Treatment Of Primary Melanoma Research Articles

Factors related to the presentation of patients with thick primary melanomas

To identify any characteristics of patients that are associated with presentation with thick primary melanoma. This was a retrospective survey of the clinical records of 1300 patients attending the Newcastle Melanoma Unit. Characteristics of 131 patients with thick melanomas (defined as 3 mm or greater in thickness) were compared with those of 543 patients with thin melanomas (defined as 0.75 mm or less in thickness). Comparisons were made using contingency table analysis, Wilcoxon rank sum tests, log rank analysis and logistic regression. The Newcastle Melanoma Unit is a tertiary referral centre for the treatment of primary melanoma. We surveyed all 1300 patients attending the Newcastle Melanoma Unit over the years 1981-1990. They represented approximately 90% of the patients in the Hunter region of New South Wales who developed melanoma during this period. Excluded from analysis were 39 patients with occult primary melanomas, 79 with multiple primary melanomas, 51 with primary melanomas of unknown thickness and seven with incomplete records, leaving 1124 patients in the study. These were selected before the results were known. The hypothesis was generated following analysis of the data. Patients with thick primary melanoma were more likely to be men (68% men and 32% women in the thick melanoma group, compared with 45% and 55% respectively in the thin melanoma group, P less than 0.005) over 60 (75% were over 50 years of age in the thick group versus 33% in the thin melanoma group, P less than 0.001) with nodular melanoma (62%, versus 2% in the thin melanoma group, P less than 0.001) and with melanoma on the head and neck (27%, versus 12% in patients with thin melanoma, P less than 0.005). The time from detection of a change in skin to diagnosis was not longer for those with thick compared to those with thin melanomas. The greatest problem of those with thin melanomas. The greatest problem of detecting melanoma at an early (surgically curable) stage appears to be in patients over the age of 50 who have nodular melanoma, particularly in the head and neck.

Should elective lymph node dissection be used for treatment of primary melanoma?

A bicenter study compared survival probability in patients with malignant melanoma clinical stage I, treated by wide excision only or wide excision with elective lymph node dissection (ELND). ELND improved the survival only in men with primary tumors of 1.51-3.0 mm thickness. In female patients those without ELND showed a better survival. Thus, the total group of patients did not benefit from ELND, i.e. its value for the improvement of survival from malignant melanoma stage I could not be statistically proven.

Malignant melanoma, evaluation of clinical follow up by questionnaire survey

A retrospective questionnaire study, by post, revealed that 69% of patients, still living following first tumour recurrence, had detected the recurrence themselves prior to routine clinic appointments. Nearly 90% developed their first recurrence in the first 5 years following primary surgical treatment. Not only could the length of routine clinic follow-up after primary melanoma treatment be shortened, but with further education of the patient and involvement of the general practitioner it seems likely that patients can be trusted to detect their own recurrences and seek appropriate advice.

Prognostic Significance of Leukocyte-Dependent Antibody Activity in Melanoma Patients<xref ref-type="fn" rid="FN2">2</xref><xref ref-type="fn" rid="FN3">3</xref>

Sera from patients with melanoma and control subjects were examined for leukocyte-dependent antibody (LDA) activity against cultured melanoma and control nonmelanoma target cells in 51Cr release cytotoxicity assays. In over a third of 344 melanoma patients, LDA activity against melanoma cells was related to tumor growth, shown by disappearance of the LDA after surgical removal of melanoma. Tumor-related LDA activity was not detected in 143 controls with various nonmelanoma malignant conditions and benign skin lesions. Approximately 5% of the patients had high-titer melanoma LDA that was unchanged by surgical removal of the tumor, and 15% had melanoma LDA revealed in their sera only after the sera had been treated to dissociate immune complexes. In patients with stage I melanoma, the disease-free interval was significantly longer in those with tumor-related LDA compared to those with no LDA. Analysis of the data in relation to known prognostic variables suggested that the main influence of LDA on prolongation of the disease-free interval was in males. An association between tumor-related LDA and a longer disease-free interval was also apparent in patients with stage II melanoma at first presentation but not in those with recurrence after prior treatment of primary melanoma. The results suggest that LDA activity against melanoma cells in the sera of patients after surgical removal of stage I or stage II melanoma is a favorable prognostic factor. Further studies are needed to determine whether induction of melanoma LDA by immunotherapy may improve the outcome in patients without naturally occurring LDA.

