Survival superiority of females with melanoma. A multivariate analysis of 6383 patients exploring the significance of gender in prognostic outcome

Improved survival in women versus men with merkel cell carcinoma

BACKGROUND

Studies have observed that women have better outcomes than men in melanoma, but less is known about the influence of sex differences on outcomes for other aggressive cutaneous malignancies.

OBJECTIVE

To investigate whether women and men have disparate outcomes in Merkel cell carcinoma (MCC).

METHODS

Patients with nonmetastatic MCC undergoing surgery and lymph node evaluation were identified from the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier analysis and Cox proportional hazards regression models were used for overall survival, and competing-risks analysis and Fine-Gray models were used for cause-specific and other-cause mortality.

RESULTS

The NCDB cohort (n = 4178) included 1516 (36%) women. Women had a consistent survival advantage compared with men in propensity score-matched analysis (66.0% vs 56.8% at 5 years, P < .001) and multivariable Cox regression (hazard ratio, 0.68; 95% confidence interval, 0.61-0.75; P < .001). Similarly, women had a survival advantage in the SEER validation cohort (n = 1202) with 457 (38.0%) women, which was entirely due to differences in MCC-specific mortality (5-year cumulative incidence: 16.4% vs 26.7%, P = .002), with no difference in other-cause mortality (16.8% vs 17.8%, P = .43) observed in propensity score-matched patients.

LIMITATIONS

Potential selection bias from a retrospective data set.

CONCLUSION

In MCC, women have improved survival compared with men, driven by MCC-related mortality.

Comprehensive Analysis of the Tumor Microenvironment in Cutaneous Melanoma associated with Immune Infiltration

Accumulating evidence suggests that the malignant phenotypes of cancers are determined not only by the intrinsic properties of cancer cells but also by components in the tumor microenvironment (TME). In this study, we comprehensively characterized the TME of cutaneous melanoma (CM). As a result, tumor stage, tissue site, ulceration, thickness as well as patient age, sex were associated with immune infiltration. Patients of higher immune infiltration exhibited better survival outcomes, and antitumor effector cells, such as CD8 T cells and M1 macrophages, were found in significantly higher numbers in those tissues. Differential expression of mRNAs and long non-coding RNAs (lncRNAs) was analyzed and utilized to construct an immune-related competing endogenous RNA network, in which a lncRNA-associated subnetwork that could positively regulate the expression of IFN-γ was highlighted. Functional analysis confirmed that this network was remarkably enriched in functional terms related to both immune response and tumor-intrinsic pathways. Finally, a total of 109 high-confidence prognostic genes were identified, and a gene module that contained several key immune checkpoint molecules or modulators (PD-1, PD-L1, PD-L2, and LCK) was screened, which confers survival benefit for CM patients as supported by both overall and relapse-free survival rates from different datasets.

Predictors of occult lymph node metastasis in cutaneous head and neck melanoma

Objective

To use the Surveillance, Epidemiology, and End Results (SEER) database to verify the findings of a recent National Cancer Database (NCDB) study that identified factors predicting occult nodal involvement in cutaneous head and neck melanoma (CHNM) while identifying additional predictors of occult nodal metastasis and comparing two distinct cancer databases.

Methods

Cases of CHNM in the SEER database diagnosed between 2004 and 2014 were identified. Demographic information and oncologic data were obtained. Univariate and multivariate analysis were performed to identify factors associated with pathologic nodal positivity.

Results

There were 34002 patients with CHNM identified. Within this population, 16232 were clinically node-negative, 1090 of which were found to be pathologically node-positive. On multivariate analysis, factors associated with an increased risk of occult nodal metastasis included increasing depth of invasion (stepwise increase in adjusted odds ratio [OR]), nodular histology (aOR: 1.47 [95% CI: 1.21-1.80]), ulceration (aOR: 1.74 [95% CI: 1.48-2.05]), and mitoses (aOR: 1.86 [95% CI: 1.36-2.54]). Factors associated with a decreased risk of occult nodal metastasis included female sex (aOR: 0.80 [0.67-0.94]) and desmoplastic histology (aOR: 0.37 [95% CI: 0.24-0.59]). Between the SEER database and the NCDB, factors associated with occult nodal involvement were similar except for nodular histology and female sex, which did not demonstrate significance in the NCDB.

