Long-term cure after complete resection and adjuvant immunotherapy for distant melanoma metastases

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Background: In phase II trials, postoperative therapy with Canvaxin allogeneic melanoma cell vaccine plus Bacillus Calmette-Guerin (BCG) improved the survival of patients with stage IV melanoma. A multicenter, phase III placebo-controlled study was undertaken to investigate the vaccine’s efficacy. Methods: After complete resection of melanoma involving up to 5 distant sites, patients were randomized to treatment with BCG plus Canvaxin (BCG-Canvaxin) or BCG plus placebo (BCG-placebo). The primary endpoint was overall survival (OS); secondary endpoints were disease-free survival (DFS) and skin test responsiveness to the study agent. Results: Between May 1998 and April 2005, 496 patients were randomized. In April 2005, entry to the study was terminated due to low probability of demonstrating treatment differences. However, 256 patients from sites enrolled in a follow-up study were monitored until March 2010. Median OS and 5-year and 10-year rates of OS were 39.1 months, 43.3% and 33.3%, respectively, in the BCG-placebo group, versus 34.9 months, 42.5% and 36.4%, respectively, in the BCG-Canvaxin group (hazard ratio, 1.053; 95% confidence interval, 0.81 to 1.36; p=0.6964). Median DFS, 5-year DFS, and 10-year DFS were 7.6 months, 23.8% and 21.7%, respectively, for the BCG-placebo group, versus 8.5 months, 30.0%, and 30.0%, respectively, for the BCG-Canvaxin group (hazard ratio, 0.882; 95% confidence interval, 0.708 to 1.097; p=0.2595). Positive skin test results correlated with improved survival. Conclusions: BCG-Canvaxin was not superior to BCG-placebo, but the highly favorable long-term survival for combined groups indicates that complete metastasectomy should be considered as initial therapy for patients with resectable stage IV melanoma (ClinicalTrials.gov identifier: NCT00052156).

Radiation therapy for high grade soft tissue sarcomas of the extremities treated with limb-preserving surgery

AIM

It is common to use either pre- or post-operative radiation for high grade sarcomas undergoing limb-conserving surgery. Since 1977, we have adopted a selective policy of post-operative radiation, given only in patients with inadequate surgical margins.

METHODS

A retrospective review of 114 patients (1977-1995) with high grade adult soft tissue sarcomas of the extremities was carried out. Amputation was required in 10 (9%). Patients with a minimum surgical margin <2 cm (n=33) received adjuvant radiation (29%).

RESULTS

No complications occurred in 81/114. Wound complications were infection (14%), seroma (6%), haematoma (4%), dehiscence (4%) and skin edge necrosis (2%). Remedial operations were required in four (3%). Overall, the local recurrence rate was 23/114. Patients with surgery only (n=57) or surgery plus systemic chemotherapy (n=24) manifested local recurrence in 15/81 (19%) and those with surgery plus radiation (n=21) or surgery and radiation and chemotherapy (n=12) suffered local recurrence in 8/33. The local recurrence rate for tumours < or =5 cm was 6/32 and for those >5 cm 17/82, P=1.0. The 5 year survival rate was 60% for tumours < or =5 cm (n=32) and 46% for tumours > or =5 cm (n=82) (P=0.009).

CONCLUSIONS

(1) Limb preservation was feasible in 91% of patients. (2) When the local treatment modality was surgery alone ('wide' margins) the local recurrence rate was 19%, and when it was surgery plus radiation (narrow margins) it was 24%. (3) Selective use of radiation (in patients with narrow margins) and reliance on surgery alone in cases amenable to wide resection may be a legitimate alternative to universal application of radiation with conservative resection.

Study of antiangiogenic agents with possible therapeutic applications in neoplastic disorders and macular degeneration

Using a previously developed method (Ambrus, et al., 1991), we found that pentoxifylline and thalidomide potentiate each others antiangiogenic effect induced by human malignant melanoma cells in the cornea of Macaca arctoides monkeys.

Blood supply of hemipelvectomy flaps: the anterior flap hemipelvectomy

In posterior flap hemipelvectomy, preservation of the gluteus maximus with the flap guarantees its viability regardless of the level of ligation of the iliac vessels. In anterior flap hemipelvectomy with the quadriceps femoris attached to the flap, the dominant blood supply is through the lateral femoral circumflex branches of the profunda vessels, which is sufficient to maintain the flap.

Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1-4 mm melanomas

BACKGROUND

The Intergroup Melanoma Surgical Trial began in 1983 to examine the optimal surgical margins of excision for primary melanomas of intermediate thickness (i.e., 1-4 mm). There is now a median 10-year follow-up.

METHODS

There were two cohorts entered into a prospective multi-institutional trial: (1) 468 patients with melanomas on the trunk or proximal extremity who randomly received a 2 cm or 4 cm radial excision margin and (2) 272 patients with melanomas on the head, neck, or distal extremities who received a 2 cm radial excision margin.

