Follow-up Of Melanoma Patients Research Articles

Imaging Assessment of Interval Metastasis from Melanoma.

Interval metastasis is a particular metastatic category of metastatic localizations in the lymph nodes in patients with melanoma. Interval nodes are generally located at nonregional lymphatic stations placed along the pathway of the spread of melanoma, such as the epitrochlear lymph node station, the popliteal fossa, and the retroareolar station. Imaging techniques for evaluation of patients with interval metastasis from melanoma diseases include ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), lymphoscintigraphy (LS), and positron emission tomography (PET). A literature review was conducted through a methodical search on the Pubmed and Embase databases. The evaluation of lymph node metastases represents a critical phase in the staging and follow-up of melanoma patients. Therefore, a thorough knowledge of the imaging methods available and the interactions between the clinician and the radiologist are essential for making the correct choice for individual patients, for a better management, and to improve treatment and survival.

Surveillance strategies in the follow-up of melanoma patients: too much or not enough?

BackgroundAfter appropriate initial therapy for patients with stage II-III melanoma, there is no consensus regarding surveillance. Thus, follow-up is highly variable among institutions and individual providers. The National Comprehensive Cancer Network recommends routine clinical examination and consideration of imaging for stage IIB-IIIC every 3-12 mo with no distinction between stages. Detection of recurrence is important as novel systemic therapies and surgical resection of recurrence may provide survival benefits. MethodsWe retrospectively reviewed 369 patients with stage II and III melanoma treated at Ohio State University from 2009-2015, who underwent surgery as primary therapy. Two hundred forty-seven patients who were followed for a minimum of 6 mo after surgical resection to achieve no evidence of disease status (NED) were included in this analysis. One hundred twenty-two were lost to follow-up after surgery and were excluded. ResultsThe rate of recurrence for stage IIA/IIB patients was 11% (14/125). Eleven of the 14 (79%) recurrences were detected by clinical symptoms or physical examination. Thirty-nine percent (49/125) of stage IIA or IIB patients were followed by clinical examination only, whereas 61% (76/125) were followed with at least two serial chest x-rays. The median time to first chest x-ray after NED status was 4.7 mo (n = 76), median time to second chest x-ray after NED status was 12.7 mo (n = 76), and 66% (50/76) continued to have additional serial chest x-rays. At median follow-up of 35 mo for the 125 patients with stage IIA/IIB, there was no difference in survival between those followed clinically (95% [95% CI: 0.88-0.99]) versus those followed with at least two serial x-rays (96% [95% CI: 0.89-0.98]). For stage IIC/IIIA-C patients, recurrence was detected in 23% (28/122) at median follow-up 31.2 mo. Fifty percent of recurrences were detected by imaging in asymptomatic patients, whereas 50% (14/28) had recurrence detected on imaging associated clinical findings. Eighty-seven percent (106/122) of stage IIC/IIIA-C patients were followed with at least two serial whole body positron emission tomography/computed tomography (CT) scans or whole body CT scans plus brain magnetic resonance imaging; median time between NED status and second scan was 10.3 mo. Of stage IIC/IIIA-C patients with recurrence, 57% (16/28) went on to surgical resection of the recurrence, whereas 11 (39%) patients received B-RAF inhibitor therapy, immune blockade therapy, or combination therapy. ConclusionsFor stage IIA and IIB melanoma, surveillance chest x-rays did not improve survival compared to physical examination alone. However, for stage IIC and IIIA-C melanoma, where the recurrence rates are higher, routine whole body imaging detected 50% of recurrences leading to additional surgery and/or treatment with novel systemic therapies for the majority of patients. Detection of melanoma recurrence is important and specific substage should be used to stratify risk and define appropriate follow-up.

The MELFO-Study: Prospective, Randomized, Clinical Trial for the Evaluation of a Stage-adjusted Reduced Follow-up Schedule in Cutaneous Melanoma Patients-Results after 1 Year.

