Prognosis of thick cutaneous melanoma

BACKGROUND: Ten percent of all patients with melanoma present with thick primary tumors (> or = 4 mm or Clark level V). To determine factors associated with outcomes, we performed a retrospective analysis of 120 patients who had definitive primary treatment of their thick cutaneous melanomas at Memorial Sloan-Kettering Cancer Center between January 1986 and April 1995. STUDY DESIGN: Data were collected via chart review and patient interview. Association between factors was determined by chi-square analysis. Survival analysis was performed by the method of Kaplan and Meier. Univariate analysis by log-rank testing and multivariate analysis using the Cox regression model were used to identify factors associated with disease-free and overall survival. RESULTS: Median age was 61 years (range 19 to 87 years). There were 80 males and 40 females. Median Breslow thickness was 6 mm (range 1.8 to 25.0 mm). Ninety-three patients (78%) underwent lymphadenectomy (52 elective and 41 therapeutic). Twenty-one percent (11 of 52) of the elective dissections were positive. Median followup was 3.8 years (5.2 years for patients no evident disease and 2.0 years for those dead of disease). Overall survival for the entire group was 62% at 5 years and 43% at 10 years. Age, gender, and anatomic site (axial versus extremity) were not factors predictive of overall survival. Increasing thickness, nodal status at presentation (American Joint Commission on Cancer stage II versus III), and the presence of ulceration were significant predictors of both disease relapse and disease-specific mortality in both univariate and multivariate analyses. There was no difference in postrelapse survival between patients suffering local, nodal, or distant relapse (p = 0.63). CONCLUSIONS: Patients presenting with thick cutaneous melanomas are expected to have more than 50% 5-year survival, and they should not be denied the opportunity for aggressive locoregional management. Thickness, positive nodal status, and ulceration are associated with a higher mortality rate. The fact that patients with local or nodal recurrences fare as poorly as those with overt distant metastases implies that the former events are predictors of subclinical systemic disease.     

Cutaneous thick melanoma. Prognosis and treatment

Among proponents of elective lymph node dissection (ELND) for clinical stage I melanoma, controversy exists as to whether there is an upper limit of tumor thickness beyond which ELND should not be considered. We reviewed 169 patients with clinical stage I and II melanoma that was greater than or equal to 3.0 mm thick and who were treated at the University of Illinois Hospital, Chicago. Of 139 patients with clinical stage I disease, 117 underwent ELND. Five- and ten-year survival rates were 55.7% and 48.9%, respectively. Multifactorial analysis demonstrated that anatomical location, level, pathologic stage, and ulceration were the best predictors of survival. Thickness did not emerge as a significant variable. Our findings do not support basing treatment decisions, eg, ELND in this group of patients, solely on the thickness of the primary tumor. We continue to recommend ELND in patients with either intermediate or thick melanomas.     

Prognosis of thick cutaneous melanoma of the trunk and extremity

The records of 129 patients with thick cutaneous melanoma of the trunk or extremity treated at Memorial Sloan-Kettering Cancer Center, New York, NY, between 1974 and 1984 were reviewed with the aim of defining prognostic variables. All primary lesions invaded subcutaneous fat, were Clark level V, or of a Breslow thickness of 4.0 mm or greater. Treatment in all cases was by wide excision with or without split-thickness skin graft; all patients underwent regional lymph node dissection. Overall survival rate for the group was 47% at 5 years and 36% at 10 years. Factors independently predictive of survival were pathologic negative nodes (71% at 5 years compared with 28% for pathologic positive nodes) and extremity site (58% at 5 years compared with 33% for truncal site). Patients with node-negative thick cutaneous melanoma of the extremity had a 5-year survival rate of 82%. Patients with node-positive truncal thick cutaneous melanoma had a 5-year survival rate of only 8%. There was no difference between the 5-year survival rate of patients with node-negative truncal thick cutaneous melanoma, 52%, and patients with node-positive thick cutaneous melanoma of the extremity, 42%. Nearly half of the patients with thick cutaneous melanoma of the extremity and trunk present with locoregional disease, at a stage when an aggressive surgical approach is warranted. Prognostic variables of pathologic nodal status and site identify patients at risk for early systemic failure.     