RESULTS

A local recurrence (LR) was associated with a high mortality rate, with a 5-year survival rate of only 9% (as a first relapse) or 11% (anytime) compared with an 86% survival for those patients who did not have a LR (P < .0001). The 10-year survival for all patients with a LR was 5%. The 10-year survival rates were not significantly different when comparing 2 cm vs. 4 cm margins of excision (70% vs. 77%) or comparing the management of the regional lymph nodes (observation vs. elective node dissection). The incidences of LR were the same for patients having a 2 cm vs. 4 cm excision margin regardless of whether the comparisons were made as first relapse (0.4% vs. 0.9%) or at anytime (2.1% vs. 2.6%). When analyzed by anatomic site, the LR rates were 1.1% for melanomas arising on the proximal extremity, 3.1% for the trunk, 5.3% for the distal extremities, and 9.4% for the head and neck. The most profound influence on LR rates was the presence or absence of ulceration; it was 6.6% vs. 1.1% in the randomized group involving the trunk and proximal extremity and was 16.2% vs. 2.1% in the non-randomized group involving the distal extremity and head and neck (P < .001). A multivariate (Cox) regression analysis showed that ulceration was an adverse and independent factor (P = .0001) as was head and neck melanoma site (P = .01), while the remaining factors were not significant (all with P > .12).

CONCLUSION

For this group of melanoma patients, a local recurrence is associated with a high mortality rate, a 2-cm margin of excision is safe and ulceration of the primary melanoma is the most significant prognostic factor heralding an increased risk for a local recurrence.

Long-term prognostic significance of HSP-70, c-myc and HLA-DR expression in patients with malignant melanoma

AIM

Use of molecular markers indicative of the tumour oncogenic potential and host response may enhance our prognostic information for more effective treatment of melanoma patients. The roles of HSP-70 protein, c-myc oncogene and HLA-DR antigen expression were examined in melanoma patients and related to prognostic factors, recurrence rate and long-term survival.

METHODS

Forty patients with tumours thicker than 1 mm were included in this study. All had elective node dissection and were followed for at least 7 years. Twenty-two had microscopic nodal metastases. Both primary melanoma tumour and lymph nodes were examined for the immunohistochemical expression of HSP-70 protein, c-myc oncogene and HLA-DR antigen.

RESULTS

Eighteen patients had a recurrence (45%) and 23 patients survived overall (57.50%). Positive HSP-70 expression was observed in 52.50% of the primary melanomas and was associated with improved overall survival, especially in the patient group with tumours > or = 1.5 mm (70%vs 26.70%, P=0.0159). C-myc oncogene was overexpressed in 47.50% and HLA-DR antigen in 42.50% of the primary melanomas, but no correlation with survival was observed. The expression profile of these molecular markers in the primary tumour did not predict the status of regional nodes. HLA-DR expression in lymph nodes was observed exclusively in the nodal tissue surrounding the metastatic melanoma tumour in five patients.

CONCLUSIONS

The immunohistochemical expression profile of HSP-70 but not of c-myc oncogene or HLA-DR antigen in the primary melanoma tumour could be of certain value in the identification of patients with graver prognosis who may benefit from more aggressive therapeutic strategies.

The platysma muscle in neck dissection

Although the platysma muscle is usually preserved during neck dissection, removal of this muscle is generally considered inconsequential. The present case report shows that sacrifice of the cervical branch of the facial nerve innervating this muscle and removal of the platysma's upper portion impairs the caudal retraction and eversion of the ipsilateral half of the lower lip in grinning or laughing.

Abdominoinguinal incision and other incisions in the resection of pelvic tumors

In the past, sarcomas located in the iliac fossa, in the area over the external iliac vessels, or those in the lesser pelvis with fixation to the lateral wall, were inaccessible through the conventional abdominal incisions, mainly due to a lack of distal exposure. They were often called unresectable or were dealt with by an external hemipelvectomy. The abdominoinguinal incision provides exposure in one continuous field of the lower abdomen and the groin area on the side involved by the tumor, or bilaterally, if needed. It provides control of the vessels proximally and distally and easy identification of the femoral nerve lateral to the femoral artery. A simplified version in the form of an L or a reverse T through transection of the ipsilateral/bilateral rectus abdominis off the pubic crest provides a significantly improved exposure for low pelvic tumors in the midline. This affords the opportunity to perform under direct vision dissection in the area of the obturator nodes and obturator foramen, as well as exposure of the distal portion of the external iliac artery and vein. The technique of internal hemipelvectomy and sacral resection for tumors involving any part of the innominate bone or the sacrum, respectively, also amplify the surgical armamentarium in the resection of pelvic tumors with pelvic wall fixation. These incisions, although developed in the management of soft tissue sarcomas of the pelvis, are applicable for other histologic types of cancer when the biology and stage of the tumor are supportive of surgery for the pelvic disease.

Risk of basal cell and squamous cell carcinoma in persons with prior cutaneous melanoma

BACKGROUND

Melanoma has been associated with an overall increase in actinic tumors, including actinic keratoses, as well as with noncutaneous malignancies.

OBJECTIVE

Determine the risk of developing basal cell and squamous cell skin cancer in patients with prior cutaneous melanoma (actinic keratoses not encountered).

METHODS

This retrospective study included 1396 white patients with prior cutaneous melanoma followed at the Roswell Park Cancer Institute in the period 1977-1978. The control group was the white population of the Detroit area in the same period (1977-1978).

RESULTS

A total of 25 patients (18 males, 7 females) developed 35 basal cell and/or squamous cell carcinomas: 18 developed basal cell carcinomas, 2 squamous cell carcinomas, and 5 both. The calculated odds ratio was 3.49 (males 3.67, females 2.86, 95% confidence interval 1.52-8.00). No correlations were found with age, type, anatomic site, and length of follow-up of cutaneous melanoma.

