Prognostic factors in patients undergoing lymphadenectomy for malignant melanoma

The prognosis of melanoma patients with metastases to two or more lymph node areas

The prognosis of melanoma patients who present with metastatic involvement of two or more noncontiguous lymph node regions before the detection of extranodal metastases has not been previously reported. We identified 21 patients with metastatic melanoma in at least two nodal basins in a review of 175 patients with melanoma undergoing lymphadenectomy at the National Cancer Institute. The median survival time of these patients was 46 months, with 55%, 27%, and 17% of the patients alive 2, 5, and 10 years, respectively, after the second lymphadenectomy. Because the prognosis of melanoma patients with metastases to two or more regional nodal areas appears equivalent to that of patients with metastatic involvement of only one regional node site, lymphadenectomy of the involved groups should be performed with therapeutically curative intent.

Stage II melanoma in the west of Scotland, 1976-1985: prognostic factors for survival

The outcome of 142 patients undergoing therapeutic lymphadenectomy for clinical stage II malignant melanoma was retrospectively assessed. 5 year survival was 26%, and survival was not altered in the 25 patients who received two courses of adjuvant combination chemotherapy after lymphadenectomy. On univariate analysis, the most significant determinants of survival were the number of malignant nodes removed at lymphadenectomy (P = 0.00004), the age of the patient (P = 0.009) and the disease-free interval between primary and stage II disease (P = 0.01). The following features were not significantly related to survival: sex, site, histogenetic type of primary tumour, tumour thickness and level of invasion. The number of malignant lymph-nodes was confirmed on multivariate analysis as the single most useful and significant predictor of survival, with the patient's age providing an additional significant contribution. In future adjuvant trials in stage II melanoma after therapeutic lymphadenectomy, patients should be stratified for both age and number of malignant nodes.

Surgical prophylaxis of malignant melanoma

A review of a 14-year experience with prophylactic pigmented skin lesion removal is presented. Data obtained during a 4-year interval of this 14-year experience is analyzed specifically. During this 4-year interval, 250 patients with melanoma were seen. Of these patients, 75 with a history of stage I (localized) melanoma and three patients with stage II (history of controlled regionally metastatic melanoma) underwent removal of multiple skin lesions on a prophylactic basis. Of the removed lesions, 28% showed hyperplasia, atypia, dysplasia, or melanoma. Nine unsuspected in situ, or level I melanomas, and three unsuspected invasive melanomas were removed from these 75 melanoma patients while excising lesions prophylactically during the 4-year interval. It is estimated that four to six additional melanomas were prevented by excision of precursor lesions. During the same 4-year interval, an additional 112 of approximately 1000 patients without a previous history of melanoma underwent prophylactic lesion removals. In 31% of the 112 patients, there was a history of melanoma in a first-degree relative. In 22% of the removed lesions there was hyperplasia, atypia, or dysplasia. Three cases of melanoma in situ were detected and it is estimated that an additional three to five cases of melanoma were prevented. Atypical findings occurred in 71, or 63%, of the patients biopsied, which represented 7% of the approximately 1000 patients screened. During the 4-year interval, an average of 17.7 lesions were removed from each of the 190 melanoma and nonmelanoma patients undergoing prophylactic skin lesion excision. This was accomplished in one to four sessions per patient. This average reflects only those patients who underwent one excision or more and does not include those patients treated without operation. When including the nonoperated patients screened during this interval, the average number of lesions removed was 2.7 per patient. Death from new melanomas was prevented during the 14-year period of this study as evidenced by the fact that no patient died or developed metastatic disease from a cutaneous melanoma that was not apparent or known about at the time of first examination.

Nuclear DNA measurements of metastatic melanoma by a computerized digital imaging system

To determine the extent of nuclear DNA abnormalities and their relationship with prognosis of stage II malignant melanoma, metastatic melanomas in lymphadenectomy specimens of 22 patients were studied by a computerized digital imaging system. The DNA ploidy pattern was aneuploid in 86% of the cases and tetraploid in the remaining 14%. In metastatic melanomas, there was a single clone in one third of patients and multiple clones in the remaining two thirds. Poor survival rate was associated with multiple clones and greater than 30% of mean coefficient of variation of DNA content. With tumor progression stem-cell lines often became heterogeneous with the development of multiple clones and widespread DNA values. These abnormalities, determined by nuclear DNA ploidy analysis, provide useful prognostic information.

Axillary dissection in melanoma. Prognostic variables in node-positive patients

We evaluated the importance of 14 clinical and pathologic variables as determinants of prognosis in patients with malignant melanoma and positive regional lymph nodes at axillary dissection. The records of 197 patients operated on between 1974 and 1984 were reviewed. Univariate analysis indicated as prognostically significant the number (p less than 0.001) and percentage (p less than 0.001) of positive nodes, highest nodal status (p less than 0.001), macroscopic or microscopic nodal metastases (p = 0.002), presence or absence of extranodal disease (p = 0.003), clinical stage (III versus less than III, p = 0.015), and site (considered as trunk versus other locations, p = 0.02). However, by multivariate analysis, only three variables were shown to be independent determinants of survival: percentage of positive nodes (p = 0.004), presence or absence of extranodal disease (p = 0.012), and site (trunk versus other locations, p = 0.019). Combining these three variables, subsets of patients with markedly different prognoses could be generated. It is possible to predict a favorable outcome for patients with less than 10% positive nodes, no extranodal disease, and a primary lesion at a site other than the trunk. It is also possible to recognize that the prognosis is very poor for patients with extranodal disease and truncal primary lesions, regardless of the percentage of positive lymph nodes. Finally it was verified that the prognosis is always unfavorable when the percentage of positive lymph nodes is very high.