Background Guidelines for evidence-based follow-up in melanoma patients are not available. This study examined whether a reduced follow-up schedule affects: patient-reported outcome measures, detection of recurrences, and follow-up costs.Methods This multicenter trial included 180 patients treated for AJCC stage IB-II cutaneous melanoma, who were randomized in a conventional follow-up schedule group (CSG, 4 visits first year, n = 93) or experimental follow-up schedule group (ESG, 1–3 visits first year, n = 87). Patients completed the State-Trait Anxiety Inventory, cancer worry scale, impact of events scale, and a health-related quality of life questionnaire (HRQoL, RAND-36). Physicians registered clinicopathologic features and the number of outpatient clinic visits.ResultsSociodemographic and illness-related characteristics were equal in both groups. After 1-year follow-up, the ESG reported significantly less cancer-related stress response symptoms than the CSG (p = 0.01), and comparable anxiety, mental HRQoL, and cancer-related worry. Mean cancer-related worry and stress response symptoms decreased over time (p < 0.001), whereas mental HRQoL increased over time (p < 0.001) in all melanoma patients. Recurrence rate was 9 % in both groups, mostly patient-detected and not physician-detected (CSG 63 %, ESG 43 %, p = 0.45). Hospital costs of 1-year follow-up were reduced by 45 % in the ESG compared to the CSG.Conclusions This study shows that the stage-adjusted, reduced follow-up schedule did not negatively affect melanoma patients’ mental well-being and the detection of recurrences compared with conventional follow-up as dictated by the Dutch guideline, at 1 year after diagnosis. Additionally, reduced follow-up was associated with significant hospital cost reduction.Electronic supplementary materialThe online version of this article (doi:10.1245/s10434-016-5263-7) contains supplementary material, which is available to authorized users.

The updated Swiss guidelines 2016 for the treatment and follow-up of cutaneous melanoma.

Cutaneous melanoma is the most deadly cutaneous neoplasm. In order to guide treatment decisions and follow-up of melanoma patients, guidelines for the management of melanoma in Switzerland were inaugurated in 2001 and revised in 2006 and 2016. Recent data on surgical and medical treatments from randomised trials necessitated modification of the treatment and follow-up recommendations.

Nevi of conjunctiva as a risk factor of melanoma

Conjunctival nevi are the most common tumors of this location. They are usually unilateral, although bilateral cases may also be met. As to clinical presentation, all nevi are divided into: stationary or progressive nevi, blue nevi, and primary acquired melanosis. Color changes are acceptable, if they occur during pregnancy or puberty. However, if postpubertal, such changes should be considered alarming, as to possible malignization. Histopathologically, nevi are composed of melanocyte clusters in the skin stroma next to the basal layer of the epidermis. To analyze the significance of timely removal of conjunctival nevi for melanoma prevention. A total of 52 patients were examined during 2009-2013. Of them, 48 patients had nevi of the conjunctiva and/or lacrimal caruncle, 1 patient was diagnosed with caruncular melanoma and 3 other - with conjunctival melanoma. Patients with stationary nevi are still being followed up. Of those who were surgically treated, none developed recurrence. Taking into account high metastatic activity of melanomas and that discovering metastases does not always happen together with diagnosing the primary lesion (often, years after treatment), the follow-up of melanoma patients must be lifelong. Timely removal of progressive conjunctival nevi is able to prevent malignancy, of which the outcome may be very unfavorable.

Prognostic Value of 25-hydroxyvitamin D3 Levels at Diagnosis and During Follow-up in Melanoma Patients.