CONCLUSION

A history of cutaneous melanoma significantly increases the risk of basal cell and squamous cell skin cancer.

Intravenous leiomyomatosis with cardiac extension: tumor thrombectomy through an abdominal approach

Intravenous leiomyomatosis is an uncommon vascular tumor that may be seen with potentially life-threatening symptoms resulting from intracardiac extension. This tumor is frequently misdiagnosed and treated without appropriate preoperative imaging and planning, which at times leads to inadequate treatment and incomplete resections. The appropriate therapy is complete excision of the tumor. We describe a patient who was treated with a new approach involving a single-stage operation without the need for median sternotomy, cardiopulmonary bypass graft, or hypothermic arrest by resection of the tumor from the point of attachment in the abdominal portion of the inferior vena cava.

Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0 to 4.0 mm). Intergroup Melanoma Surgical Trial

BACKGROUND

Ten- to 15-year survival results were analyzed from a prospective multi-institutional randomized surgical trial that involved 740 stages I and II melanoma patients with intermediate thickness melanomas (1.0 to 4.0 mm) and compared elective (immediate) lymph node dissection (ELND) with clinical observation of the lymph nodes as well as prognostic factors that independently predict outcomes.

METHODS

Eligible patients were stratified according to tumor thickness, anatomical site, and ulceration, and then prerandomized to either ELND or nodal observation. By using Cox stepwise multivariate regression analysis, the independent predictors of outcome were tumor thickness (P < .001), the presence of tumor ulceration (P < .001), trunk site (P = .003), and patient age more than 60 years (P = .01).

RESULTS

Overall 10-year survival was not significantly different for patients who received ELND or nodal observation (77% vs. 73%; P = .12). Among the prospectively stratified subgroups of patients, 10-year survival rates favored those patients with ELND, with a 30% reduction in mortality rate for the 543 patients with nonulcerated melanomas (84% vs. 77%; P = .03), a 30% reduction in mortality rate for the 446 patients with tumor thickness of 1.0 to 2.0 mm (86% vs. 80%; P = .03), and a 27% reduction in mortality rate for 385 patients with limb melanomas (84% vs. 78%; P = .05). Of these subgroups, the presence or absence of ulceration should be the key factor for making treatment recommendations with regard to ELND for patients with intermediate thickness melanomas.

CONCLUSIONS

These long-term survival rates from patients treated at 77 institutions demonstrate that ulceration and tumor thickness are dominant predictive factors that should be used in the staging of stages I and II melanomas, and confer a survival advantage for these subgroups of prospectively defined melanoma patients.

Sentinel node biopsy before and after wide excision of the primary melanoma

BACKGROUND

Initially, the technique of sentinel node biopsy involved the use of blue dye alone and was later supplemented with the use of an intraoperative probe after radiocolloid injection near the melanoma site. Ideally, it should be done before wide excision. To our knowledge, there is no information in the literature regarding the applicability or reliability of this technique after wide excision.

METHODS

We conducted a retrospective review of 142 patients (1993-1999) with melanomas > or =1.0 mm or Clark's level > or =IV. Of these, 116 patients had prior biopsy only, and 26 had wide excision. The mean melanoma thickness was 2.5 mm. The location of the primary lesion was in the upper extremity in 42 patients, the lower extremity in 33, the trunk in 49, and the head and neck area in 18.

RESULTS

The sentinel node was identified in 88 (93%) of 95 nodal basins using the blue dye alone and in 65 (98.5%) of 66 basins using dye plus probe. The sentinel node was positive in 35 (25%) of the 142 patients and 38 (24%) of the 161 nodal basins. In a mean follow-up of 30 months of 115 basins with negative sentinel nodes, 3 (3%) later developed a palpable positive node in the same basin. In the group of dye alone, the sentinel node was identified in 40 (100%) of 40 extremity primaries and in 48 (87%) of 55 trunk and head and neck primary lesions (P = .02). Nine (35%) of the 26 patients with previous wide excision (25 with primary closure or skin graft, 1 with flap rotation) and 10 (32%) of 31 of nodal basins had a positive node; in 8 of the 9 patients, the positive node was also the sentinel node. The only patient with a positive node incidentally removed along with a histologically negative sentinel node was the one with a previous wide excision and flap rotation.

CONCLUSIONS

Previous wide excision of the melanoma does not appear to negate the reliability of sentinel node biopsy, provided that no flap rotation was used to cover the defect.

Thoracoabdominal incisions and resection of upper retroperitoneal sarcomas

BACKGROUND AND OBJECTIVES

There is a widespread impression among surgeons that a thoracoabdominal incision carries a substantially higher risk of morbidity and possible mortality over abdominal incisions. We decided therefore to critically review our experience of the last 4 years with these incisions.

METHODS

This is a retrospective review of all cases of retroperitoneal sarcomas of upper abdominal quadrants in the period May 1995 through February 1999. There were 33 consecutive patients and 34 thoracoabdominal incisions (1 patient had a second operation for recurrence). Their mean age was 54 years, with 13 >60 and 7 >70 years.

