Prognostic factors in patients undergoing lymphadenectomy for malignant melanoma

Metastatic Spread of Stage I Melanoma of the Skin

1164 patients with stage I melanoma of the skin who were submitted to wide excision only of the primary tumor were studied to evaluate the rates of regional lymph node and distant metastases. Of these, 516 (44.3%) had a recurrence of the disease which was at regional lymph nodes in 264 (22.7%), at distant sites in 91 (7.8%), and simultaneously at regional lymph nodes and distant sites in 161 (13.8%). Most of the patients had a relapse within 5 years: regional node metastases were most frequently observed during the first 3 years, and distant metastases appeared later. The ratio regional:distant metastases was not different (P > 0.05) when subgroups of patients were considered according to prognostic criteria (sex, site of origin, levels, thickness, ulceration). Sex, levels, thickness and ulceration were found to be significantly related with the frequency of recurrences (regional and distant). It is concluded that the prognostic criteria considered do not predict whether the tumor will metastasize to regional nodes or to distant sites.

Treatment options for premalignant and malignant cutaneous tumors

Whenever possible, surgical excision of skin cancers should be the gold standard of treatment. There are many considerations when choosing one treatment modality over another. These include the lesion's location, the surgeon's experience and comfort level, the patient's health status and their potential compliance, access to available technology, and economic considerations for the patient and the provider. Regardless of the type of therapy, all forms of treatment share the following goals: complete disease cure, preservation of normal tissue, preservation of function, and optimal cosmesis.

Adjuvant radiotherapy for cutaneous melanoma: Comparing hypofractionation to conventional fractionation

PURPOSE

To examine locoregional control after adjuvant radiotherapy (RT) for cutaneous melanoma and compare outcomes between conventional fractionation and hypofractionation.

METHODS AND MATERIALS

Between January 1980 and June 2004, 56 patients with high-risk disease were treated with adjuvant RT. Indications for RT included: recurrent disease, cervical lymph node involvement, lymph nodes >3 cm, more than three lymph nodes involved, extracapsular extension, gross residual disease, close or positive margins, or satellitosis. Hypofractionation was used in 41 patients (73%) and conventional fractionation was used in 15 patients (27%).

RESULTS

The median age was 61 years (21->90). The median follow-up among living patients was 4.4 years (range, 0.6-14.4 years). The primary site was located in the head and neck in 49 patients (87%) and below the clavicles in 7 patients (13%). There were 7 in-field locoregional failures (12%), 3 out-of-field regional failures (5%), and 24 (43%) distant failures. The 5-year in-field locoregional control (ifLRC) and freedom from distant metastases (FFDM) rates were 87% and 43%, respectively. The 5-year cause-specific (CSS) and overall survival (OS) was 57% and 46%, respectively. The only factor associated with ifLRC was satellitosis (p = 0.0002). Nodal involvement was the only factor associated with FFDM (p = 0.0007), CSS (p = 0.0065), and OS (p = 0.016). Two patients (4%) who experienced severe late complications, osteoradionecrosis of the temporal bone and radiation plexopathy, and both received hypofractionation (5%).

CONCLUSIONS

Although surgery and adjuvant RT provides excellent locoregional control, distant metastases remain the major cause of mortality. Hypofractionation and conventional fractionation are equally efficacious.

Cutaneous melanoma: therapeutic lymph node and elective lymph node dissections, lymphatic mapping, and sentinel lymph node biopsy

Early clinical observation in cancer patients suggested that tumors spread in a methodical, stepwise fashion from the primary site, to the regional lymphatics, and only then to distant locations. Based on these observations, the regional lymphatics were believed to be mechanical barriers, at least temporarily preventing the widespread dissemination of tumor. Despite evidence now available disputing its validity, this barrier theory has guided the surgical management of the regional lymphatics in cancer patients for more than a century, influencing the use of such surgical modalities as therapeutic lymph node dissection, elective lymph node dissection, and most recently lymphatic mapping and sentinel lymph node biopsy. No published randomized controlled trial exists that demonstrates improved overall patient survival for cancer of any type, including melanoma, after surgical excision of regional lymphatics. This article will review the biology of lymphatics as it relates to regional tumor metastasis, and based on available information, offer practical recommendations for the clinical dermatologist and their patients who have cutaneous melanoma.

Radiation therapy following lymph node dissection in melanoma patients: treatment, outcome and complications

Adjuvant radiation treatment following lymph node dissection in the melanoma patient has been suggested and investigated in an attempt to gain regional control and improve survival. In this review we discussed the treatment, the loco-regional control, disease-free and survival rates and complications. Historically melanoma has been thought of as a relatively radioresistant tumour. Nowadays, radiation delivered according to the hypofractionated schedule is the most used, although there are no data to confirm that this schedule improves the therapeutic impact. Almost all the reviewed studies were retrospective, which could have led to an underestimation of the true incidence of the treatment toxicity and morbidity. Adjuvant radiotherapy after lymph node dissection for metastases of melanoma seems to improve loco-regional control without improving overall survival. The available data indicate the need for improved regional control rates in patients with extranodal extension, multiple involved nodes (more than three) and patients with large involved nodes (larger than 3 cm). The complications seem manageable and consist mainly of fibrosis and edema.

