Isolated regional perfusion in the treatment of subungual melanoma

Treatment outcomes of advanced stage malignant melanoma in hand and foot after amputation in Korean patients

BACKGROUND

A retrospective study was conducted to review the overall survival and treatment outcomes of high grade melanoma in the extremity to explore the clinical features of malignant melanoma of the hand and foot, and the therapeutic efficacies and survival rate after amputation.

METHODS

The clinical data of 30 patients with malignant melanoma of the hand and foot (confirmed by pathological examination), who were admitted and treated in our hospital between 2001 and 2010, were analyzed retrospectively. We analyzed variables affecting overall and disease-free survival.

RESULTS

Thirty patients (18 men and 12 women) treated with an amputation procedure for malignant melanoma in the hand or foot constituted the study cohort. The average age of the patients at the time of diagnosis was 58.7 years. Univariate analysis for overall melanoma survival revealed that diagnosis at over 70 years of age, postoperative lymph node metastasis, and location of the tumor were significant prognostic factors. And on the Kaplan-Meier survival curve, old age, American Joint Committee on Cancer stage and postoperative lymph node metastasis showed statistically significant differences in the 5-year survival rate. Also, amputation with aggressive lymph node dissection showed improved long term survival in advanced stage melanoma.

CONCLUSIONS

In Korean melanoma patients, for the treatment of high grade melanomas in the extremities after amputation, early diagnosis and postoperative follow-up for evaluation of lymph node metastasis are critical factors for long-term survival. And by performing lymph node dissection during amputation, we may improve the survival rate in advanced stage melanoma patients.

Nail apparatus melanoma

Nail apparatus melanoma is a relatively rare variant of melanoma with a disproportionately high mortality when compared with melanoma elsewhere. The aetiology and natural history remain poorly understood. There is no clear epidemiological association with race, skin type or sun exposure. Universally accepted clinical and histological criteria for the diagnosis of early nail apparatus melanoma have not been defined. The two cardinal clinical signs are melanonychia striata and Hutchinson's sign. These are useful but not pathognomonic of melanoma. Diagnostic delay is frequent and patients commonly have advanced disease at the time of diagnosis. Surgical excision is advocated for treatment of stage I disease; however, the most appropriate re-excision margins, including the level of amputation where required, have not been determined. Early diagnosis and excision of the tumour is the only treatment known to increase survival. Adjuvant systemic chemotherapy, isolated limb perfusion, and routine elective lymph node dissection have been used, but no survival benefit has been demonstrated.

Mortality, major amputation rates, and leukopenia after isolated limb perfusion with phenylalanine mustard for the treatment of melanoma

BACKGROUND

Isolated limb perfusion (ILP) is a treatment for cutaneous melanoma performed by several centers worldwide. The final data analysis of the World Health Organization and European Organization for Research and Treatment of Cancer in the use of ILP as adjuvant treatment for cutaneous melanoma is pending. ILP is effective to treat recurrent cutaneous melanoma. We determined the published rates of morbidity and mortality of ILP and put that component of the procedure into contemporary perspective.

METHODS

A MEDLINE search was conducted of the English-language literature from 1980 to 1995 for all publications reporting perfusion with phenylalanine mustard alone or combined with other agents. Patients treated by staged perfusion or fractional doses of chemotherapy were excluded. All published series were analyzed for the rate of mortality, number of major amputations, and presence of leukopenia.

RESULTS

The 30-day mortality rate for > 2,000 patients was 0.6%. Death often resulted from cardiopulmonary complications or overwhelming sepsis from leukopenia. Leukopenia occurred in 0.7% of patients reviewed, caused by leakage of chemotherapeutic agents into the systemic circulation. Major amputations occurred in 0.8% of patients, and most were of the lower extremity.

CONCLUSIONS

The definition of efficacy of ILP in the treatment of extremity melanomas remains to be clearly defined. However, based on this review of worldwide publications, the risk of death, amputation, and leukopenia is low.

Pathologic fracture secondary to subungual melanoma

Subungual melanoma is uncommon, and delays in diagnosis and misdiagnosis occur frequently. We describe a 61-year-old black male who presented with a non-healing area in his left thumb nailbed with many of the features of subungual melanoma. However, the patient also had a pathologic fracture of the distal phalanx, leading to some initial confusion about the diagnosis. Despite aggressive multimodality therapy, the disease rapidly progressed, resulting in the patient's death. Pathologic fracture due to subungual melanoma may indicate a particularly poor prognosis.

Single-centre prospective study of isolated limb perfusion with melphalan in the treatment of subungual malignant melanoma

Subungual melanoma is rare and experience in treating this condition with isolated limb perfusion is limited. Between 1985 and 1990, 24 patients were treated by digital amputation and isolated limb perfusion with melphalan and mild hyperthermia. The disease was staged according to the M.D. Anderson classification: stage I (17 patients), stage IIIA (one), stage IIIB (two) and stage IIIAB (four). Thirteen lesions were on the foot and 11 on the hand. Seven patients have developed locoregional recurrence. The estimated overall 2- and 5-year probabilities of survival were 77 and 46 per cent respectively, while for disease-free survival the rates were 58 and 51 per cent. When these results were compared retrospectively with those in 111 patients treated by amputation alone, no significant difference in survival was demonstrated. This experience suggests that isolated limb perfusion with melphalan and mild hyperthermia confers no additional survival benefit over appropriate surgery.