RESULTS

Eighteen patients were extubated immediately at the end of the procedure and the rest within 24 h. In the majority of instances (32 of 34 or 94%), the patients left the intensive care unit within 48 h. The most common postoperative complication was atelectasis (7 of 34, 21%). There was no postoperative death. The retroperitoneal tumor was resected in all 34 cases (100%).

CONCLUSIONS

The thoracoabdominal incision for upper quadrant retroperitoneal sarcomas is tolerated well by the patients with a morbidity similar to that observed after routine abdominal incisions. It allows complete resection of the tumor in most (all in this series) cases.

Desmoid tumour: a pleomorphic lesion

BACKGROUND

Desmoid tumour (DT) is an uncommon locally invasive non-metastasizing neoplastic lesion. The aetiology of this tumour is unknown and its treatment is controversial. Twelve cases of DT are presented and the literature is reviewed.

METHODS

Twelve cases of DT treated at our institution during a 3.5-year period are analysed and the literature reviewed. Ten patients were referred with a primary tumour, one with local recurrence and one patient with a second primary desmoid tumour. One patient had multiple mesenteric DT (familial adenomatous polyposis coli-FAP), and in the remaining 11 patients the tumour was located in the abdominal wall in four, at an extremity in three, in the upper back in two patients, in the pelvis in one and retroperitoneally in one.

RESULTS

The largest mesenteric DT was marginally excised en bloc with total jejunectomy. In the remaining 11 DT, complete excision to microscopically tumour-free margins was possible in nine cases and to microscopically involved margins in two cases. At a mean follow-up of 22 months (range 7-38 months), one patient was alive with stable disease (Gardner's syndrome), 10 patients were alive and free of recurrence and one patient (9%) developed local recurrence which was re-excised-she is disease-free 10 months later.

CONCLUSIONS

Complete excision is the main modality of treatment for primary and recurrent DT. This is feasible in most cases except for tumours involving the base of the bowel mesentery. Surgical resection alone achieved local control of the tumour in most of the patients in this series (92%).

Validation of the accuracy of intraoperative lymphatic mapping and sentinel lymphadenectomy for early-stage melanoma: a multicenter trial. Multicenter Selective Lymphadenectomy Trial Group

OBJECTIVE

To evaluate the multicenter application of intraoperative lymphatic mapping, sentinel lymphadenectomy, and selective complete lymph node dissection (LM/SL/SCLND) for the management of early-stage melanoma.

SUMMARY BACKGROUND DATA

The multidisciplinary technique of LM/SL/SCLND has been widely adopted, but not validated in a multicenter trial. The authors began the international Multicenter Selective Lymphadenectomy Trial (MSLT) 5 years ago to evaluate the survival of patients with early-stage primary melanoma after wide excision alone versus wide excision plus LM/SL/SCLND. This study examined the accuracy of LM/SL/SCLND in the MSLT, using the experience of the organizing center (John Wayne Cancer Institute [JWCI]) as a standard for comparison.

METHODS

Before entering patients into the randomization phase, each center in the MSLT was required to finish a 30-case learning phase with complete nuclear medicine, pathology, and surgical review. Selection of MSLT patients in the LM/SL/SCLND treatment arm was based on complete pathologic and surgical data. The comparison group of JWCI patients was selected using these criteria: primary cutaneous melanoma having a thickness > or =1 mm with a Clark level > or =III, or a thickness <1 mm with a Clark level > or =IV (MSLT criterion); LM/SL performed between June 1, 1985, and December 30, 1998; and patient not entered in the MSLT. The accuracy of LM/SL/SCLND was determined by comparing the rates of sentinel node (SN) identification and the incidence of SN metastases in the MSLT and JWCI groups.

RESULTS

There were 551 patients in the MSLT group and 584 patients in the JWCI group. In both groups, LM performed with blue dye plus a radiocolloid was more successful (99.1 %) than LM performed with blue dye alone (95.2%) (p = 0.014). After a center had completed the 30-case learning phase, the success of SN identification in the MSLT group was independent of the center's case volume or experience in the MSLT.

CONCLUSIONS

Lymphatic mapping and sentinel lymphadenectomy can be successfully learned and applied in a standardized fashion with high accuracy by centers worldwide. Successful SN identification rates of 97% can be achieved, and the incidence of nodal metastases approaches that of the organizing center. A multidisciplinary approach (surgery, nuclear medicine, and pathology) and a learning phase of > or =30 consecutive cases per center are sufficient for mastery of LM/SL in cutaneous melanoma. Lymphatic mapping performed using blue dye plus radiocolloid is superior to LM using blue dye alone.

Primary malignant melanoma of the esophagus: report of two cases and review of the literature

We reported two cases of primary malignant melanoma of the esophagus, treated with interpositioning of the left colon subcutaneously over the sternum. We also reviewed the world literature on this rare but fatal disease.

Treatment and local control of primary extremity soft tissue sarcomas

BACKGROUND AND OBJECTIVES

Modern series of adult extremity soft tissue sarcomas utilize combinations of modalities in all patients. Remaining questions: 1) is it necessary to strive for wide margins in the multimodality era; 2) to use adjuvant therapy in every high-grade sarcoma? 3) Does previous partial or marginal resection seriously interfere with the definitive resection?

METHODS

In a retrospective review of 194 extremity soft tissue sarcomas (1977-1994), limb preservation was possible in 181/194 (93%) of cases. Patients with narrow margins received adjuvant radiation. Some patients were referred after partial (n = 39) or "complete" (n = 63) excision.

