Cutaneous Malignant Melanoma

Cutaneous malignant melanoma occurs in three forms: lentigo maligna melanoma, superficially spreading melanoma, and nodular melanoma. The histology, the clinical development and the biological malignancy of these tumours differ. The purpose of the study reported here was to provide a clearer picture of the surface morphology of the malignant cells and to relate their fine structure to both the tumour type and the clinical development of the malignant melanoma. This investigation of 28 tumours from 22 patients of Scandinavian origin shows that at the electron microscope level there is no difference between malignant cells in the invasion nodulus of superficially spreading melanoma and nodular melanoma. The primary tumours were often built up of 2 or 3 differently differentiated cell clones. Metastases were built up of the same cells or cell clones that were found in the primary tumour. In several cases the surface of the malignant cells was folded, and covered with microvilli, microblebs and blebs. These surface alterations could be related in several cases to changes in the cytoskeleton of the cell (microtubuli and microfilament complexes). The clinical course of the malignant melanoma could best be correlated to the histogenetic type of tumour, depth of invasion, nucleus polymorphy and the quantity and arrangement of the microfilament complexes.     

Surgery for Abdominal Metastases of Cutaneous Melanoma

The objective of this study was to support our hypothesis that surgical resection of abdominal metastases of melanoma, regardless of symptomatology, could provide prolonged palliation and improved survival. We performed a retrospective chart review at M.D. Anderson Cancer Center. A series of 251 melanoma patients (stages I, II, or III at registration) who developed intraabdominal metastases during follow-up were studied. Altogether, 96 patients underwent 119 laparotomies; 51 underwent endoscopic or percutaneous procedures; and 116 patients were treated medically. Surgery was associated with a median survival of 11 months, significantly longer than that with other treatment (p < 0.001). Tumor was extirpated during 37% of the first laparotomies, and in an additional 33% very good palliation was achieved with incomplete resection. Tumor extirpation was associated with 10-month symptom-free survival (SFS), significantly longer than that with any other approach (p < 0.0001). In the nonsurgically treated patients, good palliation was achieved in 8% to 17% of patients with no complete response. The median SFS after surgery was 5 months, but 23% of patients were symptom-free more than 12 months; 87 patients with minimal symptoms; and 72 severely symptomatic patients underwent surgery. Complete resection was feasible in 42% and 34%, respectively. Surgery was associated with 12 months median survival in both groups. There was a significant survival benefit from surgery in patients with gastrointestinal (GI) tract metastases in contrast to those who had non-GI metastases. For the 96 surgically treated patients, a time interval of more than 4 years between diagnosis of the primary lesion and the abdominal recurrence predicted decreased risk of death (p= 0.038). The 30-day postoperative complication and mortality rates were 19.0% and 3.3%, respectively. Complete surgical resection of melanoma metastases in the abdomen is associated with median and symptom-free survival benefits. Symptomatic and asymptomatic patients benefit equally, especially if abdominal metastases appear more than 4 years after the initial diagnosis and do not involve non-GI viscera. Less than complete resection can provide durable palliation.     

Malignant Clival Chordoma with Postoperative Cutaneous Metastases

The authors report the case of a chordoma with malignant cytologic features, presenting as a mass lesion in the clival and infratemporal region at the level of the craniocervical junction in an 8-year-old female. Following gross resection of the mass, the patient subsequently developed distant subcutaneous and peritoneal metastases from the lesion. The rare histologic features, the surgical approach to the lesion, and the follow-up management of this unique case are discussed.     

Locoregional Lymphadenectomy in the Surgical Management of Anorectal Melanoma

Background

The effect of lymph node metastasis on local tumor control and distant failure in patients with anorectal melanoma has not been fully studied. Understanding the significance of lymphatic dissemination might assist in stratifying patients for either organ preservation or radical surgery.

Methods

A retrospective review of all patients with anorectal melanoma who underwent surgery at our institution between 1985 and 2010. Abdominoperineal resection (APR) was performed in 25 patients (39 %), and wide local excision (WLE) in 40 (61%). Extent of primary surgery and locoregional lymphadenectomy (mesorectal vs. inguinal vs. none) and pattern of treatment failure were analyzed. Recurrence-free survival (RFS) and disease-specific survival (DSS) were calculated.

Results

In patients undergoing APR, DSS was not associated with presence (29 %) or absence (71 %) of metastatic melanoma in mesorectal lymph nodes. There was a trend toward improved DSS in patients with clinically negative inguinal lymph nodes (n = 17) compared with patients with proven inguinal metastasis (n = 6; P = 0.12). Type of surgery (WLE vs. APR) was not associated with subsequent development of distant disease. Twelve patients (18 %) had synchronous local and distant recurrence. Synchronous recurrence was not associated with surgical strategy used to treat primary tumor (P = 0.28). Perineural invasion (PNI) was significantly correlated with RFS (P = 0.002).