Conclusion

Regarding clinically node-negative CHNM, the SEER database and the NCDB have similarities in demographic information but differences in baseline population sizes and tumor characteristics that should be considered when comparing findings between the two databases.

Level of evidence

4.

Sex Differences in Melanoma

PURPOSE OF REVIEW

The goal of this review has been to elucidate the sex differences in cancer incidence and mortality in cutaneous melanoma. We have evaluated biological and behavioral research to determine where the critical questions exist.

RECENT FINDINGS

The most recent findings, through 2015, are exploratory in nature but seem to indicate that the differences are more likely due to biological variations rather than behavioral. While behavioral studies do show that women are more likely than men to seek health care and practice healthy behaviors, these differences are not sufficiently strong to explain the variation in incidence and mortality in cutaneous melanoma. Evolved differences in the immune systems of females and the role of sex steroid hormones in immunomodulation are two promising avenues for research. Studies in mice demonstrate that the newer immunotherapies are more effective in females and sex steroid hormones, such as estrogen receptor beta are inversely associated with tumor aggressiveness while testosterone increases it.

SUMMARY

Our analysis indicates that biological factors need to be investigated more thoroughly to understand the variation in incidence and mortality in cutaneous melanoma. Such understanding could lead to reducing incidence and mortality for both males and females (male incidence is 27.4 per 100,000; female 16.8 per 100,000; male mortality is 3.9 per 100,000; female mortality 1.6 per 100,000). It is most likely that behavioral differences between the sexes cannot account for the preponderance of male mortality. In addition to the important role of genetic factors, it is critical to evaluate further additional biological factors and their interactions with genetics and behavior.

A 14-Protein Signature for Rapid Identification of Poor Prognosis Stage III Metastatic Melanoma

PURPOSE

To validate differences in protein levels between good and poor prognosis American Joint Committee on Cancer (AJCC) stage III melanoma patients and compile a protein panel to stratify patient risk.

EXPERIMENTAL DESIGN

Protein extracts from melanoma metastases within lymph nodes in patients with stage III disease with good (n = 16, >4 years survival) and poor survival (n = 14, <2 years survival) were analyzed by selected reaction monitoring (SRM). Diagonal Linear Discriminant Analysis (DLDA) was performed to generate a protein biomarker panel.

RESULTS

SRM analysis identified ten proteins that were differentially abundant between good and poor prognosis stage III melanoma patients. The ten differential proteins were combined with 22 proteins identified in our previous work. A panel of 14 proteins was selected by DLDA that was able to accurately classify patients into prognostic groups based on levels of these proteins.

CONCLUSIONS AND CLINICAL RELEVANCE

The ten differential proteins identified by SRM have biological significance in cancer progression. The final signature of 14 proteins identified by SRM could be used to identify AJCC stage III melanoma patients likely to have poor outcomes who may benefit from adjuvant systemic therapy.

Trends in the diagnosis and clinical features of melanoma in situ (MIS) in US men and women: A prospective, observational study

BACKGROUND

The incidence of melanoma in situ (MIS) is increasing, but little is known about its clinical and epidemiologic features.

OBJECTIVE

We sought to determine trends in diagnosis and clinical features of MIS.

METHODS

Incident cases of melanoma were collected prospectively from the Nurses' Health Study (1976-2010) and Health Professionals Follow-up Study (1986-2010).

RESULTS

MIS incidence increased from 2 to 42 per 100,000 person-year among women, and from 11 to 73 per 100,000 person-year among men, exceeding the rate of increase of invasive melanomas. Melanoma mortality initially increased during the follow-up period then plateaued. Men were more likely than women to develop in situ melanomas on the upper half of the body (P < .001). Invasive melanomas were diagnosed at a younger age than MIS (P < .001), and were more likely to be found on the lower extremities than MIS (P < .001).