RESULTS

Local recurrence was observed in 181/141 (13%) of patients treated with wide or compartmental resection, and in 10 of 42 (24%) of those treated with conservative resection plus radiation (P = 0.14). The 5-year survival rate for grade III, >/=5-cm sarcomas was not significantly different (P = 0.82) with adjuvant (46%) or without (48%) adjuvant systemic chemotherapy. Five-year survival varied (P = 0.0001) according to grade. Patients referred with partial, or "complete" (63%, 38/63, had residual tumor at reoperation) excision had a local recurrence rate of 8% and 6%, and 5-year survival rates of 75% and 84%, respectively.

CONCLUSIONS

1) It is important to strive for wide margins even when adjuvant radiation is intended. 2) When a wide margin is possible, adjuvant radiation may not be necessary. 3) Adjuvant systemic chemotherapy may be considered for high-grade tumors, preferably within a prospective protocol. 4) A partial or "complete" excision of the tumor before referral to a tertiary center does not appear to compromise the limb preservation, local control, or survival rates of these patients.

Repair after radical groin dissection

The above-described repair following ilioinguinal dissection with division of the inguinal ligament is essentially a Cooper's ligament repair providing a secure, durable reconstruction. In our experience, there has not been a case of incisional hernia after radical incontinuity groin dissection using the above reconstruction.

Long-term survival of a female patient with primary malignant melanoma of the urethra

Primary malignant melanoma of the female urethra comprises 0.2% of all melanomas and has poor prognosis. In the period 1972-1992, 75 cases of primary urethra carcinomas were treated at the Roswell Park Cancer Institute. Among them, only an 80-year-old woman was diagnosed with primary malignant melanoma. Despite conservative treatment, she lived for 7 years. We believe that local surgical excision can be an option for treatment in selected patients as it retains quality of life.

The abdominoinguinal incision: the equivalent of thoracoabdominal incision for the lower quadrants of the abdomen

In the past, tumors of the iliac fossa, those of the area of the external iliac vessels, and those fixed to the wall of the lesser pelvis with extension into and involvement of the pubic bone were often considered unresectable through the conventional surgical incisions or were treated with hemipelvectomy. For such tumors, although there was exposure of the cephalad aspect through routine incisions, there was lack of exposure on the caudal or lateral aspects, which often extended anteriorly to involve the lower abdominal wall or continued behind the inguinal ligament or through the obturator foramen into the thigh. The abdominoinguinal incision provides exposure for resection of the majority of these tumors with preservation of the extremity. It involves a lower midline incision, which is extended from the pubic symphysis transversely to the midinguinal point on the affected side and then vertically for a few centimeters in the femoral triangle. The femoral vessels are exposed, the ipsilateral rectus abdominis and anterior sheath are divided off the pubic crest, the inguinal ligament is divided off the pubic tubercle, the inferior epigastric vessels are ligated and divided near their origin from the vessels, and the lateral third of the inguinal ligament is detached from the iliac fascia. This incision provides full exposure of the lower abdominal aorta, inferior vena cava, and iliac vessels on the side of involvement in their continuity with the femoral vessels. With improved exposure and vascular control, the majority of tumors with lateral pelvic fixation become resectable.

Abdominoinguinal incision in adenocarcinoma of the sigmoid or cecum: report of two cases

PURPOSE

This study illustrates a technique allowing resection of a sigmoid adenocarcinoma with lateral fixation and a cecal adenocarcinoma with involvement of the psoas muscle and ureter.

METHODS

The abdominoinguinal incision, an incision used in the resection of a sarcoma of the lower abdominal quadrants, was applied in the case of a sigmoid adenocarcinoma with posterolateral fixation and infiltration of the anterior abdominal wall and in a case of a cecal adenocarcinoma involving the right psoas muscle and ureter.

RESULTS

In the first case, resection of the tumor mass en bloc with resection of the sigmoid and lower anterior abdominal wall muscles, including the inguinal ligament, was performed. Reconstruction of the muscular fascial defect was done with the rotation of a right rectus abdominis flap. The patient was well 12 months later. In the second case, the cecal carcinoma was resected en bloc with the right psoas and ureter; a right nephrectomy was also performed. This patient was well eight months later.

CONCLUSIONS

The abdominoinguinal incision may provide the exposure needed to allow the resection of a sigmoid or a cecal adenocarcinoma with posterolateral fixation, often considered unresectable with conventional abdominal incisions.

Distant skin and soft tissue metastases from sarcomas

BACKGROUND AND OBJECTIVES

This small series documents the clinical and pathological features and the rarity of distant skin and soft tissue metastases from sarcomas.

MATERIALS AND METHODS

Five cases of sarcomas from different anatomical locations that had metastasized to skin and subcutaneous soft tissue were identified in three women and two men. The age range was 41-77 years. The primary tumors had wide excisions, followed by either radiation or chemotherapy, or both. The histological types were epithelioid sarcoma, malignant fibrous histiocytoma, malignant peripheral nerve sheath tumor, and leiomyosarcoma. Metastases occurred to the skin and soft tissue of the chest wall, leg, breast, and abdominal wall. The diagnosis was established by excision biopsies for three cases and by needle biopsy and fine-needle aspiration for two cases.