The management of regional lymph nodes in cancer

Early clinical observation in cancer patients suggested that tumours spread in a methodical, stepwise fashion from the primary site to the regional lymphatics, and only then to distant locations. Based on these observations, the regional lymphatics were believed to be mechanical barriers preventing the widespread dissemination of tumour. Despite evidence now available disputing its validity, this barrier theory has guided the surgical management of the regional lymphatics for more than a century, influencing the use of such surgical modalities as therapeutic lymph node dissection, elective lymph node dissection and most recently sentinel lymph node biopsy. No published randomized controlled trial exists that demonstrates improved overall survival for patients with cancer of any type undergoing surgery of the regional lymphatics. We believe the presence of tumour in the regional lymphatics indicates the presence of systemic disease, and therapeutic interventions should be directed accordingly.

The role of molecular staging in malignant melanoma

AIMS

To review the role of tyrosinase RT-PCR in the detection of clinically occult metastatic disease, both within the regional lymph nodes and peripheral blood of patients with malignant melanoma. Secondly, to assess whether the detection of such minimal disease has clinical implications for patients with melanoma.

METHODS

A review of the literature was undertaken by searching the MEDLINE database for the period 1966-2002 without any language restrictions. Keywords included 'Molecular staging of melanoma', 'Reverse transcription polymerase chain reaction', 'Malignant melanoma' and 'Tyrosinase'.

CONCLUSIONS

Detection of tyrosinase RT-PCR positive cells within the peripheral blood correlates with the clinical stage of malignant melanoma, the primary tumour thickness and other known prognostic indicators. Positive tyrosinase RT-PCR is associated with a reduction of disease-free survival and overall survival. Current studies demonstrate a higher rate of recurrence in RT-PCR positive patients with clinical stage II and III disease. Implications of a positive result within the regional lymph nodes are less well defined. A significant correlation has been demonstrated between positive results and increasing primary melanoma thickness. However, a large number of false-positive results have been demonstrated, due to benign naevi and schwann cells, which may hamper any statistically significant conclusions being reached.

Selective sentinel lymphadenectomy for malignant melanoma

To date, selective sentinel lymphadenectomy (SSL) should be considered a standard approach for staging patients with primary invasive melanoma greater than or equal to 1 mm. It is imperative that the multidisciplinary team master the techniques of preoperative lymphoscintigraphy, intraoperative lymphatic mapping, and postoperative pathologic evaluation of the sentinel lymph nodes (SLNs). A SLN is defined as a blue, "hot", or any subsequent lymph node greater than 10% of the in vivo count of the hottest lymph node and as an enlarged or indurated lymph node. Frozen sections are not recommended. For extremity melanoma, delayed SSL may be performed. Preoperative lymphoscintigraphy for extremity melanoma may be done the night before so that surgery can be scheduled as the first case of the following day. Every surgeon who uses blue dye should be cognizant of the potential adverse reaction to isosulfan blue and treatment for such a potential fatal reaction. A complete lymph node dissection is done if the SLN is found to be positive. Elective lymph node dissection should not be done if SSL can be done as a staging procedure. It is important for investigators involved with SSL to follow the clinical outcome of their patients so that the role of SSL can be further defined.

Common prognostic factors for stage III melanoma patients and for stage I and II melanoma patients with recurrence to their regional lymph nodes

This study was undertaken in order to identify the prognostic factors for stage III malignant melanoma patients. In addition we compared the survival data of these patients with data from patients presenting with stage I and II disease who subsequently developed a regional nodal recurrence, in order to identify common prognostic factors and to compare the biological behaviour of the two groups. We retrospectively examined two groups of patients. The first consisted of 116 patients with stage III malignant melanoma and the second consisted of 57 patients with stage I and II malignant melanoma that were found to have regional lymph node metastases diagnosed at least 6 months after surgical treatment of their primary lesion. The age of the patients, the number of disease-involved lymph nodes, the site of the primary lesion and the presence or not of palpable lymph nodes proved to be significant prognostic factors of the first group. We also analysed the survival data of the second group and compared it with data from the stage III patients. The 5 year survival starting from the time after diagnosis of the primary lesion was 47.37% compared with 25.86% in stage III patients; however, this difference was not statistically significant. Patients who present with stage III malignant melanoma seem to have a more aggressive phenotype than stage I and II malignant melanoma patients who present with recurrent disease in their regional lymph nodes. Disease behaviour is dictated by the number of disease-involved lymph nodes, the site of the primary lesion and the type of surgical procedure performed (elective or therapeutic lymph node dissection).

Primary cutaneous malignant melanoma and its precursor lesions: diagnostic and therapeutic overview

During the past few decades, scientific data relating to melanoma have flourished. New information regarding acquired nevi, dysplastic nevi (atypical nevi), and congenital nevi has given us a better understanding of these precursor lesions and their relationships to malignant melanoma. The roles of laboratory testing, photography, and newer diagnostic tools (eg, epiluminescence) to evaluate patients for melanoma or precursor lesions have fallen under close scrutiny. Traditional surgical therapeutic interventions continue to be replaced by less aggressive protocols based on prospective randomized studies. Many new interventions such as sentinel lymph node procedures are currently being evaluated at research/referral centers around the world. We present clinicians with an evidence-based summary of the current literature with regard to primary cutaneous melanoma, its diagnosis, precursor lesions, and therapy.