Objective histopathologic grading of cutaneous malignant melanomas by stereologic estimation of nuclear volume. Prediction of survival and disease-free period

Modern stereologic techniques enable unbiased and shape-independent estimation of the three-dimensional nuclear volume (Vv). This study investigates the prognostic impact of Vv in 47 patients with malignant melanomas (10 years of follow-up) and compares Vv to traditional prognostic parameters and two-dimensional morphometric estimates. The averaged Vv was 226 microns3 and 457 microns3 in Stage I and II melanomas, respectively. The Vv was significantly increased in the case of ulceration, nodular melanoma, and Clark's level greater than III. The Vv showed only poor correlation to two-dimensional morphometric estimates. Cox regression analysis indicated Vv to possess excellent prognostic information, only rivaled by tumor ulceration, the latter being a 100% predictor of metastatic spread. Histologic type, Clark's level of invasion, tumor thickness (according to Breslow), and patient sex were without independent prognostic significance, which may be due to attributes of the small data base. It is concluded that Vv may be a powerful prognostic indicator in cutaneous melanomas, suitable for objective malignancy grading. The clinical and prognostic value of nuclear Vv needs further investigation in a larger and contemporary series of patients with malignant melanomas.

Cutaneous malignant melanoma. II. The natural history and prognostic factors influencing the development of stage II disease

The survival history of 259 patients with Stage I cutaneous malignant melanoma who were at risk for developing regional nodal metastases (Stage II) were studied. Eighty-seven of 377 Stage I patients (23%) developed regional nodal metastases (Stage IIB) with 40% 5-year survival. Fifty patients had regional nodal metastases at presentation, with or without a known primary (Stages IIA or IIC, respectively), with a 42% 5-year survival. A step-down multivariate analysis using the Cox regression model revealed four risk factors as being highly significant for predicting a more favorable survival outcome: (1) thinner Breslow thickness (P = 0.0001), (2) pathologic Stage I disease (P = 0.004), (3) no clinical ulceration (P = 0.0004), and (4) being a woman younger than 50 years of age (P = 0.029). These results are discussed in reference to other series.

The management of vaginal melanoma

Between 1964 and 1987 ten patients with vaginal melanoma were treated at The University of Michigan Hospital. Five of the six patients who underwent radical surgery had adequate information concerning the first site of relapse, and in four of these five, pelvic sites or locoregional lymph nodes were the first sites of recurrent disease. One of these patients developed a 17-cm pelvic recurrence, which responded with a 75% reduction in size 3 months after completion of radiotherapy given in high individual fractions (400 cGy X 11). Three patients were managed with local resection, and all developed recurrent locoregional disease. One patient presented with metastatic disease. We conclude that locoregional control of vaginal melanoma is difficult to achieve with surgery alone. We hypothesize that preoperative radiotherapy to the pelvis (500 cGy X 6 given 3 days a week to the whole pelvis with subsequent consideration for a vaginal boost field) may improve the poor rate of locoregional control of vaginal melanoma that is seen when surgery alone is used.

S-100 protein: a prognostic indicator in cutaneous malignant melanoma?

A series of 215 cases of cutaneous malignant melanoma referred to a single department of clinical oncology between 1940 and 1969 was studied to assess the accuracy of the Breslow thickness and the role of S-100 protein in predicting the clinical prognosis. Histological examination of these tumours showed that although the Breslow thickness correlated well with prognosis, in a significant number of cases it did not reliably forecast clinical outcome. From this series, tissue from those patients who survived disease-free for more than 10 years and those who died within a year of diagnosis was stained immunohistochemically for S-100 protein. Contrary to the findings of earlier studies, strong staining for S-100 protein was associated with improved survival (P less than 0.001). A marked increase in the incidence of cutaneous malignant melanoma was noted during the period of the study.

Prognostic factors related to survival and groin recurrence following therapeutic lymph node dissection for lower limb malignant melanoma

A retrospective analysis was carried out of 133 patients undergoing therapeutic lymph node dissection for malignant melanoma of the lower limb. A radical ilio-obturator dissection (RID) was performed in 106 patients and a superficial femoral dissection (SFD) in the remaining 27. On univariate analysis five factors were found to be significant indicators of prognosis. These were: Clark level of the primary (P = 0.02); primary melanoma thickness (P = 0.04); total number of positive nodes (P less than 0.001); number of positive femoral nodes (P less than 0.001); and number of positive ilio-obturator nodes (P less than 0.001). On multiple regression analysis only the number of positive nodes in each compartment remained a significant independent factor (P less than 0.001). The morbidity associated with RID was not significantly greater than after SFD. RID was, however, associated with a reduction in subsequent groin recurrence. Radical nodal clearance is the operation of choice. This technique provides maximum prognostic information, reduces the likelihood of local untreatable disease and possibly improves overall survival rates--especially when only one iliac node is involved.

Frequency of occult residual melanoma after excision of a clinically positive regional lymph node

A retrospective study of the medical records of 102 patients with Stage II malignant melanoma was conducted to determine the frequency of occult residual melanoma after excision of a clinically positive regional lymph node. Twenty-one patients met the study criteria for evaluation. Fifteen of 22 dissections were positive for melanoma (68.1%). These results support definitive regional lymph node dissection if the results of excisional biopsy are abnormal. No conclusions can be drawn from these data regarding the survival advantage of therapeutic regional lymph node dissection.