RESULTS

Three patients died within 7 months of the diagnosis of soft tissue metastases that were always histologically high grade and never solitary. One patient is alive with lung metastasis discovered 17 months after excision of primary. Lung metastases occurred either simultaneously or within a short period after soft tissue metastases.

CONCLUSION

Distant skin and soft tissue metastases from sarcomas are very rare and often occur as a terminal event.

Is the capacity for lymph node-mediated distant dissemination the same for all nodal groups in malignant melanoma?

This study addresses two hypotheses: (1) that the inherent potential of melanoma metastatic to regional nodal groups for lymph-mediated distant dissemination may not be the same for all nodal groups; and (2) that the risk of distant metastases in patients with clinically involved nodal metastases is higher than in patients with clinically occult nodal metastases. It involved a retrospective chart review of patients with histologically involved axillary or inguinal nodes treated at Roswell Park Cancer Institute (RPCI) (244 patients) or at the participating institutes from the Intergroup Surgical Trial (IST) (108 patients). The distant recurrence rates of 623 melanomas with axillary or inguinal drainage from the IST data were also reviewed. In the RPCI data there was a significant difference in the overall and disease-free survival (P=0.0001) between patients with microscopic versus palpable involvement of the regional nodes in the axilla, while no such difference was observed for patients with groin metastases (P=0.30 and 0.36, respectively). The same trend was noted in the IST data. In the latter data the distant recurrence rate for melanomas drained via the axilla was significantly higher (P=0.026) than for those drained by the groin. In conclusion, lymph-mediated distant dissemination may be more aggressive from the axilla than from the groin in melanoma.

Richter hernia of the stomach

A case report is presented of Richter hernia of the stomach, after en bloc excision of multiple organs for sarcoma of the left upper quadrant of the abdomen. To our knowledge this is the first case reported in the literature. The conditions for the development of this hernia are : (1) the freeing of the greater curvature of the stomach (following removal of the spleen and tail of the pancreas); and (2) fascial dehiscence following a left thoracoabdominal incision involving rib resection.

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.

Anterior compartment resection of the thigh in soft-tissue sarcomas

AIMS

Soft-tissue sarcomas of the anterior thigh present technical problems due to the proximity of the femoral vessels, and the disability caused by a standard anterior compartment resection.

METHODS

We treated 44 consecutive patients with primary sarcomas in the anterior thigh with wide resection (n = 15), and modified (n = 26) or standard (n = 3) compartment resection. No patient had amputation as primary treatment.

RESULTS

The overall rate of local recurrence was 6/44 (14%). Local recurrence was observed in 1/3 patients with standard anterior compartment resection and 5/41 (12%) of those with wide excision or modified compartment resection. It was noted in 1/6 (17%) patients with adjuvant radiation and 5/38 (13%) of those treated with surgery alone. One of six patients with local recurrence required amputation. The 5-year survival rate was 66% varying significantly according to grade.

CONCLUSIONS

Limb preservation was possible in 98% of patients. Wide resection or modified compartment resection was feasible in the majority (93%) of patients resulting in improved function.

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.

Soft tissue sarcomas of the hand and foot: management and survival

BACKGROUND

Soft tissue sarcomas of the hands and feet present a challenge for limb-preserving resections.

METHODS

A retrospective review of 19 patients with sarcomas of the hand or foot was done. Wide or local excision was performed in 14 patients (74%), and amputation in 5 patients (26%). Of the latter group, three amputations involved a digit or toe, and two (10%) were major amputations (one Syme amputation and one below-knee amputation). When the minimum surgical margin was narrow (1 to 2 mm), adjuvant radiation was given postoperatively (n = 4).

RESULTS

Local recurrence was observed in four patients (21%). Two of these required an amputation for local control. Local recurrence was observed in one of four patients (25%) treated with marginal resection and radiation and three of 15 (20%) of those with resection alone.

CONCLUSIONS

A sizable percentage (37%) of patients with soft tissue sarcomas of the hand and foot ultimately required an amputation, although often the amputation was a minor one involving only a toe or a digit. Limb preservation was successful in the majority of patients (63%). The local recurrence rate was 21%, which may be improved with more frequent use of adjuvant therapy. The 5-year survival rate was 82%, which is better than that usually quoted for overall extremity soft tissue sarcomas.

Molecular oncogene markers and their significance in cutaneous malignant melanoma

BACKGROUND

Oncogenes and other molecular tumor markers that predict tumor aggressiveness may allow individualization and optimization of surgical therapy of intermediate-thickness malignant melanoma. We examined the expression of selected markers, including the HLA-DR antigen, the heat shock protein-70 (HSP-70), and the c-myc oncogene in primary melanoma and regional nodes and related these findings to metastatic potential and survival.

METHODS

Forty patients with primary melanoma (1.5-4.0 mm) were studied, all of whom had prophylactic lymph node dissection and were followed for 18 months to 7 years. The primary tissue and nodes were examined using immunohistochemical techniques for the presence of HLA-DR antigen and HSP-70 protein and the expression of the c-myc oncogene.

