Prognostic factors in patients undergoing lymphadenectomy for malignant melanoma

Surgical management of regional lymph nodes in cutaneous melanoma

The initial evaluation of melanoma patients should include an assessment of the regional lymph nodes for metastatic disease. Clinical palpation of the nodes is an important but relatively crude index of metastatic melanoma. In clinically normal nodes, the risk of microscopic metastatic melanoma can be predicted by such prognostic factors as thickness, ulceration, and anatomic location of the melanoma. Other prognostic factors, including the level of invasion and growth pattern (nodular and superficial spreading) provided no additional predictive information after these dominant factors were accounted for. Stage I patients with intermediate thickness melanoma (0.76-4.00 mm) have an improved survival rate with elective lymphadenectomy, while those with thin (less than 0.76 mm) and thick (greater than or equal to 4.00 mm) melanomas do not benefit from elective node dissection. Stage II melanoma patients with documented nodal metastases have relatively poor survival rates because of a high risk for distant microscopic metastases. A surgical strategy for deciding about the timing, the extent, and the treatment goals of regional node dissection in melanoma patients is reviewed.

Clinical aspects of unknown primary melanoma

Of 980 patients with malignant melanoma treated during the past seven years, 55 (5.6%) were found to have metastatic disease and no detectable primary tumor. Thirty-six of these patients with "unknown primary melanoma" had disease limited to lymph nodes (Stage II), whereas 19 had disseminated melanoma (Stage III). The sex and age distribution of these 55 patients were similar to those of a control group of 86 patients with palpable lymph node metastases from a known primary. The site of lymph node metastases for Stage II patients in each group was similar although unknown primary patients seemed to have slightly more involved lymph nodes. By studying patients with the same stage and similar extent of disease, the prognosis of unknown primary melanoma could be determined and compared to known primary melanoma. The overall recurrence rate of patients with unknown primary was no higher than that of patients with known primary. This observation appeared to be true even when patients were compared with respect to adjuvant immunotherapy. The use of adjuvant immunotherapy appeared to favorably affect recurrence rates among the unknown primary patients. Since the recurrence rate for patients with unknown primary melanoma was no higher than that of patients with known primary melanoma, we advocate aggressive surgical management. The occasional long-term survivor with Stage III unknown primary suggests that judicious surgical intervention may benefit these patients as well.

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.

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.