LIMITATIONS

This is a strictly descriptive study without examination into mechanisms.

CONCLUSION

We found epidemiologic and clinical differences for in situ and invasive melanomas, which support further examination into the variations in etiologic pathways. The lack of improvement in mortality despite the increase in detection of in situ relative to invasive lesions further highlights the need to improve invasive melanoma-specific clinical screening features.

Defining the effects of age and gender on immune response and outcomes to melanoma vaccination: a retrospective analysis of a single-institution clinical trials' experience

BACKGROUND

The impacts of patient age and gender on immune response (IR) and clinical outcome after cancer vaccines are not known. We hypothesized younger and female patients would have higher IR rates and better survival.

METHODS

Patients with resected stage IIB-IV melanoma in three clinical trials (Mel43, Mel44, Mel48) were vaccinated with 12 melanoma-associated peptides restricted by class I MHC. The cumulative incidence rate of CD8(+) T cell responses (direct interferon-gamma ELIspot assay) by week 7 was compared by age and gender. Overall survival (OS) and disease-free survival (DFS) landmark analyses were compared by Kaplan-Meier estimates and in multivariate analyses.

RESULTS

T cell responses were evaluated in 327 patients and detected in 50 % of males and 48 % of females, with no difference in IR by gender or menopausal status. Males had trends toward longer DFS (p = 0.12) and OS (p = 0.09). Cumulative incidence of IR was higher in patients <64 years of age versus older patients (p = 0.03). OS and DFS were similar by age group (p > 0.50). In multivariate modeling, younger age was associated with better IR (OR 0.40, p value 0.003), without an impact of age or gender on clinical outcomes.

CONCLUSION

These data support the hypothesis that older patients are less likely to develop T cell responses to a cancer vaccine. Nonetheless, significant proportions of older patients mount immune responses with comparable survival outcomes. Thus, these data support including older patients in cancer vaccine trials, but suggest value in stratifying patients by age </>64 years.

Association of sentinel lymph node biopsy with survival for head and neck melanoma: survival analysis using the SEER database

IMPORTANCE

Sentinel lymph node biopsy (SLNB) provides prognostic information for melanoma; however, a survival benefit has not been demonstrated.

OBJECTIVE

To assess the association of SLNB with survival for melanoma arising in head and neck subsites (HNM).

DESIGN, SETTING, AND PARTICIPANTS

Propensity score-matched retrospective cohort study using the Surveillance Epidemiology and End Results (SEER) database to compare US patients with HNM meeting current recommendations for SLNB, treated from 2004 to 2011 with either (1) SLNB with or without neck dissection, or (2) no SLNB or neck dissection.

INTERVENTIONS

SLNB with or without neck dissection.

MAIN OUTCOMES AND MEASURES

Disease-specific survival (DSS) estimates based on the Kaplan-Meier method, and Cox proportional hazards modeling to compare survival outcomes between matched pair cohorts.

RESULTS

A total of 7266 patients with HNM meeting study criteria were identified from the SEER database. Matching of treatment cohorts was performed using propensity scores modeled on 10 covariates known to be associated with SLNB treatment or melanoma survival. Cohorts were stratified by tumor thickness (thin, >0.75-1.00 mm Breslow thickness; intermediate, >1.00-4.00 mm; and thick, >4.00 mm) and exactly matched within 5 age categories. In the intermediate-thickness cohort, 2808 patients with HNM were matched and balanced by propensity score for SLNB treatment; the 5-year DSS estimate for those treated by SLNB was 89% vs 88% for nodal observation (log-rank P = .30). The hazard ratio for melanoma-specific death was 0.87 for those undergoing SLNB (95% CI, 0.66-1.14; P = .31). In each of the other cohorts analyzed, including those with thin and thick melanomas, and cohorts with melanoma overall, no significant difference in DSS was demonstrated.

CONCLUSIONS AND RELEVANCE

This SEER cohort analysis demonstrates no significant association between SLNB and improved disease-specific survival for patients with HNM.

Is oestrogen an important player in melanoma progression?