A low 25-hydroxyvitamin D3 (25(OH)D3) serum concentration at melanoma diagnosis might be associated with worse survival. We prospectively studied the prognostic value of 25(OH)D3 at diagnosis and during follow-up. MelanCohort is a cohort of invasive melanoma patients. Serum 25(OH)D3 was measured by mass spectrometry and standardized on month of blood drawn, age, sex, and body mass index (BMI). Role of 25(OH)D3 levels and risk of relapse was analyzed in a Cox proportional hazards model adjusting for age, sex, BMI, and American Joint Committee on Cancer (AJCC) stage. All statistical tests were two-sided. One thousand one hundred seventy-one patients were included. 25(OH)D3 levels at diagnosis (median = 49.0 nmol/L) were inversely correlated with prognostic factors such as AJCC stage (P < .001 Kruskal-Wallis), Breslow's thickness (P < .001 Spearman correlation), and ulceration (P < .001 Kruskal-Wallis), but not with risk of relapse. Changes in 25(OH)D3 levels during follow-up were associated with worse prognosis: With a third quartile Q3 of average change per year (-0.30 to 4.60 nmol/L/Y) used as reference, hazard ratios for the first, second, and fourth quarters were 1.94 (95% confidence interval [CI] = 1.36 to 2.76), 1.23 (95% CI = 0.85 to 1.78), and 1.61 (95% CI = 1.14 to 2.28), respectively. In sensitivity analyses, no changes were observed either by AJCC stage, number of 25(OH)D3 measures performed, or by 25(OH)D3 level at baseline. No evidence of reverse causation was identified. Analyses performed on overall survival yielded similar results. We show that 25(OH)D3 variation during follow-up is an independent melanoma prognostic marker, but not its level at diagnosis. Previously reported associations between low 25(OH)D3 level at diagnosis and poor prognosis seem to be due to insufficient adjustment for prognostic factors.

Surveillance imaging with FDG-PET in the follow-up of melanoma patients at high risk of relapse.

9003 Background: In the modern era of melanoma treatment, approaches to imaging surveillance following surgery require reconsideration. The aim of this study was to evaluate disease sub-stage speci...

Prospective evaluation of follow-up in melanoma patients in Germany – Results of a multicentre and longitudinal study

BackgroundPatient numbers requiring long-term melanoma surveillance are constantly rising. Surveillance is costly and guideline recommendations vary substantially. MethodsIn this German nationwide study, information on surveillance and treatment of patients diagnosed with melanoma and melanoma in situ (MMis) between April and June 2008 was prospectively collected over four years. Additionally, patient self-report questionnaires were evaluated to assess anxiety, depression, health-related quality of life, socio-demographic information and use of disease specific health information sources at year 4 after primary diagnosis. ResultsComplete data was available for 668 patients from 67 centres, of whom 96.0% were in regular melanoma surveillance. In year 3–4 of surveillance, only 55.6% of locoregionary metastases were detected during surveillance visits. Only 33.3% were self-detected by the patient even though 69.4% were documented as being clinically visible or palpable. Costs of 4year surveillance of 550 patients without tumour recurrence (stage I–IIC and MMis) accumulated to 228,155.75 €. Guideline-adherence for follow-up frequency, lymph node ultrasound, S100 serum level tests and diagnostic imaging recommendations was approximately 60% in year 3–4 of surveillance. Multivariate regression analysis showed that certain patient/tumour characteristics and regional differences were significantly associated with guideline deviations. The percentage of patients who exceeded published cut-off scores indicating clinically relevant symptoms of anxiety and depression were significantly increased. Patients frequently reported lack of psychosocial support and education but ascribed great importance to these. ConclusionsWe recommend further reduction of melanoma follow-up in low-risk melanoma patients and improvement of psycho-social support and patient education for all melanoma patients.

Detection and quantification of CSF malignant cells by the CellSearch® technology in patients with melanoma leptomeningeal metastasis