The role of sentinel lymph nodes in malignant melanoma

Selective sentinel lymph node dissection should be considered a standard approach in the treatment of primary malignant melanoma. With the combination of blue dye and radioisotope mapping, the sentinel lymph nodes (SLNs) can be harvested with pinpoint accuracy. This article compares blue dye and radioisotope mapping techniques. Based on the clinical outcome data of selective sentinel lymph node dissection, micrometastasis to the SLNs carries a poor prognosis for patients with primary invasive melanoma.

A historical perspective on the development of intraoperative lymphatic mapping and selective lymphadenectomy

Intraoperative lymphatic mapping (ILM) and selective lymphadenectomy are revolutionary concepts that, in a short period, have shown the potential to alter dramatically the management of many patients with solid neoplasms. The rapid adaptation of this approach to the staging of solid neoplasms by the surgical oncology community has resulted in an explosion of data. Initially described as a surgical technique in which each surgeon had to climb a learning curve, ILM and selective lymph node dissection (SLND) are now recognized as a multidisciplinary surgical approach to the management of the patient with cutaneous melanoma and breast cancer. The potential values of ILM and SLND are being examined vigorously now in numerous other solid neoplasms.

Prognosis and surgical management of patients with palpable inguinal lymph node metastases from melanoma

BACKGROUND

The appropriate management of melanoma metastatic to inguinal lymph nodes remains controversial. The aim of this study was to identify disease- and treatment-related factors that influence the outcome of patients undergoing therapeutic groin dissection for clinically detectable melanoma lymph node metastases.

METHODS

A retrospective analysis was performed on data collected from the case records of patients who had a therapeutic inguinal lymph node dissection performed between 1984 and 1998.

RESULTS

Some 132 patients were suitable for inclusion. Sixty patients had superficial inguinal lymph node dissection (SLND) and 72 had combined superficial inguinal and pelvic lymph node dissection (CLND). There was no difference in postoperative morbidity or major lymphoedema between SLND and CLND. The overall survival rate was 34 per cent at 5 years. On univariate analysis, age (P = 0.003), the number of involved superficial lymph nodes (P = 0.001) and the presence of extracapsular spread (P = 0.003) were found to have a significant impact on survival. The presence or absence of pelvic lymph node metastases in patients who had CLND was a significant prognostic factor for survival (5-year survival 19 versus 47 per cent; P = 0.015).

CONCLUSION

The prognosis of patients with clinically detectable melanoma metastases to the groin is variable and related to the biological characteristics of each case. CLND provided additional prognostic information and optimal regional control with no increased morbidity compared with SLND.

Judging the therapeutic value of lymph node dissections for melanoma

BACKGROUND

The management of the regional lymph nodes remains controversial for early-stage melanoma and for those patients with lymph node metastases; American Joint Committee on Cancer stage III. This study examines the importance of quality of the surgical resection measured by the extent of lymph node dissection (quartile of the total number of lymph nodes removed) to determine if this factor is an important prognostic factor for survival.

STUDY DESIGN

We reviewed our computer-assisted database of more than 8,700 melanoma patients prospectively collected from 1971 through the present to identify patients who underwent lymph node dissection for stage III melanoma. We included only patients who had their nodal dissections performed at our institute. Patients who underwent sentinel lymph node dissection were excluded. These patients were then analyzed as a group and by individual lymphatic basins: cervical, axillary, and inguinal basins. Univariate and multivariate analyses were used to examine the model that included tumor burden, thickness of the primary melanoma, gender, age, clinical status of the lymph nodes (palpable versus not palpable), and the primary site. The survival and recurrence rates were analyzed using the Cox proportional hazards model.

RESULTS

Five hundred forty-eight patients underwent regional lymph node dissections. Of these patients, 214 underwent axillary dissections, 181 inguinal dissections, and 153 cervical dissections. The extent of the nodal dissections was based on the quartile of nodes excised, ranging from 1 to 98 (mean +/- SD = 25.8 +/- 15.8). Patients were stratified by tumor burden and quartile of number of lymph nodes removed. The overall 5-year survival of patients with four or more lymph nodes having tumor and the highest quartile of lymph nodes removed was 44% and was 23% for the lowest quartile of total lymph nodes excised (p = 0.05). By univariate analysis, tumor burden (p = 0.0001), quartile of total lymph nodes removed (p = 0.043), and primary site (p = 0.047) were statistically significant for predicting overall survival. Gender, clinical status of the nodes, primary tumor thickness, age, and dissected basin were not significant (p > 0.05). By multivariate analysis only the tumor burden (p = 0.0001) and quartile of lymph nodes resected (p = 0.044) were statistically significant.

CONCLUSIONS

The extent of lymph node dissection for melanoma when analyzed by quartiles is an independent factor in overall survival. This factor appears to be more important with increasing tumor burden in the lymphatic basin. The extent of lymph node dissection should be considered as a prognostic factor in the design of clinical trials that involve stage III melanoma.

