Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system

Vulvar melanoma: diffuse melanosis and metastasis to the placenta

Mucocutaneous melanoma, including vulvar melanoma, is rare and has a worse prognosis and higher recurrence rate than traditional cutaneous melanoma. Diffuse cutaneous melanosis is another rare clinical presentation of metastatic melanoma. It is essential for dermatologists to be alerted to rare presentations of melanoma, to facilitate early detection. We present the first case to our knowledge of metastatic vulvar melanoma with diffuse cutaneous melanosis in a pregnant young woman. Despite the occurrence of placental metastasis, a healthy, unaffected baby was born. This case exemplifies the aggressiveness of vulvar melanoma. The genitalia should be included in routine total body skin examinations. Pregnant women with generalized melanosis may be at increased risk for placental metastasis of melanoma. Pregnancy does not alter the incidence or prognosis of melanoma; however, patients with a poor prognosis or high recurrence risk should be informed of potential pregnancy complications associated with melanoma recurrence or metastasis.

The process for continuous improvement of the TNM classification

The TNM classification is a worldwide benchmark for reporting the extent of malignant disease and is a major prognostic factor in predicting the outcome of patients with cancer. The objectives for cancer staging were defined by the International Union Against Cancer (UICC) TNM Committee almost 50 years ago and are still broadly applicable today. To keep pace with the modern demands of evidence-based practice, the UICC introduced a structured process for introducing changes to the TNM classification. The elements of the TNM process were determined to include the development of unambiguous criteria for the information and documentation required to consider changes in the classification, establishment of a well-defined process for the annual review of relevant literature, formation of site-specific expert panels, and the participation of experts from all over the world in the TNM review process. Communication between the oncology community and those involved in the TNM classification was established as being essential to the success of the process. The process, which was introduced in 2002, will be tested over the next 3-4 years and evaluated. In addition to the formal process, individual initiative, involvement by the national staging committees, and group consensus are required. Furthermore, increased involvement by the experts should improve the understanding and dissemination of the TNM classification.

Partial regression of primary cutaneous melanoma: is there an association with sub-clinical sentinel lymph node metastasis?

Whether partial regression of a primary melanoma has an adverse impact on prognosis is controversial. As an indirect mechanism of addressing this question we drew a correlation between the histopathological characteristics of 107 cutaneous melanomas and the presence of sub-clinical metastasis in corresponding sentinel lymph nodes. Partial regression of the primary tumor, defined as focal replacement of the lesion by a scar, unrelated to a previous biopsy, was observed in 20 (19%) cases in the group as a whole. Excluding cases in which an accurate Breslow thickness of the primary melanoma could not be established and/or the presence of a capsular nevus was detected in the sentinel node, a total of 97 remained. Seventeen cases (Breslow thickness 0.63-9.7; mean 2.4 mm) showed partial regression and 80 (Breslow thickness 0.25-7.00; mean 1.8 mm) were devoid of regression. Of the 17 cases with regression 5 (29%) had nodal metastasis (by histopathology and/or molecular analysis) and of the 80 cases without regression 23 (29%) had nodal metastasis (by one or both evaluations). Our data reveals no association between partial regression of the primary melanoma and sentinel node involvement by the disease. The Breslow thickness proved to be the only significant independent variable related to nodal metastasis. Of interest, ulceration of the primary lesion was significantly associated with nodal disease on univariate, but not on multivariate, analysis. While acknowledging that the cohort size may lack the statistical power to demonstrate subtle associations, our data supports the known relevance of tumor thickness and ulceration to regional lymph node metastasis and thereby, to outcome of melanoma in its early stages, but fails to support a similar role for partial regression.

Melanoma of the head and neck: current concepts in staging, diagnosis, and management

Major advances in the understanding of the causes and risk factors for melanoma and for the prevention and management of this tumor have taken place since the beginning of the past century, when the diagnosis of melanoma was synonymous with death. As many as 80% of early melanomas can be cured, and a high rate of locoregional control for even far-advanced melanoma is plausible. The major challenge for the years to come lies in curtailing the steady rise in the incidence of melanoma by increasing patient education and adopting measures to prevent the increasing mortality rates associated with this disease. Cure rates can be improved by early diagnosis by physicians and instant referral to experienced oncologists. Finally, new advances in diagnostic and treatment strategies carry the hope for further improvements in locoregional control and survival rates.

Endogenous immune response to early- and intermediate-stage melanoma is correlated with outcomes and is independent of locoregional relapse and standard prognostic factors

BACKGROUND

Standard prognostic factors, including precise staging of the regional lymph nodes, cannot accurately determine which early-stage melanomas will metastasize. The immune response to a 90-kd tumor-associated antigen correlates with occult nodal disease and survival of patients receiving vaccine therapy for melanoma. We hypothesized that this response might have prognostic significance independent of standard prognostic features.

STUDY DESIGN

Patients with primary melanomas 1.01 to 2.00 mm and tumor-negative regional lymph nodes were identified. Group 1 comprised 50 patients who died of metastases within 7 years after complete surgical treatment; group 2 comprised 50 patients who were matched with group 1 for six standard prognostic features but who lived at least 10 years without recurrence. Postoperative sera were analyzed for an immune complex to TA90 and for immunoglobulin-G and immunoglobulin-M antibodies against TA90.

RESULTS

Median thickness of the primary melanoma was 1.40 +/- 0.31 mm and 1.42 +/- 0.32 mm in groups 1 and 2, respectively; median Clark's level of invasion was III in both groups, and 26 patients in each group had ulcerated primaries. Median TA90-IC level and rate of TA90-IC positivity (optical density greater than 0.410) were 0.557 +/- 0.43 and 82%, respectively, in group 1 and 0.305 +/- 0.15 and 18%, respectively, in group 2 (p < 0.001). The anti-TA90 IgM level was significantly elevated in 12% of group 1 (median titer 1:150) and 62% of group 2 (median titer 1:800) (p < 0.001). There was no significant difference in anti-TA90 IgG levels between the two groups.

CONCLUSIONS

A positive TA90-IC level and absence of an anti-TA90 IgM response correlate with distant metastasis when melanoma is low risk or intermediate risk by standard prognostic factors.

Cost effectiveness and cost utility of adjuvant interferon alpha in cutaneous melanoma: a review

Although interferon alpha (IFN) has been approved since 1995 in the US as adjuvant therapy for high-risk melanoma patients, its cost effectiveness and economic value have only been recently addressed. There are very few papers that address the overall cost and cost components of treating melanoma patients, all of them focusing on the US. These studies showed the large cost of treatment of stage III and IV patients (around $US40,000-60,000 [1997/8 values]). Chemotherapy and adjuvant immunomodulators comprised a large part of this cost. Cost-effectiveness studies performed for the US, Spain and Italy have been largely based on the results of the pivotal Eastern Cooperative Oncology Group (ECOG) 1684 trial using high-dose (10-20 Megaunits [MU]/m(2)) IFN in mainly stage III patients. Incremental cost-effectiveness ratios for adjuvant IFN versus observation from these studies fall in the range of $US13,000-40,000 per life-year gained (1998 values), depending on the time horizon, discount rate and cost of IFN, with an extrapolated life-gain over lifetime ranging between 1.9 and 3 years. Only one study, the French Cooperative Melanoma Group trial in stage IIA/B patients, used low-dose (3 MU(2)) IFN and yielded a quite favourable incremental cost effectiveness ratio (cost per life-year gained) ranging from $US12,954 over 5 years (survival gain 3 months) to $US1,544 over a lifetime (extrapolated survival gain 2.6 years) [1995 values]. Although these results could be seen as supporting the more widespread use of adjuvant IFN in melanoma, it should be stressed that they were based on the only two positive clinical trials out of a total of ten. Moreover, the impact on survival was lost in both positive trials at > or = 8 years' follow-up and thus the costs assessments are likely to be overly optimistic. The eight negative high-dose (HDI) and low-dose (LDI) IFN trials have failed to show an impact on survival (HDI: ECOG 1690 and North Central Cancer Treatment Group [NCCTG]; LDI: ECOG 1690, WHO-16, UK Coordinating Committee on Cancer Research [UKCCRC] and Austrian, Scottish and European Organisation for Research and Treatment of Cancer trials). Mature results from more recent trials are pending. A definitive appraisal of the cost effectiveness of IFN in melanoma patients will have to await these results and their economic analyses.

