Melanoma Of Lower Extremity Research Articles

Disparities by sex in Hispanic patients with cutaneous melanoma: A national database analysis.

e23045 Background: Melanoma is the fifth most common form of malignancy in the United States.1 Studies have established that Hispanic patients have worse melanoma-specific survival compared to non-Hispanic White individuals.2 However, there is a paucity of literature investigating sex differences in patient characteristics and outcomes within Hispanic melanoma patients. Thus, the aim of this study is to further examine sex differences in melanoma characteristics and disease-specific survival within Hispanic patients. Methods: Individuals of Hispanic descent diagnosed with microscopically confirmed cases of cutaneous melanoma (ICD-O-3 codes 8720/3-8780/3; Primary Site codes C44.0-C44.9) between 2000 and 2020 were identified through the Surveillance, Epidemiology, and End Results (SEER) database. Statistical analyses involved Chi-squared tests, Kaplan-Meier and log-rank methods, and multivariate Cox regression, with significance set at a p-value < 0.05. Results: In a cohort of 12,328 Hispanic melanoma patients (43.3% male, 56.7% female), a significant association between sex and age was found (p < 0.001). The greatest proportion of males were in the 60-79 age group (39.7%), while females were predominantly in the 40-59 age group (39.0%). Greater number of males had truncal melanomas (31.4%) compared to females having lower extremity melanomas (35.2%) (p < 0.001). Females exhibited higher rates of localized disease (80.3% vs 70.2%) while males were more frequently diagnosed with regional (18.5% vs 13.8%) and distant disease (11.3% vs 5.9%) (p < 0.001). Males demonstrated greater mean Breslow thickness (1.80 vs 1.44; p < 0.001), elevated rates of lymph node positivity (37.2% vs 27.2%; p < 0.001), and metastatic disease (2.8% vs 1.6%; p < 0.001). On univariate Kaplan-Meier analysis, males demonstrated significantly reduced disease-specific survival (182.9 months) compared to females (214.2 months) (p < 0.001). After adjusting for age, disease stage, annual income, rural vs urban residence, and primary tumor site, male sex independently increased disease-specific mortality compared to females (HR = 1.31; 95% CI 1.16-1.48; p < 0.001). Conclusions: Our investigation reveals that Hispanic males tend to receive melanoma diagnoses at older ages, advanced-stage disease, and primarily on the trunk.3 Furthermore, our study is the first to highlight a significantly reduced disease-specific survival in males compared to females. The observed sex differences may arise from a complex interplay of behavioral factors and immunological, hormonal, or genetic influences.4 Men exhibit a lower likelihood of engaging in skin self-examinations and seeking medical assistance. Limitations to this study include use of data reported through a national database. Nonetheless, this study underscores the significance of sex-specific variations in presentation and disease-specific survival among Hispanic patients.

Anatomic Region of Cutaneous Melanoma Impacts Survival and Clinical Outcomes: A Population-Based Analysis.

The objective was to determine the effects of the anatomic site of a cutaneous melanoma on the survival outcomes of diagnosed individuals. We conducted a cross-sectional study using data from the Surveillance, Epidemiology, and End Results Program (SEER) Database from 2004-2014 and included 178,892 cases of individuals diagnosed with cutaneous melanoma. Overall survival (OS) for each anatomic site as well as associated demographics, primary site, stage, and pathologic prognostic factors (Breslow's depth of invasion (DOI), level of mitoses, and ulceration), were analyzed. Lower extremity melanoma (LEM) was the most likely to have locoregional nodal spread, yet head and neck melanoma (HNM) was the most likely to present at the most advanced stage of disease (IV). Independent of other factors, HNM was associated with the greatest risk of death (HR 1.90 [95% CI, 1.85-1.96]) compared to other sites, and males experienced worse overall survival (OS) (HR 1.74 [95% CI, 1.70-1.78]) compared to females. The last and greatest risk of death is associated with LEM and HNM, respectively. Given these survival differences, consideration should be given to incorporating the primary site of melanoma into staging to ensure treatment is efficacious as possible.