Current therapy of cutaneous melanoma

Melanoma is a growing public health problem. Optimal care of the melanoma patient is multidisciplinary, but plastic surgeons and other surgical specialties play a central role in the management of these patients. Although surgery remains the mainstay of therapy for melanoma, several recent clinical studies have helped to clarify the biology of the disease and have changed the patterns of care for patients with melanoma. The advent of lymphatic mapping for interrogation of regional lymph nodes and interferon as the first effective postsurgical adjuvant therapy have had a major impact on the care of melanoma in the United States and elsewhere. This article will review the current clinical approach and therapy for cutaneous melanoma. The diagnosis, prognostic variables, staging evaluation, current surgical and medical treatment, and follow-up guidelines for patients with all stages of melanoma are reviewed. Recent studies, controversies, and directions of future investigational therapies will be discussed.

Lymph node tumor volumes in patients undergoing sentinel lymph node biopsy for cutaneous melanoma

BACKGROUND

Regional lymph node tumor volumes in patients undergoing sentinel lymph node (SN) biopsy (SNB) for treatment of cutaneous melanoma have not been described. The objectives of this study were to describe the lymph node tumor volumes typically seen in this population and to correlate tumor volumes with tumor thickness and positive SN characteristics.

METHODS

Review of a consecutive series of patients with clinically localized cutaneous melanoma who underwent SNB of nonpalpable regional lymph node basins followed by complete lymphadenectomy (LND) was performed. Multiple lymph node sections from positive SNs and nonsentinel nodes (NSNs) in LND specimens were examined microscopically. Individual tumor deposit diameters were measured using an ocular micrometer. Aggregate tumor volumes were calculated for SN and LND specimens. Tumor volumes and SN and LND positivity rates were correlated with tumor thickness, the number of positive SNs, and the presence of multiple SN tumor deposits.

RESULTS

SNB procedures were performed for 149 melanomas in 189 regional nodal basins. The mean tumor depth was 2.48 mm. The mean number of SNs/basin was 2.1. Thirty-two of 149 SNB procedures (21.5%) revealed a total of 34 nodal basins with at least one positive SN. The median tumor volume in positive SNs was 4.7 mm3 (range, 0.1-3618 mm3; mean, 209 mm3). The median aggregate tumor volume in positive LND specimens was 4.9 mm3 (range, 0.1-3618 mm3; mean, 224 mm3). Six basins (17.6%) contained at least one positive NSN. The regional node aggregate tumor volume correlated weakly with tumor thickness (Pearson's correlation coefficient = .302, P = .0934). NSN positivity was not predicted by tumor thickness, American Joint Committee on Cancer tumor stage, number of positive SNs, or number of metastatic deposits within SNs.

CONCLUSIONS

Most melanoma-positive SNs contain minute tumor volumes. Tumor thickness and patterns of SN metastases may not be predictive of tumor burden or the presence of positive NSNs.

A rational approach to melanoma follow-up in patients with primary cutaneous melanoma. Scottish Melanoma Group

From the Scottish Melanoma Group database for south-east Scotland we evaluated 5-year follow-up in patients with cutaneous malignant melanoma excised between 1979 and 1994 and devised an 'evidence-based' review protocol. Of the 1568 with stage I melanoma, 293 (19%) developed a recurrence, 32 had a second primary melanoma and 97 had an in-situ melanoma. The disease-free interval shortened progressively with increasing tumour thickness. Overall, 80% of recurrences were within the first 3 years, but a few patients (< 8%) had recurrences 5 or 10 years after the initial surgery. In-situ melanomas did not recur. Almost half (47%) the recurrences were noted first by the patient, and only 26% were detected first at a follow-up clinic. One hundred and thirty-nine patients (89%) were still under review when their recurrences were detected, and 102 (65%) had been seen within the previous 3 months. Questionnaires were completed by 120 patients: sun protection and avoidance, and mole examination were more likely after melanoma excision. We recommend 3-monthly review of patients with invasive lesions for the first 3 years. Thereafter, those with lesions >/= 1.0 mm need two further annual reviews. Patients with in-situ lesions should be reviewed once, to confirm adequate excision (0.5 cm margins) and to give appropriate education. Surveillance beyond 5 years is only justified if there are special risk factors.

Therapeutic node dissections in malignant melanoma

BACKGROUND

Therapeutic lymphadenectomies involve the dissection and removal of clinically enlarged, histologically positive nodes at the regional nodal basin, in the absence of detectable distant disease.

METHODS

The literature dealing with therapeutic lymphadenectomies in malignant melanoma was reviewed.

RESULTS

The rate of wound complications varies with the particular nodal basin. The 5-year survival varies from 19% to 38%, with an average of 26%. Survival is affected primarily by the number of histologically positive nodes and extracapsular spread, and secondarily by the extent of disease at the various levels of the nodal basin, fixation of the nodes, and, probably, the preceding disease-free interval. Prognostic parameters of the primary lesion, e.g., thickness, ulceration, and location, also may have an effect on survival. The rate of local recurrence at the nodal basin after lymphadenectomy has varied from 0.8% to 52%. Adjuvant therapy with interferon alfa-2b has improved the 5-year disease-free survival from 26% to 37%.