Vulvar Melanoma: Review of Diagnosis, Staging, and Therapy

OBJECTIVES

To update, assimilate, and bridge the contemporary literature on vulvar and cutaneous melanoma regarding diagnosis, staging, and therapy to provide a useful clinical reference for managing and counseling for affected patients.

MATERIALS AND METHODS

A computerized search for reports in the literature up to June 2003 was carried out using PubMed and MEDLINE databases. Multidisciplinary involvement was used in evaluating the available data and formulating conclusions.

RESULTS

More than 300 reports were reviewed. Diagnosis, staging, and therapy aspects of vulvar melanoma are summarized.

CONCLUSIONS

Vulvar melanoma represents a subtype of cutaneous melanoma, with similar prognostic and staging factors. The most recent American Joint Committee on Cancer staging system for cutaneous melanoma is applicable to vulvar melanoma. Sentinel lymph node biopsy is reliable for staging the regional lymph node basin for vulvar melanoma. Standardized documentation of clinical and histopathologic parameters is needed to standardize grouping of cases for future comparison studies.

Pathology of melanocytic lesions: New, controversial, and clinically important issues

Patients with primary cutaneous melanocytic lesions rely not only on the knowledge, skills, and experience of their treating clinician but also on the fundamentally important input of their pathologist for accurate diagnosis and appropriate management. Free and precise communication between pathologists and surgeons is important and undoubtedly improves patient care, particularly when managing difficult or complicated cases. To provide both patient and surgeon with the necessary information they require to make the most appropriate decisions, the pathology report should include all pathologic factors that are important in determining the patient's prognosis and management. Use of a synoptic format for pathology reporting of melanomas can facilitate this. Recent studies have established that the dermal mitotic rate of a primary cutaneous melanoma is a major prognostic determinant, and have shown that its assessment and that of other important histopathologic prognostic variables are reproducible between pathologists. Sentinel node (SN) biopsy has provided a minimally invasive procedure that can accurately predict the regional node status of melanoma patients. It is well demonstrated that the use of immunohistochemical stains assists in the detection of melanoma micrometastases in SNs, although it remains unclear which is the optimal pathologic protocol for SN evaluation and whether there is a role for reverse transcriptase polymerase chain reaction (RT-PCR) in SN assessment. False negative SN biopsies may occur as a result of errors in lymphatic mapping or sentinel lymphadenectomy, or because of a deficiency in the process of histopathologic evaluation. Recent studies have shown that the likelihood of non-SN involvement when the SN is positive correlates mostly with the extent of SN involvement, in particular the tumor penetrative depth (defined as the maximum distance of melanoma cells from the inner margin of the SN capsule). It appears that assessment of the micromorphometric features of positive SNs may be useful in predicting which patients have a low probability of having metastatic tumor in non-SNs, and therefore in selecting patients who potentially may be spared a completion lymph node dissection. It is likely that future advances in our understanding of the molecular biology of melanoma will provide new insights into tumor classification, improve diagnostic accuracy and prognostic ability, and lead to the development of more precisely targeted therapies.

Palliative therapy of disseminated malignant melanoma: a systematic review of 41 randomised clinical trials

We undertook a systematic review of 41 randomised studies in disseminated melanoma, identified by a comprehensive search. We aimed to investigate rates of response to various treatment modalities and the outcome for the patients. We analysed seven studies that compared polychemotherapy with single-agent dacarbazine, six that compared different chemotherapeutic schedules with each other, five on the addition of tamoxifen to a reference therapy, and six that included non-specific immunostimulators. In 17 studies, the addition of interferon alfa, interleukin 2, or both, to a reference therapy was investigated, including trials with biochemotherapy. Many trials had small sample sizes and did not report a power analysis; not all were analysed by intention to treat. Although some treatment regimens, especially polychemotherapeutic schedules, seem to increase response rates, none of the treatment schedules was proven to prolong overall survival. Patients with disseminated melanoma should be treated with well-tolerated drug regimens, such as single-agent treatments or in combination with interferon alfa. Systemic treatments should preferably be investigated in randomised trials so that the potential benefits of new treatment concepts can be thoroughly examined.

Immunopharmacologic analysis of an autologous, hapten-modified human melanoma vaccine

PURPOSE

We have previously reported a clinical trial of a human cancer vaccine consisting of autologous tumor cells modified with the hapten, dinitrophenyl (DNP), in patients with clinical stage III melanoma. Here we present a follow-up report expanded to 214 patients with 5-year follow-up.

PATIENTS AND METHODS

Two hundred fourteen patients with clinical stage III melanoma (117 patients with stage IIIC and 97 patients with stage IIIB) who were melanoma-free after standard lymphadenectomy were treated with multiple intradermal injections of autologous, DNP-modified vaccine mixed with bacille Calmette-Guérin. Four vaccine dosage schedules were tested sequentially, all of which included low-dose cyclophosphamide. Patients were tested for delayed-type hypersensitivity (DTH) to autologous melanoma cells, both DNP-modified and unmodified, and to control materials.

RESULTS

The 5-year overall survival (OS) rate of the 214 patients was 44%. DTH responses to unmodified autologous melanoma were induced in 47% of patients. The OS of this DTH-positive group was double that of DTH-negative patients (59.3% v 29.3%; P <.001). In contrast, positive DTH responses to DNP-modified autologous melanoma cells and to purified protein derivative developed in almost all patients but did not affect OS. Surprisingly, the OS after relapse was also significantly longer in patients who developed positive DTH to unmodified tumor cells (25.2% v 12.3%; P <.001). Finally, the development of DTH was dependent on the schedule of administration of the vaccine, specifically, the timing of an induction dose administered at the beginning of the treatment program.

CONCLUSION

This study underscores the importance of the immunopharmacology of the autologous, DNP-modified vaccine and may be relevant to other cancer vaccine technologies.

Adjuvant interferon in high-risk melanoma: the AIM HIGH Study--United Kingdom Coordinating Committee on Cancer Research randomized study of adjuvant low-dose extended-duration interferon Alfa-2a in high-risk resected malignant melanoma

PURPOSE

To evaluate low-dose extended duration interferon alfa-2a as adjuvant therapy in patients with thick (> or = 4 mm) primary cutaneous melanoma and/or locoregional metastases.

PATIENTS AND METHODS

In this randomized controlled trial involving 674 patients, the effect of interferon alfa-2a (3 megaunits three times per week for 2 years or until recurrence) on overall survival (OS) and recurrence-free survival (RFS) was compared with that of no further treatment in radically resected stage IIB and stage III cutaneous malignant melanoma.

RESULTS

The OS and RFS rates at 5 years were 44% (SE, 2.6) and 32% (SE, 2.1), respectively. There was no significant difference in OS or RFS between the interferon-treated and control arms (odds ratio [OR], 0.94; 95% CI, 0.75 to 1.18; P =.6; and OR, 0.91; 95% CI, 0.75 to 1.10; P =.3; respectively). Male sex (P =.003) and regional lymph node involvement (P =.0009), but not age (P =.7), were statistically significant adverse features for OS. Subgroup analysis by disease stage, age, and sex did not show any clear differences between interferon-treated and control groups in either OS or RFS. Interferon-related toxicities were modest: grade 3 (and in only one case, grade 4) fatigue or mood disturbance was seen in 7% and 4% respectively, of patients. However, there were 50 withdrawals (15%) from interferon treatment due to toxicity.