The oestrogen-dependent regulation of cell behaviour is realised by stimulation of specific oestrogen receptors. The classical oestrogen receptors ERα and ERβ are transcription factors, and they modulate expression of hormonally regulated genes, while the third one, GPER, is thought to be responsible for the observed rapid, non-genomic cellular response. Oestrogen dependency is attributed to a number of cancers, including breast, ovarian and endometrial cancer; however, there is still growing evidence that melanoma should also be cited as a hormonally dependent tumour. This comes from the observations of gender-related differences in melanoma progression and reports concerning the history of the malignant course of melanomas during pregnancy. Although, the observations of oestrogen regulation of melanoma progression are controversial, the effect of oestrogen should not be neglected, as the skin possesses its own hormonal microenvironment. This aspect of melanoma progression should be taken under careful consideration as it may offer new therapeutic possibilities.

Molecular pathology of skin neoplasms of the head and neck

CONTEXT

Skin neoplasms include the most common malignancies affecting humans. Many show an ultraviolet (UV)-induced pathogenesis and often affect the head and neck region.

OBJECTIVE

To review literature on cutaneous neoplasms that show a predilection for the head and neck region and that are associated with molecular alterations.

DATA SOURCES

Literature review.

CONCLUSIONS

Common nonmelanoma skin cancers, such as basal and squamous cell carcinomas, show a UV-induced pathogenesis. Basal cell carcinomas are characterized by molecular alterations of the Hedgehog pathway, affecting patched and smoothened genes. While squamous cell carcinomas show UV-induced mutations in several genes, driver mutations are only beginning to be identified. In addition, certain adnexal neoplasms also predominantly affect the head and neck region and show interesting, recently discovered molecular abnormalities, or are associated with hereditary conditions whose molecular genetic pathogenesis is well understood. Furthermore, recent advances have led to an increased understanding of the molecular pathogenesis of melanoma. Certain melanoma subtypes, such as lentigo maligna melanoma and desmoplastic melanoma, which are more often seen on the chronically sun-damaged skin of the head and neck, show differences in their molecular signature when compared to the other more common subtypes, such as superficial spreading melanoma, which are more prone to occur at sites with acute intermittent sun damage. In summary, molecular alterations in cutaneous neoplasms of the head and neck are often related to UV exposure. Their molecular footprint often reflects the histologic tumor type, and familiarity with these changes will be increasingly necessary for diagnostic and therapeutic considerations.

Sex-dependent liver colonization of human melanoma in SCID mice--role of host defense mechanisms

The possibility that endocrine factors may influence the clinical course of malignant melanoma is suggested by the superior survival data of women. In preclinical models we observed a higher rate of colony formation by human melanoma cells in male compared to female SCID mice, but only in the case of the liver and not in other organs. The gender difference could be seen at an early phase of colony formation. On the other hand, in our human melanoma cell lines we failed to detect steroid receptor protein expression, and treatment with sex hormones did not considerably influence their in vitro behavior. Investigating the possible contribution of host cells to the observed gender difference, we performed in vivo blocking experiments applying pretreatment of the animals with Kupffer cell inhibitor gadolinium chloride and the NK cell inhibitor anti-asialo GM1 antibody. While Kupffer cell blockade enhanced melanoma liver colonization equally in the two sexes, a more prominent increase was observed in female than in male mice in the case of NK cell inhibition. Further supporting the importance of NK cells in the lower liver colonization efficiency of melanoma cells in females, gender difference in colony formation was lost in NSG mice lacking NK activity. Although in humans no organ selectivity of gender difference in melanoma progression has been observed according to data in the literature, our results possibly indicate a contribution of natural host defense mechanisms to gender difference in survival of patients with melanoma or other tumor types as well.

Superior Outcome of Women With Stage I/II Cutaneous Melanoma: Pooled Analysis of Four European Organisation for Research and Treatment of Cancer Phase III Trials

Purpose

Several studies observed a female advantage in the prognosis of cutaneous melanoma, for which behavioral factors or an underlying biologic mechanism might be responsible. Using complete and reliable follow-up data from four phase III trials of the European Organisation for Research and Treatment of Cancer (EORTC) Melanoma Group, we explored the female advantage across multiple end points and in relation to other important prognostic indicators.