CONCLUSIONS

Therapeutic node dissections in melanoma provide an appreciable 5-year survival rate, which is further augmented by adjuvant therapy. Many series report a significant rate of local recurrence at the nodal basin following therapeutic dissection. Complete lymphadenectomy reduces the rate of local failure with its attendant morbidity.

Classification and staging of melanoma

Although a standardized and uniformly accepted cancer staging system is an essential and fundamental requirement to enable meaningful comparisons across patient populations, the sometimes capricious biologic behavior of melanoma makes developing such a staging system particularly difficult. Since the earliest well-documented attempts at classifying patients with cutaneous melanoma were described more than 50 years ago, the identification of increasingly powerful prognostic factors has led to sequential modifications of the cutaneous melanoma staging system. The current AJCC staging system is based on relatively well-established prognostic factors; however, several recent reports have identified additional prognostic factors not included in the current system, and other studies support the re-evaluation of some of the currently employed staging criteria. Some of the more controversial areas include the relevance of level of invasion versus tumor thickness, optimal cutoffs for tumor thickness, importance of ulceration, the grouping of satellites with in-transit metastases, the inclusion of microsatellites and local recurrences as a separate staging criterion, the replacement of size of nodal mass with number of positive nodes, the importance of nodal metastases in more than one nodal basin, and the prognostic significance of distant metastases. Therefore, future modifications of the staging system are anticipated to better incorporate these observations. Stage-specific staging recommendations for the patient with melanoma provide the clinician with a framework to most efficiently assess extent of disease in an era of cost-conscious clinical practice. In the asymptomatic patient with primary melanoma (stage I or II), we recommend a chest roentgenogram and evaluation of alkaline phosphatase and LDH levels; extensive radiologic evaluations are not indicated, because the rate of detection in this population is extremely low. Additional staging information should also be obtained by the technique of lymphatic mapping and sentinel lymphadenectomy. For patients with local-regional disease (stage III, satellites, and local recurrence), a selective approach to imaging studies is warranted. For this patient population, we recommend complete blood count, liver function tests including alkaline phosphatase and LDH, a chest roentgenogram, and a CT scan of the abdomen. Although the yield of these tests, particularly CT of the abdomen, in detecting distant metastases in asymptomatic patients is low, they may identify false-positive abnormalities and provide an important baseline for future studies in this high-risk population. For patients with disease below the waist or in the head and neck region, we recommend CT of the pelvis and CT of the neck, respectively. Additional studies should be done only if clinically indicated. Finally, patients with known systemic disease (stage IV) should be more comprehensively evaluated, because the likelihood of detecting asymptomatic metastases is higher. Accordingly, in addition to the work-up outlined previously for stage III patients, we also perform a CT scan of the chest and MR imaging of the brain; other studies (e.g., bone scan, gastrointestinal series) are performed on the basis of symptoms.

Role of elective lymph node dissection in melanoma

In the last several years, much debate has centered on the management of the regional lymph nodes in malignant melanoma. The regional lymph nodes are the most common site of melanoma metastases and surgical excision of these involved nodes is the most effective treatment for either cure or local disease control. The issue still in question is the approach to the clinically negative regional lymph node basin. Retrospective studies have yielded conflicting results regarding the value of routine elective lymph node dissection (ELND) when nodes are clinically negative. Four prospective randomized clinical trials have been completed which have indicated that routine ELND is not worthwhile for the majority of melanoma patients. However, ELND may be associated with improved outcome in certain subgroups of patients: those <60 years age with 1 to 2 mm thick melanomas with or without ulceration. In addition, lymphatic mapping with sentinel lymph node biopsy has become increasingly available and has allowed clinicians an alternative to ELND. In the absence of sentinel lymph node biopsy, the role for ELND in these subgroups of patients is one of the remaining unresolved issues.

Efficacy of hyperthermic isolated limb perfusion for extremity-confined recurrent melanoma

BACKGROUND

Recurrent melanoma of the extremity has been treated by local excision, systemic chemotherapy, amputation, or a combination of these approaches. Hyperthermic isolated limb perfusion (HILP) provides a method of limb preservation through isolation, allowing the administration of chemotherapy in higher doses than is possible through systemic treatment.

METHODS

An experimental group of 59 HILP patients with melanoma recurrences of the extremity was studied prospectively. A control group of 248 melanoma patients with similar recurrences was excluded from HILP because their recurrences were in non-extremity locations. The experimental group underwent HILP and excision; the control group had excision only. The experimental procedure consisted of vascular isolation of the affected extremity and a 1-hour perfusion with melphalan. Temperatures were maintained at 40 degrees C in the perfusion circuit.

RESULTS

The HILP patients had a lower rate of locoregional recurrence (P=.028) and demonstrated increased survival (P=.026) compared to the control group. In multivariate regression analysis, which included age, ulceration and thickness of the primary, and the treatment variable of perfusion, age (P=.02) and perfusion for the treatment of recurrence (P=.006) were significant predictors of survival.

CONCLUSIONS

HILP improves prognosis by sterilizing the treated extremity, controlling locoregional disease, and perhaps preventing metastasis, thus having a positive impact on overall survival.