Incidence and patterns of lymphatic drainage to the epitrochlear and popliteal sentinel lymph nodes in malignant melanoma of the distal extremities: a single‐institution retrospective study

In most cutaneous melanomas of the distal extremity, sentinel lymph nodes (SLNs) are identified in the axillary or inguinal basin; however, they may be occasionally found in the epitrochlear or popliteal basins. The incidence and patterns of lymphatic drainage to the epitrochlear or popliteal SLNs are unclear. To clarify the incidence and clinical characteristics of melanoma draining to these ectopic SLNs, we performed a retrospective study of the patients with distal extremity melanoma who underwent SLN biopsy at the National Cancer Center Hospital between April 2010 and December 2017. We identified 27 patients with melanoma of the distal upper extremity and 113 patients with melanoma of the distal lower extremity. All patients with distal upper and lower extremity melanomas had SLNs in the axillary and inguinal basins. Epitrochlear SLNs were found in 14.8% (4/27) of the patients with upper extremity melanoma, and the frequency increased by 36.4% (4/11) when the primary melanoma was located in the basilic vein area (P = 0.00188). Popliteal SLNs were found in 21.2% (24/113) of the patients with lower extremity melanoma, and the frequency increased by 37.9% (22/58) when the primary melanoma was located in the lesser saphenous vein area (P < 0.0001). The incidence of SLNs identified in the epitrochlear or popliteal basin is not uncommon, and physicians need to be aware of these ectopic SLNs, especially when the primary melanoma is located in the basilic vein or lesser saphenous vein areas accordingly.

Cutaneous melanoma: a study on the updated pathologic stage, solar elastosis, and tumor-infiltrating lymphocytes

Background Melanoma ranks as the third most common cutaneous malignancy, but it is the most lethal if early surgical treatment is neglected. Recently, updates were made on the American Joint Committee on Cancer staging system, as well as guidelines for surgical excision. Previously, grading systems were made to measure cumulative damage (solar elastosis) and to evaluate the immune reaction against the tumor [tumor-infiltrating lymphocytes (TIL)]. Aim To apply the fore mentioned advances to a series of 146 Egyptian patients primarily treated by surgery. The histochemical stains used for solar elastosis included Verhoeff stain and Alcian blue stain, pH 2.5. For phenotyping of lymphocytes and natural killer cells, the following immune markers were used: CD3, CD8, CD4, and CD56. Results Most tumors (64.4%) presented with an advanced size (>4 mm), lymph node metastases (66.7%), and inadequate excision margin (66.4%). In association analysis, only age more than 50 years, head and neck location, and the superficial spreading histologic type were significantly associated with solar elastosis. Moreover, only old age (>50 years) and large tumor thickness (>4 mm) are associated with low level of TIL, denoting poor immune reaction. Conclusion The presentation of Egyptian patients with advanced stages of melanoma calls for the implementation of public education program including self-examination of skin to detect melanoma at an early stage. Moreover, prospective follow-up studies are needed to develop guidelines of surgical excision suitable for our advanced cases. The negativity of both solar elastosis and TIL in melanoma of lower extremity supports the trauma of combined immunodeficiency and trauma in oncogenesis at this location.

Management of sentinel lymph nodes in lower extremity melanoma with dual-basin (inguinal and popliteal) drainage on lymphoscintigraphy

Management of sentinel lymph nodes in lower extremity melanoma with dual-basin (inguinal and popliteal) drainage on lymphoscintigraphy

Malignant Melanoma with Simultaneous Inguinal and Popliteal Lymph Node Metastases: A Rare Case Report

Metastatic malignant melanomas of the distal leg and the foot traditionally metastasize to the lymph nodes of the groin. Rarely, the first site of nodal metastasis can be the popliteal fossa. The rate of popliteal metastasis in lower extremity melanomas ranges from 0.3% to 7%. Simultaneous popliteal and inguinal lymph node metastases are also quite rare. We present a case of a melanoma located in the heel with palpable popliteal lymph node involvement but without evidence of inguinal lymph node involvement on clinical examination and PET imaging. However, the histopathological results revealed that the inguinal lymph nodes had been infiltrated with melanoma. This case report is presented to draw surgeons’ attention to lymph node metastases in both the inguinal and popliteal regions, even when neither clinical examination nor imaging reveals the inguinal metastasis.

Malignant Melanoma in African-Americans: A Population-Based Clinical Outcomes Study Involving 1106 African-American Patients from the Surveillance, Epidemiology, and End Result (SEER) Database (1988-2011).

