A rational approach to the surgical management of melanoma

Microstages in malignant melanoma--the basis for an elective lymph node dissection

Our experience has shown that an increasing depth of invasion of the primary tumor is connected with a higher incidence of regional lymph node metastases. The incidence of subsequent metastases or recurrences is compared retrospectively for two groups: (1) 175 patients with elective dissection and (2) 33 patients with excision only. All patients suffered from high-risk melanomas of clinical stage I. The frequency of subsequent metastases was 21% (N = 36) for the first group and 46% (N = 15) for the second group (p less than or equal to 0.01). The 5-year survival rate (Berkson-Gage) of patients with high-risk melanomas and secondaries is 41% for the patient group (N = 27) in which elective dissection was performed and 21% for patients with therapeutic dissection (N = 52). The results speak for the elective dissection in cases of high-risk melanomas.

Diagnosis, treatment and prognosis of early melanoma. The importance of depth of microinvasion

There are many clinicopathologic features of the lesion and host which influence the natural course of melanoma. Currently, the most important prognostic factor appears to be the depth of invasion of the primary lesion. Using either the Clark's level of microinvasion or the tumor thickness as measured by Breslow, there is good correlation of decreasing survival rates, and increasing incidence of occult metastasis in regional nodes with deeper invasion of the tumor. Thus, proper diagnosis and treatment of primary melanoma depends on the information of depth of microinvasion. And patients with high-risk of developing occult metastasis in regional nodes can be identified. Although two recent studies question the value of performing prophylactic regional lymphadenectomy, none of these studies utilized depth of microinvasion to select patients who have a high chance of having extension or relapse only in regional nodes.

Clinical course of cutaneous malignant melanoma related to histopathological criteria of primary tumour

By using cumulative survival curves the influences of histological criteria of the primary tumour on the prognosis of 204 patients with clinical stage I malignant melanoma were evaluated. Tumour thickness, level of invasion in the dermis plus ulceration appear to have greatest influence on prognosis. Other factors influencing prognosis include that histogenetic type of melanoma, malignant cell invasion into blood vessels as well as intralesional transformation. On the other hand, it appears from our material that the number of mitoses, the type of malignant cell, regression phenomena and the amount of the inflammatory cell infiltrate have no significant influence on prognosis.

Primary mucosal malignant melanoma. Appraisal of role of radiation therapy

Primary malignant melanoma of the vagina and esophagus are reported and the literature on the subject is extensively reviewed. The role of large fraction irradiation is appraised. In both cases, no exenterative surgery was imposed but instead, intermittent large fraction irradiation with protracted high doses was elected for local control.

Assessment of biopsy techniques and histopathologic interpretations of primary cutaneous malignant melanoma

The biopsy techniques utilized for diagnosis in 1,161 patients with primary cutaneous malignant melanoma treated at the New York University Medical Center were reviewed. Eight hundred sixty-four (74%) biopsies were of the excisional type and 269 (23%) were incisional. Twenty-eight biopsies (3%) could not be assessed. Two hundred fifty-two consecutive patients referred for treatment of malignant melanoma to the authors for the last three years were studied to determine whether standard techniques of biopsy and uniform criteria for histopathologic diagnosis and staging were being utilized. One hundred forty-nine of these patients (59%) had total excisional biopsies of their lesions and 103 (41%) had incisional biopsies. Of the latter group, 66 (64%) were for lesions less than 2 cm in diameter and were situated in areas other than the face. The biopsy specimens obtained from 123 patients were reviewed by at least one other pathologist as well as our own (A.B.A.). For these 123 patients a difference of histologic diagnosis between pathologists occurred in 11 (9%). In 58 (47%) there was a discrepancy in assignment of Clark levels or a failure to assess Clark levels. Tumor thicknesses as measured by Breslow were read in only 22 (18%) of these 123 patients. The inadequacies of many of the biopsy specimens and discrepancies in histopathologic interpretation indicate that acceptable biopsy techniques and reproducible diagnostic criteria have not yet been generally adapted for primary cutaneous malignant melanomas.

Mangement of malignant melanomas: an overview

This paper presents an overview of the management of malignant melanoma. It considers the value of wide reexcision relative to the depth of invasion of the melanoma. It considers the indications for elective lymphadenectomy and presents a critical review of chemotherapy, immunotherapy and other procedures, such as X ray. The conclusion is that surgery, wherever feasible, is still the best approach.

A multifactorial analysis of melanoma: prognostic histopathological features comparing Clark's and Breslow's staging methods

A multifactorial analysis was used to identify the dominant prognostic variables affecting survival from a computerized data base of 339 melanoma patients treated at this institution during the past 17 years. Five of the 13 parameters examined simultaneously were found to independently influence five year survival rates: 1) pathological stage (I vs II, p = 0.0014), 2) lesion ulceration (present vs absent, p = 0.006), 3) surgical treatment (wide excision vs wide excision plus lymphadenectomy, p = 0.024), 4) melanoma thickness (p = 0.032), and 5) location (upper extremity vs lower extremity vs trunk vs head and neck, p = 0.038). Additional factors considered that had either indirect or no influence on survival rates were clinical stage of disease, age, sex, level of invasion, pigmentation, lymphocyte infiltration, growth pattern, and regression. Most of these latter variables derived their prognostic value from correlation with melanoma thickness, except sex which correlated with location (extremity lesions were more frequent on females, trunk lesions on males). This statistical analysis enabled us to derive a mathematical equation for predicting an individual patient's probability of five year survival. Three categories of risk were delineated by measuring tumor thickness (Breslow microstaging) in Stage I patients: 1) thin melanomas (<0.76 mm) were associated with localized disease and a 100% cure rate: 2) intermediate thickness melanomas (0.76-4.00 mm) had an increasing risk (up to 80%) of harboring regional and/or distant metastases and 3) thick melanomas (>/=4.00 mm) had a 80% risk of occult distant metastases at the time of initial presentation. The level of invasion (Clark's microstaging) correlated with survival, but was less predictive than measuring tumor thickness. Within each of Clark's Level II, III and IV groups, there were gradations of thickness with statistically different survival rates. Both microstaging methods (Breslow and Clark) were less predictive factors in patients with lymph node or distant metastases. Clinical trials evaluating alternative surgical treatments or adjunctive therapy modalities for melanoma patients should incorporate these parameters into their assessment, especially in Stage I (localized) disease where tumor thickness and the anatomical site of the primary melanoma are dominant prognostic factors.

Malignant melanoma of the head and neck

Sixty-nine patients with head and neck melanoma were prospectively evaluated from 1971 to 1977. Patients presenting for initial therapy underwent wide excision of their primary tumor, and those with deeply invasive melanoma also underwent regional lymphadenectomy, whether their nodes were clinically positive or negative. The results suggest that the prognosis of this tumor is similar to that of melanoma arising at other sites. Clinical stage and primary-tumor histopathologic microstage both correlated with disease recurrence. At 1 to 75 months, patients with clinical Stage I disease had a 13% recurrence rate, while 58% of those with Stage II disease developed recurrence. Patients with superficially invasive melanoma had a 10% recurrence rate, while 17%-33% of those with deeply invasive disease developed recurrence. However, the presence of node metastases, rather than the microstage of the primary tumor, appeared to be the dominant indicator of outcome. Radical excision of the primary tumor may reduce the incidence of local disease recurrence. We believe that regional lymphadenectomy is indicated for deeply invasive melanoma.