RESULTS

Of 40 patients, there were 23 with lesions 1 to 2.9 mm thick and 17 with lesions 3 to 4 mm thick. Nodal metastases were present in 25 of the 40 patients who had elective node dissection. HLA-DR antibody stained the primary tumor in 10 patients (25%), but there was no correlation with survival in this group. HLA-DR antibody stained the stroma and cellular infiltrates surrounding the primary tumor in 28 of 40 patients; in this group there was a correlation of HLA-DR staining of the peritumoral stroma with improved survival overall. HLA-DR staining of the peritumoral stroma also influenced survival when patients were stratified by tumor thickness groups 1 to 2.9 mm and 3 to 4 mm and presence of nodal metastases. HSP-70 was demonstrated in the primary tumor in 25% of patients, who were also shown to have significantly improved survival when compared with those whose primary tumor did not stain with HSP-70. C-myc was expressed in the primary tumor in 25%, but showed no correlation with survival. None of these proteins correlated with or predicted the presence of nodal metastases.

CONCLUSION

We conclude that the use of specific molecular-oncogene markers in intermediate-thickness primary melanoma may identify patients at high risk for conventional treatment failure and reduced survival who may profit from more aggressive surgery, adjuvant therapy, or both.

Sarcomas near extremity joints in adults

BACKGROUND AND OBJECTIVES

There are technical difficulties in resecting soft tissue sarcomas extending to or crossing a joint. The objective of this study was to determine the rate of amputation and local recurrence rate for these sarcomas and compare them with the respective rates for overall extremity sarcomas.

METHODS

Retrospective review of 78 patients with sarcoma near a joint compared with 215 patients with extremity sarcomas accrued during the same period, 1977-1994. Of these 78 patients, 64 were in the lower and 14 in the upper extremity. Most common histologic subtypes were malignant fibrous histiocytoma (15/78, 19%), synovial sarcoma (11/78, 14%), liposarcoma (11/78, 14%), and leiomyosarcoma (10/78, 13%). The surgical treatment consisted of local excision in 10 (13%), wide excision in 56 (72%), and amputation in 12 (15%). Adjuvant radiation was given to 26 patients.

RESULTS

Local recurrence was noted in 20% (16/78) patients. The incidence of local recurrence in the surgery alone group (n = 52) was 15% (8/52) and in the surgery plus adjuvant radiation group (n = 26) it was 31% (8/26); P = 0.11. Of the 16 patients with local recurrence, 9 (56%) required amputation. The 5-year and 10-year survival rates for the entire group of patients were 68% and 60% respectively. On multivariate analysis survival varied according to grade (P = 0.05) and tumor size (P = 0.02).

CONCLUSIONS

Amputation was finally required in 27% (21/78) for local control of the disease. The local recurrence rate was 20%. These rates appear to be somewhat higher than those reported in our overall extremity sarcoma series and those in most modern series of overall extremity sarcomas, but the 5- and 10-year survival rates are similar to those of the latter.

Intraperitoneal chemotherapy in disseminated abdominal sarcoma

BACKGROUND

There is no information in the literature concerning the use of cytoreductive surgery with intraperitoneal chemotherapy for sarcomas disseminated intraabdominally.

METHODS

A prospective study was initiated of exploratory laparotomy, removal of all macroscopic tumor when feasible, and intraperitoneal chemotherapy with cis-DDP 100 mg/m2 every 4 weeks. Patients were to be explored in 6 months or earlier for detectable tumor recurrence. Twenty-eight consecutive patients enrolled in the study.

RESULTS

Complete resection of all macroscopic tumor was possible in 79% of patients. Survival rates at years 1-5 were 54%, 21%, 7%, 7%, and 7%, respectively. Of the two long-term survivors, one was found to be disease free at the second-look operation with a catheter free of adhesions, whereas the other had recurrent disease and all her lesions were resected. Of 20 patients who underwent a second-look procedure, the Tenkhoff intraperitoneal catheter was found to be densely surrounded by adhesions in 19. In the 19 patients with adhesions, there was no tumor around the catheter for a radius of 15-20 cm, but the rest of the peritoneal cavity contained multiple tumor nodules.

CONCLUSION

Removal of all macroscopic tumor is possible in 79% of the patients with sarcoma disseminated in the abdominal cavity. Intraperitoneal chemotherapy with cis-DDP after cytoreductive surgery resulted in a 5-year survival rate of only 7%.

Tourniquet infusion chemotherapy for extremity in-transit lesions in malignant melanoma

BACKGROUND

Perfusion remains the standard of regional chemotherapy for extremity in-transit lesions from melanoma. However, there is an interest in other forms of intraarterial chemotherapy due to the simplicity and feasibility of repeat administration of the latter.

METHODS

Review of 51 patients with extremity in-transit lesions from melanoma treated with the tourniquet infusion (TI) method on the basis of a prospective protocol. Drugs used were either Adriamycin (group A) or Dacarbazine (DTIC) + cisDDP (group B). The median number of courses was two. Lesions were resected at the same time as TI (n = 27) or after a month or more of observation in the absence of complete regression.

RESULTS

There was no significant difference in response rates between groups A and B. The overall objective response rate in 24 evaluable patients was 75%, being complete in seven (29%), partial (> 50%) in 11 (46%), minor (< 50%) in three (12.5%), and progression of disease in three (12.5%). At a mean follow-up time of 40 months, no recurrence was observed in the treated extremity in 18 patients (35%), but further recurrences were noted in 31 patients (61%). The 5-year survival rate was 30%.