Malignant melanoma accounts for 75% of all skin cancer deaths and is potentially curable if identified early. Although melanoma is rare in African–Americans (AA), it is associated with a worse prognosis than in Caucasians. This study examines the demographic, pathologic, and clinical factors impacting AA melanoma outcomes.Data for 1106 AA and 212,721 Caucasian cutaneous melanoma patients were abstracted from the Surveillance, Epidemiology, and End Result (SEER) database (1988–2011). Data were grouped on the basis of histological subtypes: “Superficial Spreading” (SS), “Nodular” (NM), “Lentigo Maligna” (LM), “Acral Lentiginous” (AL), and “Not otherwise specified” (NOS).Cutaneous malignant melanoma occurs most commonly in the sixth and seventh decade of life. Caucasian patients presented most commonly with trunk melanomas (34.5%), while lower extremity melanomas were more common in AAs (56.1%), P < 0.001. AAs presented with deeper tumors, more advanced stage of disease, and higher rates of ulceration and lymph node positivity than Caucasians. Cancer-specific mortality was significantly higher, while 5-year cancer-specific survival was significantly lower among AAs for NM and AL subtypes. Multivariate analysis identified male gender, regional and distant stage, NM and AL subtypes as independently associated with increased mortality among both ethnic groups.AAs present most often with AL melanoma on the lower extremities, and with deeper and more advanced stage lesions. AAs have higher cancer-specific mortality for NM and LM than Caucasians. Melanoma education for AA patients and health care providers is needed to increase disease awareness, facilitate early detection, and promote access to effective treatment.

Saphenous vein sparing superficial inguinal dissection in lower extremity melanoma.

Aim. The classic inguinal lymph node dissection is the main step for the regional control of the lower extremity melanoma, but this surgical procedure is associated with significant postoperative morbidity. The permanent lymphedema is the most devastating long-term complication leading to a significant decrease in the patient's quality of life. In this study we present our experience with modified, saphenous vein sparing, inguinal lymph node dissections for patients with melanoma of the lower extremity. Methods. Twenty one patients (10 women, 11 men) who underwent saphenous vein sparing superficial inguinal lymph node dissection for the melanoma of lower extremity were included in this study. The effects of saphenous vein sparing on postoperative complications were evaluated. Results. We have observed the decreased rate of long-term lymphedema in patients undergoing inguinal lymphadenectomy for the lower extremity melanoma. Conclusion. The inguinal lymphadenectomy with saphenous vein preservation in lower extremity melanoma patients seems to be an oncologically safe procedure and it may offer reduced long-term morbidity.

Long-Term Treatment Outcome after Only Popliteal Lymph Node Dissection for Nodal Metastasis in Malignant Melanoma of the Heel: The Only “Interval Node” Dissection Can Be an Adequate Surgical Treatment

We present a patient with malignant melanoma on his heel. Wide local excision was performed, along with sentinel lymph node biopsy of the inguinal and popliteal lesions. The primary site was clear of tumor at all margins; the inguinal nodes were negative, but the popliteal node was positive for metastatic melanoma. Only radical popliteal lymph node dissection was performed. The patient went on to receive adjuvant chemoimmunotherapy. There was no recurrence or complication until the long-term followup. Popliteal drainage from below the knee is uncommon, and the rate of popliteal-positive and inguinal-negative cases is estimated to be less than 1% of all melanomas. There is no established evidence about how to treat lymph nodes in these cases. Because we considered popliteal nodes as a regional, not interval, lymph node basin, only popliteal lymph node dissection was performed, and good postoperative course was achieved. The first site of drainage is the sentinel node, and the popliteal node can be a sentinel node. The inguinal node is not a sentinel node in all lower extremity melanomas. This case illustrates the importance of individual detailed investigation of lymphatic drainage patterns from foot to inguinal and popliteal nodes.