Therapeutic node dissections in malignant melanoma

In the absence of distant disease, therapeutic node dissections in malignant melanoma, i.e., dissections of regional nodal basins for palpable suspicious or biopsy-proven positive nodes, offer the chance of cure. The 5-year survival rates after therapeutic lymphadenectomy closely correlate with expected cure rates. Although they varied greatly in the literature, from 19% to 38%, the currently obtainable survival rates are in the upper ranges of this spectrum because patients now are closely followed-up and operated for early palpable nodal disease. Properly done, these procedures carry a low morbidity, but they should be done thoroughly to completely eradicate regional disease and avoid recurrences in the same nodal basin to achieve the maximum survival that is surgically attainable.

Advances in melanoma therapy

This review discusses several advances in melanoma therapy that have recently occurred or are presently in a developmental stage. We discuss the history and present dogma regarding assessment of the regional lymph nodes and adjuvant therapy for melanoma. Of special interest is radiolymphatic sentinel node mapping of the lymph nodes and adjuvant interferon alfa-2b for thick primary lesions and stage III disease. We also discuss several evolving novel and innovative genetic immunotherapy approaches for patients with stage IV disease.

Management of cutaneous melanoma M0: state of the art and trends

This article reviews the epidemiology, diagnosis and treatment of cutaneous melanoma, including the most recent developments. The combination of positive family history, fair complexion, number of nevi, exposure to sun and/or chromosomal alterations seem to be implicated in the pathogenesis of cutaneous melanoma. Melanomas can be classified according to their growth patterns, and tumour microstaging is of straightforward predictive value for survival and risk of metastasis, although new factors are also being investigated. As yet, surgical excision is the only effective treatment available for primary tumours, resection margins varying according to tumour thickness. Elective node dissection is, however, no longer advocated for melanomas thinner than 1.5 mm, and there is disagreement as to its role for thicker lesions. In contrast, selective node dissection at the time of definitive surgery is becoming more widely accepted, with regional node dissection being restricted to positive cases. Therapeutic dissection is required for lymph node involvement, the most common pattern of recurrence from melanoma, which affects nearly 30% of all patients. Complete remission rates from isolated limb perfusion, which has been employed in patients with multiple recurrences or in-transit metastases, range from 40 to 90%, depending on drugs and techniques used in different series; the best responses so far have been obtained with tumour necrosis factor in combination with melphalan. Patients with thick lesions (> 4 mm) or lymph node metastases have a high risk of micrometastases that would warrant adjuvant therapy. The only agent found to affect survival is interferon alpha-2.

Computed tomography in staging of patients with melanoma metastatic to the regional nodes

BACKGROUND

This study addresses the yield and clinical impact of computed tomography (CT) imaging in otherwise asymptomatic patients with stage III melanoma metastatic to the regional nodes.

METHODS

The database from the University of Michigan Mutlidisciplinary Melanoma Clinic was reviewed and identified 127 asymptomatic patients with stage III melanoma (regional nodal disease) who received CT scans of the head, chest, abdomen, and/or pelvis. Scans were confirmed as true positive, false positive, and normal.

RESULTS

Four hundred twenty-six head and body CT scans were performed at the time of presentation of stage III disease. Twenty patients had a true-positive CT scan revealing unsuspected metastases. Fifteen patients had abnormal CT scans subsequently shown to be a benign process or second malignancy. The incidence of true-positive CT scans was not different between the groups of patients who had clinically apparent versus occult nodal disease. There was a significantly higher incidence of abdominal and pelvic metastatic sites identified by CT scan in patients with inguinal nodal disease compared with axillary or head and neck node-positive patients.

CONCLUSIONS

The yield of detection of unsuspected metastases by CT scans in asymptomatic patients with stage III melanoma was not insignificant. Because patients with resected stage III disease are recommended to have adjuvant interferon-alpha for 1 year, CT staging plays an important role in identifying appropriate candidates for treatment. The toxicity of interferon-alpha therapy is not insignificant. The value of routine CT in asymptomatic patients with nodal metastasis deserves further prospective study.

Adjuvant therapy for cutaneous malignant melanoma

We discuss the current status of adjuvant therapy for melanoma by first reviewing the rationale and goals of adjuvant therapy and then analyzing the results of published randomized trials. We pay particular attention to adjuvant interferon trials that raise many challenging issues in the management of patients with melanoma at high risk of recurrence. Past adjuvant trials have used immunotherapeutic approaches, chemotherapy, radiation therapy, as well as hormonal and retinoid therapy. We also summarize ongoing adjuvant trials.

Favorable prognostic factors in recurrent and metastatic melanoma

Survival among patients with recurrent and metastatic melanoma varies widely. Several clinical and pathologic variables correlate with improved survival. Awareness of these favorable prognostic characteristics should assist in patient counseling and help identify those who may benefit from more aggressive therapeutic intervention.

Current therapy for cutaneous melanoma

We review the current therapy for melanoma. The diagnosis, prognostic variables, staging, treatment, and follow-up guidelines for cutaneous melanoma are reviewed from the earliest to the most advanced stages. New guidelines for margins are discussed. A new, evolving, innovative radiographic technique, positron emission tomography using 2-fluorine-18-fluoro-2-deoxy-D-glucose, may be useful to identify subclinical nodal and visceral disease. Recent advances with respect to tumor vaccines, gene therapy, immunotherapy, and interleukin 2 as well as current concepts regarding lymph node dissection are discussed.