Patients and Methods

Patients diagnosed with localized melanoma were included in EORTC adjuvant treatment trials 18832, 18871, 18952, and 18961 and randomly assigned during the period of 1984 to 2005. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% CIs for women compared with men, adjusted for age, Breslow thickness, body site, ulceration, performed lymph node dissection, and treatment.

Results

A total of 2,672 patients with stage I/II melanoma were included. Women had a highly consistent and independent advantage in overall survival (adjusted HR, 0.70; 95% CI, 0.59 to 0.83), disease-specific survival (adjusted HR, 0.74; 95% CI, 0.62 to 0.88), time to lymph node metastasis (adjusted HR, 0.70; 95% CI, 0.51 to 0.96), and time to distant metastasis (adjusted HR, 0.69; 95% CI, 0.59 to 0.81). Subgroup analysis showed that the female advantage was consistent across all prognostic subgroups (with the possible exception of head and neck melanomas) and in pre- and postmenopausal age groups.

Conclusion

Women have a consistent and independent relative advantage in all aspects of the progression of localized melanoma of approximately 30%, most likely caused by an underlying biologic sex difference.

A Systematic Review of Prognosis and Therapy of Anal Malignant Melanoma: A Plea for More Precise Reporting of Location and Thickness

Anal malignant melanoma (AMM) is a rare tumor with poor prognosis. We performed a systematic review of reports on wide local excision (WLE) and abdominoperineal resection (APR) for treatment of AMM in an attempt to define a precise set of reporting measures for outcomes of treatment of AMM. A systematic review of the literature was performed. Demographic data, surgical treatment, pathology, and survival rates were recorded. We compared WLE versus APR in terms of the overall survival time, the disease-free survival, and overall survival at 60 months. Twenty-one reports met the inclusion criteria. Notably, of these, 10 did not specify thickness of the primary melanoma. Interestingly, groin lymph node status was described in 19 of 21 reports, whereas location was specified in only 12 papers and thickness (depth in mm) in only 11. The median survival times of patients undergoing WLE (n = 324) and those undergoing APR (n = 369) are comparable (20 and 21 months, respectively). The mean median survival at 60 months was 15 per cent for WLE and 14 per cent for APR. The mean disease-free survival at 60 months was found to be 10 per cent for WLE and 6 per cent for APR. Patient selection for such a rare neoplasm yields very similar outcomes for both conservative and radical treatments. There is a wide variation in the reporting of both clinical and treatment outcomes. More uniformity of reporting of pathologic features and node status is essential before rational assessment of results can be done.

Female survival advantage relates to male inferiority rather than female superiority: A hypothesis based on the impact of age and stroke severity on 1-week to 1-year case fatality in 40,155 men and women

BACKGROUND

It is generally believed that differences in age, stroke characteristics, and cardiovascular risk factors account for observed sex-specific differences in stroke survival.

OBJECTIVES

We aimed to study female stroke survival advantage before and after the average age of menopause, and whether female survival advantage applies only to patients for whom stroke is the most likely cause of death.

METHODS

The Danish National Indicator Project, a registry designed to list all hospitalized stroke patients in Denmark beginning in March 2001, had 40,155 registered patients as of February 2007. All registered patients had undergone evaluation including stroke severity (as measured by the Scandinavian Stroke Scale [SSS], using a total score of 0-58, in which lower scores indicate more severe strokes), computed tomography, and cardiovascular risk factors. Patients were followed from admission until death or censoring. Case fatality (stratified by 1 week, 1 month, 3 months, and 1 year) in men and women was correlated with age and stroke severity. Adjustment for cardiovascular risk factors was performed by means of multivariate regression analysis.