CONCLUSION

The results from this study, taken in isolation, do not indicate that extended-duration low-dose interferon is significantly better than observation alone in the initial treatment of completely resected high-risk malignant melanoma.

Is sentinel lymph node mapping indicated for isolated local and in-transit recurrent melanoma?

OBJECTIVE

To determine the feasibility of sentinel lymph node mapping in local and in-transit recurrent melanoma.

SUMMARY BACKGROUND DATA

The accuracy of intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL) for identification of occult lymph node metastases is well established in primary melanoma. We hypothesized that LM/SL could be useful to detect regional node metastases in patients with isolated local and in-transit recurrent melanoma (RM).

METHODS

Review of our prospective melanoma database of 1600 LM/SL patients identified 30 patients who underwent LM/SL for RM. Patients with tumor-positive sentinel nodes (SNs) were considered for completion lymph node dissection.

RESULTS

Of the 30 patients, 17 were men and 13 were women; their median age was 57 years (range, 29-86 years). Primary lesions were more often on the extremities (40%) than the head and neck (33%) or the trunk (8%). At least 1 SN was identified in each lymph node basin that drained an RM. Of the 14 (47%) patients with tumor-positive SNs, 11 (78%) underwent complete lymph node dissection; 4 had tumor-positive non-SNs. The median disease-free survival after LM/SL was 16 months (range, 1-108 months) when an SN was positive and 36 months (range, 6-132 months) when SNs were negative. At a median follow-up of 20 months (range, 2-48 months), there were no dissected basin recurrences after a tumor-negative SNs.

CONCLUSIONS

LM/SL can accurately identify SNs draining an RM, and the high rate of SN metastases and associated poor disease-free survival for patients with tumor-positive SN suggests that LM/SL should be routinely considered in the management of patients with isolated RM.

p53 Codon 72 Arg Homozygotes Are Associated with an Increased Risk of Cutaneous Melanoma

The p53 gene plays an important role in cell cycle control, facilitating DNA repair activities in response to DNA damage. Aberrant cell cycle control impairs DNA repair and increases the probability of mutations that can lead to carcinogenesis. The p53 gene is polymorphic at codon 72 (Arg/Pro) of its protein, which is functionally distinct, leading to inquiry into its role in carcinogenesis. In this hospital-based case-control study of 289 newly diagnosed patients with melanoma and 308 cancer-free control subjects, we evaluated whether the p53 codon 72 variant is associated with risk of cutaneous melanoma (CM). The controls were frequency-matched to the cases by age, sex, and ethnicity. The frequency of the p53 Arg allele was 78.2% in cases and 73.2% in controls (p=0.045), and the genotype frequencies of p53 Arg/Arg, Arg/Pro, and Pro/Pro were 62.6%, 31.1%, and 6.3%, respectively, in the cases, and 53.9%, 38.6%, and 7.5%, respectively, in the controls (p=0.096). Logistic regression analysis revealed that the p53 Arg/Arg genotype was associated with a significantly increased risk of melanoma (adjusted odds ratio (OR)=1.43; 95% confidence interval (CI)=1.02-2.02) compared with other genotypes, and this association was more evident in subgroups of older subjects (OR=2.32; 95% CI=1.39-388), and subjects with Fitzpatrick's skin type III or IV (OR=1.69; 95% CI=1.11-2.59). In conclusion, this study found some evidence that in subjects over 50, p53 Arg/Arg genotype is associated with increased risk of CM as compared to genotypes Arg/Pro or Pro/Pro. Further larger studies are needed to substantiate our findings.

Epidemiology of cutaneous melanoma and non-melanoma skin cancer in Schleswig-Holstein, Germany: incidence, clinical subtypes, tumour stages and localization (epidemiology of skin cancer)

BACKGROUND

Population-based figures on skin cancer are essential for a realistic assessment of the personal disease burden, prevention modes and the need for caring. The Robert Koch Institute in Germany estimates the incidence of melanoma skin cancer as seven cases in 100 000 persons (age-standardized by the European standard rate). Population-based studies presumably show higher incidence rates of 10-16 cases in 100 000 persons. Few data exist for non-melanoma skin cancer (NMSC) as this is not systematically registered in Germany.

OBJECTIVES

To present the first population-based results from the Schleswig-Holstein (Germany) Cancer Registry on incidence, stage distribution, clinical types and localization of skin cancer and to compare the results with other studies.

METHODS

The Cancer Registry of the Bundesland Schleswig-Holstein with 3500 registering institutions, 100 of which are dermatological institutions, investigates all notifiable incident cancer cases according to international standards. From the recorded data all melanoma and NMSC cases were identified and evaluated.

RESULTS

Between 1998 and 2001, 1784 malignant melanoma (MM) and 12 956 NMSC cases underwent diagnostic and analytical evaluation. For MM, age-standardized incidence rates were 12.3 and 14.8 in 100 000 men and women, respectively, and the mean age of men was greater than that of women (56.6 vs. 54.9 years, P < 0.05). Superficial spreading melanoma was the most frequent clinical type (39.1%). The tumours were predominantly located on the trunk in men (46.8%) in contrast to leg and hip in women (39.5%). For NMSC, the age-standardized incidence rates were 100.2 and 72.6 in 100 000 men and women, respectively. More than 80% of all tumours were basal cell carcinoma.

CONCLUSIONS

The first population-based data from Schleswig-Holstein on the characteristics (age, sex, histological subtypes, localization and stage) of skin tumours agree well with the existing literature and may thus be regarded as representative. However, markedly higher incidences for MM and NMSC in the north of Germany compared with other parts of the country were observed. As the incidence rates from the north of Germany fit well into the European geographical pattern, we assume no regional increase. Therefore, the official German estimates on cutaneous tumours may largely depend on regional factors and may not be regarded as representative for all regions in Germany.

Thin melanomas: predictive lethal characteristics from a 30-year clinical experience

OBJECTIVE

To guide treatment and clinical follow-up by defining the natural history of thin melanomas and identifying negative prognostic characteristics that may delineate high-risk patients.

SUMMARY BACKGROUND DATA

In following > 10,000 patients with cutaneous melanoma over the past 30 years, our institution has observed nodal or metastatic disease in approximately 15% of patients with a thin (<1 mm) primary lesion.

METHODS

A database query of patients with cutaneous melanoma returned 1158 patients with primary lesion < or = 1 mm thick and who received their initial treatment at a single institution. Median follow-up was 11 years (range, 1 to 34 years). Patient and melanoma characteristics as well as outcomes were recorded and statistically analyzed.

RESULTS

6.6% of patients had nodal or distant disease at presentation. Over time, an additional 9.4% developed metastases, including nodal and distal recurrences. Overall incidence of advanced disease was 15.3%. Univariate analysis identified male gender (P = 0.01), advanced age (>45 years; P = 0.05), and Breslow thickness (>0.75 mm; P = 0.008) as significant negative prognostic characteristics. Of patients with these 3 high-risk characteristics, 19.7% developed advanced disease (likelihood ratio 6.3; P = 0.007 versus nonhigh-risk patients). This group had more than twice the incidence of nodal recurrences. Patients with recurrence had significantly decreased 10-year survival (82% versus 45%; P < 0.0001). Surprisingly, neither ulceration nor Clark level predicted advanced disease.

CONCLUSIONS

Thin melanomas are potentially lethal lesions. Long-term follow-up identified a high-risk population of older males with tumors between 0.75 mm and 1.0 mm whose risk of recurrent disease approaches 20%. Traditionally accepted negative prognostic factors such as ulceration and discordant Clark levels are not predictive for metastasis in this population. Given the poor prognosis associated with recurrent disease, we recommend close clinical evaluation and follow-up to maximize accurate staging and therapeutic options.