Groin dissection in malignant melanoma

One hundred seventeen patients with malignant melanoma who had groin dissection were reviewed. The estimated 5 year survival rate for patients with node involvement was 40 percent. For patients with involved inguinal nodes only, the 5 year survival rate was 47 percent. The estimated 5 year survival rate for patients with clinically enlarged and histologically involved nodes was 37 percent and the incidence of involved deep nodes in this group was 44 percent. For patients with clinical and histologic involvement of the inguinal and deep nodes, the estimated 5 year survival rate was 30 percent. In patients with clinical involvement of the inguinal nodes, radical groin dissection with in-continuity removal of the deep nodes appeared to improve the previously reported survival rates.

Prognostic factors in patients with regional cervical nodal metastases from cutaneous malignant melanoma

A retrospective analysis with a minimum 10 year follow-up was performed on 287 patients who underwent radical or modified neck dissections with histologically involved regional nodal metastases from cutaneous malignant melanoma. The cumulative 5 year and 10 year survival rates calculated from the time of node dissection were 33 percent and 28 percent, respectively. Age and sex of the patient, site of known primary tumor, clinical stage at presentation, and time interval from the treatment of the primary tumor to node dissection did not independently affect survival. However, an unknown site of primary disease, the presence of only one histologically involved node, and the absence of extranodal tumor invasion at the time of node dissection were statistically significant individual prognostic factors for an improved survival rate.

Spontaneous regional lymph node metastases of three variants of the B16 melanoma: relationship to primary tumor size and pulmonary metastases

We studied the patterns of spontaneous regional lymph node metastases of three variants (F1, F10, and BL6) of the B16 melanoma in C57BL/6 mice and related the incidence to primary tumor size and pulmonary metastases. The incidence of regional lymph node and pulmonary metastases correlated with increasing primary tumor size (p less than or equal to 0.0001). The incidence of pulmonary metastases in mice whose regional lymph nodes did not contain tumor also correlated with increasing primary tumor size (p less than or equal to 0.0001). This propensity for direct hematogenous spread was more apparent in BL6 tumors than in F1 and F10 tumors (p less than or equal to 0.0001). BL6 tumors also metastasized to regional nodes at smaller primary tumor sizes (p less than or equal to 0.04). Heterogeneous variants that metastasize earlier to regional lymphatic and hematogenous sites dictates the natural history of the primary tumor. Whether prophylactic lymphadenectomy for melanomas is therapeutic may depend on dissemination-related phenotypic characteristics.

Influence of anatomic location on prognosis of malignant melanoma: attempt to verify the BANS model

Stage I cutaneous malignant melanomas between 0.76 and 1.69 mm thick (Breslow measurement) in BANS (upper part of the back, posterior aspects of the arms, posterior and lateral aspects of the neck, posterior aspect of the scalp) areas have been reported to portend a relatively poor prognosis compared to non-BANS sites. We were unable to confirm the 15% poorer survival for BANS area lesions (84% BANS, 99% non-BANS) originally reported. In this report of 211 patients, malignant melanomas in BANS sites had a 4.6% poorer 5-year cumulative survival rate (88.9% BANS, 93.5% non-BANS; p = 0.35). Although many more patients need to be studied, we believe this small difference in survival is insufficient to influence therapeutic management strategies.

Improved survival rates of patients with acral lentiginous melanoma treated with hyperthermic isolation perfusion, wide excision, and regional lymphadenectomy

Twenty-three patients with extremity malignant melanoma who fit the clinical and pathologic criteria for acral lentiginous melanoma were treated in a prospective, nonrandomized trial of wide local excision, regional lymphadenectomy, and hyperthermic isolation perfusion. There were 17 patients (73.9 percent) pathologically judged to be in stage I and 6 (26.1 percent) in stage II. Three patients entered the study with regional recurrence. Delay in diagnosis of the lesions averaged almost 3 1/2 years. Increasing awareness about the occurrence of acral lentiginous melanoma may result in earlier diagnosis, increased survival rates, and cure. Life table survival analysis revealed 5 and 10 year survival rates of 75 percent and 58 percent, respectively. This supports the findings of Krementz et al and suggests not only that a marked improvement in survival can be achieved through the use of hyperthermic isolation perfusion, but that the survival of patients with acral lentiginous melanoma is comparable with that of patients with other extremity malignant melanomas treated with aggressive multimodality therapy.

Recurrence potential of thin primary melanomas

Between April 1971 and January 1985, the University of California at Los Angeles (UCLA) Division of Surgical Oncology has seen 649 patients diagnosed with thin primary melanomas, as defined by a Clark level less than IV and Breslow depth less than 0.76 mm. Thirty-six patients, whose primary diagnosis was confirmed by UCLA pathologists, presented with or subsequently developed melanoma metastases. Twenty-four (67%) had Clark level II lesions, whereas the remaining 12 (33%) had Clark level III lesions. Metastases were noted more frequently in men than in women, with a man-to-woman ratio of 3 to 2. The site of the primary lesion in this group was most frequently on the trunk (16 of 36 cases, 44%), followed by the head and neck (9 of 36 cases, 25%) and arm and shoulder (7 of 36 cases, 19%). Metastasizing thin lesions were least likely to occur on the leg and hip (4 of 36 cases, 11%). Twenty of these lesions were recently reexamined, and 17 of 20 cases (85%) demonstrated evidence of regression. Twenty-eight patients (78%) had their first metastases to regional lymph nodes. Fifteen remained alive with no evidence of disease at a median follow-up of 99 months. Twenty patients died from systemic metastases, and one patient was alive with brain metastasis at the time of this article. Although infrequent, metastases from thin melanomas do occur, suggesting the need for careful long-term follow-up and immediate investigation of adenopathy even in low-risk patients.