RESULTS

A total of 20,854 (51.9%) men and 19,301 (48.1%) women were registered. Women were significantly older than men at the time of stroke (74.5 vs 69.7 years, respectively; P < 0.001) and had signficantly more severe strokes, as expressed by the mean SSS score (39.6 vs 43.3; P < 0.001). Stratification of 1-week to 1-year case fatality according to age and stroke severity indicated that women survived significantly better than men from the mid-fifties onward, when controlling for age, stroke severity, and cardiovascular risk factor profile. The observed female survival advantage increased with age. The female survival advantage was seen in patients with severe as well as mild strokes, but not in those younger than age 50 years.

CONCLUSIONS

Our findings dispute the effects of female sex hormones as the underlying cause of female survival superiority over men. Instead, we propose the hypothesis that the progressive deficiency of male sex hormones (testosterone), beginning in men in middle age, is the underlying cause of the gap in survival rates between men and women. Accordingly, the female survival advantage is rooted in male inferiority rather than innate female superiority.

Long-term outcomes after local excision and radical surgery for anal melanoma: data from a population database

PURPOSE

Anal melanoma is rare and associated with a poor outcome. Previous studies that have reported outcomes after surgical treatment are limited by both small number of participants and treatment at single centers only. This study evaluates survival of patients undergoing surgery for anal melanoma from a prospective, population-based database.

METHODS

Characteristics and survival of patients undergoing rectal resection or local excision for anal melanoma of the anus, anal canal, and overlapping region of the rectum from 1982 to 2002 were obtained from the Surveillance, Epidemiology and End Results database and compared.

RESULTS

A total of 160 patients were included in the study. Details of previous surgical procedures were available for 109 of the study patients: 60 (55%) underwent local excision and 49 (45%) rectal resection. Patients who underwent local excision were significantly older (73.5 vs 65.1 years, P < .001), whereas those who had undergone rectal resection had a greater proportion of regional disease (73.5% vs 16.7%, P < .001). The median survival of the 2 groups was similar (rectal resection vs local excision: 17 vs 28 months, P = .3). Rectal resection and local excision were associated with similar survival for patients in both regional (P = .6) and localized (P = .95) stages. Outcomes for patients who were appropriately pathologically staged after rectal resection depended on localized vs regional stage (5-year survival: 43.1% vs 12.5%, P = .17). Survival for patients in localized and regional stages who underwent rectal resection was similar to that for patients with corresponding clinical stage who underwent local excision.

CONCLUSION

Survival of patients with anal melanoma is similar after local excision or rectal resection irrespective of whether patients have localized or regional stage of disease.

Reactive oxygen species and melanoma: an explanation for gender differences in survival?

Epidemiological research consistently shows a female advantage in melanoma survival. So far, no definite candidate for the explanation of this phenomenon has emerged. We propose that gender differences in oxidative stress caused by radical oxygen species (ROS) underlie these survival differences. It is known that males express lower amounts of anti-oxidant enzymes, resulting in more oxidative stress than females. The primary melanoma environment is characterized by high ROS levels, from exogenous sources as well as ROS production within melanoma cells themselves. ROS are known to be able to promote metastasis through a wide variety of mechanisms. We hypothesize that the higher levels of ROS in men enhance selection of ROS-resistance in melanoma cells. Subsequently, ROS can stimulate the metastatic potential of melanoma cells. In addition, due to the lower anti-oxidant defenses in men, ROS produced by melanoma cells cause more damage to healthy tissues surrounding the tumor, further stimulating metastasis. Therefore, ROS may explain the observed differences between males and females in melanoma survival.

Primary ano-rectal malignant melanomas within a population-based national patient series in Sweden during 40 years

PURPOSE

To analyze 251 patients (101 males and 150 females) diagnosed with ano-rectal malignant melanoma (ARMM) reported to the Swedish National Cancer Registry during 1960-1999.

METHODS

Incidence, gender and age profiles, primary anatomical sites and density of the melanomas along with geographic distribution, and prognosis were investigated.