Pharmacogenetic candidate genes for melanoma

The incidence of melanoma is rising at an alarming rate and has become an important public health concern. If detected early, melanoma carries an excellent prognosis after appropriate surgical resection. Unfortunately, advanced melanoma has a poor prognosis and is notoriously resistant to radiation and chemotherapy. The relative resistance of melanoma to a wide-range of chemotherapeutic agents and high toxicity of current therapies has prompted a search for effective alternative treatments that would improve prognosis and limit side effects. Advances in molecular genetics are revealing in increasing detail the mechanisms responsible for the development of melanoma. Hopefully, elucidation of these pathways will provide a means of screening high-risk individuals and allow new drug development for prevention and treatment by identification of specific pharmacological targets. This review will summarize the genetics of melanoma with the goal of providing insights into potential pharmacogenetic candidate genes.

Thick Melanoma in the Elderly

The objective of this analysis is to ascertain the natural history of elderly patients greater than 65 years of age with thick melanoma (T4) who were treated with surgery only. Although there are multiple data on elderly patients, there is not a systematic review of survival in elderly patients over 65 years, and with our analysis we tried to enlighten this field in view especially of the growing population of the elderly in the United States. We retrospectively evaluated 112 patients with thick (≥4 mm) melanoma aged 65 or greater. Mean age was 73 years. Mean follow-up was 36 months. The overall survival (OS) and disease-free survival (DFS) were 69 and 52 months, respectively. Univariate analysis predicted worse OS and DFS when patients have positive lymph nodes, high mitotic rate, and increasing thickness. By multivariate analysis, lymph node status was most predictive of OS and DFS. Lymph node status is the most important prognostic factor in elderly patients with thick melanoma. Our analysis has shown that elderly patients that received no adjuvant treatment did significantly worse than the historical controls. Patients with nodal metastases are candidates for adjuvant therapy. Those without nodal disease constitute a favorable patient group and thus have much better prognosis and may not need adjuvant therapy. However, they must be closely monitored or enrolled in randomized trials. Thus, treatment for melanoma patients older than 65 should be as aggressive as in younger patients, and these patients should not be denied adjuvant treatment based on their age only.

Changing epidemiology of malignant cutaneous melanoma in Europe 1953-1997: rising trends in incidence and mortality but recent stabilizations in western Europe and decreases in Scandinavia

We analyzed time trends in incidence of and mortality from malignant cutaneous melanoma in European populations since 1953. Data were extracted from the EUROCIM database of incidence data from 165 cancer registries. Mortality data were derived from the WHO database. During the 1990s, incidence rates were by far highest in northern and western Europe, whereas mortality was higher in males in eastern and southern Europe. Melanoma rates have been rising steadily, albeit with substantial geographic variation. In northern Europe, a deceleration in these trends occurred recently in persons aged under 70. Joinpoint analyses indicated that changes in these trends took place in the early 1980s. In western Europe, mortality rates have also recently leveled off [estimated annual percentage change (EAPC) from -13.6% (n.s.) to 3.3%], whereas in eastern and southern Europe both incidence and mortality rates are still increasing [incidence EAPCs 2.3-8.9%, mortality EAPCs -1.8% (n.s.) to 7.2%]. Models including the effects of age, period and birth cohort were required to adequately describe the rising incidence trends in most European populations, with a few exceptions. Time trends in mortality were adequately summarized on fitting either an age-cohort model (with the leveling off of rates starting in birth cohorts between 1930 and 1940) or an age-period-cohort model. The most plausible explanations for the deceleration or decline in the incidence and mortality trends in recent years in northern (and to a lesser extent western) Europe are earlier detection and more frequent excision of pigmented lesions and a growing public awareness of the dangers of excessive sunbathing.

Detection of micrometastases in sentinel lymph nodes from melanoma patients

The technique of sentinel lymph node (SLN) dissection is a reliable predictor of metastatic disease in the lymphatic basin draining the primary melanoma. Reverse transcription-polymerase chain reaction (RT-PCR) is emerging as a highly sensitive technique to detect micrometastases in SLNs, but its specificity has been questioned. A prospective SLN study in melanoma patients was undertaken to compare in detail immunopathological versus molecular detection methods. Sentinel lymphadenectomy was performed on 57 patients, with a total of 71 SLNs analysed. SLNs were cut in slices, which were alternatively subjected to parallel multimarker analysis by microscopy (haematoxylin and eosin and immunohistochemistry for HMB-45, S100, tyrosinase and Melan-A/MART-1) and RT-PCR (for tyrosinase and Melan-A/MART-1). Metastases were detected by both methods in 23% of the SLNs (28% of the patients). The combined use of Melan-A/MART-1 and tyrosinase amplification increased the sensitivity of PCR detection of microscopically proven micrometastases. Of the 55 immunopathologically negative SLNs, 25 were found to be positive on RT-PCR. Notably, eight of these SLNs contained naevi, all of which were positive for tyrosinase and/or Melan-A/MART-1, as detected at both mRNA and protein level. The remaining 41% of the SLNs were negative on both immunohistochemistry and RT-PCR. Analysis of a series of adjacent non-SLNs by RT-PCR confirmed the concept of orderly progression of metastasis. Clinical follow-up showed disease recurrence in 12% of the RT-PCR-positive immunopathology-negative SLNs, indicating that even an extensive immunohistochemical analysis may underestimate the presence of micrometastases. However, molecular analyses, albeit more sensitive, need to be further improved in order to attain acceptable specificity before they can be applied diagnostically.

Prediction of disease outcome in melanoma patients by molecular analysis of paraffin-embedded sentinel lymph nodes

PURPOSE

A significant number of patients who develop recurrence after a histopathologically negative sentinel lymph node (SLN) biopsy will demonstrate occult metastases on re-evaluation of the SLNs with serial sectioning and immunohistochemistry. Reverse transcriptase polymerase chain reaction (RT-PCR) has been evaluated to improve disease staging and avoid false-negative findings in fresh or frozen-section SLNs. The purpose of this study was to develop a multimarker RT-PCR assay for assessing melanoma patients' archived paraffin-embedded (PE) SLNs.

PATIENTS AND METHODS

Archived PE histopathologically positive (n = 37) and negative (n = 40) SLNs from patients with primary melanoma were analyzed using a semiquantitative multimarker RT-PCR assay.

RESULTS

Marker expression in histopathologically positive and negative SLNs were as follows: 89%, 92%, 35%, and 43% (positive) and 40%, 33%, 5%, and 13% (negative) for tyrosinase, melanoma antigen recognized by T cells-1, tyrosinase-related protein-1, and tyrosinase-related protein-2, respectively. Twenty-five percent of histopathologically negative SLN patients were upstaged using at least two markers. Of these, 80% developed a recurrence. Furthermore, at a median follow-up of 55 months, patients with histopathologically negative SLNs who expressed zero or one marker had a significantly improved disease-free (P <.002) and overall (P <.03) survival versus those expressing two or more markers.

CONCLUSION

These findings demonstrate the feasibility of a multimarker RT-PCR assay for evaluating archived PE SLNs. More significantly, identification of molecular risk factors can be detected in histopathologically negative SLNs for distinguishing early-stage melanoma patients with a worse prognosis.

Reassessing the role of lymphatic mapping and sentinel lymphadenectomy in the management of cutaneous malignant melanoma

Lymphatic mapping and sentinel lymphadenectomy was developed as a minimally invasive technique to provide regional lymph node staging information for patients at high risk for metastatic melanoma, but without clinically palpable disease. Only patients who demonstrate micrometastases undergo complete regional lymphadenectomy, sparing approximately 80% of patients the expense and morbidity of an elective lymph node dissection. This technique has been widely accepted as the preferred method to determine the pathologic status of the regional lymph nodes and the staging information gained is incorporated into the latest version of the American Joint Committee on Cancer staging system for cutaneous melanoma. Still, there is much controversy as to the use of this technique as a staging procedure and its overall therapeutic benefit in the treatment of patients with melanoma. Currently ongoing clinical trials will determine if lymphatic mapping and sentinel lymphadenectomy directly influences overall survival for patients with malignant melanoma. We review the latest technical aspects of this procedure and discuss the controversies surrounding its use.