Therapy of primary cutaneous melanoma

The essential tenets of early recognition, biopsy, and appropriate surgical treatment of melanoma are reviewed. The controversies of elective regional lymph node dissection and isolated limb perfusion are discussed, as well as the newer modalities of immunotherapy.

The classification of malignant melanoma, its histological reporting and registration: a revision of the 1972 Sydney classification

A group of pathologists with an interest in malignant melanoma met in Sydney in 1982 to update the classification of melanoma formulated in Sydney in 1972. The group recommended that malignant melanoma be classified as follows: malignant melanoma with an adjacent component of superficial spreading type, malignant melanoma with an adjacent component of lentigo maligna type, malignant melanoma with an adjacent component of acral lentiginous type, malignant melanoma with an adjacent component of mucosal lentiginous type, malignant melanoma with no adjacent component, malignant melanoma of unclassifiable histogenetic type. The data recorded in the surgical pathology report should include: diagnosis of primary malignant melanoma, histogenetic classification, presence/absence of ulceration, micrometer-measured thickness, microanatomical level, mitotic rate/mm2, presence/absence of vascular invasion, presence/absence of regression, completeness of resection. The recommendations for the examination of specimens and the recording of data for research purposes and for tumour registries are described.

Prognostic factors for stage I melanoma of the skin: a review

The prognosis of melanoma of the skin has been investigated in many studies. In this report papers on the prognosis of stage I melanoma published since 1975 in the leading oncology journals have been reviewed. Further the data collected by the WHO Collaborating Centre for Evaluation of Methods of Diagnosis and Treatment of Melanoma are analysed, and the results compared with those of other series. Three factors emerge as clearly influencing prognosis: sex, maximum tumour thickness and ulceration. The role of other factors and particularly that of an interaction between tumour thickness and ulceration conjectured by some authors remains questionable.

Prognostic histopathological factors in malignant melanoma

An analysis of prognostic factors in 4000 patients with cutaneous malignant melanoma at the Sydney Melanoma Unit and the University of Alabama in Birmingham has demonstrated that the histological features of the primary melanoma become less predictive of survival the more advanced the disease becomes. Thus, whilst 4 features of primary lesions were independent predictors in localized disease (tumour thickness, ulceration, level of invasion and regression), only one of the stronger ones (ulceration) remained predictive in patients with regional lymph node metastases. Once distant spread was evident, there were no parameters of the primary lesion that predicted survival. Thus, in patients with advanced disease prognosis was dictated by the extent of metastatic involvement: the number of positive lymph nodes in stage II patients and the number and location of metastatic sites in stage III patients.

Prophylactic lymphadenectomy for B16 melanoma in C57/BL6 mice: survival based on size and heterogeneous variant of the primary

Survival following prophylactic lymphadenectomy by hip disarticulation in mice with three B16 melanoma variants was studied. C57/BL6 mice inoculated with viable tumor cells (F1, F10, and BL6) into the left hind foot pad were randomized to wide excision (WE) of the primary tumor alone or wide excision plus prophylactic lymphadenectomy (WE plus PL) at 1-, 2-, 3-, 4-, and 5-mm primary tumor sizes (each group, N = 6). Overall survival time was improved by WE plus PL. A significant survival advantage and cure was apparent for the F1 and F10 variants with primary tumor sizes of 2 and 3 mm (F1, 2 and 3 mm, P less than 0.001; F10, 2 mm, P less than 0.006; 3 mm, P less than 0.001), but not for the BL6 variant. Prophylactic lymphadenectomy provides a therapeutic advantage in mouse melanomas of intermediate size in two of the three variants of B16.

Prognosis of patients with pathologic stage II cutaneous malignant melanoma

The prognostic relevance of the extent of nodal metastases, lesion thickness, level of invasion, site of lesion, satellitosis, age, sex, and year of diagnosis and treatment were assessed in 213 consecutive patients with pathologic Stage II malignant melanoma (157 with clinical Stage I disease and 56 with clinical Stage II disease). Of these factors, only three were significant: 1) clinical status of the lymph nodes (p less than 0.0001); 2) thickness of the primary lesion in the ranges of less than 2.0 mm, 2.0 to 4.9 mm, and 5.0 mm or greater (p = 0.002); and 3) level of invasion (p = 0.0002). The extent of nodal metastases in those patients with clinical Stage I disease was not significant. The difference in survival between patients with clinically negative/histologically positive nodes (clinical Stage I) and clinically positive/histologically positive nodes (clinical Stage II) was apparent throughout the follow-up period. The 5- and 10-year survival rates for the clinical Stage I patients were 44% and 28%, respectively, and for the clinical Stage II patients 21% and 12%, respectively (p less than 0.0001). A 5-year cumulative survival rate of 65% was achieved for clinical Stage I patients having primary lesions of less than 2.0 mm in thickness, while it was 19% for patients having primary lesions of 5.0 mm or more in thickness. For pathologic Stage II malignant melanoma patients, prognosis is most dependent on the clinical status of the lymph nodes, not on the number of lymph nodes with micrometastases.