Clinicopathologic and Survival Differences between Upper and Lower Extremity Melanomas

This analysis was performed to compare differences in clinicopathologic factors, sentinel lymph node (SLN) status, and survival between upper extremity (UE) and lower extremity (LE) melanoma patients. Post hoc analysis of a prospective clinical trial was performed of all patients with extremity melanomas with complete data. Survival was evaluated with Kaplan-Meier analysis. Univariate and multivariate analyses were performed. A total of 1115 patients aged 18 to 70 years with extremity melanomas ≥ 1.0 mm Breslow thickness were analyzed; all underwent SLN biopsy with completion lymphadenectomy for a tumor-positive SLN. Compared with UE patients, LE melanoma patients were younger, predominantly female, and had a higher rate of SLN metastasis. Kaplan-Meier analysis revealed worse 5-year disease-free survival (DFS) and worse local and in-transit recurrence-free survival in LE versus UE melanoma patients, but no difference in overall survival (OS). Subgroup analysis revealed that older patients (age > 51 years) with LE melanomas had worse DFS, local and in-transit recurrence-free-survival, and OS. LE tumor location was not an independent risk factor for OS or DFS. Compared with UE melanoma patients, those with LE melanomas have a greater risk of tumor-positive SLN and local/in-transit recurrence.

Management of Popliteal Sentinel Nodes in Melanoma

Although most melanomas on the distal lower extremity drain exclusively to inguinal lymph nodes, a small percentage (<5%) drain to interval nodes in the popliteal basin. We investigated a possible relationship between tumor-draining popliteal and inguinal nodes in patients with lower-extremity melanoma. We queried our melanoma database to identify patients who underwent sentinel node biopsy (SNB) for an infrapopliteal melanoma. Patterns of nodal drainage and nodal metastasis were analyzed. Of 461 patients who underwent SNB for a primary infrapopliteal melanoma, 15 (3.2%) had drainage to the popliteal basin. Thirteen melanomas were on the posterior leg and foot, and 2 were on the anterior lower leg. Mean Breslow thickness was 2.4 mm. All 15 patients with popliteal drainage also had inguinal drainage and therefore underwent concurrent inguinal and popliteal SNB. The average number of popliteal sentinel nodes was 1.4 (range 1 to 3). Eight patients (53%) had a tumor-positive popliteal sentinel node, and 6 of the 8 underwent completion popliteal lymphadenectomy. Four of the 8 patients (50%) also had tumor-positive inguinal sentinel nodes; all underwent complete inguinal lymphadenectomy. We also identified 9 additional patients who underwent SNB for locoregional recurrent melanomas of the infrapopliteal leg. Three (33%) of these patients had concurrent inguinal and popliteal SNB, with 1 isolated tumor-positive popliteal node found. In our series, a high percentage of popliteal sentinel lymph nodes contained metastases, and these patients frequently also had inguinal metastases. In our patients, all inguinal metastases were associated with concomitant popliteal metastases. Although it is anatomically separate, the inguinal basin appears to be a functional extension of the popliteal basin.

Why Does No One Want to Perform Lymph Node Dissection Anymore?

In this issue of Annals of Surgical Oncology, Kingham et al. from Memorial Sloan-Kettering Cancer Center present their single-institution retrospective experience of melanoma patients who did not undergo completion lymph node dissection (CLND) for a tumor-positive sentinel lymph node (SLN). Of 313 patients who had a tumorpositive SLN, 271 underwent CLND and 42 did not. Of the 42 patients who did not undergo CLND, 5 did not do so because they were found to have stage IV disease on further workup, leaving 37 patients who should reasonably have considered CLND. The nodal recurrence rates were no different in the no-CLND group (7%) versus the CLND group (6%). Because the disease-free and disease-specific survival rates were similar between the groups, the authors question the value of CLND. We must recognize the limitations of this study. It is a small, retrospective review from a single institution. The groups are not well balanced in terms of clinicopathologic factors. Patients in the no-CLND group versus the CLND group were older (median age, 70 vs. 56 years, P .01), more often had lower-extremity melanomas (40% vs. 13%, P .01), and had a trend toward thicker (3.5 vs. 2.8 mm, P .06), more often ulcerated (62 vs. 44%, P = .09) melanomas. Why did the patients not undergo CLND in this study? In 33% of cases, it seems that the surgeon essentially talked the patient out of having a CLND. Although patient refusal was cited as the most common reason for failure to perform CLND (45%), it is likely that the surgeon’s opinion strongly influenced the patients’ decisions in these cases as well. The patients who chose to forego CLND did not do so for random reasons; selection bias is a major drawback of this study. In my experience, most patients choose CLND if recommended by their surgeon. So what does this study really tell us? I believe it tells us that the experienced melanoma surgeons at Memorial Sloan-Kettering Cancer Center were very good at selecting patients who were unlikely to have nodal recurrence and/or were very likely to develop distant metastatic disease, and thus were unlikely to benefit from CLND. It does not tell us that CLND is of no value. The authors cite population studies that indicate that only 50–69% of melanoma patients in the United States who have a tumor-positive SLN undergo CLND. So why are surgeons so reluctant to perform CLND these days? To address this question, we must consider the reasons for performing CLND. There are two goals: regional disease control and cure. The patients who undergo CLND for a tumor-positive SLN fall into three camps: (1) those who do not need CLND because they do not have, and never will have, additional nodal disease; (2) those who will not benefit from CLND because they are going to die of distant metastatic disease or because their disease will recur in the regional nodes, despite the best possible lymph node dissection; and (3) those who have nonsentinel node metastases for whom CLND will prevent regional nodal recurrence and, in some cases, result in cure. The third camp undoubtedly represents the smallest group. The article by Kingham et al. implies that the third camp does Society of Surgical Oncology 2009