Cost-effectiveness of sentinel lymph node biopsy in thin melanomas

BACKGROUND

Consideration of sentinel lymph node biopsy (SLNB) is recommended for thin melanomas with poor prognostic features; however, few metastases are identified. The purpose of this study was to assess the cost effectiveness of SLNB in this population.

METHODS

The prospective melanoma database was reviewed to identify patients with melanomas <1.2 mm thick who had undergone SLNB. Physician and hospital charges were collected from the appropriate billing department.

RESULTS

A total of 138 patients were identified over an 8-year period (1994-2002). Two patients with positive SLNs were identified (1.4%), one with a melanoma <1 mm thick. Patient charges for SLNB ranged from $10,096 to $15,223 US dollars, compared with $1000 to $1740 US dollars for wide excision as an outpatient. Using these charges, the cost to identify a single positive SLN would be between $696,600 and $1,051,100 US dollars. The cost for wide excision would be between $69,000 and $120,100 US dollars. Assuming that all patients with a positive SLN would die of melanoma, the cost per life saved would be $627,000 to $931,000 US dollars.

CONCLUSIONS

The cost of performing SLNB in this population is great and only a small number will have disease identified that will alter treatment. These data call into question the appropriateness of SLNB for thin melanomas.

The Utility of Sentinel Lymph Node Biopsy in Head and Neck Melanoma in the Pediatric Population

Intraoperative lymph node mapping and sentinel lymph node biopsy have proven beneficial techniques in staging adult patients with melanoma of the head and neck, where there is great variability in lymphatic drainage. This technique has also been applied to pediatric patients with truncal cutaneous melanomas in an effort to determine nodal status without the morbidity associated with complete lymph node dissection. Nevertheless, the utility of sentinel lymph node biopsy in head and neck melanoma in the pediatric population has not been established. The objective of the authors' study was to determine the clinical utility of intraoperative lymph node mapping and sentinel lymph node biopsy of head and neck melanoma in the pediatric population. The authors reviewed the records of seven pediatric patients with head and neck melanoma or borderline melanocytic proliferations of unknown biologic potential who underwent intraoperative lymph node mapping and sentinel lymph node biopsy between 1998 and 2001. All sentinel lymph node specimens were examined by a melanoma dermatopathologist for the presence of metastatic melanoma. The mean operative time for each case was 3 hours, 8 minutes (range, 2 hours, 15 minutes to 3 hours, 50 minutes). All seven pediatric patients who underwent extirpation of a primary head and neck melanoma and preoperative lymphoscintigraphy had unique and identifiable basins of drainage to regional nodal groups. Four of seven patients had at least one positive sentinel lymph node. Overall, five of 19 sentinel nodes (26 percent) resected had evidence of metastatic melanoma. Of the patients with positive sentinel lymph nodes, two of the primary lesions were diagnosed as melanoma while two were initially considered atypical melanocytic proliferations of uncertain biologic potential with melanoma in the differential diagnosis. Sentinel lymph nodes in pediatric patients with melanoma of the head and neck can be successfully mapped and biopsied, as in adult patients. In addition, this procedure can provide critical diagnostic information for those pediatric patients with diagnostically challenging, controversial, or borderline melanocytic lesions.

Prognosis for patients with thin cutaneous melanoma: long-term survival data from New South Wales Central Cancer Registry and the Sydney Melanoma Unit

BACKGROUND

Estimates of long-term survival for patients with thin (< or = 1 mm) primary cutaneous melanomas vary widely. Two separate methods were used to study the survival of patients with melanoma from New South Wales (NSW), Australia, and from the Sydney Melanoma Unit (SMU).

METHODS

The NSW Central Cancer Registry (NSWCCR) provided data on all patients who were diagnosed with cutaneous melanomas that measured < or = 1 mm thick between 1983 and 1998, inclusive. Patients with metastases at the time of diagnosis were not included, leaving 18,088 patients for analysis. The SMU data base was analyzed to extract data for all patients with thin melanomas who met the same criteria from 1979 to 1998, inclusive. All patients who had their primary tumors treated definitively elsewhere were excluded, leaving 2746 patients for analysis. Ten-year Kaplan-Meier survival rates were calculated, and significant differences were determined using log-rank analysis. Prognostic factors were evaluated with Cox proportional hazards analysis.

RESULTS

The NSWCCR analysis revealed a 10-year survival rate of 96.4%. The 10-year survival rate for patients at SMU was 92.7%. Among the patients at SMU who died, the median time to recurrence was 49.8 months, and the median time to death was 65.9 months. The 10-year survival for patients at SMU who had lesions that measured < or = 0.75 mm was 96.9% compared with 84.3% for patients who had lesions that measured 0.76-1.0 mm. For patients who had ulcerated melanomas measuring < or = 1 mm thick, the 10-year survival rate was 83%, compared with 92.3% for patients who had nonulcerated melanomas.

CONCLUSIONS

The results of the current study confirmed the excellent survival rate for patients with thin melanomas. Higher-risk subsets of patients who may warrant consideration for aggressive investigation and treatment are identifiable.

Lymph node status and survival in cutaneous malignant melanoma--sentinel lymph node biopsy impact

AIM

The survival benefit of sentinel lymph node biopsy (SLB) with lymphadenectomy for microscopic melanoma metastases to regional lymph nodes (SLND) is uncertain. The aim of the study was to analyse the factors influencing clinical outcome (overall survival (OS) and disease free survival (DFS)) of patients undergone lymph node dissection (LND) as result of positive sentinel lymph node disease (SLND) or as consequence of clinically detected metastases (CLND).

PATIENTS AND METHODS

This was a single-institution retrospective analysis of survival data of 350 consecutive, prospectively collected, melanoma patients who underwent radical LND in 1995-2001. One hundred and forty-five patients underwent SLND and 205 underwent CLND.

RESULTS

The median OS and DFS times of the entire group of melanoma patients, computed from the date of primary lesion excision, were 46.3 months and 26.5 months (5-year OS ratio 41.8% and 5-year DFS ratio 31.5%). The factors which correlated with poor OS by multivariate analysis were: primary tumour Breslow thickness >4 mm (p=0.001), extracapsular extension of lymph node metastases (p=0.004), male sex (p=0.001) and metastases to more than one regional lymph node (p=0.04). The negative factors for DFS were: nodal extracapsular invasion (p=0.00002) and primary tumour Breslow thickness >4 mm (p=0.004). There were no significant differences in OS and DFS between SLND and CLND groups, when calculated from the date of primary tumour excision. However, if OS and DFS were estimated from the date of LND, the SLND group demonstrated significantly better survival in comparison with CLND.

CONCLUSION

The study demonstrates no survival benefit from SLB with subsequent radical regional LND in malignant melanoma patients with lymph node metastases.

Interobserver reproducibility of ulceration assessment in primary cutaneous melanomas

In the recently revised melanoma staging system proposed by the American Joint Committee on Cancer (AJCC), ulceration assessment by the pathologist is a pivotal parameter. Patients upstaged because of ulceration might be included in adjuvant trials conducted in AJCC stage II melanoma patients. Therefore, accuracy based on interobserver reproducibility for melanoma ulceration assessment is crucial for proper clinical management. In some cases, it is extremely difficult, even for an experienced pathologist, to distinguish between trauma-induced ulceration, artifact and tumoral ulceration. Whether this difficulty may be resolved by the use of a more precise definition of ulceration has not been evaluated. Therefore, we have proposed a refined definition of melanoma ulceration and we tested whether this definition might improve the interobserver interpretative reproducibility of ulceration in primary cutaneous melanomas. The results of this study support the need for a more precise definition of melanoma ulceration that rules out biopsy trauma or processing artifact and could be incorporated into a standardised pathology worksheet for reporting primary melanomas.