Adjuvant therapy of cutaneous malignant melanoma: a critical review

The emergence of revised definitions for the high-risk patient with cutaneous malignant melanoma prompts us to re-examine the current status of adjuvant therapy in this disease. We wish to address the question, "once a cutaneous melanoma is surgically removed and the patient is currently free of disease but at high risk for metastases, what can be done to prevent recurrence"?

Occult melanoma in lymph nodes detected by antiserum to S-100 protein

Sections of 1,273 nodes from 58 patients with melanoma were stained in an immunoperoxidase assay using an antiserum to S-100 protein and aminoethyl carbazole as indicator. By the hematoxylin and eosin (H. and E.) technique, 128 nodes were seen to contain melanoma (10%); by the anti-S-100 protein technique, 363 (29%) were found to be tumor-positive. The additional tumor-positive nodes contained single tumor cells or small groups of tumor cells and were adjacent to nodes that were partly or wholly replaced by melanoma. Penetration of nodes by single tumor cells was seldom seen in node groups containing no tumor that was visible on H. and E. staining. The anti-S-100 protein approach more accurately identified those patients who would die of their recurrent disease less than 5 years after lymphadectomy.

Prognosis of skin melanoma with regional node metastases (stage II)

566 stage-II melanoma patients treated at the National Cancer Institute of Milan, Italy, were analyzed to evaluate the prognosis. Among the criteria considered, four were significantly associated with survival when considered as single factors: growth pattern, levels of invasion, the number of involved lymph nodes, and the extent of metastatic growth. As regards growth pattern, the observed 5-year survival rates were 41.9% for superficial spreading melanoma and 20.5% for nodular melanoma (P = 10(-3)). As regards levels, the 5-year survival rates were as follows: level II, 20.9%; level III, 33.1%; level IV, 43.2%; level V, 10.2% (P = 10(-3)). Patients with a partial node metastasis had 64.5% 10-year survival, while those with extension beyond the capsule had 32.6% 10-year survival (P = 10(-9). Patients with one metastatic node had 43.4% 10-year survival, and patients with three or more positive nodes had 26.0% 10-year survival (P = 10(-9)). Multifactorial analysis shows that growth pattern and extent of node metastases significantly affect survival (P = 10(-2) and P = 10(-4), respectively) while the number of involved nodes turns to borderline P-value (0.051) and the levels are no longer significant (P = 0.4).

Malignant melanoma of the skin. I. The association of tumor depth and type, and patient sex, age, and site with survival

The occurrence and behavior of cutaneous melanomas in a group of 1123 patients studied prospectively, is described in terms of histologic type, tumor thickness and levels of invasion, the patients' sex and age, and the anatomic location of the primary tumors. Associations amongst these attributes, and with survival, are also examined. The characteristics of the patients in this study (who on average are somewhat younger, and have better prognoses and survivals than those reported by most other groups) are compared with data obtained (primarily over the past decade) in other geographical areas, and with different patient populations. Evidence is presented that sex, tumor location, and age (in the case of males) are also predictive of survival.

Surgery in recurrent malignant melanoma

Seventy-nine consecutive patients with resectable, recurrent malignant melanoma were treated with surgical excision, followed by adjuvant chemotherapy. Of 7 Stage IIIA patients, 6 remain alive; 5 are disease-free at 27 months. Of 33 patients with advanced stage IIIB disease with fixed tumor masses, including 16 cases that involved two nodal groups, 10 patients (30%) remain disease-free at 30 months. Of 12 Stage IIIAB patients, one remains disease-free at 26 months. Of 27 Stage IV patients, 7 (25%) remain disease-free at 36 months. Characteristic of those patients who remain disease-free is the initial presence of 3 or less discrete metastatic lesions, and a long prior disease-free interval. Surgical removal of metastatic lesions of malignant melanoma, in combination with chemotherapy, offers improved palliation in patients with a small number of metastatic lesions and a long previous disease-free interval.

Prognostic parameters in recurrent malignant melanoma

In 361 patients with recurrent malignant melanoma, the clinical stage was the strongest determinant of subsequent survival (P less than 0.01). In Stage IV, the number of initial, distinct lesions was important. Patients presenting with a single metastatic nodule had median survival ten months, whereas those with two or more metastatic nodules had median survival 6.9 months (P less than 0.05). The length of disease-free interval from excision of the primary to recurrence correlated consistently with subsequent survival in patients with regional lymph node metastases. Those with disease-free interval less than one year had median survival 15.8 months with 16% surviving at five years, while those with interval one year or longer had median survival 23.7 months with 30% surviving at five years (P less than 0.05). In Stage IV, the correlation of survival with disease-free interval became significant only with 24 months as the demarcation point of length of disease-free interval. Age and sex affected the disease-free interval, but not survival after recurrence.

Judging prognosis in malignant melanoma of the skin. A problem of inference over small data sets

Data was generated for 828 clinical stage 1 melanoma patients, divided into groups according to sex, tumor location, and tumor level for each of the 56 groups. Summary data, including the number of patients, number of patients dying as a result of melanoma, range of tumor thickness, mean and median tumor thickness, and mean length of follow-up of the surviving patients, are shown. Patients with melanoma of the palms and soles, subungual melanomas, and mucosal melanomas were excluded. A physician with a new melanoma patient could select the appropriate group for his or her patient, matched with respect to sex, location, and level, and then make a judgment regarding the prognosis, based on the survival experience of the group. In a few groups, the small numbers of patients provides only a rough impression of survival, but with many groups, a fair estimate can be made. The effectiveness of elective lymph node dissection was examined by creating 111 pairs of patients, matched by sex, level, location, and tumor thickness (to within +/- 12%), in which one member of the pair had an elective node dissection (ELND) and the other did not. There was no statistically significant difference between the survival of the two groups.