Conclusions

Outcome following resection of anorectal melanoma is independent of locoregional lymph node metastasis; lymphadenectomy should be reserved for gross symptomatic disease. PNI is a powerful prognostic marker warranting further exploration in clinical trials.     

Gastrointestinal Metastases from Malignant Melanoma: Report of a Case

Malignant melanoma metastases in the gastrointestinal tract (GIT) are found in more than 60% of autopsies on patients who have died with disseminated melanoma; however, the rate of GIT metastases detected clinically averages only 2%. This discrepancy seems to be attributed to the nonspecific symptoms and signs of GIT involvement, which include weakness, fatigue, bleeding, anemia, and abdominal pain. Sometimes a diagnosis is only made when bowel obstruction occurs. We report a case of long-term survival after surgery for multiple melanoma metastases in the gastrointestinal tract and review the relevant literature. Both our case report and the literature review demonstrate the benefits of surgery for patients with melanoma metastases in the GIT. We also stress the need for meticulous follow-up, detailed history-taking, and rapid evaluation of any vague and unclear abdominal signs and symptoms for patients with melanoma.     

Prognosis and Determinants of Outcome Following Locoregional or Distant Recurrence in Patients with Cutaneous Melanoma

Objective Information on prognosis for patients with cutaneous melanoma after locoregional or distant recurrence is sparse and controversial. The aim of this study was to analyze factors influencing outcome after the development of a first relapse. Methods Information was extracted from the Sydney Melanoma Unit database for 873 melanoma patients with American Joint Committee on Cancer (AJCC) Stage I and II disease treated between 1960 and 2002 who relapsed following treatment of their primary melanoma. Clinical and pathologic factors predicting survival were analyzed using the Cox proportional hazards regression model. Results Initial presentation of recurrence was local: 95 patients (10.9%), in transit: 86 patients (9.9%), regional lymph node: 300 patients (34.4%), and distant: 392 patients (44.9%). Independent prognostic factors for survival of the 481 patients with only locoregional recurrence were type of recurrence, primary tumor ulceration, and patient age. Predictors for longer survival in the 392 patients with distant metastasis at the time of first presentation with recurrence were lung vs other sites and diagnosis of relapse after 1990 compared with diagnosis before 1980. Conclusions The type of recurrence is the most important prognostic factor in melanoma patients who relapse. Primary tumor ulceration is the most important pathologic predictor. The results of this study suggest that management of distant metastases may have improved over the last 25 years, but many confounders and improved staging techniques make assessment of this unreliable.     

Runx3和Ki-67蛋白在皮肤恶性黑色素瘤中的表达

目的：检测Runx3和Ki-67蛋白在皮肤恶性黑色素瘤（CMM）中的表达水平,以探讨Runx3和Ki-67在CMM发生、发展过程中的作用。方法：采用免疫组织化学法研究Runx3和Ki-67蛋白在皮肤恶性黑色素瘤、皮肤交界痣及正常皮肤中的表达。结果：Runx3蛋白在CMM中阳性表达率为23.68%,与皮肤交界痣（85.00%）和正常皮肤（90.00%）相比,差异具有统计学意义（P〈0.05）;Ki-67蛋白在CMM中阳性表达率为78.95%,与皮肤交界痣（25.00%）和正常皮肤（25.00%）相比差异具有统计学意义（P〈0.05）。结论：皮肤恶性黑色素瘤的产生可能与Runx3蛋白的表达降低及Ki-67蛋白的表达升高有关。     

Clinical Course of Cutaneous Malignant Melanoma Related to Histopathological Criteria of Primary Tumour

By using cumulative survival curves the influences of histological criteria of the primary tumour on the prognosis of 204 patients with clinical stage I malignant melanoma were evaluated. Tumour thickness, level of invasion in the dermis plus ulceration appear to have greatest influence on prognosis. Other factors influencing prognosis include the histogenetic type of melanoma, malignant cell invasion into blood vessels as well as intralesional transformation. On the other hand, it appears from our material that the number of mitoses, the type of malignant cell, regression phenomena and the amount of the inflammatory cell infiltrate have no significant influence on prognosis.     

Value of Frozen-Section Analysis of Sentinel Lymph Nodes for Primary Cutaneous Malignant Melanoma

OBJECTIVE: To analyze a large, single-institution experience with routine frozen section (FS) of the sentinel lymph node (SLN) in patients with primary cutaneous melanoma. SUMMARY BACKGROUND DATA: Controversy exists over the utility of intraoperative FS analysis of the SLN in patients with primary cutaneous melanoma. METHODS: All patients with clinically node-negative cutaneous melanoma undergoing SLN biopsy from 1991 to 1999 were identified from a prospective database. All SLNs were examined by FS. Step-sectioning and immunohistochemistry of permanent section were performed for SLNs negative by FS. RESULTS: At least one SLN was identified in 98% (360/368) of patients. There were 74 (20%) SLNs positive on permanent section; FS was positive in 59% of these. The accuracy, sensitivity, and specificity of FS were 92%, 59%, and 100%. Because isolated recurrence developed in six patients in the nodal basin in which the SLN was negative, the failure rate was 1.7%. The false-negative rate for SLN biopsy was 7.5%. CONCLUSIONS: Because the prevalence of metastases within the SLN and sensitivity of FS analysis are low, routine use of FS for all patients undergoing SLN biopsy is not recommended.     