Clinical and histologic involvement of regional lymph nodes in malignant melanoma. Adjuvant vindesine improves survival

BACKGROUND

This report is a study of prognostic factors, including adjuvant chemotherapy, that influence survival of patients with malignant melanoma who have clinical and pathologic involvement of regional lymph nodes.

METHODS

A total of 169 evaluable patients with malignant melanoma metastatic to regional lymph nodes were registered consecutively and prospectively between June 1977 and December 1986 in the computerized data base of the melanoma registry at Westminster Hospital. Eighty-seven of these patients received adjuvant chemotherapy with vindesine after resection of palpable metastatic lymph nodes, and 82 had no systemic treatment after surgery. All were followed up for at least 2 years (median, 8 years) after involvement of regional lymph nodes was noted or until death. Statistical analyses included simple life-table comparisons, unadjusted for covariates. In addition, Breslow's thickness, ulceration of the primary lesion, its anatomical location, number of regional lymph nodes histologically involved, dissection site, patient age and sex, and adjuvant vindesine therapy were included as covariates in Cox regression models.

RESULTS

The disease-free interval (P = 0.0001), time to dissemination from lymph node metastases (P < 0.0001), survival time after lymph node dissection (P = 0.0227) and overall survival time after initial diagnosis of malignant melanoma (P = 0.0095, log-rank chi-square test) were superior for the 87 patients who received adjuvant chemotherapy with vindesine. Cox regression analysis confirmed adjuvant vindesine as a highly significant variable influencing all of these outcomes, including overall survival time after first diagnosis (P = 0.003).

CONCLUSIONS

The apparent effect of adjuvant vindesine on overall survival in this study is large (hazard ratio, 0.52) and highly statistically significant. Adjuvant vindesine therapy merits consideration for malignant melanoma metastatic to regional lymph nodes. However, these results observed in concurrent, but nonrandomized, patients clearly require confirmation.

Local control following therapeutic nodal dissection for melanoma

Regional recurrence of melanoma is usually treated with surgical resection alone. Unfortunately sites of failure following surgical resection are poorly documented. Little information exists regarding local failure following surgery. In order to define local control, a retrospective analysis was performed of all patients undergoing a potentially curative lymph node dissection for metastatic melanoma. From 1978 to 1988, 48 patients underwent lymph node dissection with removal of all known disease (15 axillary, 25 groin and 8 radical neck dissections). Seven patients had stage II disease with simultaneous resection of the primary lesion and nodal dissection. The remaining 41 patients had stage I disease with dissection delayed until nodal metastasis became apparent. Of these 48 patients, 25 experienced local failure for an overall local control rate of 48%. Univariate and multivariate analysis showed only age to be a statistically significant prognostic indicator of local failure with a rate of 31% for patients < 50 years of age vs. 66% for patients > 50 years of age (P = 0.02). Nodal size, number of nodes involved, extracapsular extension, initial stage, location, or sex did not influence prognosis. Although not statistically significant, time to recurrence was much shorter in patients with extracapsular extension, 5 months vs. 16 months. With an overall local failure rate of 52% following a potentially curable therapeutic nodal dissection further local treatment should be considered.

[Inguinal recurrence after therapeutic lymphadenectomy in malignant melanoma]

In a retrospective study, 73 stage-II melanoma patients with 22 superficial and 51 deep groin dissections were observed over a maximum of 9 years of follow up (median 67.5 months). The 5-year survival rate of 29.8% was consistent with that yielded by comparable analyses of other investigators. However, the probability of recurrence in the node dissection field was as high as 35%. All groin recurrences occurred in the first 29 months after lymph node clearance (median 6 months). Patients with groin recurrence following lymph-node dissection had a poor prognosis (median survival 12 months). In a multifactorial analysis (Cox model), the only prognostic factor of probability of recurrence was the development of regional in-transit cutaneous metastases (p = 0.0028). Factors that did not affect the appearance of recurrent metastases in the node dissection field were: site of primary melanoma, tumor thickness, epidermal ulceration, degree of lymph node involvement (p = 0.2) age, sex, degree of surgery (superficial or deep groin dissection) and adjuvant chemotherapy. Because regional in-transit cutaneous metastases mostly occur synchronously with groin recurrence or later, they are a typical concomitant phenomenon rather than a prognostic factor of recurrence.

[Axillary recurrence after lymph node excision in malignant melanoma]

In a retrospective study 143 patients with 155 axillary lymphadenectomies were observed with a maximum of 8 years of follow-up (mean 51.9 +/- 25.8 months). At the time of their lymphadenectomies, 39 patients had histologically negative nodes (stage I), 85 patients lymph-node metastases (stage II), 19 patients axillary node involvement and distant metastases (stage III). The estimated 5-year survival rates were 77.5% in stage I and 28.6% in stage II. Axillary recurrence after dissection of tumor-free lymph nodes rarely happened, but in stage II the probability of recurrence was as high as 30.7%. All axillary recurrences occurred in the first 20 months after lymphadenectomy. In a multivariate analysis (Cox model), the only prognostic factor of probability of recurrence in stage II was the development of regional in-transit cutaneous metastases (p = 0.048). Factors that did not affect the appearance of recurrent metastases in the node dissection field were: epidermal ulceration, vascular invasion, tumor thickness, degree of lymph-node involvement, age, sex, and adjuvant chemotherapy. Median survival after axillary recurrence following therapeutic lymph-node excision (5 months) was comparable with survival after lymphadenectomy in stage III (7 months). There was a high incidence (> 30%) of regional in-transit cutaneous metastases in both groups. Regardless of the poor prognosis, we found 15% axillary recurrences after lymph-node clearance in stage III.