Differential expression of vascular endothelial growth factor-A isoforms at different stages of melanoma progression

Vascular endothelial growth factor-A (VEGF-A) is an important mediator of angiogenesis in normal and neoplastic tissues. Total VEGF-A levels have been associated with melanoma progression, but the relative contributions of each isoform is unknown. To determine whether differences in the production of any or all of the major VEGF-A isoforms are related to stage of progression, we compared message levels for the three major isoforms of VEGF in melanoma specimens from different stages of progression.Primary melanomas (N = 18), primary recurrences (N = 5), regional dermal metastases (N = 11), nodal metastases (N = 12), normal lymph nodes (N = 18), and distant metastases (N = 9) were prospectively collected. Samples from the horizontal and vertical growth phases of primary tumors were also collected from five additional patients. Message levels for the three major VEGF-A isoforms were measured using real-time quantitative reverse-transcriptase polymerase chain reaction and normalized to beta-actin mRNA levels. There was a marked increase in the expression of all three VEGF-A isoforms from the vertical growth phase tissue as compared with the horizontal growth phase tissue. Primary tumors, local recurrences, regional dermal metastases, nodal metastases, and distant metastases all produced more VEGF(121) and VEGF(165) than negative nodes. Nodal metastases produced the highest level of these two isoforms, higher even than distant metastases. There was no significant difference in VEGF(189) message among the groups. Melanomas in the vertical growth phase produce more VEGF-A (all isoforms) than in the horizontal growth phase. Nodal metastases produce the highest levels of VEGF(121) and VEGF(165), but not VEGF(189) as compared with other stages of progression. These data suggest that the soluble forms of VEGF-A might be an important factor in melanoma metastasis to regional lymph nodes.

Epidermal hyperplasia overlying human melanoma correlates with tumour depth and angiogenesis

The aim of this study was to determine whether epidermal hyperplasia overlying cutaneous human melanoma is associated with increased tumour angiogenesis, tumour growth and the potential for metastasis. Forty-two surgical specimens of cutaneous human melanoma of different depths, each containing epidermis present in the tumour-free margin, were analysed by immunohistochemistry for the expression of the pro-angiogenic molecules basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF) and interleukin-8 (IL-8) and the anti-angiogenic molecule interferon-beta (IFN-beta). The epidermis overlying intermediate and thick (1.0-10.0 mm), but not thin (0.5-1.0 mm), melanoma specimens was hyperplastic. Although the expression level of bFGF, VEGF and IL-8 in the epidermis directly overlying the tumour was similar to that in the distant epidermis, the expression of IFN-beta was significantly decreased in keratinocytes overlying intermediate and thick, but not thin, melanomas. The microvessel density was also increased in intermediate and thick specimens. Human melanoma cells were injected subcutaneously into nude mice. The resulting tumours were used to determine the association between overlying epidermal hyperplasia and neoplastic angiogenesis. Similar to human autochthonous melanomas, epidermal hyperplasia was found only over lesions produced by metastatic cells. Although there was no change in the expression of the pro-angiogenic molecules, the expression of IFN-beta was significantly decreased in the hyperplastic epidermis. Conditioned medium collected from cultures of the metastatic cell line induced in vitro proliferation of mouse keratinocytes, whereas conditioned medium collected from cultures of the non-metastatic cell line did not. Collectively, the data demonstrate that metastatic melanoma cells induce keratinocyte proliferation, leading to decreased expression of the negative regulator of angiogenesis, IFN-beta, and hence to increased angiogenesis.

The genetics of malignant melanoma: lessons from mouse and man

Therapeutic resistance and proclivity for metastasis are hallmarks of malignant melanoma. Genetic, epidemiological and genomic investigations are uncovering the spectrum of stereotypical mutations that are associated with melanoma and how these mutations relate to risk factors such as ultraviolet exposure. The ability to validate the pathogenetic relevance of these mutations in the mouse, coupled with advances in rational drug design, has generated optimism for the development of effective prevention programmes, diagnostic measures and targeted therapeutics in the near future.

Insights into the mechanisms of lymph node metastasis

The mechanisms by which malignant tumors leave the primary tumor site, invade lymphatics, and metastasize to regional lymph nodes (RLNs) are complex and interrelated. Although the phenomenon of lymph node metastasis has been recognized for over 200 years, the exact mechanisms have only recently been the subject of intense interest and sophisticated experimentation. Sentinel lymph node biopsy has rapidly entered the clinical mainstream for melanoma and breast carcinoma, and this technique has provided confirmation of the orderly anatomic progression of tumor cells from primary site to the RLNs through lymphatic capillaries and trunks. Exciting studies involving the pathophysiology of interstitial fluid pressure in tumors and the peritumoral extracellular matrix have focused on lymphatic flow and tumor microenvironment and microcirculation. Molecular techniques have led to the definition of unique markers found on lymphatic endothelial cells. These markers have enabled scientists to identify peritumoral and intratumoral lymphatics and to visualize the ingrowth of tumor cells into the lumena of lymphatic capillaries. Tumor-secreted cytokines, such as vascular endothelial growth factors (VEGF)-C and -D, bind to VEGF receptors on lymphatic endothelial cells and induce proliferation and growth of new lymphatic capillaries; this process is similar to the well-known mechanism of angiogenesis, which results from the proliferation of new blood vessel capillaries. Lymphangiogenesis is associated with an increased incidence of RLN metastasis, and it is possible that this step is essential to the metastatic process. Directional movement toward lymphatics and lymph nodes appears to follow a chemokine gradient, and it is likely that some tumor cells that express certain types of chemokine receptors are more likely to metastasize to the RLNs. In contrast, tumor cells that do not express specific receptors that are responsive to lymphatic chemokines may not metastasize. New knowledge regarding the molecules involved in these processes should enable improvements in prognostic and possibly therapeutic approaches to the management of malignant tumors.

Phase I study of intranodal delivery of a plasmid DNA vaccine for patients with Stage IV melanoma

BACKGROUND

Based on the likelihood of transfecting large numbers of local antigen-presenting cells, a Phase I study in patients with Stage IV melanoma was conducted to determine the practicality, toxicity of, and immune responses to repeated infusions into a groin lymph node of escalating doses of a DNA plasmid encoding tyrosinase epitopes.

METHODS

Cohorts of 8 patients each received 200 microg, 400 microg, or 800 microg of DNA intranodally by pump over 96 hours every 14 days for 4 cycles. Blood was collected for immunologic assays and to measure plasmid in serum prior to treatment, 4 weeks later, and 8 weeks later. Scans and X-rays were performed at baseline and after 8 weeks.

RESULTS

Treatment was tolerated well, with only five patients demonstrating Grade 1-2 toxicity. Vaccine delivery by 96-hour infusions of plasmid into a groin lymph node resulted in only 1 episode of catheter leakage in 107 cannulations. Detection of plasmid in serum was rare and transient in two patients. Immune responses by peptide-tetramer assay to tyrosinase 207-216 were detected in 11 of 26 patients. No clinical responses were seen. Survival of the heavily pretreated patients on this trial was unexpectedly long, with 16 of 26 patients alive at a median follow-up of 12 months.

CONCLUSIONS

Infusion of a DNA plasmid vaccine into a groin lymph node was practical and well tolerated. Immune responses to a novel tyrosinase epitope were noted. Overall survival in this trial of heavily pretreated patients was unexpectedly long, with 16 of 26 patients alive after a follow-up of 12 months, favoring immune responders.