Outcome of Patients with a Positive Sentinel Lymph Node who do not Undergo Completion Lymphadenectomy

Completion lymph node dissection (CLND), although considered a standard approach for patients with melanoma and a positive sentinel lymph node (SLN), is not performed in as many as 50% of indicated cases. This study evaluates the outcome of patients who had a positive SLN but did not undergo CLND at Memorial Sloan-Kettering Cancer Center. A prospective database was used to identify all patients with a positive SLN from 1992 to 2008. Patient and tumor characteristics, number of positive SLNs, recurrence pattern, reason for not performing a CLND, and current status were evaluated. There were 2269 patients who underwent SLN biopsy. Three hundred thirteen had a positive SLN, of whom 271 (87%) had a CLND and 42 (13%) did not. Patients in the no-CLND group were older (median age 70 vs. 56 years, P < .01), and had a trend toward thicker melanomas (3.5 vs. 2.8 mm, P < .06). A significantly higher percentage of no- CLND patients had lower-extremity melanomas (40% vs. 13% CLND; P < .01). The most common reason for not performing a CLND was patient refusal (45%). There were similar rates and patterns of recurrence between the two groups. Recurrence-free survival and disease-specific survival were also similar between the groups. It remains unclear whether CLND must be performed in all melanoma patients with a positive SLN. For selected informed patients who choose not to participate in the Multicenter Selective Lymphadenectomy Trial II trial, or in centers where the trial is not available, nodal observation may be an acceptable option.

Complete Lymph Node Dissection for Sentinel Node-Positive Melanoma: Assessment of Practice Patterns in the United States

Currently, complete lymph node dissection (CLND) is recommended after identification of a metastatic lymph node by sentinel lymph node biopsy (SLNB). Guidelines suggest that CLND should be performed as a separate procedure, and a sufficient number of nodes should be examined. Our objective was to examine the utilization, timing, and adequacy of CLND for melanoma in the United States. From the National Cancer Data Base, patients diagnosed with stage I to III melanoma during 2004-2005 were identified. Multiple logistic regression was used to assess factors associated with CLND utilization, timing (separate operation from SLNB), and adequacy (examination of > or = 10 nodes). Of the 44,548 patients identified, 47.5% were pathologic stage IA, 23.8% stage IB, 14.1% stage II, and 14.6% stage III. Of the 17% (2942 of 17,524) with nodal metastases on SLNB, only 50% underwent a CLND. Patients were significantly less likely to undergo a CLND after SLNB if > 75 years old or had lower extremity melanomas. Of the patients who underwent a CLND, only 42% underwent the CLND at a separate procedure after the SLNB. Of those who underwent a CLND, 69.2% had > or = 10 nodes examined. Patients were significantly less likely to have > or = 10 nodes examined if they were > 75 years old or had lower extremity melanomas. Patients treated at NCCN/NCI-designated centers were significantly more likely to undergo nodal evaluation in concordance with established guidelines. Only half of patients with sentinel node-positive melanoma underwent CLND. Quality surveillance measures are needed to monitor, standardize, and improve the care of patients with malignant melanoma.

