 20 percent. Patients with low grade tumors had median and five-year survival rates of 33.3 months and 44 percent, respectively, while patients with high grade tumors had median and five-year survival rates of 22.4 months and zero percent, respectively, p = 0.01. Patients undergoing complete resection had a median survival period of 33.3 months, while patients receiving less than complete resection had a median survival period of 15.4 months, p = 0.003. Factors found to be significant by multifactorial analysis included tumor size, grade, stage at presentation, and invasion of adjacent organs.

CONCLUSIONS

Sarcoma of the small and large bowel is an uncommon entity. Survival rates are relatively poor. Aggressive surgical intervention is the mainstay of therapy.

Malignant melanoma of the anorectal region

The charts of 15 patients with malignant melanoma of the anorectal region treated at Roswell Park Cancer Institute in the period 1975-1991 were reviewed. All the lesions except one developed at the pectinate line, in the area of transitional mucosa. Two of the patients at the time of initial presentation had distant metastases. Of the remaining 13, 8 were treated with abdominoperineal resection (APR) and 5 with local excision (LE). The incidence of local recurrence was 50% in the LE group and 22% in the APR group. Patients treated with APR had a 25%, 5-year survival rate compared with 0% for those treated with LE, although one of the latter group died 55 months following LE due to unrelated causes without recurrence. The median survival of those with LE was 15.7 months and of those with APR 13.7 months.

Liver metastases from soft tissue sarcomas

Twenty-three patients with liver metastases from soft tissue sarcoma were reviewed. Patients with metastases to the liver first had poorer survival than those who developed spread to other sites first (P = .0035). The median time from diagnosis of the primary tumor to diagnosis of liver metastases was 14 months; the median time from diagnosis of liver metastases to death was 7 months. The median survival from diagnosis for four patients who underwent liver resection was 54 months compared to 20 months for those who did not undergo resection (NS). Soft tissue sarcomas rarely metastasize to the liver; when this occurs it is usually late in the course of the disease and after it has spread to other sites. The opportunity for successful liver resection is infrequent but may prolong survival.

Prognostic parameters in localised melanoma: gender versus anatomical location

Extremity location and female gender are both considered favourable prognostic parameters in primary melanoma, but since they cluster in the same group of patients, the question remains as to whether they are both independent variables. Multivariate analysis of 695 patients with primary, localised melanoma was used. The effects of gender and anatomical location were compared directly by sequentially controlling one factor while the other remained free. Following multivariate analysis, significant prognostic factors related to survival were the thickness of the primary lesion (P < 0.0001), the age of the patient at diagnosis (P < 0.0001), the gender of the patient (P = 0.0008) and the anatomical location of the primary lesion (P = 0.005). Thicker lesions, patients older than 50 years, males, and trunk, head and neck locations had poorer prognoses. There was a significant difference in survival according to gender within each location, extremity (P = 0.002) or trunk, head and neck (P = 0.0004); however, there was no significant difference in survival according to anatomical location within each gender, male (P = 0.11) or female (P = 0.29). The thickness of the primary lesion, the age of the patient at diagnosis, the gender and the anatomical location of the melanoma are all significant prognostic parameters in localised melanoma. Gender appears to have a more pronounced effect on survival than anatomical location.

Gastrointestinal metastases from malignant melanoma

Between 1980 and 1992, 68 patients with clinical indications of involvement of the gastrointestinal (GI) tract with metastatic melanoma were treated at Roswell Park Cancer Institute. Presenting symptoms were anaemia, abdominal pain, nausea and vomiting. Sites commonly involved were the small bowel (75%), the large intestine (25%), and the stomach (16%). Twenty-one patients were considered unsuitable for surgery; their median survival after diagnosis of GI metastases was 2.9 months. Forty-seven patients underwent abdominal surgery; effective palliation was achieved in most of them. Complete resection of GI metastases was accomplished in 47% of patients. The median survival after operation was 27.6 months for patients with complete resection of GI metastasis and no other disease, 5.1 months for patients with resection of involved GI tract and other metastases present, and 1.9 months for patients who had a by-pass procedure only. The 5-year survival for patients with complete resection of GI metastases and no other evidence of disease was 28.3%. The other groups had only 1-year survivors. Surgical intervention is justified on the basis of these findings, and extended palliation can be achieved in patients with complete resection of metastatic disease.

Survival of patients with stage IA malignant melanoma

There is ongoing clinical research on prognostic parameters relevant to stage IA melanoma. The object is to identify those factors associated with an increased risk of recurrence. The charts of 197 patients first treated at our Institute between 1980 and 1992 along with 62 patients referred for follow-up or treatment of recurrent disease, all having been initially diagnosed with stage IA disease, were reviewed. Only one patient (0.5%) of those first treated at our Institute manifested recurrence and this was a local recurrence. No statistically significant differences were found between patients who relapsed and those who did not with regard to lesion thickness, level of invasion, evidence of ulceration, location of the primary lesion, gender, or age. Generally, stage IA melanomas have excellent prognosis. However, there are patients who experience recurrent and metastatic disease. At the present time, there are no reliable indicators available for use in predicting which patients are at risk.

Groin dissection in malignant melanoma

A total of 205 patients who underwent groin dissection for malignant melanoma were reviewed to document complications and survival rates. Wound complications included skin-edge necrosis in 8 per cent, wound infection in 16 per cent, lymphocele in 5 per cent and lymphorrhoea in 11 per cent. Lymphoedema of the operated leg below the knee was noted in 40 per cent, but all patients had localized oedema of the anteromedial thigh. The 5-year overall and disease-free survival rates were 43 and 35 per cent respectively when only the inguinal nodes were involved; they were 34 and 21 per cent with involvement of both the inguinal and deep nodes. The 10-year survival rate for these two groups was 39 and 25 per cent respectively, which suggests that a thorough, complete dissection of the deep nodes is worth-while when the inguinal nodes are palpably positive.