Stage I melanoma of the skin: the problem of resection margins

The importance of the width of resection margins in the treatment of primary malignant melanoma of the skin was evaluated on the basis of 593 stage I patients collected by the W.H.O. Collaborating Centres for Evaluation of Methods of Diagnosis and Treatment of Melanoma. The chances of cure of these patients were reduced with increasing thickness ( P < 0.001), while survival was not influenced by the size of resection margins ( P = 0.66). Local recurrences, as first sign of relapse of the disease, were observed in 25 patients (4.2%). The percent of recurrences increased from 1.1 to 5.8% with increasing thickness and decreased from 10.8 to 3.0% with increasing margins of resection. This last trend was probably due to a different ratio of thick/thin tumors in various groups of resection margins, because the increase of local recurrences with decreasing margins was no more significant considering patients with maximum thickness equal or less than 2 mm and more than 2 mm. The rate of local recurrences was significantly lower ( P < 0.025) in patients with maximum thickness no more than 2 mm. The authors do not draw final conclusions on this matter because the number of patients with ‘narrow’ excision is too limited and because surgeon's choice of treatment may bias the results. A prospective randomized trial is proposed to evaluate whether or not ‘narrow’ excision may be considered the treatment of choice of thin ≦ 2 mm) cutaneous melanoma.

Diagnosis, treatment and prognosis of early melanoma. The importance of depth of microinvasion.

There are many clinicopathologic features of the lesion and host which influence the natural course of melanoma. Currently, the most important prognostic factor appears to be the depth of invasion of the primary lesion. Using either the Clark's level of microinvasion or the tumor thickness as measured by Breslow, there is good correlation of decreasing survival rates, and increasing incidence of occult metastasis in regional nodes with deeper invasion of the tumor. Thus, proper diagnosis and treatment of primary melanoma depends on the information of depth of microinvasion. And patients with high-risk of developing occult metastasis in regional nodes can be identified. Although two recent studies question the value of performing prophylactic regional lymphadenectomy, none of these studies utilized depth of microinvasion to select patients who have a high chance of having extension or relapse only in regional nodes.

Treatment of primary malignant melanoma of the extremities by isolated regional perfusion: H. Schraffordt Koops ( University Hospital, Groningen, The Netherlands)

Treatment of primary malignant melanoma of the extremities by isolated regional perfusion: H. Schraffordt Koops ( University Hospital, Groningen, The Netherlands)

Surgical treatment of malignant melanoma of the skin.

AbstractSurgery is the primary therapeutic modality in the treatment of primary melanomas and metastases to lymph nodes. Surgery also plays an important role in the therapy of locally recurrent tumors and distant metastases in selected cases. Wide excision of the primary tumor in stage I malignant melanoma results in a recurrence rate of about 2%. Surgical techniques for lymph node dissection are the same for melanoma as those performed for other malignancies. There is little question that dissection is necessary in obviously involved nodal areas, but controversy remains regarding the value of lymph node dissection of clinically uninvolved regional nodes. A prospective, randomized study by the World Health Organization has shown no improvement in survival for patients who underwent elective regional node dissection.Surgery is the treatment of choice when melanoma recurs locally as a single cutaneous or subcutaneous nodule. Surgery may also result in long‐term, disease‐free survival in patients with a solitary distant metastasis after treatment of a primary lesion.

A preliminary report of a pilot trial in adjuvant chemotherapy of primary melanoma.