Clinical presentations of cutaneous melanoma

Cutaneous melanoma is responsible for the majority of skin cancer deaths. Early and accurate detection are the most important means to improve patient survival. This article reviews the common clinical presentations of head and neck cutaneous melanoma, and discusses lesions that might be clinically mistaken for melanoma.     

直肠肛管恶性黑色素瘤的临床特征分析

目的了解原发性直肠肛管恶性黑色素瘤的临床特点。方法回顾性分析9例原发性直肠肛管恶性黑色素瘤的临床资料,并复习文献。结果直肠肛管恶性黑色素瘤以女性多见,平均发病年龄56岁,病程5.8个月;首发症状以血便为最常见,其次为肛门肿物突出。94.7%的直肠肛管恶性黑色素瘤在距离肛缘5.0cm范围内;肿瘤最大径(3.3±2.1)cm;其中54.5%可活动;有19.1%的肿瘤表面光滑;6.6%的肿瘤质地软;14.0%同期发现转移,肝转移最常见,腹股沟淋巴结转移其次;的病例出现误诊,超过者被误诊为良性疾病;手术治疗中以Miles术为主,经肛门局部切除术其次。结论直肠肛管恶性黑色素瘤极易误诊。手术治疗为主。     

Sentinel lymph node biopsy in thick malignant melanoma: A 10-year single unit experience

Between the years 2000-2010, 195 patients were diagnosed with ≥4?mm Breslow thickness malignant melanoma in our unit. Median follow-up was 36.8 months. 49% of patients were male and 51% were female. Median age was 74 years. The commonest melanoma type was nodular (55%). The commonest tumour location was on the extremity (45%). 64% of tumours were ulcerated. Median mitotic rate was 9. Median Breslow thickness was 7?mm 66 patients underwent sentinel lymph node biopsy. 44 (67%) patients had negative results and the remaining 22 (33%) patients were positive for metastatic melanoma. There was no statistically significant correlation between any of the patient or tumour variables (age, sex, melanoma type, melanoma site, Clark level, Breslow thickness, mitotic rate, ulceration) and sentinel lymph node status. Patients with Breslow thickness melanoma of <6?mm had a significantly better 5-year disease free and overall survival compared with those patients with >6?mm Breslow thickness melanoma (63.5% vs. 32.9%; P?=?0.004 and 73.9% vs. 54.7%; P?=?0.02 respectively). Recurrence rate was 50% in those with positive sentinel lymph node biopsy compared to 23% in those with negative results. Distant recurrence was the commonest in both groups. 5-year disease free survival was 64.1% in the SLNB -ve group and 35.4% in the SLNB +ve group (P?=?0.01). There was no significant difference in overall survival between the SLNB -ve and SLNB +ve groups (70.3% vs. 63.7% respectively; P?=?0.66). We conclude that sentinel lymph node biopsy in our unit has provided no survival benefit in those with thick melanoma over the past 10 years but is an important predictor of recurrence free survival. Breslow thickness remains an important predictor of disease free and overall survival in thick melanoma.     

Multivariate prognostic model for patients with thick cutaneous melanoma: importance of sentinel lymph node status

Background The overall prognosis of patients with thick cutaneous melanoma (TCM) is generally thought to be poor. Surgically staging these patients with sentinel lymph node (SLN) biopsy remains controversial. This study was performed to determine whether SLN status improved our ability to predict outcome over other known prognostic factors and to develop a model incorporating independent prognostic factors to estimate the risk of recurrence for an individual patient. Methods A prospective database identified patients with TCM (>4.0 mm or Clark level V) and clinically negative nodes who underwent SLN biopsy. Univariate and multivariate analyses were performed. Results From 1991 to 2001, 126 patients were identified; 75 (60%) were male. The median age was 60 years. The median tumor thickness was 5.5 mm, and 43% were ulcerated. Thirty percent of patients had a positive SLN. Recurrence was seen in 50 patients (40%). Median follow-up, relapse-free survival, and overall survival were 25, 50, and 68 months, respectively. Factors independently predictive of recurrence were age ≥60 years, depth >5.5 mm, ulceration, and SLN positivity. SLN status was the most significant prognostic factor (P< .001). The relative risk of recurrence for an individual patient ranged from 1 in patients for whom no adverse factors were present to 29.4 when all factors were present. Conclusions SLN status was the strongest independent predictor of outcome in patients with TCM. However, patients with TCM are prognostically heterogeneous, and all independently predictive factors should be considered when an individual patient’s risk of recurrence is assessed.     