Melanoma is the most frequent solid tumor associated with leptomeningeal metastasis (LM). The usual diagnostic tools, that is, cytomorphological assessment of cerebro-spinal fluid (CSF) and gadolinium-enhanced MRI of the entire neuraxis both lack effectiveness. The CellSearch Veridex technology for the detection of circulating tumor cells (CTC) in blood was designed for the follow-up and prognosis of breast, prostate, colorectal, and lung cancer, which express EpCAM markers. We have previously adapted this technology to detect malignant cells in the CSF of breast cancer LM. Our objective here was to check if this technology would also allow the detection and the enumeration of CTC in the CSF of melanoma patients presenting with LM although melanoma does not express EpCAM markers. On the occasion of the intrathecal treatment of LM in 2 melanoma patients, 5 mL of CSF and 7.5 mL of blood were collected on CellSave Preservative Tubes and analyzed within 3 days after CSF sampling using a melanoma-dedicated kit. The CellSearch Veridex technology was then adapted to direct enrichment, enumeration, and visualization of melanoma cells in the CSF. CD146+, HMW-MAA+, CD34-, and CD45- cells with typical morphology could be observed and enumerated sequentially with reproducible results, corresponding to CSF melanoma cells (CSFMC). In contrast to the current gold standard cytomorphological analysis, this new approach allowed a precise quantification of CSFMC in all samples concomitantly analyzed. This methodology, established on a limited volume of sample and allowing delayed processing, could prove of great interest in the diagnosis and follow-up of melanoma patients with LM.

Updated Swiss guidelines for the treatment and follow-up of cutaneous melanoma

Melanoma is the most common lethal cutaneous neoplasm. In order to harmonise treatment and follow-up of melanoma patients, guidelines for the management of melanoma in Switzerland were inaugurated in 2001 and revised in 2006. A new classification and recent results in randomised trials necessitated changes concerning staging and modifications of the recommendations of therapy and follow-up.

Melanoma patients receive more follow‐up care than current guideline recommendations: a study of 546 patients from the general Dutch population

Follow-up of melanoma patients has been a continuing issue for discussion in the past years partly due to ever increasing incidence of this disease, as well as the lack of agreement regarding the reasons for, and the frequency of follow-up. Patients' perspectives are often not included in this continuing discussion on follow-up of melanoma patients. To examine to what extent follow-up was experienced, according to the guideline of 2005, by physicians and melanoma patients in a Dutch population from the south-east area of the Netherlands. The patient's perspective and satisfaction over said follow-up shall also be taken into account. Follow-up among melanoma survivors was investigated and compared with the recommendations of the current Dutch national guideline. All 699 melanoma patients registered at the Eindhoven Cancer Registry (between 1998 and 2008), and treated in 3 regional hospitals, were contacted via postal mail. The survey questioned about treatment, symptoms, impact on daily life and follow-up. Patients with multiple melanomas (n = 16) were excluded. Response rate was 80%, 418 patients were still under surveillance for their melanoma. The average time since diagnoses was 4 years, 71% had stage I melanoma. Almost 80% of patients with a Breslow thickness <1 mm, reported more frequent follow-up visits than the guideline recommends. Only 5% of the patients wanted to reduce their follow-up frequency. Eighty percent of patients were under supervision of a dermatologist: physical examination (25%), lymph node palpation (11%) and/or scar inspection (20%) did not regularly occur. These proportions were significantly higher among other specialism. Follow-up frequency was higher than recommended by the current melanoma guideline in a large group of patients, mainly those with lower Breslow thickness.

Is GP-led follow-up feasible?

Is GP-led follow-up feasible?

Akkumulation von Tatoo-Pigment im Sentinellymphknoten

A 22-year-old woman presented with a superficial spreading melanoma on her right thigh (tumor thickness 1.0 mm, Clark-Level III). She also had decorative tattoos on her right ankle, right groin and coccyx. The staging results gave no indication for metastases. Intra-operatively, we observed a black pigmented lymph node highly suspicious for metastatic disease, but histological examination excluded metastatic spread and detected the accumulation of black pigment within the lymph node. Clinical differentiation between tattoo pigments and metastatic disease within lymph nodes is not possible. Histological confirmation of an enlarged pigmented lymph node is therefore essential before radical surgery is performed. Hence, accumulation of tattoo pigment within enlarged and pigmented lymph nodes needs to be included into the differential diagnosis and the documentation of decorative tattoos is important during skin cancer screening as well as during the follow-up of melanoma patients.