Management of the regional lymph nodes in patients with cutaneous malignant melanoma

One of the most difficult decisions in the management of patients with melanoma remains whether or not to dissect electively the regional lymph nodes of patients with high risk primary tumors. There is abundant evidence that a proportion of such patients will eventually develop nodal metastases and that the probability of metastasis increases with increasing tumor thickness and depth of invasion. If elective node dissection is performed on all patients with high risk primaries, most patients (who have no tumor in the nodes) will be subjected to a potentially morbid operation from which they can achieve no benefit. On the other hand, a "wait and see" policy accepts that a minority of patients will go on to develop nodal metastases and that if definitive therapy is delayed until metastases are detected clinically their likelihood of survival is much reduced. We describe a new technique of dye-directed selective lymphadenectomy that allows accurate and objective identification of individual patients who have subclinical metastases, the individuals who a priori are most likely to benefit from lymphadenectomy. We also discuss new approaches to the assessment of prognosis after lymphadenectomy for node-spread melanoma, a group of patients in whom the prognosis is not uniformly bad. We end with a consideration of quality assurance aspects of the pathological evaluation of lymphadenectomy specimens.

Treatment of unknown primary melanoma

Sixty-four patients with unknown primary melanoma were identified among 1045 new patients with melanoma (6%) seen during an 11-year period. Their mean age was 44.5 years (median age, 42.7 years). Of these, 39 (59%) were men, and 25 (38%) were women. In 34, only one site was involved. Common single sites were the axilla (29%), groin (24%), and neck (32%). Most of the melanomas (88%) were melanotic. Patients with localized melanoma surgically treated (n = 34) had a median survival of 53 months, and a 5-year survival rate of 45%. The respective rates for disseminated melanoma were 7 months and 10% (P = 0.00001). Localized, unknown primary melanoma should be treated with radical excision because a substantial proportion of patients so treated survive 5 years.

Prognostic factors in patients with melanoma metastatic to axillary or inguinal lymph nodes. A multivariate analysis

Although pathologic nodal status is a major determinant of outcome in melanoma, there is substantial prognostic heterogeneity among node-positive patients. This study was undertaken to further clarify significant variables predicting survival in patients with melanoma metastatic to axillary or groin nodes. From 1019 patients with melanoma undergoing axillary or groin dissection between 1974 and 1984, the authors identified 449 patients with histologically positive nodes. Both univariate and multivariate analyses were performed using the Kaplan-Meier product limit method and the Cox model of proportional hazard regression. The major determinant of survival was pathologic stage (PS) according to the 1983 AJCC staging system. Three hundred fifty patients (78%) were classified PS-III (one nodal group involved), with a survival of 39% at 5 years and 32% at 10 years. Factors independently predictive of a favorable outcome in these patients were nontruncal primary site (p = 0.0002), microscopic nodal involvement (p = 0.001), number of positive nodes less than three (p = 0.003), and absence of extranodal disease (p = 0.01). Ninety-nine patients (22%) were classified PS-IV, 51 with two nodal stations involved (N2), 25 with intransit disease and one nodal station involved (N2), 7 with extraregional soft tissue metastases (M1), and 16 with visceral metastases (M2). Survival for PS-IV patients was 9% at 5 and 10 years, respectively. Within PS-IV, factors independently predictive of a more favorable outcome were the absence of extranodal disease (p = 0.0001), female sex (p = 0.03), and a long interval from diagnosis to lymph node dissection (p = 0.04). These factors were incorporated into a model predicting relative risk of death from disease for both PS-III and PS-IV patients, separating patients into groups at high, intermediate, and low risk of recurrence after lymphadenectomy.

Axillary node dissection in malignant melanoma

Axillary node dissection was performed in 212 patients with malignant melanoma. For 212 initial dissections plus 49 repeat procedures (261 operations), wound infection occurred in 25 (10%) and arm edema in 10 (4%), with other complications being infrequent. The arm edema resolved promptly and completely six (2%) patients after elevation of the arm, while four (2%) patients have had permanent, moderate edema. The estimated 5-year survival rate for patients with clinically and histologically negative nodes was 74%. Among those with histologically positive nodes, when the nodes were not palpable, this rate was 73%; when the nodes were palpable and less than 2 cm in diameter, it was 46%; when they were palpable and 2 to 4 cm in diameter, it was 22%; when the nodes were larger than 4 cm in diameter, it was 18%; and when the nodes were fixed, it was 13%. The 5-year survival rate for 17 patients with positive nodes above the level of the axillary vein was 18%; 1 of 6 patients with resection of the axillary vein due to involvement is disease-free 57 months later. In patients who developed recurrence, further resection when feasible resulted in 13% of these patients being disease-free 5 years after the original axillary dissection.