Primary Management of Cutaneous Melanoma: Excision and Sentinel Node Biopsy

During the last decade, the treatment of primary cutaneous melanoma has considerably changed. The aggressive behaviour of this disease stimulated surgeons to perform extensive resections and manage the regional nodes in a radical way. However, numerous studies indicate that a less aggressive treatment with lesser cosmetic and functional injury is associated with a similar outcome. There is no doubt that the quality of life will be significantly improved by using narrower excision margins and by further refinements of the sentinel node technique.     

Management of Symptomatic Malignant Melanoma of the Gastrointestinal Tract

Background: Melanoma metastatic to the gastrointestinal (GI) tract is asymptomatic or presents with pain, bleeding, or obstruction. To determine whether surgery influences outcomes, we reviewed our experience with this patient population.Methods: Medical records of patients with metastatic melanoma to the GI tract were reviewed. Patients were divided into four groups, i.e., complete resection, partial debulking, unresectable, or unexplored. Analysis was performed using the Kaplan-Meier method.Results: Fifty patients with melanoma metastatic to the GI tract were identified (40 men and 10 women; mean age, 44 years). Presenting symptoms included pain (62%), bleeding (28%), and obstruction (18%). Diagnosis was confirmed using contrast studies (38%), endoscopy (20%), or computed tomography (30%). Thirty-six patients (61%) underwent a total of 39 operations. Seventeen patients underwent complete resection, whereas 14 underwent partial debulking. Five patients had unresectable lesions, and 14 patients did not undergo exploration because of medical contraindications. The operative mortality rate was 2.5% (1 of 39). The mean survival times for the unexplored and unresected groups were similar (4.1 months). Patients who underwent partial resection exhibited a longer mean survival time (8.9 months) than did patients in the unresected group (P < .001). The complete-resection group demonstrated a mean survival time of 23.5 months, which was significantly longer than that for patients who underwent less than complete resection (P < .0001).Conclusions: Metastatic melanoma to the GI tract can result in significant morbidity and death. Surgical resection can be performed safely. Patients for whom all sites of disease are completely resected experience significant improvements in survival times, compared with patients who undergo less than complete resection. For selected patients, surgical treatment of metastatic melanoma involving the GI tract is appropriate therapy.Presented at the 1998 meeting of The Society of Surgical Oncology.     

Pedunculated Malignant Melanoma

BACKGROUND: The pedunculated melanoma is an unusual variant of nodular melanoma that presents a challenge in staging and management. OBJECTIVE: We discuss the clinical and histopathologic characteristics of a case of pedunculated melanoma and present a brief review of the literature. METHODS: Routine stain with hematoxylin and eosin was performed on tissue specimens. RESULTS: The pedunculated melanoma was excised. Sentinel lymph node dissection was performed and was negative for the presence of melanoma. CONCLUSIONS: Pedunculated melanoma is a rare type of melanoma. Conventional staging methods for melanoma may not be reliable in this type of tumor. Complete workup, possibly including sentinel lymph node dissection, should be performed in all patients with pedunculated melanomas.     

The Management of Cervical Lymph Nodes in Patients with Cutaneous Melanoma

Background

The aim of this study was to review the management of cervical lymph nodes in patients with cutaneous melanoma and to analyze factors influencing prognosis.

Methods

This was a retrospective cohort study of patients who had cervical node surgery at the Sydney Melanoma Unit from 1990 to 2004.

Results

Of 716 patients who met the study criteria, 339 had a sentinel node biopsy (SNB) and 396 had a neck dissection. Locoregional recurrence occurred in 27.6?% of those undergoing therapeutic neck dissection and 60?% eventually developed distant metastases. Radiotherapy was given as adjuvant treatment in 110 of the patients who had a therapeutic neck dissection (41?%), but this was not associated with improved regional control (p?=?.322). Multivariate analysis showed that nodal positivity (p?<?.001) and primary tumor ulceration (p?=?<?.027) were the most important predictors of locoregional recurrence and that primary tumor Breslow thickness (p?=?.009) and node positivity (p?=?.046) were the most important factors predicting survival. SNB-positive patients who underwent immediate completion lymphadenectomy had a 5-year survival advantage over those who had a therapeutic neck dissection for macroscopic disease (54?% vs 47?%, p?=?.028).

Conclusions

Nodal status was the most important factor predicting disease-free and overall survival in patients with melanoma of the head and neck. Adjuvant radiotherapy was not associated with better locoregional control in the non-randomized cohorts of patients in this study.