Factors prognostic for survival in patients with malignant melanoma spread to the regional lymph nodes

To establish clinical and histologic determinants of survival, records of all UCLA patients with resectable melanoma metastatic to the lymph nodes during the years 1954-1976 were reviewed. These 150 patients were treated first with wide excision, lymphadenectomy, and with radiation/chemotherapy and/or additional surgery only if further recurrences developed. None received adjuvant immunotherapy or chemotherapy. In 97 of 139 patients with identified primary tumors, slides of the primary lesion were reviewed. Putative prognostic factors included age, sex, parity, site of primary tumor, presence of satellitosis, clinical status of nodes, histologic characteristics of primary lesion (Clark's level, thickness of tumor, presence/width of ulceration, and number of mitoses/HPF), time from biopsy of primary tumor to lymphadenectomy, and number of positive nodes. kaplan-Meier estimates of survival for the entire group at one, two, five, and ten years were 73, 55, 37, and 33%, respectively. Median follow-up period of survivors was four years. Univariate analyses using the log-rank test showed that thickness of the primary lesion (p less than 0.001), width of ulceration (p = 0.003), absence of ulceration (p = 0.024), and number of positive nodes (p = 0,.033) were prognostic for survival. In multivariate analysis by the Cox procedure, thickness of the primary (p = 0.001) and number of melanoma-containing nodes (p = 0.043) were prognostic for survival. Location of the primary tumor became marginally significant (p = 0.12) in the multrivariate model. These findings demonstrate the prognostic importance of characteristics of both the primary lesion and extent of regional dissemination. Future prospective randomized trials for (adjuvant) therapy of Stage II melanoma should be stratified by these variables.

Therapeutic considerations in the management of melanoma

The utilization of Breslow-Clark microstaging has proved helpful in deciding whether or not to perform elective regional node dissection for patients with melanoma. The marked biologic diversity of the disease, however, mandates a strict therapeutic policy of individualization with respect to prognostic variables and special clinical presentation. Specifically, melanomas associated with ulcerations, truncal location, and regional node involvement appear to be more aggressive. Lesions with cutaneous penetration more than 1.5 mm in depth, and showing blood and lymphatic vessel invasion are more often associated with regional node involvement and worse prognosis. The association of any of these adverse prognostic signs with an intermediate thickness lesion (0.76-1.5 mm) may justify elective node dissecton. Head and neck, mucosal, and subungual melanomas are all associated with poor prognosis due to rapid growth and early dissemination. The role of elective node dissection in these patients in unclear.

Metastases in malignant melanoma

A study has been made of 76 cases of metastatic melanoma presenting over a ten year period. Of this group, 64.5 per cent developed clinical metastases within 12 months of presentation with the primary disease while 80 per cent had developed metastases by three years. Fifty per cent of our patients had ulcerated lesions, and most patients had thick lesions on histological examination. The site of the first metastasis occurred in the regional lymph nodes in 65 per cent and in viscera in 22 per cent. Subsequent clinical metastases were widespread and their distribution is recorded. Of those patients with nodal involvement, 75 per cent had only one node involved in histological examination. Only 14 of the 76 patients are alive and of these nine are alive without disease. The surviving patients had regional node, intransit or local metastases present. Disease beyond these areas was fatal. We have recorded the therapeutic modalities used without attempting to study them objectively.

Uveal melanoma: location, size, cell type, and enucleation as risk factors in metastasis

In this series of 3,432 cases of malignant melanoma of the choroid and ciliary body, mortality from metastasis 15 years after enucleation was 46 per cent. This mortality was at least ten times greater than has been observed with tumors of the iris, probably owing to the greater size and more malignant cytology of choroidal and ciliary body tumors. In 56 per cent of the 3,432 cases, the melanomas were composed of a mixture of spindle and epithelioid cells. The 15-year mortality of patients with melanomas of mixed cell type was three times that of patients with tumors of pure spindle cell type. In 30 per cent of the cases in this series, the melanomas of the choroid and ciliary body were larger than 15 mm in diameter. Size was highly correlated with mortality. The distribution of deaths following enucleation in the 3,432 cases was a log-normal function of time from enucleation. This indicated that metastasis occurred in these fatal cases close to the time of enucleation. The authors were also able to infer that many years were usually required for these uveal melanomas to grow from small (7 to 10 mm in diameter) to large (greater than 15 mm in diameter). These observations are consistent with the hypothesis that dissemination of tumor cells at the time of enucleation has been a major cause of metastasis with small and medium-sized uveal melanomas.

Factors related to thickness of melanoma. Multifactorial analysis off variables correlated with thickness of superficial spreading malignant melanoma in man

Computer analyses to identify correlations between thickness of primary superficial spreading malignant melanoma and eighteen variables previously reported to be related to prognosis were performed on a series of malignant melanomas. The variables that showed statistically significant (less than or equal to 0.05) direct relationships to thickness were level (Clark), elevation of lesion, age of patient, least and greatest diameters of lesion, history of bleeding, ulceration, clinical and histologic stage, anatomic location, pedunculation, and satellitosis. The variables that did not correlate with thickness were clinical diagnosis of regional lymphadenopathy, in-transit metastasis, duration of lesion, sex, history of a previous malignant melanoma, and history of a pre-existing lesion at the site of the development of melanoma. Multiple regression analysis of the factors that showed statistically significant correlation with thickness of the primary lesion revealed a subset of six dominant variables that were most predictive of thickness, namely, level, elevation, largest diameter of lesion, ulceration, histologic stage, and age of the patient.