Long-term follow-up of patients with minimal sentinel node tumor burden (&lt; 0.1mm) according to Rotterdam criteria: A study of the EORTC Melanoma Group

9005 Background: Many studies have identified Sentinel Node (SN) tumor burden as a prognostic factor for additional non- SN (NSN) positivity and / or disease-free (DFS) and melanoma specific survival (MSS). It remains unclear if pts with minimal SN tumor burden can safely be managed without Completion Lymph Node Dissection (CLND). Pts with minimal SN tumor burden might be at risk for late recurrences (&gt; 5 years). Methods: Slides of 595 SN positive patients were reviewed for this pan-European study collaboration in 5 major centers. Slides were reviewed for the microanatomic location and SN tumor burden according to the Rotterdam Criteria (&lt; 0.1mm, 0.1 - 1.0mm and &gt; 1.0 mm) for the maximum diameter of the largest metastasis. MSS, DFS and distant metastasis-free survival (DMFS) rates were calculated, as was NSN positivity. Results: In 595 SN positive pts, the mean and median Breslow thickness was 4.73 and 3.5 mm. Ulceration was present in 51% of melanomas. 67 pts had metastases &lt; 0.1 mm (11%), 226 pts (38%) had 0.1 - 1.0 mm metastases and 302 pts had metastases &gt; 1.0 mm (51%). Mean and median follow-up was 48 and 40 months for all patients (range 1 - 172). Patients with metastases &lt; 0.1 mm had mean and median follow-up of 61 and 57 months, 46% (31pts) had follow up &gt; 5 years and 25% (17 pts) had follow-up longer than 80 months (range 3 - 132). 5-year MSS rates were 94% for metastases &lt; 0.1 mm, 70% for 0.1 - 1.0 mm and 57% for &gt; 1.0 mm (p&lt;0.001). 5-year DMFS rate was 91% for metastases &lt; 0.1 mm. NSN positivity occurred in 5% of &lt; 0.1mm, 17% of 0.1 - 1.0 and 29% of metastases &gt; 1.0 mm (p&lt;0.001). Conclusions: This large multicenter experience (n=595) has demonstrated that long-term follow-up of melanoma patients with minimal SN tumor burden (&lt; 0.1 mm) indicates very low relapse rates and excellent MSS, seemingly identical to SN negative patients. With prolonged follow-up, an increase in the occurrence of relapses of any kind between 5 and 10 years follow up has not been identified, and excellent 10-year survival rates are expected. No significant financial relationships to disclose.

Follow-Up of Melanoma Patients: The Need for Evidence-Based Protocols

Over the past decade it has become clear that sensible, safe, evidence-based guidelines are required for the followup of cancer patients. Patient expectations for high-quality care have increased, although ever-increasing restrictions are being imposed on expensive health care resources. Therefore the need for constructive, cost-effective, highquality guidelines for patients with a range of cancer types has now become urgent. For patients who have had a melanoma frequent clinical consultation and regular imaging studies are still common practice in many centres, despite a lack of evidence regarding their influence on overall survival, disease-free survival or quality of life. Why is this so? In the first place we cling to historical precedent. It is well known that this form of cancer is unpredictable, and the assumption has therefore been made that it should be monitored frequently and carefully. Secondly, it seems appropriate to detect recurrence at an early stage, since effective treatment of local, in-transit and regional node metastases offers the possibility of cure, and long-term survival can also follow complete resection of systemic metastases. Third, patient satisfaction and patient reassurance are provided by frequent clinical consultation. In this and a recent issue of Annals of Surgical Oncology two interesting studies are reported. The study of Meyer et al. is a retrospective report of 118 American Joint Committee on Cancer (AJCC) stage II and III melanoma patients who underwent regular structural imaging with a minimum follow-up of 2 years. Recurrence occurred in 35% (n = 43), of which 43% (n = 15) were distant metastases. However, only 7% (n = 3) of these patients were asymptomatic and had their recurrence detected by routine imaging. Another 26% (n = 11) were detected by routine clinical follow-up, including medical history and physical examination. This study is consistent with previous reports that found two-thirds of melanoma recurrences were patient detected. The study of Morton et al. evaluated 108 patients with AJCC stage IIIA and IIIB melanoma who were prospectively enrolled in a monitoring schedule of 6-monthly chest X-rays (CXR) in addition to clinical follow-up. They found metastases in 21% (n = 23) of the patients, which were detected in 48% (n = 11) by surveillance CXR. The other pulmonary metastases were not detected by CXR surveillance. The authors found sensitivity and specificity for surveillance CXR was 48% [95% confidence interval (CI) 0.27–0.68] and 78% (95%CI 0.77–0.79), respectively. In only 13% (n = 3) was metastasectomy considered appropriate. Moreover, 19 patients had a false-positive result for melanoma metastasis, 10 of whom underwent a pulmonary biopsy. This study confirms earlier results of retrospective studies: routine CXR does not seem to contribute to an improvement in survival of melanoma patients, nor is it cost effective. The results of these two valuable studies underscore the limited value of routine imaging in the follow-up of melanoma patients. However, both studies have their shortcomings. First the retrospective nature by the study of Meyer et al. and the lack of a control group in the study by Morton et al. reduce the level of evidence according to standard methodology. Second, the low number of patients in both studies makes them underpowered due to the low rate of events. Nevertheless, this type of clinical report is of great importance since large-scale prospective studies and appropriately designed randomised studies are extremely difficult to perform in this particular field; they might even be a waste of time and money based on current knowledge. The Author(s) 2009. This article is published with open access at Springerlink.com