CONCLUSION

TI provides an objective response rate of 75% for in-transit lesions, but after TI and resection of in-transit lesions as needed, the recurrence rate in the treated extremity is high (61%). Further work is needed with higher drug doses, local hyperthermia, or the administration of suitable doses of new regimens that are more successful with perfusion.

Round cell liposarcoma with the insertion (12;16)(q13;p11.2p13)

Cytogenetic analysis of a short-term culture from a round cell liposarcoma revealed ins(12;16)(q13;p11.2p13) as a sole abnormality in all metaphase cells studied. This chromosome rearrangement, thus far not described in liposarcomas, leads to recombination of bands 12q13 and 16p11.2 and, thus, seems to be the equivalent of t(12;16)(q13;p11), a translocation that is highly specific for the myxoid type of liposarcoma. Our case represents the fourth fully karyotyped round cell liposarcoma that displays a cytogenetic rearrangement of bands 12q13 and 16p11, thus supporting the concept that round cell liposarcoma is related to myxoid liposarcoma and constitutes its poorly differentiated form. The fact that ins(12;16) was the only detectable chromosome aberration suggests that the presence of secondary cytogenetic aberrations is not a prerequisite for the development of a round cell histology in liposarcoma.

Leiomyosarcoma of the inferior vena cava: a clinicopathologic review and report of three cases

BACKGROUND AND OBJECTIVES

We operated on three patients with leiomyosarcoma of the inferior vena cava.

METHODS

Complete excision was possible in all three patients.

RESULTS

One patient developed widespread metastasis at 23 months, one patient is alive with no evidence of disease at 70 months, and one patient is alive at 15 months. The third patient had subcutaneous and pulmonary metastases at the time of presentation, which are radiologically nondetectable at present following postoperative chemotherapy.

CONCLUSIONS

The clinicopathologic features, prognostic factors, and treatment of 130 cases found in a comprehensive literature search and our three cases are reported.

Forequarter amputation with fasciocutaneous deltoid flap reconstruction for malignant tumors of the upper extremity

BACKGROUND

Malignant tumors of the upper extremity involving a considerable portion of the medial axillary wall may require forequarter amputation to achieve gross resection of tumor. These resections frequently leave a large defect, often requiring a split thickness skin graft or free flap to close the wound. To address this problem of wound closure, we have modified our technique and devised a reconstructive component as part of our forequarter amputation procedure.

METHODS

The medical records of seven patients who underwent forequarter amputation and fasciocutaneous deltoid flap reconstruction between 1982 and 1994 were reviewed.

RESULTS

All the amputation sites were completely closed with a fasciocutaneous deltoid flap without the use of additional skin grafts or free flaps. After a median follow-up of 12 months, there were no local recurrences. Three patients (43%) are alive and disease free 5, 12, and 19 months after their forequarter amputation. One patient is alive with disease after 14 months. The remaining three patients died of their disease.

CONCLUSION

The fasciocutaneous deltoid flap is technically easy to perform, provides wound coverage without the use of skin grafts, and is especially useful for tumors involving the media axillary wall and in patients with previous axillary radiation.

Surgical treatment of malignant melanoma

The surgical treatment of the primary melanoma site has been made more rational through correlations of rates of local control with various margins of resection in the context of the dominant prognostic indicator for localized melanoma, the thickness of the primary lesion. It is now known that for lesions less than 1 mm in thickness, a 1-cm margin is satisfactory. For lesions 1 to 4 mm thick, a 2-cm margin is adequate according to the results of a multi-institutional, randomized, surgical trial. Lesions thicker than 4 mm should be treated with a margin larger than 2 cm where the anatomy permits, although the main concern for these lesions is their high propensity for distant dissemination. Elective dissection has not been shown to alter survival significantly in prospective randomized trials. Surgical treatment of distant metastases is indicated for the palliation of a symptomatic lesion, for example, solitary brain metastasis or gastrointestinal metastases.

Local recurrence in malignant melanoma: long-term results of the multiinstitutional randomized surgical trial

BACKGROUND

In the past, radical margins of excision were prescribed for cutaneous melanoma based on preconceived notions rather than on hard clinical evidence.

METHODS

In a prospective study of 742 patients with intermediate-thickness melanoma (1-4 mm), 470 patients with trunk or proximal extremity lesions were randomized into a 2- or 4-cm margin. Patients with distal extremity or head and neck lesions (n = 272) received uniformly a 2-cm margin.

RESULTS

The overall rate of local recurrence was 3.8%. This rate in the randomized portion (n = 470) was 2.1% for the 2-cm margin and 2.6% for the 4-cm margin (p = 0.72). A progressive increase in local recurrence rates was observed with thickness: 2.3% for lesions 1.0-2.0 mm, 4.2% for those 2.01-3.0 mm, and 11.7% for those 3.01-4.0 mm thick (p = 0.001). Local recurrence occurred in 1.5% of those without ulceration and in 10.6% of those with ulceration of the primary lesion (p = 0.001). The local recurrence rate was not significantly affected by the margin of resection even among the thicker or ulcerated lesions. It also was not affected significantly by the method of closure of the primary site or management of the regional nodes, or the age or gender of the patients.

CONCLUSIONS

A 2-cm margin is as effective as a 4-cm margin in local control and survival of intermediate-thickness melanomas. The local recurrence rate is significantly affected by the thickness of the primary lesion and the presence or not of ulceration.