A prognostic model for clinical stage I melanoma of the trunk. Location near the midline is not an independent risk factor for recurrent disease

Fifteen variables were studied for their usefulness in predicting recurrent disease in 254 patients with clinical stage I melanoma of the trunk. Thickness of the primary tumor correctly predicted outcome with an accuracy of 90 percent or greater in 176 patients with melanoma primaries with a thickness of less than 1.70 mm or 5.5 mm or greater. No other variables significantly increased predictive accuracy over these ranges of thickness. A Cox proportional hazards analysis of the remaining 78 patients with primary tumors 1.70 to 5.49 mm thick demonstrated that the following four variables functioned as independent risk factors for recurrent disease: (1) thickness of the primary tumor (p = 0.0005), (2) mitoses/mm2 greater than 6 (p = 0.006), (3) a nearly absent or minimal lymphocyte response at the base of the tumor (p = 0.009), and (4) location on the upper trunk (p = 0.03). Trunk lesions located near the midline did not have a worse prognosis than more lateral melanomas of similar thickness.

Malignant melanoma: A search for occult lymph node metastases

Lymph nodes regarded as "negative" following routine pathologic examination were reexamined in seven patients with malignant melanoma who later developed systemic metastases. A total of 185 lymph nodes were serially sectioned; five to seven levels of each lymph node were examined for the presence of occult metastases. In this manner previously undetected tumor was found within a solitary lymph node of one patient. It is concluded that attempts to detect occult melanoma metastases by routine serial sectioning of lymph nodes is not of practical applicability.

Changes in clinical presentation and management of malignant melanoma

Records of 147 patients with primary cutaneous malignant melanoma treated at the Lahey Clinic from 1955--1979 were reviewed. Complete clinical follow-up data were obtained, and all pathologic material was reviewed. Proposed new risk categories based on a modification of the Clark and Breslow categorizations are outlined. The incidence of low-risk melanoma has dramatically increased (from 23--53%) and that of high-risk melanoma has decreased (from 34--10%) over the period of this study. Dermal punch biopsy gives accurate staging information and carries no increased risk of local recurrence, nodal metastases, or death from disease. Resection of a margin of clinically uninvolved skin measuring twice the diameter of the primary melanoma minimizes local recurrence (2.5% or less), does not adversely affect survival, and reduces the need for skin grafting. Arbitrary wide margins are not justified. Regional lymphadenectomy offers no improvement in survival in patients with low-risk and moderate-risk melanoma and can play only a minor role at most in improving survival for patients with high-risk melanoma.

A prognostic model for clinical stage I melanoma of the upper extremity. The importance of anatomic subsites in predicting recurrent disease

Thirteen variables were studied for their relative usefulness in predicting recurrent disease in 107 patients with clinical Stage I melanoma of the upper extremity. After a mean follow-up period of 54 months, the only patents who have had recurrent disease to date are those who primary lesions were located either on the hand or posterior upper arm. The five-year disease-free survival role for 44 patients with melanoma at these sites was 68%. None of 63 patients with melanoma located on the forearm of anterior upper arm have had recurrent disease (i.e., the five-year, disease-free survival rate was 100% (p = 0.00004), compared with the hand or posterior arm group). A Cox proportional hazards (multivariate) analysis demonstrated that two primary tumor histologic variable, thickness in millimeters and ulceration, interacted to produce the best prognostic model for those 44 patients with melanoma of the hand or posterior upper arm. Twenty-one patients with primary lesions at these sites had primary tumors less than 2.25 mm in thickness and no evidence of ulceration histologically. Their five-year, disease-free survival role was 95%. For the remaining 23 patients with primary tumors on the hand or posterior upper arm who had either histologic evidence of ulceration or primary tumors greater than or equal to 2.25 mm, the five-year disease-free survival rate was 37% (p = 0.002, compared with group nonulcerated, thin lesions). The excellent survival rate for patients with melanomas on the forearm or anterior upper arm was not completely explained by pathologic stage, by primary tumor thickness, or by histologic ulceration of the primary tumor.

Correlation of thicknesses of superficial spreading malignant melanomas and ages of patients

In a prospective study of 455 consecutive patients with superficial spreading malignant melanomas entered into the data base of the Melanoma Cooperative Group of New York University Medical Center, it was found by linear-regression analysis that there is a statistically significant (p = 0.005) positive correlation between the ages of the patients and the thickness of their lesions. Although the reasons for the correlation between ages and thicknesses ae not certain, several possible explanations were considered, namely: (1) the greater prevalence of superficial spreading malignant melanomas in the aged on the lower limbs where thicker lesions were present in our patients, (2) the altered skin of the elderly, which may favor deeper penetration by these neoplasms, (3) impaired immunologic responses in the aged, (4) the delay in diagnosis of malignant melanomas in the elderly because of obsuration of them by numerous benign pigmented lesions that frequently develop with aging, and (5) lesser concern of the elderly with their physical appearances in particular and medical problems in general.

The results of node resection for clinically enlarged lymph nodes in malignant melanoma

Patients with malignant melanoma who require a block dissection for clinically enlarged lymph nodes have a relatively good prognosis if only one node is involved histologically and the primary is on the lower limb. Sixty per cent of these patients with single nodes show a 10 year disease-free survival rate, compared with 9% for those with multiple node involvement. The local recurrence rate at the resection site of hyperplastic nodes was 26% but fell to 10% when only a single node was involved. The disease-free interval and the survival time are a useful measure of the effectiveness of node resection.