The role of sentinel lymph node biopsy in patients with thick melanoma. A single centre experience

AimsTo evaluate the role, if any, of sentinel lymph node mapping (SLNM) with biopsy (SLNB) in patients with thick cutaneous melanoma.MethodsConsecutive patients with thick (Breslow ≥4 mm) cutaneous melanoma, undergoing SLNB were identified from a departmental database comprising 550 patients in total from 2000 to 2010. Factors examined included demographic data, histological subtype, site and depth of lesion, percentage of positive SLNs, regional recurrence in the setting of a negative SLNB result (false-negative rate), complications, further lymphadenectomy, and follow-up (disease free and overall survival), where available.ResultsSixty-four eligible patients (37 men, 27 women) underwent primary excision and SLNM. Median patient age was 59 years (range 8–82 years). Mean Breslow depth was 7 mm (range 4–19 mm). Thirty melanomas were located on the limbs, 19 on the head and neck and 15 on the trunk. Twenty-three (35%) were ulcerated. Of the 57 patients who had a sentinel node identified, 18 (31%) had metastatic melanoma identified. The mean survival time for patients with a negative SLN was 79 months versus 18 months for those with a positive node. Patients with a negative SLN have a 5 year disease free survival of 79% versus 11% (p < 0.001) and an overall 5 year survival rate of 85% versus 32% when compared to node positive patients.ConclusionsThe status of the SLN is predictive of disease recurrence and overall survival in patients with a thick primary cutaneous melanoma. This modality should be employed, where applicable, in this cohort of patients.     

Surgical margins and prognostic factors in patients with thick (>4 mm) primary melanoma

Background: Randomized trials have demonstrated the efficacy of 1- and 2-cm excision margins for thin and intermediate-thickness melanomas, respectively. The optimal margin of excision for thick melanomas is still unknown, however. We evaluated whether the margins used for intermediate-thickness melanomas can be applied safely to thicker lesions. Methods: The charts of 278 patients with thick primary melanomas treated between 1985 and 1996 were retrospectively reviewed. Patients with distant metastases at presentation or with follow-up less than 6 months were excluded. Median follow-up was 27 months. Known melanoma prognostic factors and excision margins were evaluated for their impact on local recurrence (LR), disease-free survival (DFS), and overall survival (OS). Results: Median tumor thickness was 6.0 mm, and 57% were ulcerated. At presentation, 201 patients (72%) were node negative and 77 (28%) were node positive (palpable or occult). The 5-year OS and DFS rates were 55% and 30%, respectively. The LR rate for all patients was 12%. Although nodal status, thickness, and ulceration were significantly associated with OS by multivariate analysis, neither LR nor excisional margin (<2 cm vs. >2 cm) significantly affected DFS or OS in these patients. Conclusions: Because margins of excision greater than 2 cm do not improve LR, DFS, or OS compared to a margin of 2 cm or less, a 2-cm margin of excision is adequate for patients with thick melanoma. Because nodal status is a significant prognostic factor in these patients, staging by sentinel node biopsy should be considered in patients with thick melanomas and clinically negative nodal basins to allow proper entry and stratification in adjuvant therapy trials. Presented at the 50th Annual Cancer Symposium of The Society of Surgical Oncology, Chicago, IL, March 20–23, 1997.     