Malignant melanoma

In the European Community cutaneous melanoma accounts for 1 and 1.8% of cancers occurring in men and women, respectively. The incidence rate is increasing faster than that of any other tumour. Sun exposure, patient's phenotype, family history, and history of a previous melanoma are the major risk factors. The change over a period of months is the main sign of a skin lesion turned into a melanoma. The ABCDE scheme for early detection of melanoma is commonly accepted. A new staging classification will be published in the next AJCC/UICC Cancer Staging System Manual in 2002. The clinical course of melanoma is determined by its dissemination and depends on thickness, ulceration, localisation, gender and histology of the primary tumour. Tumour stage at diagnosis remains the major prognostic factor. Surgery is the standard treatment option for operable local-regional disease. Sentinel node biopsy represents a promising experimental approach in the clinical detection and early treatment of occult lymph node involvement. For metastatic inoperable patients systemic chemotherapy can be attempted, while radiation therapy has to be considered as palliative treatment. No studies concerning frequency of follow-up are currently available, but common procedures may be performed.

Surgical treatment of splenic metastases in patients with melanoma

BACKGROUND

Surgery is rarely undertaken for metastatic melanoma in the spleen. To identify indications for surgical treatment, results after splenectomy for metastatic melanoma were analyzed.

STUDY DESIGN

A retrospective study in which all patients at the Sydney Melanoma Unit recorded as having splenic metastases between January 1990 and May 2001 were identified. For those who underwent surgery, indications for splenectomy, operative complications, and outcomes were documented.

RESULTS

Splenectomy was performed in 15 patients, and 98 patients were treated conservatively. Indications for surgery were rupture of the spleen (n = 1), discomfort or pain (n = 7), and the spleen as an apparently solitary site of metastasis (n = 7). All seven symptomatic patients were free of pain after recovery from surgery. Postoperative morbidity occurred in two patients (14%) but there was no mortality. Median overall survival after splenectomy was 11 months, with a survival of 23 months for the subgroup of patients treated for a solitary lesion. Two patients who underwent splenectomy were disease free after more than 2 years of followup. Median overall survival of the conservatively treated patients was 4 months, which was statistically shorter than median survival of the patients who underwent splenectomy (p = 0.02).

CONCLUSIONS

Splenectomy can provide good palliation for symptomatic patients with melanoma metastases in the spleen. A selected group of patients with solitary splenic metastases can achieve longterm disease-free survival after splenectomy.

The amount of metastatic melanoma in a sentinel lymph node: does it have prognostic significance?

BACKGROUND

The amount of metastatic disease in the sentinel lymph node (SLN) is examined as a prognostic factor in malignant melanoma.

METHODS

SLN mapping was performed on 592 patients with stage I and II malignant melanoma from March 1, 1994, through December 31, 1999. One hundred four patients were found to have 134 sentinel SLNs containing metastatic melanoma. The slides were reviewed, and the size of the metastatic melanoma in each SLN was measured. The size of the metastatic deposit was defined as macrometastasis (>2 mm), micrometastasis (< or =2 mm), a cluster of cells (10-30 grouped cells) in the subcapsular space or interfollicular zone, or isolated melanoma cells (1 to > or =20 individual cells) in subcapsular sinuses.

RESULTS

The number of metastases in each SLN was isolated melanoma cells, n = 5 (3.7%); cluster of cells, n = 35 (26.1%); < or =2 mm, n = 45 (33.6%); and >2 mm, n = 49 (36.7%). Seventy-nine patients (76%) had a single positive SLN. The size of the largest nodal metastasis was used to stratify patients with multiple positive SLNs. The overall 3-year survival for patients with SLN micrometastases was 90%, versus 58% for patients with SLN macrometastases (P =.004).

CONCLUSIONS

The amount of metastatic melanoma in an SLN is an independent predictor of survival. Patients with SLN metastatic deposits >2 mm in diameter have significantly decreased survival.

Body site of cutaneous malignant melanoma--a study on patients with hereditary and multiple sporadic tumours

Individuals with an increased risk of developing cutaneous malignant melanoma (CMM) include members of kindreds with hereditary cutaneous malignant melanoma (HCMM) and patients who have already been treated for a CMM. Some of these patients develop multiple primary cutaneous malignant melanomas (MCMMs). Ultraviolet radiation is the main instigator of CMM. There are indications that patients in these high-risk groups react differently to sunlight than patients who develop a single sporadic CMM. The objectives of this study were to analyse tumour site in patients with HCMM and sporadic MCMM. Data on 2517 patients with 2608 CMMs from a population-based regional cancer registry were used. The new computer program EssDoll was used for the analyses of primary tumour sites. This software is able to analyse any chosen body area(s) with reference to the number of tumours arising there. When the site of the first and second tumours in patients with sporadic MCMM were analysed in a skin 'field division', there was a significant concordance with respect to site (P < 0.0001). In patients with MCMM, the second primary tumour was significantly thinner than the first (P = 0.001). Primary tumour sites in patients with HCMM were compared with those in patients with a single sporadic CMM. In HCMM we found significantly fewer tumours in the head and neck area and more on the trunk. These differences remained significant in two different body area models, even when stratified for age (P < 0.05). In conclusion, a site-concordance was noted for sporadic MCMM. This may be the result of a 'field effect'. Our results indicate that intermittent ultraviolet exposure may be of relatively greater importance than chronic exposure in HCMM.

Isolated limb perfusion with melphalan in the treatment of malignant melanoma of the extremities: a systematic review of randomised controlled trials

Isolated limb perfusion is a surgical procedure for delivering a high dose of chemotherapeutic or immunochemotherapeutic agent to a localised area, thus avoiding the severity of side-effects caused by systemic administration. This technique is generally used for treatment of patients with tumours of the limbs and extremities. We have done a systematic review of randomised controlled trials assessing the effectiveness of this treatment in patients with melanoma of the extremities. Four trials of 1038 patients met our inclusion criteria and were analysed. Although our analysis confirmed the reported increase in survival in two of the trials, neither had sufficient power to detect significant benefit for perfusion. Results from the trials showed that prophylactic perfusion has an equivocal effect on survival in patients with limb melanoma. Therefore, current evidence suggests that prophylactic isolated limb perfusion cannot be recommended as a routine adjunct to standard surgery in patients with high-risk primary limb melanoma, but only as a treatment for local disease control if other forms of locoregional therapy are not available.

Revised American Joint Committee on Cancer staging criteria accurately predict sentinel lymph node positivity in clinically node-negative melanoma patients

BACKGROUND

The American Joint Committee on Cancer (AJCC) has recently modified staging criteria for primary melanoma patients and recommends sentinel lymph node (SLN) biopsy in many because microscopic nodal metastasis represents the most important factor predicting survival. The purpose of this study was to correlate the incidence of SLN metastasis with revised AJCC staging.

METHODS

The records of 1375 melanoma patients undergoing SLN biopsy were reviewed. Univariate and multivariate analyses were performed to identify predictors of a positive SLN. Patients were stratified by using revised AJCC criteria to determine whether such groups also predicted positive SLNs.

RESULTS

A positive SLN was found in 16.9% of patients. By multivariate analysis, tumor thickness (relative risk [RR], 3.4) and ulceration (RR, 2.2) were dominant independent predictors of SLN metastases; age < or =50 years (RR, 1.8) and axial tumor location (RR, 1.5) were also significant. When patients were stratified by AJCC staging criteria, a significant increase in SLN metastases between successive stages was demonstrated.

CONCLUSIONS

Stratification of patients by using AJCC classification reveals an increasing risk of SLN metastases with successive stage groups. Given the significant association of SLN status and survival, the ability of the revised AJCC staging system to predict survival is likely due to its ability to predict the risk of occult nodal disease.

