Prognosis of level V malignant melanoma

Sentinel Lymph Node Status is a Main Prognostic Parameter Needful for the Correct Staging of Patients with Melanoma Thicker than 4 mm: Single-Institution Experience and Literature Meta-Analysis

PURPOSE OF THE STUDY

The usefulness of sentinel lymph node biopsy in thick melanomas is debated. The aim of this study was to evaluate the possible prognostic significance of sentinel lymph node biopsy in T4 melanoma patients and to verify whether this was a homogeneous group of patients with similar poor behavior.

MATERIALS AND METHODS

A retrospective observational study was performed. Data were extracted from the Tuscan Regional Referral Center database. The outcome of sentinel lymph node-negative and sentinel lymph node-positive T4 melanomas were compared. A systematic review of published series on this issue and a meta-analysis were performed.

RESULTS

Among 125 T4 melanoma patients, 53 patients (42.4%) were sentinel lymph node-positive and 72 (57.6%) patients were sentinel lymph node-negative. The 5-year and the 10-year melanoma specific survival were 81.9% and 72.3% for sentinel lymph node-negative patients and 42.4% and 17.9% (P < 0.001) for sentinel lymph node-positive patients. A positive sentinel lymph node showed an HR of 3.08. The meta-analysis confirmed that there was a significantly greater risk of death for patients with thick melanoma and positive sentinel lymph node (RR 1.75).

CONCLUSIONS

The results of the study point out that the sentinel lymph node biopsy is required for the correct staging of patients with melanoma thicker than 4 mm and that the status of sentinel lymph node is a significant predictor of melanoma specific survival. This knowledge allows early surgical and adjuvant treatment as well as appropriate trial enrollment and tailored follow-up.

Prognosis of thick cutaneous melanoma

BACKGROUND

Ten percent of all patients with melanoma present with thick primary tumors (> or = 4 mm or Clark level V). To determine factors associated with outcomes, we performed a retrospective analysis of 120 patients who had definitive primary treatment of their thick cutaneous melanomas at Memorial Sloan-Kettering Cancer Center between January 1986 and April 1995.

STUDY DESIGN

Data were collected via chart review and patient interview. Association between factors was determined by chi-square analysis. Survival analysis was performed by the method of Kaplan and Meier. Univariate analysis by log-rank testing and multivariate analysis using the Cox regression model were used to identify factors associated with disease-free and overall survival.

RESULTS

Median age was 61 years (range 19 to 87 years). There were 80 males and 40 females. Median Breslow thickness was 6 mm (range 1.8 to 25.0 mm). Ninety-three patients (78%) underwent lymphadenectomy (52 elective and 41 therapeutic). Twenty-one percent (11 of 52) of the elective dissections were positive. Median followup was 3.8 years (5.2 years for patients no evident disease and 2.0 years for those dead of disease). Overall survival for the entire group was 62% at 5 years and 43% at 10 years. Age, gender, and anatomic site (axial versus extremity) were not factors predictive of overall survival. Increasing thickness, nodal status at presentation (American Joint Commission on Cancer stage II versus III), and the presence of ulceration were significant predictors of both disease relapse and disease-specific mortality in both univariate and multivariate analyses. There was no difference in postrelapse survival between patients suffering local, nodal, or distant relapse (p = 0.63).

CONCLUSIONS

Patients presenting with thick cutaneous melanomas are expected to have more than 50% 5-year survival, and they should not be denied the opportunity for aggressive locoregional management. Thickness, positive nodal status, and ulceration are associated with a higher mortality rate. The fact that patients with local or nodal recurrences fare as poorly as those with overt distant metastases implies that the former events are predictors of subclinical systemic disease.

Cutaneous malignant melanoma in the young

Between the years 1967 and 1993, 3246 patients were diagnosed with malignant melanoma at Frenchay Hospital, Bristol. This paper reports 47 patients, 21 years of age or under, including 10 preadolescent cases under 14 years of age. It represents a further follow-up of a cohort originally published from this centre in 1986 in addition to 18 new cases. Most (89%) of the lesions occurred on the trunk and extremities, with females showing a predominance of lesions on the lower limbs. 83% of the melanomas were of the superficial spreading type: 72% invaded to Clark level III and IV. Thickness ranged from 0.29 mm to 50.00 mm (median 1.20 mm). Ulceration was present in 17% of cases and 32% of melanomas arose within a pre-existing small congenital melanocytic naevus. Overall 5-year survival was 81%, with a mean follow-up of 8.5 years. Ulceration and tumour thickness of greater than 1.5 mm were associated with a poor prognosis.

Thick cutaneous melanoma of the trunk and extremities: an institutional review

The objective of this study was to review our experience with thick cutaneous melanoma of the trunk and extremities and to identify subgroups of long-term survivors. Ninety-one patients admitted between the years 1977 and 1987, with cutaneous melanoma of the trunk or extremities, Breslow thickness > or = 4.0 mm, or a Clark's level V lesion form the basis of this review. Node positive clinical stage II patients had a 5-year survival rate of 32%. Five-year survival for node positive clinical stage III patients was 0% (P < 0.0001). Node negative clinical stage II patients, and those found to be histologically node positive, had no survival difference, P = 0.88. Sixty per cent of node negative patients with an extremity primary survived 5 years, while patients with a node positive truncal primary had a survival of 14%, P = 0.005. In conclusion, most patients present with local-regional disease. Patients with node negative extremity lesions have the best chance for cure.