It is well known that level of skin invasion and tumor thickness are significant prognostic factors in the evolution of primary melanoma. The prognosis of primary melanoma Clark III to V skin invasion level and more than 1.5 mm thick confirms this statement. Even the prophylactic dissection of regional lymph nodes has not improved results. In an attempt to obtain better results in the treatment of primary melanomas, a pilot trial was carried out combining surgery and adjuvant chemotherapy. A group of 21 patients with Clark III, IV and V level primary melanoma who underwent adjuvant polychemotherapy (velba + dactinomycin + procarbazine) for 1 year after surgery showed a very low incidence of recurrences (5%) after 24 months of observation. The historical control group, with the same level of tumor skin invasion, treated only surgically had in the same follow-up period a recurrence rate of 65%. This difference was statistically significant (p less than 0.01). All patients who received adjuvant chemotherapy survived 2 years whereas survival was 77% (p less than 0.05) in the surgical historical control group. Favorable results with the same protocol of adjuvant chemotherapy were not obtained in the group of 16 patients with stage II melanoma when compared with primary tumors. However, 4 recurrences were observed after 12 months of observation; toxic side effects of adjuvant chemotherapy were mild and tolerable. Considering the insufficient number of clinical trials with adjuvant chemotherapy, as well as sometimes controversial results, further randomized clinical studies are needed to establish the actual value of this conbined method in the treatment of primary melanoma with a high risk of dissemination.

Characteristics of the Primary Lesion of Malignant Melanoma as a Guide to Prognosis and Therapy

The histologic materal from the original lesion of 113 patients suffering from Clinical Stage I and Clinical Stage II malignant melanomas were reviewed in an attempt to correlate depth of invasion with prognosis and to test whether or not current methods of microstaging were a valid guide to therapy. Both the microstaging methods of Clark and Breslow were eminently successful in indicating the prognosis of the patient, but were of no greater utility than other histologic parameters such as mitotic activity, perineural, vascular, or lymphatic invasion, or the presence of superficial ulceration. The value of elective node dissection for the treatment of primary malignant melanoma is uncertain. Deterents against empiric dissection are its low yield of occult metastases, its inability to prevent recurrence in a substantial portion of patients independent of the status of the nodes, and the difficulty in demonstrating an improved survival rate when this method of therapy is employed. Neither Clark's nor Breslow's methods or microstaging appeared to yield adequate criteria by which to choose node dissection. A simplified method of microstaging is proposed utilizing well defined anatomic levels, and yields statistically valid criteria for the performance of elective node dissection. Using this method, elective node dissection is advocated solely for those tumors that clearly invade the reticular dermis. Patients with tumors restricted to the papillary dermis do not appear to be benefited by empiric node dissection.

A clinical trial of BCG immunotherapy as an adjunct to surgery in the treatment of primary malignant melanoma

A preliminary analysis of a controlled trial of BCG immunotherapy as an adjunct to surgery in the treatment of primary malignant melanoma has been carried out. The length of follow-up varied from 5 years to 6 months. No obvious benefit from BCG immunotherapy has been found so far. On the other hand the treatment is painful with an appreciable morbidity. Skin tests for delayed hypersensitivity have shown no recognisable differences in patients treated with surgery and those who also had BCG, or in the pattern of responses in those who developed recurrences and those who did not. In view of these early findings trial entry has been closed.

A clinical trial of BCG immunotherapy as an adjunct to surgery in the treatment of primary malignant melanoma

A clinical trial of BCG immunotherapy as an adjunct to surgery in the treatment of primary malignant melanoma

Malignant: Some aspects of the treatment of primary malignant melanoma of the extremities by isolated regional perfusion

Malignant: Some aspects of the treatment of primary malignant melanoma of the extremities by isolated regional perfusion

Some aspects of the treatment of primary malignant melanoma of the extremities by isolated regional perfusion.