Close monitoring and lifetime follow-up is optimal for patients with a history of melanoma

Malignant melanoma, a potentially lethal form of skin cancer, is becoming more common each year in the United States and worldwide. The cure rate, however, is also increasing due to better education, earlier detection, and more effective treatment. Thus, there are more melanoma survivors who are at risk for recurrence of melanoma and also a second primary. Because there are few prospective screening and surveillance results in the medical literature, recommendations for follow-up of melanoma survivors have been based on the natural history of the disease, physical examinations, laboratory tests, and radiologic evaluations.

Sentinel lymph node mapping for thick (>or=4-mm) melanoma: should we be doing it?

BACKGROUND

Thick (>or=4-mm) primary melanomas are believed to be associated with a high incidence of occult distant metastases. The use of sentinel lymph node (SLN) mapping and biopsy in the treatment lesions has been questioned.

METHODS

A retrospective review of a computerized database identified 114 patients who underwent successful SLN mapping and biopsy from January 1, 1994, to December 31, 1999. Records were reviewed for clinicopathologic features of the patients and their tumors. Survival curves were constructed from Kaplan-Meier estimates and analyzed with log-rank tests and Cox proportional hazards modeling.

RESULTS

There were 75 men and 39 women with a mean age of 57 years (range, 24-85 years). The primary tumor sites were head and neck (n = 29; 25.4%), trunk (n = 44; 38.6%), and extremities (n = 41; 36%). Tumor thickness ranged from 4 to 17 mm (median, 5.2 mm; mean, 6.3 mm). Ulceration was present in 40 (35.1%) tumors. Thirty-seven patients (32.5%) had a positive SLN biopsy, and 18 of these patients (48.6%) had a single tumor-positive lymph node after dissection. The mean follow-up was 37.8 months. The overall 3-year survival for SLN-negative patients was 82%, versus 57% for SLN-positive patients (P =.006). Lymph node status and tumor ulceration were independent predictors of overall survival in multivariate Cox regression analysis.

CONCLUSIONS

The pathologic status of the SLN in patients with thick melanomas is a strong independent prognostic factor for survival, and SLN mapping should be routinely performed.

Melanoma chemoprevention: a role for statins or fibrates?

Although numerous second-generation isoprenylation inhibitors are proposed or under investigation for the treatment and/or prevention of cancer (eg, R115777, SCH 66336, L-778,123, BMS-214662), the chemotherapeutic and chemopreventive potential of commonly prescribed first-generation isoprenylation inhibitors, the statins, and other classes of lipid-lowering medications, the fibrates, has yet to be seriously explored. Two lipid-lowering medications, lovastatin and gemfibrozil, have been associated with a decreased incidence of melanoma in large, prospective, randomized, double-blind, placebo-controlled clinical cardiology trials. This article reviews melanoma biology and the clinical evidence for the use of lipid-lowering medications for melanoma chemoprevention and/or adjuvant chemotherapy.

Adjuvant immunization of HLA-A2-positive melanoma patients with a modified gp100 peptide induces peptide-specific CD8+ T-cell responses

PURPOSE

To measure the CD8+ T-cell response to a melanoma peptide vaccine and to compare an every-2-weeks with an every-3-weeks vaccination schedule.

PATIENTS AND METHODS

Thirty HLA-A2-positive patients with resected stage I to III melanoma were randomly assigned to receive vaccinations every 2 weeks (13 vaccines) or every 3 weeks (nine vaccines) for 6 months. The synthetic, modified gp100 peptide, g209-2M, and a control peptide, HPV16 E7, were mixed in incomplete Freund's adjuvant and injected subcutaneously. Peripheral blood mononuclear cells obtained before and after vaccination by leukapheresis were analyzed using a fluorescence-based HLA/peptide-tetramer binding assay and cytokine flow cytometry.

RESULTS

Vaccination induced an increase in peptide-specific T cells in 28 of 29 patients. The median frequency of CD8+ T cells specific for the g209-2M peptide increased markedly from 0.02% before to 0.34% after vaccination (P <.0001). Eight patients (28%) exhibited peptide-specific CD8+ T-cell frequencies greater than 1%, including two patients with frequencies of 4.96% and 8.86%, respectively. Interferon alfa-2b-treated patients also had significant increases in tetramer-binding cells (P <.0001). No difference was observed between the every-2-weeks and the every-3-weeks vaccination schedules (P =.59).

CONCLUSION

Flow cytometric analysis of HLA/peptide-tetramer binding cells was a reliable means of quantifying the CD8+ T-cell response to peptide immunization. This assay may be suitable for use in future trials to optimize different vaccination strategies. Concurrent interferon treatment did not inhibit the development of a peptide-specific immune response and vaccination every 2 weeks, and every 3 weeks produced similar results.

The Sydney Melanoma Unit--a multidisciplinary melanoma treatment center

The undoubted success of the SMU as a specialist multidisciplinary melanoma treatment center has clearly been the result of many factors. Perhaps chief among these was the vision and commitment that led Dr. Milton to establish it in the first place, and the sharing of that vision and commitment by those who were associated with him and by those who joined the SMU later. Another vitally important element, however, has been the continuing sense of unity and purpose fostered by the weekly SMU clinical meetings, which are truly multidisciplinary, in which all staff are encouraged to participate, and at which the desirability of adherence to agreed, evidence-based treatment guidelines is emphasized. A further influential factor has been the SMU's strong commitment to clinical and basic research as a concomitant of high quality clinical care, with stimulation, encouragement, and advice provided at its monthly multidisciplinary research meetings, where all current and proposed clinical and laboratory studies are discussed. As a result of these activities, despite an ever-increasing number of people working within it, the SMU has been able to present to referring doctors, to patients, and to the community a unified commitment to the best possible patient care and to high quality clinical and laboratory research. These groups have responded by recognizing the SMU as the major referral center for melanoma in Australia, as evidenced by the steadily increasing number of patients referred to it for treatment each year. Melanoma is a more pressing health problem in Australia than elsewhere, because it is the third most common cancer in women (after breast cancer and colorectal cancer), and the fourth most common cancer in men (after prostate cancer, colorectal cancer, and lung cancer). Nevertheless the experiences of the SMU as a large multidisciplinary melanoma treatment center are likely to have relevance and application in other countries, where the incidence of melanoma is lower but continues to rise, and may within a few years approach rates currently recorded in Australia.

Clinical outcome of stage I/II melanoma patients after selective sentinel lymph node dissection: long-term follow-up results

PURPOSE

Although sentinel lymph node (SLN) status is part of the new American Joint Committee on Cancer staging system, there is no final proof that the SLN procedure in melanoma patients influences outcome of disease. This study investigated the accuracy of the SLN procedure and clinical outcome in melanoma patients after at least 60 months of follow-up.

PATIENTS AND METHODS

Between 1993 and 1996, 209 patients with stage I/II cutaneous melanoma underwent selective SLN dissection by the triple technique. If the SLN contained metastatic disease, a completion lymphadenectomy was performed. Survival analyses were performed using the Kaplan-Meier approach. Factors associated with survival were analyzed using the Cox proportional hazards regression model.

RESULTS

The success rate was 99.5%. Median follow-up was 72 months. Forty patients (19%) had a positive SLN. The false-negative rate was 9%. Five-year overall survival was 87% for the entire group and 92% and 67% for SLN-negative and SLN-positive patients (P <.0001), respectively. All patients with a positive SLN and a Breslow thickness < or = 1.00 mm survived, and SLN-positive patients with a Breslow thickness less than 2.00 mm tend to have a better prognosis compared with SLN-negative patients with a Breslow thickness greater than 2.00 mm. SLN status (P =.002), Breslow thickness (P =.002), and lymphatic invasion (P =.0009) were all found to be independent prognostic factors for overall survival.

CONCLUSION

With a success rate of 99.5% and a false-negative rate of 9% after long-term follow-up, the triple-technique SLN procedure is a reliable and accurate method. Survival data seem promising, although a therapeutic effect is still questionable. As shown in this study, not all SLN-positive patients have a poor prognosis.