Adjuvant regional isolated perfusion with melphalan for patients with Clark V melanoma of the extremities

From 1978 to 1990, 32 patients with Clark V melanoma were treated by wide excision of the primary and adjuvant regional isolated perfusion with melphalan. M.D. Anderson stage of disease was stage I in 22 and stage IIIb in 10 patients. Five-year survival rates were 58% and 27%, respectively. Seven patients developed a recurrence in the perfused limb [stage I, 2, stage IIIb, 5 patients (P = 0.03)], and 4 of 17 patients developed regional lymph node metastases. Of the well-known prognostic variables, only ulceration of the primary tumor significantly influenced survival (P = 0.03). We did not see any improvement in survival rates compared with literature data on nonperfused patients. In the absence of data on locoregional recurrence rates in nonperfused Clark V melanoma patients, we cannot say whether adjuvant perfusion diminished this risk. Therefore, the results of the prospective randomized EORTC/WHO trial in primary high-risk extremity melanoma have to be awaited.

Malignant melanoma in children: its management and prognosis

Malignant melanoma is rare in children, representing 1% to 3% of all pediatric malignancies. Thirty-three children with malignant melanoma were treated at St Jude Children's Research Hospital from 1967 to 1988. Their ages ranged from 1 day to 20 years (median, 12 years); 23 were boys and 10 were girls; and 5 of the 33 (15%) were black. Four of the 33 children had been treated for a previous malignancy. In 3, melanoma arose within a bathing trunk nevus. The extremity was the most common site (13), followed by the trunk (9), head and neck (7), and perineum (1). In 3 patients the primary site could not be determined. Upon initial presentation to St Jude Hospital, 17 patients had localized disease (stage I), 10 had regional node involvement (stage II), and the remaining 6 patients had disseminated disease (stage III). Using both Clark's level and Breslow's thickness as indicators, the incidence, initial stage, prognosis, and survival were compared. By Clark's level, 7 patients, (6 of whom were stage I) were level II or III, and 22 patients were level IV or V. Though 16 of 22 level IV and V patients were initially stage I, 10 patients eventually developed progressive disease. Similar observations were noted when using Breslow's thickness to evaluate the primary. In 5 of 27 evaluable patients, Breslow's depth of invasion was less than 1.5 mm. All 5 of these patients were diagnosed with stage I disease and have not shown progressive disease.

Diagnostic excision of the Rosenmüller's node. Screening for occult metastases before elective regional lymph node dissection in patients with lower limb melanoma?

Elective radical groin dissection was performed on 297 consecutive patients with high-risk melanoma of the leg, Anderson Stages I, IIA, IIIA. By separate histologic examination of the so-called "Rosenmüller's node," the other inguinal, and the external iliac lymph nodes, the diagnostic excision of the Rosenmüller's node was tested as a suitable mode of screening for metastases before a planned elective regional lymph node dissection. Eighty patients (27%) presented with what was histologically determined to be occult groin metastases. Rosenmüller's node was involved in 30 of these cases; in the remaining 50, however, it was not affected; that is, 63% of the cases were false-negative. Thus, the involvement of Rosenmüller's node is not representative of metastases in the other ilioinguinal lymph nodes, but is rather a matter of chance. In women with superficial spreading melanoma the rate of occult lymph node metastases was significantly lower than that in men with melanomas of the other type. Iliac lymph node involvement was observed in 18 patients (22%) depending on clinical stage and depth of invasion of the primary tumor.

Tumor metastasis-associated heparanase (heparan sulfate endoglycosidase) activity in human melanoma cells

We discovered previously a tumor metastasis-associated heparan sulfate (HS)-degrading endoglycosidase in mouse melanoma cells that is a unique endo-beta-glucuronidase (heparanase) capable of specifically cleaving HS at intrachain sites (Nakajima et al., J. Biol. Chem., 259 (1984) 2283. Using unmodified- and chemically modified-HS and heparin substrates we demonstrate that human Hs939 and mouse B16 melanoma cells possess a HS-degrading endoglycosidase of similar specificity. Melanoma heparanase showed high activity against N-desulfated N-acetylated HS, and we therefore synthesized a solid-phase heparanase substrate crosslinking partially N-desulfated N-[14C] acetylated HS to agarose gel beads via one covalent linkage. Using this solid-phase substrate 15 human malignant melanoma cell lines were assayed for heparanase activity. All of the melanoma cells tested had heparanase activity, and almost all possessed activities comparable or greater than that of the murine B16-F1 melanoma line. Human A375 melanoma variants of high lung metastatic potential in athymic nude mice had significantly higher heparanase activities than did A375 parental cells of low metastatic potential.