7017 POSTER Timing of lymph node involvement is an important prognostic factor in stage III patients with thick (>4.0 mm) lower extremity melanoma

Primary tumours of the meninges with a relatively high tendency for malignant behaviour are uncommon in childhood. This study concerns 18 cases of meningeal tumours in children under the age of 16, of which 13 were meningiomas and five were other tumours arising in the meninges. Meningiomas showed a preponderance in females as in adult series, and the majority were supratentorial in localisation. The percentage of meningeal tumours and meningiomas among all brain tumours in our centre were 3.72% and 2.69%, respectively. Four out of 13 meningiomas were fibroblastic, four were transitional, one was meningothelial, two were psammomatous and two were papillary meningiomas. Seven (38.8%) out of 18 tumours showed anaplastic features, including two papillary meningiomas, two hemangiopericytomas, one mesenchymal chondrosarcoma, one pleomorphic sarcoma and one anaplastic meningeal tumour. Papillary meningiomas with hemangiopericytoma-like solid areas were seen frequently in our cases (15.3%). Meningoangiomatosis was associated with two meningeal tumours. MIB1 (Ki-67) labelling indices (LIs) ranged between 0% and 13,6% (mean 1.83%) in benign, and between 1% and 20% (mean 7.2%) in malignant tumour, including papillary meningiomas. Mean MIB-1 LIs were 5.61% and 1.14% in non-recurrent and recurrent cases, respectively. MIB-1 LIs showed significant differences between benign and malignant meningeal tumours but no significant correlation either with prognosis or recurrence.

98 POSTER Prognosis of stage pT4N+ melanoma of lower extremity depends on the time of lymph nodes involvement

98 POSTER Prognosis of stage pT4N+ melanoma of lower extremity depends on the time of lymph nodes involvement

A 73-Year-Old Woman With a Cough

(CHEST 2005; 128:1018–1021) A 73-year-old woman presents to her physician complaining of a nonproductive nagging cough. Her medical history is remarkable for breast cancer treated by mastectomy 25 years prior to hospital admission and left lower extremity melanoma treated by excision 15 years prior to admission. She has a history of type II diabetes, a history of asthma that began around the age of 12 years, hypothyroidism, and a history of childhood acne treated with radiation therapy. She also has a 10 pack-year history of smoking, having stopped 43 years ago. Her surgical history is notable for a tonsillectomy, adenoidectomy, nasal polyps, dilatation and curettage, hysterectomy, and thyroidectomy. At presentation, the patient is receiving levothryoxine, conjugated estrogen, and latanoprost eye drops. She reports multiple allergies to medications, including iodinated contrast, erythromycin, codeine, tetracycline, nitrofurantoin, aspirin, atropine, and bacitracin. Physicial examination shows a well-nourished woman breathing comfortably on room air. Her pulse is 81 beats/min, respiratory rate is 18 breaths/min, and BP is 112/54 mm Hg. Her neck is supple to palpation without evidence for cervical or supraclavicular lymphadenopathy. Her oropharynx is within normal limits. Her chest is clear to auscultation without evidence for wheezing or crackles. Her cardiac examination is within normal limits. A chest radiograph (Fig 1) demonstrates a focal, oblong, 4-cm mass in the right middle lobe. Chest CT (Fig 2) shows that this mass is of slight increased attenuation compared to the skeletal muscle. No adenopathy is noted. The patient undergoes bronchoscopy, which demonstrates no evidence for an endobronchial lesion in the central or segmental airways. Whole-body positron emission tomography (PET) is then performed and shows intermediate uptake in the majority of the mass with a small focus of markedly increased 18-fluorodeoxyglucose (FDG) uptake within the center of the lesion (Fig 3). There is intermediate uptake in the right hilum on the PET scan. The patient is subsequently referred for a right middle lobe lobectomy.

Lymphatic mapping and sentinel lymph node biopsy in patients with melanoma of the lower extremity.