Prospective monitoring of adjuvant treatment in high-risk melanoma patients: lactate dehydrogenase and protein S-100B as indicators of relapse

At present there is no international consensus on laboratory testing during the follow-up of melanoma patients. We carried out a prospective monitoring study on the usefulness of lactate dehydrogenase (LDH) and protein S-100B assessment in high-risk melanoma patients. Ninety-seven patients treated within prospective randomized trials on the adjuvant treatment of melanoma received quarterly clinical visits and blood examinations. During the median observation period of 30 months disease progression was observed in 52 of 97 patients (53.1%). The clinical course of melanoma was correlated to elevated LDH and S-100B serum concentrations. The comparative analysis revealed that (i) neither LDH nor S-100B were indicators of in-transit metastases, (ii) clinically apparent lymph nodes were rarely detected because of elevated S-100B (29.4%) or LDH (11.8%) only, and (iii) the S-100B assessment was superior to LDH in the identification of early distant metastasis (53.8 vs. 23.1%; P=0.008). The rate of false-positive (elevated) LDH-serum levels and S-100B-serum levels in clinically disease-free melanoma patients did not differ significantly (S-100B 1.9% vs. LDH 1.6%). Our data indicate that only protein S-100B might be used as a highly specific and relatively sensitive marker of early distant metastasis. Both markers, LDH and S-100B, are not able to identify loco-regional metastases with a low tumor load in high-risk melanoma patients.

Diagnostic value of melanoma inhibitory activity serum marker in the follow-up of patients with stage I or II cutaneous melanoma

In the follow-up of melanoma patients, there is still a need for an optimal serum marker to discover recurrent disease at an early stage. Melanoma inhibitory activity (MIA) has been investigated as a serum marker for cutaneous melanomas. Although the prognosis for melanoma based on stage is generally good, the disease identified at later stages is associated with high levels of morbidity and mortality. The value of MIA testing in early-stage melanoma was the goal of this study. Five thousand three hundred and thirty-four MIA serum values from 1079 consecutive melanoma patients in stages I and II were obtained during routine follow-up at scheduled intervals. Sensitivity and specificity of MIA were calculated. The area under the receiver-operating characteristics curve and Somers' Dxy rank correlation were assessed. Metastasis occurred in 137 patients with a sensitivity of MIA testing of 67.6% in stage I and 65.6% in stage II patients. The specificity was 76.9% for stage I and 66.7% for stage II patients. The most reliable normal upper limit for MIA was redefined at 12.0 ng/ml, when compared with 8.8 and 15.0 ng/ml. Multivariate analysis revealed significantly more frequent false-positive values in elderly women and in men with an increased Breslow thickness.MIA adapted with a new cut-off level is then a useful serum marker even in the follow-up of not yet relapsed early-stage melanoma patients. In older women and in men with an increased tumor thickness, the higher rate of false-positive values should be considered before starting further diagnostics. Additional prospective studies to clarify the clinical combination with other serum markers seem promising.