甲下黑色素瘤的临床特点与治疗结果

目的 总结甲下黑色素瘤的临床特点和治疗结果.方法 回顾性分析1994年1月至2010年7月由北京积水潭医院收治,并经病理检查证实为甲下黑色素瘤的31例患者的临床资料,其中21例行病变指(趾)超关节截指(趾)术;4例行序列截指(趾)术;6例行局部/扩大切除术.其中5例淋巴转移患者同时行局部淋巴结清扫,并辅以全身化学治疗和免疫治疗.结果 31例中18例获得随访,随访年限3～16年.4例行序列截指(趾)术后随访均未复发;8例行超关节截指(趾)中2例复发;6例行局部病灶切除或扩大切除术中5例复发.侵袭性甲下黑色素瘤患者1年生存率为88.9%(8/9),3年生存率为66.7%(6/9),5年生存率为33.3%(3/9).结论 甲下黑色素瘤是一种恶性程度很高的肿瘤,具有非特异性的临床表现,治疗应以手术为主,辅以化疗、免疫等综合治疗.     

Role of sentinel lymph node biopsy in patients with thick (>4 mm) primary melanoma

Lymphatic mapping and sentinel lymphadenectomy have become a routine part of the treatment algorithm for primary melanoma. Their role in the management of thick (>4 mm) lesions is evolving. Our purpose was to evaluate the influence of single lymph node (SLN) histology on survival of patients with thick melanomas. A computerized patient database was accessed to obtain records on patients with thick melanomas. Survival curves were constructed with the Kaplan-Meier method, and a Cox regression analysis was used to establish statistical significance. Between 1997 and 2002, 266 SLN biopsy procedures were performed, using both radioisotope and blue dye, in 259 patients with malignant melanoma. Forty-five patients (17%) had thick melanomas. Twenty patients (44%) had at least one positive sentinel lymph node. The mean disease-free survival (DFS) of SLN-positive patients was 44 months compared with 53 months in SLN-negative patients (P = 0.0221). Increasing Breslow thickness was associated with a decrease in DFS, whereas no other histologic parameters such as Clark level, mitotic rate, or ulceration had an influence on DFS. Our data indicate that the status of the SLN node is predictive of disease-free survival in patients with thick melanomas. SLN biopsy is thus justified in patients with thick melanoma.     

Prognostic factors in node-negative breast cancer.

One hundred patients with node-negative breast cancer were examined to analyze the influence of tumor size, nuclear grade, and DNA content determined by flow cytometry on overall survival. Patients with diploid cancers lived significantly longer than those with aneuploid cancers (126 +/- 8 vs 80 +/- 11 months). Patients with an S-phase fraction less than 10% lived significantly longer than those with S-phase fractions 10% or greater (122 +/- 8 vs 85 +/- 10 months). Tumor size had the major impact on survival, and multivariate analysis of variance by the Cox proportional hazards model showed the greatest effect on prognosis. Tumor grade did not significantly influence overall survival.     

原发性消化道黑色素瘤的临床分析

目的 总结原发性消化道黑色素瘤的临床特点。方法 回顾性分析我院近10年住院治疗的8例原发性消化道黑色素瘤临床资料并复习献。结果 8例原发性消化道黑色素瘤中，原发灶位于直肠6例，小肠1例，食管1例，除1例直肠黑色素瘤术前得到确诊外，其余7例均被提诊，直肠黑色素瘤以便血，肛门疼痛和排便困难为主要症状；多表现为息肉样，均位于距齿状线以上5cm以内；少有色素沉着，小肠黑色素瘤以梗阻，腹痛，贫血为主要症状；造影和CT有助于发现病变，但确诊仍需病理学，食管黟 以素瘤多为黏膜下；胃镜可发现色素沉着；病理活检可协肋诊断。结论 原发性消化道黑色素瘤的临床表现与其他肿瘤类似，极易误诊，病理活检是确诊的主要手段。     

足部恶性黑色素瘤21例临床分析

目的 探讨足部恶性黑色素瘤的临床表现、诊断与治疗.方法 回顾性分析我科1994年至2006年收治的21例足部恶性黑色素瘤患者.其中男性19例,女性2例,平均年龄63.8岁(42～86岁).结果 所有患者均经病理证实为足部恶性黑色素瘤.21例患者确诊后均接受了外科手术治疗,术后5例接受化疗,2例接受生物学治疗.19例随访3～41个月.2例患者分别于术后6个月及31个月死亡,其余患者目前均存活.结论 目前恶性黑色素瘤仍是不能根治的疾病.足底为负重功能区,应根据手术切除后缺损的部位和范围,选择合适的皮瓣修复对足部功能恢复起着十分重要的作用.