Hyperthermic isolated limb perfusion for malignant melanoma: response and survival

Response to and survival after hyperthermic isolated limb perfusion (HILP) with melphalan in patients with malignant melanoma at the Royal Brisbane Hospital were reviewed in order to assess the major determinants of response to treatment. Data were collected by clinical chart review and direct patient contact. Response was assessed by clinical observation and measurement of nodules. Survival was calculated from the date of perfusion to the date of patient death. Since 1965 there have been 85 patients (38 men, 47 women) who have undergone 109 limb (102 leg, 7 arm) perfusions. The mean age was 58 years (range 32-82 years). The number of patients per disease stage (M.D. Anderson classification) was as follows: stage I, 5 patients; stage II, 8 patients; stage IIIa, 41 patients; stage IIIab, 25 patients; and stage IIIb, 8 patients. The mean duration of perfusion was 81 minutes. Melphalan was given in divided doses, with a mean total dose 1.39 mg/kg. The mean maximal limb temperature was 41.5 degrees C. Major complications occurred during 20 perfusions (18%). There was one postoperative death from myocardial infarction, and one patient required amputation. Median patient follow-up was 2.65 years (range 1-27 years). A complete response was noted in 34 patients (40%), a partial response in 36 patients (42%), and no response in 11 patients (13%). Response could not be assessed in four patients. The actuarial 5-year survival for the whole group was 45%: stage I, 80%; stage II, 75%; stage IIIa, 44%; stage IIIab, 23%; stage IIIb, 56%. The two significant determinants of response to perfusion were disease stage (p = 0.00005) and nodal status (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical management and prognostic factors in patients with subungual melanoma

OBJECTIVE

Forty-six cases of subungual melanoma were reviewed to identify significant clinicopathologic prognostic factors, determine the role of DNA content analysis in the biologic assessment of these tumors, and evaluate the effectiveness of amputation level, lymph node dissection (LND), and regional limb perfusion on the survival of these patients.

BACKGROUND

Subungual melanoma is a unique and rare subtype of melanoma, constituting only 1% to 3% of cases. Thus, little is known about prognostic factors and optimal management of patients with this disease. Moreover, the appropriate level of amputation and LND and limb perfusion in the management of subungual melanoma remain controversial.

METHODS

Forty-six patients underwent amputation alone or in combination with LND and/or regional limb perfusion for primary subungual melanoma. The effects of these treatment modalities and the prognostic significance of patient and tumor-related variables, including DNA flow cytometric data, on overall survival were assessed.

RESULTS

Univariate statistical analysis identified six factors that significantly affected patient survival. They were stage at diagnosis (p = 0.0001), percentage of aneuploid cells (p = 0.01), presence of ulceration (p = 0.02) or bone invasion (p = 0.02), thickness of the primary lesion (p = 0.03), and percentage of cells in S-phase (p = 0.03). Multivariate analyses identified tumor stage and S-phase fraction as independent prognostic factors in these patients. Survival did not differ among patients who received amputation alone or those who underwent amputation in combination with LND or perfusion (p = 0.90); however, the use of limb perfusion reduced the incidence of locally recurrent disease. The level of amputation did not affect patient survival (p = 0.74) or the incidence of local recurrence.

CONCLUSIONS

The study identified several significant prognostic factors, including DNA flow cytometric parameters, in patients with subungual melanoma. In addition, it showed that conservative amputation of the affected digit at the level of the proximal interphalangeal or metacarpophalangeal/metatarsophalangeal joint appears to be safe, provided that clear margins are obtained. Although isolated limb perfusion may reduce the incidence of local recurrence, LND, or limb perfusion in the routine management of subungual melanoma remains controversial.

Acral melanoma: a review of 185 patients with identification of prognostic variables

One hundred eight-five patients with acral melanoma treated since 1972 were reviewed. These included 53 subungual lesions, 123 plantar lesions, and 9 palmar lesions. Eighty percent presented with stage I disease. Mean age was 57 years. Males outnumbered females 1.1:1. Seventeen percent (17%) were blacks. Actuarial 10-year survival was 58% for stage I patients and 35% for stage II patients. Univariate Cox regression analyses identified 5 prognostic variables affecting survival: stage at diagnosis (P less than 0.001), race (P less than 0.001), ulceration (P = 0.012), Clark's level (P = 0.014), and thickness of the primary lesion (P = 0.013). Factors unrelated to survival included sex of the patient, site (volar vs. subungual), histology, and treatment with amputation. Multivariate analysis for patients with stage I lesions identified race (P = 0.001) and ulceration (P = 0.018) as significant variables, with thickness approaching significance (P = 0.094). In an additional series of 71 patients with melanomas arising from extremity sites near the junction of glabrous and non-glabrous skin, survival was significantly poorer for those arising from glabrous skin (P = 0.024), and reflects a higher incidence of metastatic disease at diagnosis. Specific active immunotherapy was the principal adjuvant used for these patients, and survival was comparable to that reported with regional perfusion therapy. Acral melanoma a) has a strong racial predilection, b) carries a grave prognosis, and c) arises from glabrous skin. It is a clinical entity distinct from other extremity melanomas. Surgical management with either wide excision or amputation is appropriate for the primary lesion.

Subungual Melanoma of the Hand

Thirteen patients with subungual melanoma on the fingers had a mean delay before diagnosis of 1.2 years. Four patients presented with local recurrence after inadequate initial treatment and two presented with systemic metastases. Mean primary subungual melanoma thickness was 6.1 mm. and nine patients had Clark level IV or V disease. All patients underwent digital amputation. Two of seven patients who had localised disease initially are alive at 29 and 44 months. One of four patients who had locally recurrent melanoma is alive at 36 months. Both patients with systemic disease at presentation died. Advanced disease and delayed presentation contributed to the poor prognosis of subungual melanoma in our patients.