This paper reviews the changing concepts in the treatment of patients with malignant melanoma localized on the arm or leg. In addition to conventional surgical treatment, isolated regional perfusion of the extremities is discussed. An evaluation is presented of clinical and histological criteria applied to determine indications for conventional surgical treatment and for perfusion. It is maintained that isolated regional perfusion of arm or leg should be performed when the primary tumor meets one of the following criteria: (1) depth of tumor invasion beyond the papillary layer (Clark levels III, IV and V); (2) vascular invasion; (3) tumor diameter exceeding 1 cm; (4) ulceration. If none of these four criteria applies, conventional surgical treatment alone has proved to give very good results.

Treatment of primary melanoma by intralesional vaccinia before excision

Treatment of primary melanoma by intralesional vaccinia before excision

Malignant melanoma of the extremities: a clinicopathologic study using levels of invasion (microstage).

A clinicopathologic study was done in 151 patients with malignant melanoma of the extremities who were surgically treated in Memorial Hospital and had 5-to 9-year followup. Microstaging was done according to the depth of invasion, as determined by Clark's levels as well as by direct measurement. This was related to treatment and to clinical course. There was a correlation between the depth of invasion by Clark's levels and the incidence of lymph node metastases in patients with Stage I melanoma who had elective node dissection. The incidence of nodal metastases was 4% for Level II, 7% FOR Level III, 25% for Level IV, and 70% for Level V. There was a correlation between Clark's level of invasion and survival aftter surgery. The 5-year cure rate was 100% for Level II, 88% for Level III, 60% for Level IV, and 15% for Level V melanoma. The presence of nodal metastases augured a much worse prognosis than Clark's level per se. In patients with Level IV melanoma, the 5-year cure rate was 82% in patients with negative nodes and 27% in those with nodal metastases after elective node dissection. Microstaging primary melanoma according to Clark's levels serves as a useful standard with which to compare surgical results. In this series of extremity melanomas there was no difference between local recurrence and lymphadenectomy for Level II melanoma. For Level III and Level IV melanoma, wide excision and lymphadenectomy gave higher cure rates than wide excision only, both at 5 and 9 years after surgery. The results were significant only for patients with Level III, however. Use of the measured depth of invasion added significant clinicopathologic information. The incidence of nodal metastases at elective node dissection was 5 to 9% for melanoma showing 0.6 to 2.0 mm of invasion, 22% for melanoma measuring 2.1 to 3.0 mm, and 39% for melanoma invading beyond 3.0 mm. The 5-year cure rate was 100% for melanoma measuring less than 1.0 mm, 83% for melanoma invading 1.1 to 2.0 mm, 58% for lesions measuring 2.1 to 3.0 mm, and 55% for melanoma invading over 3.0 mm. The microstage technique combining Clark's levels and the measured depth of invasion has an important use as a prognostic index and as a standard upon which to select treatment for primary melanoma of the extremities.

METASTATIC NASAL MELANOMA PRESENTING AS INTUSSUSCEPTION OF THE ILEUM

A 74-year-old man presented with intestinal obstruction four years after treatment for primary malignant melanoma of the nose. The cause of the obstruction was a solitary polypoid secondary deposit in the distal part of the ileum which had resulted in an Intussusception. This case is unusual because primary melanoma of the nasal cavity is a rare tumour, and metastatic melanoma of the small intestine Is an uncommon lesion, which is infrequently diagnosed during life.

Isolation perfusion: An adjunct to surgical excision in the primary treatment of melanoma of the extremities

We have presented our experience with nineteen patients with melanoma of an extremity with regional lymph nodes clinically free of metastases, treated by regional lymphadenectomy, isolation perfusion with phenylalanine mustard, and wide local excision. The rationale for this approach is reviewed. Our series is too small to be of statistical significance, but our own experience added to that of others utilizing this plan of treatment has encouraged us to continue this vigorous attack on melanoma located on an extremity.