Ultrasonography in dermatology

Ultrasonography is an essential tool for most medical specialties; training in its use is required for dermatology residency programs in Germany. Ultrasonography is a versatile, painless, low-risk, non-invasive procedure which can be done anywhere and easily repeated; it provides real-time visual information about benign and malignant processes in the skin and subcutis. High frequency sonography with 20 MHz scanners is well-established for measuring the thickness of the skin or its tumors and assessing inflammatory skin disorders. Mid-frequency sonography with 7.5-15 MHz sounds is widely used in dermatologic oncology, both for pre-operative staging and follow-up of melanoma patients. The interpretation of sonographic images such as borders of lesions, echogenicity, artifacts and vascular patterns with duplex color sonography requires structured education and intensive training. The wide variety of diagnostic information provided by sonography underlines its essential position in certified skin cancer centers.

Detection of Melanoma Relapse: First Comparative Analysis on Imaging Techniques versus S100 Protein

Background: Early detection of melanoma recurrence is essential for the patient’s prognosis. The serum S100 level may be a useful tool to detect relapse early. Objective: To compare the efficacy of imaging techniques and serum S100 in the early detection of melanoma progression. This is the first report of a comparison of a serum marker with an imaging tool in the follow-up of melanoma patients. Methods: From 1992 to 2003, we screened 192 patients suffering from melanoma recurrence after a disease-free interval. Of those, 127 patients were identified whose S100 levels had been assessed parallel to imaging procedures. Results: Serum S100 was elevated in 37% of patients at the time of relapse. In stage III, 32% of the patients had elevated S100 levels whereas in case of progression to stage IV, 48% of the patients presented with increased S100. In 5.5% of patients, S100 was the first indicator of disease progression. Imaging procedures lead to detection of melanoma recurrence in 26.8%. Conclusion: A rising level of serum S100 is a specific and sensitive marker of melanoma progression.

Ultrasonographic detection of regional lymph node metastases in patients with intermediate or thick malignant melanoma

Careful monitoring of regional lymph nodes and early detection of metastases in malignant melanoma patients has an impact on their survival, since it may permit beneficial surgical therapy. Palpation is routinely used in clinical practice. The value of ultrasonography for routine follow-up of melanoma patients, still, is not generally accepted. The aim of our study was to assess the sensitivity and specificity of ultrasound and clinical examination respectively, in the detection of melanoma regional node metastases. Additionally, we evaluated whether early detection of metastases improved overall survival. One hundred and forty-eight melanoma patients with an intermediate or thick primary lesion were followed between January 1997 and May 2001. Clinical examination and concomitant regional lymph node ultrasonography were performed, every 3-4 months. If suspicious findings were identified, regional lymph node dissection was undertaken. Forty-four from the initial 148 patients relapsed with regional lymph nodal metastases. In 11 patients (25%) palpation failed to reveal the disease and metastases were depicted only by ultrasonography. In only 1 patient ultrasonography was false-negative. The sensitivity and specificity of palpation were 72.7 and 97% respectively, while those of ultrasonography were 97.7 (p<0.001) and 98% respectively. Ultrasonography was more sensitive in detecting lymph node metastases in the axilla (100%) and the groin (93.3%). When overall survival of patients presenting with local-regional recurrence was calculated--depending on the number of involved lymph nodes--a survival benefit (p<0.05) was found for patients with only one lymph node metastasis. In conclusion, ultrasonography is superior to clinical examination in the early detection of regional lymph node metastases from an intermediate or thick malignant melanoma and should be a part of those patients' surveillance.