Early versus delayed shoulder motion following axillary dissection: a randomized prospective study

The role and timing of physical therapy following axillary dissection for melanoma, or in conjunction with modified radical mastectomy has not been extensively studied. A prospective randomized clinical trial was carried out over an 18-month period in the Surgery Branch, National Cancer Institute (NCI) and Department of Rehabilitation Medicine, Clinical Center, in which patients were assigned to receive one of two postoperative physical therapy regimens. Patients were assigned to receive graduated increases in allowed range of motion (ROM), either beginning on postoperative day 1 (early) or day 7 (delayed). All patients were advanced to full pain-free ROM when the suction catheters were removed. A total of 36 patients with 40 axillary dissections (19 for melanoma, 21 for breast cancer) were included in this study. Patients randomized to receive early motion had more total wound drainage (805 +/- 516 cc vs. 420 +/- 301 cc, p < 0.01), more days of drainage (10.3 +/- 5.3 vs. 6.2 +/- 2.7, p < 0.01), and later postoperative day of discharge (12.8 +/- 5.1 days vs. 9.2 +/- 4.0 days, p < 0.02) than did patients who started motion on day 7. Wound complications including infection and small areas of skin breakdown occurred more frequently in the early group (seven patients vs. one patient, p < 0.02). No significant differences in the per cent of patients achieving functional ROM could be identified between these two groups at one, three or six months after operation. Transient serratus anterior palsy (12 patients) and latissimus dorsi palsy (2 patients) occurred in approximately 30% of all patients, regardless of group (breast vs. melanoma, early vs. delayed), but returned to normal in all patients. The early institution of flexion and abduction exercises following axillary dissection thus appears to have a deleterious effect on wound healing and drainage. Adequate functional ROM is attained in all patients with a minimum of complications when active motion exercises are delayed for up to 7 days after axillary dissection.

A multifactorial analysis of melanoma: III. Prognostic factors in melanoma patients with lymph node metastases (stage II)

Twelve prognostic features of melanoma were examined in a series of 185 patients with nodal metastases (Stage II), who underwent surgical treatment at our institution during the past 20 years. Forty-four per cent of the patients presented with synchronous nodal metastases (substage IIA), 44% of the patients had delayed nodal metastases (substage IIB), and 12% of the patients had nodal metastases from an unknown primary site (substage IIC). The patients with IIB (delayed) metastases had a better overall survival rate than patients with IIA (synchronous) metastases, when calculated from the time of diagnosis. These differences could be explained on the basis of tumor burden at the time of initial diagnosis (microscopic for IIB patients versus macroscopic for IIA patients). Once nodal metastases became evident in IIB patients, their survival rates were the same as for substage IIA patients, when calculated from the onset of nodal metastases. The survival rates for both subgroups was 28% at five years and 15% for ten years. Substage IIC patients (unknown 1 degrees site) had better five-year survival rates (39%), but the sample size was small and the differences were not statistically significant. A multifactorial analysis was used to identify the dominant prognostic variables from among 12 clinical and pathologic parameters. Only two factors were found to independently influence survival rates: 1) the number of metastatic nodes (p = 0.005), and the presence or absence of ulceration (p = 0.0019). Additional factors considered that had either indirect or no influence on survival rates (p > 0.10) were: anatomic location, age, sex, remission duration, substage of disease, tumor thickness, level of invasion, pigmentation, and lymphocyte infiltration. All combinations of nodal metastases were analyzed from survival differences. The combination that showed the greatest differences was one versus two to four versus more than four nodes. Their five-year survival rates were 58%, 27% and 10%, respectively (p < 0.001). Ulceration of the primary cutaneous melanoma was associated with a <15% five-year survival rate, while nonulcerative melanomas had a 30% five-year survival rate (p < 0.001). The combination of ulceration and multiple metastatic nodes had a profound adverse effect on survival rates. While tumor thickness was the most important factor in predicting the risk of nodal metastases in Stage I patients (p < 10(-8)), it had no predictive value on the patient's clinical course once nodal metastases had occurred (p = 0.507). The number of metastatic nodes and the presence of ulceration are important factors to account for when comparing surgical results, and when analyzing the efficacy of adjunctive systemic treatments.

Malignant melanoma patients with positive nodes and relatively good prognoses: microstaging retains prognostic significance in clinical stage I melanoma patients with metastases to regional nodes

Fifteen variables were tested for their value in predicting recurrent disease in 46 clinical Stage I melanoma patients with metastases to regional nodes. A stepwise proportional hazards general linear model (Cox multivariate analysis) separated these melanoma patients with regional node metastases into at least two risk groups. Twenty patients in the relatively low-risk group had a five-year disease-free survival of 80% (in spite of having nodal metastases). This compares to a five-year disease-free survival of 17.5% for 26 patients in the high-risk group (P less than 0.001, Lee-Desu Statistic). Criteria for the high-risk group required that a patient have only one of the following two values: (1) The number of regional lymph nodes that contained tumor divided by the total number of nodes removed x 100% (percentage of positive nodes) greater than or equal to 20%; or (2) a primary tumor thickness of greater than 3.5 mm (regardless of node percentage). Conversely, patients in the low-risk group had neither of the above features. The high-risk group could further be stratified by the lymphocytic response at the base of the tumor. These findings have direct immediate application to the elective regional node dissection controversy and to adjuvant therapy studies containing these patients.