Lymphatic mapping and sentinel lymph node biopsy is a new technique used in the surgical treatment of patients with malignant melanoma. The purpose of this study was to evaluate the results of this approach for patients with melanoma of the lower extremity. Between May of 1994 and June of 1997 at the H. Lee Moffitt Cancer Center and Research Institute, 85 consecutive patients with clinical stage I and II melanoma of the lower extremity underwent lymphatic mapping and sentinel lymph node biopsy. These nodes were identified in all 85 patients by intraoperative lymphatic mapping with both radiolymphoscintigraphy and a vital blue dye injection. Eleven patients (12.9 percent) had histologically positive sentinel lymph nodes, and 10 patients underwent inguinal complete lymph node dissections. All 10 patients had no further histologically positive lymph nodes confirmed by subsequent complete dissection. Among 74 patients with histologically negative sentinel lymph nodes, only 2 patients (2.7 percent) developed inguinal nodal metastases during a mean follow-up period of 21.8 months (range, 13.5 to 58.3 months). The sensitivity of lymphatic mapping and sentinel lymph node biopsy in this series was 100 percent and the specificity was 97.3 percent. Therefore, we conclude that the use of lymphatic mapping and sentinel lymph node biopsy can accurately stage patients with melanoma of the lower extremity and provide a rational surgical approach for these patients.

Ultra-late recurrence (15 years or longer) of cutaneous melanoma

Melanoma can remain clinically quiescent for decades before regional or distant recurrence appears. This protracted disease free interval challenges the concept of a "cure" for melanoma. To understand this prolonged dormancy better, the authors retrospectively studied patients who developed recurrent melanoma 15 years or longer after their initial diagnosis ("ultra-late" recurrence). These cases were identified from 2766 melanoma diagnoses available in the Cancer Registry at the Massachusetts General Hospital (MGH). Histologic features of the primary lesion were also included when possible. Twenty cases were retrieved from the MGH database. There were equal numbers of women and men, although women were younger at the time of initial diagnosis (mean age of women: 29.8 years vs. 43.0 years for men). No patients had more than one primary cutaneous melanoma. The trunk was the most common primary site (35%), although there was no predominant anatomic localization. The average disease free interval was 17.3 years for women, 20.0 years for men, 18.1 years for patients with regional recurrence, and 19.0 years for patients with distant metastases. Distant recurrence was the most common type of recurrence (50% of women and 60% of men). The estimated probability of survival (5 years after recurrence) was 0.8 for regional disease and 0.2 for distant disease. With the available histologic records, it appears that almost all tumors were Clark Level III or IV with thicknesses ranging from 0.8-2.3 mm. In contrast to the published cases, this study did not find that women with lower extremity melanomas were at higher risk for developing ultra-late recurrence. Ultra-late recurrence of melanoma, although uncommon, can occur in any patient without identifiable risk factors. Because many prognostically favorable melanomas (thin melanomas on extremities) can recur after prolonged disease free intervals, the possibility of delayed recurrence remains and must be kept in mind.

Ultra‐late recurrence (15 years or longer) of cutaneous melanoma

BACKGROUND Melanoma can remain clinically quiescent for decades before regional or distant recurrence appears. This protracted disease free interval challenges the concept of a "cure" for melanoma. METHODS To understand this prolonged dormancy better, the authors retrospectively studied patients who developed recurrent melanoma 15 years or longer after their initial diagnosis ("ultra-late" recurrence). These cases were identified from 2766 melanoma diagnoses available in the Cancer Registry at the Massachusetts General Hospital (MGH). Histologic features of the primary lesion were also included when possible. RESULTS Twenty cases were retrieved from the MGH database. There were equal numbers of women and men, although women were younger at the time of initial diagnosis (mean age of women: 29.8 years vs. 43.0 years for men). No patients had more than one primary cutaneous melanoma. The trunk was the most common primary site (35%), although there was no predominant anatomic localization. The average disease free interval was 17.3 years for women, 20.0 years for men, 18.1 years for patients with regional recurrence, and 19.0 years for patients with distant metastases. Distant recurrence was the most common type of recurrence (50% of women and 60% of men). The estimated probability of survival (5 years after recurrence) was 0.8 for regional disease and 0.2 for distant disease. With the available histologic records, it appears that almost all tumors were Clark Level III or IV with thicknesses ranging from 0.8-2.3 mm. In contrast to the published cases, this study did not find that women with lower extremity melanomas were at higher risk for developing ultra-late recurrence. CONCLUSIONS Ultra-late recurrence of melanoma, although uncommon, can occur in any patient without identifiable risk factors. Because many prognostically favorable melanomas (thin melanomas on extremities) can recur after prolonged disease free intervals, the possibility of delayed recurrence remains and must be kept in mind. Cancer 1997; 79:2361-70. © 1997 American Cancer Society.