RESULTS

The age-standardized incidence of ARMM was significantly higher for females (1.0 per 10(6) females) than for males (0.7 per 10(6) males) throughout the 40-year-period. The incidence increased with age peaking at 75-84 years in both genders. 54% of the tumours were primary in the anal canal, 24% engaged the whole ano-rectal unit and 10% were located at the anal verge (11% unknown primary site). Although ARMM were rare in absolute numbers, their density (number of tumours/square unit) was higher than that of cutaneous malignant melanomas (CMM) on average. No linkage between the geographic distribution of ARMM and population density was found. The prognosis was very poor albeit with a significant gender difference with a five-year survival rate of 10.6% for males and 15.7% for females. The survival rates for both genders improved during the 40-year-period but significantly more for females than males.

CONCLUSION

The reason(s) for the difference in incidence and prognosis according to gender is unknown. The majority of ARMM emerged primary in the anal canal and a primary location exclusively in the colonic mucosa of the rectum is questionable. The higher density of ARMM as compared to the average density of CMM tallies with the result of our previous studies on vulvar melanoma and might be instrumental in exploring non-UV light associated factors in melanoma genesis. The concentration of patients with anal squamous cell carcinoma to population-dense urban areas, as previously reported, was not found in cases of ARMM.

Sex-related time-dependent variations in post-stroke survival--evidence of a female stroke survival advantage

BACKGROUND

Women live longer than men, yet most studies show that gender has no influence on survival after stroke.

METHODS

A registry was started in 2001, with the aim of registering all hospitalized stroke patients in Denmark, and it now holds 39,484 patients of which 48% are female. We studied the influence of gender on post-stroke mortality, from the time of admission through the subsequent years until death or censoring (mean follow-up time: 538 days). All patients underwent an evaluation including stroke severity, computed tomography and cardiovascular risk factors. Independent predictors of death were identified by means of a survival model based on 22,222 individuals with a complete data set.

RESULTS

Females were older and had severer stroke. Interestingly, the risk of death between genders was time dependent. The female/male stroke mortality rate favoured women from the first day of stroke and remained so during the first month suggesting a female survival advantage. Throughout the second month the rate reversed in favour of men suggesting that women in that period are paying a 'toll' for their initial survival advantage. Hereafter, the rate steadily decreased, and after 4 months women continued to have the same low risk as in the first week.

CONCLUSIONS

Our study suggests a female superiority in stroke survival competence.

Malignant melanoma in the 21st century, part 2: staging, prognosis, and treatment

Critical to the clinical management of a patient with malignant melanoma is an understanding of its natural history. As with most malignant disorders, prognosis is highly dependent on the clinical stage (extent of tumor burden) at the time of diagnosis. The patient's clinical stage at diagnosis dictates selection of therapy. We review the state of the art in melanoma staging, prognosis, and therapy. Substantial progress has been made in this regard during the past 2 decades. This progress is primarily reflected in the development of sentinel lymph node biopsies as a means of reducing the morbidity associated with regional lymph node dissection, increased understanding of the role of neoangiogenesis in the natural history of melanoma and its potential as a treatment target, and emergence of innovative multimodal therapeutic strategies, resulting in significant objective response rates in a disease commonly believed to be drug resistant. Although much work remains to be done to improve the survival of patients with melanoma, clinically meaningful results seem within reach.

Prognosticators of melanoma, the melanoma report, and the sentinel lymph node

Since the 1960s, the clinical characteristics of melanoma, its histopathology and its biological basis have been the subject of intense study at pigmented lesion clinics in North America, Europe, and Australia. More recently, the immense database of the Melanoma Committee of the American Joint Committee on Cancer (AJCC) has been exploited through complex mathematical models to measure the impact of various histologic features of primary melanomas and of sentinel lymph node deposits and to correlate these parameters with patient survival. The wealth of modern information available to pathologists and clinicians has become of vital interest to the prognostication of the individual patient with melanoma. The purpose of this review is to bring to the attention of anatomic pathologists the essential characteristics of the pathology report for primary cutaneous melanoma in the modern era.

Correlation Between Prognostic Factors and Increasing Age in Melanoma

BACKGROUND

Age of patients with melanoma varies directly with mortality and inversely with the presence of sentinel lymph node (SLN) metastasis. To gain further insight into this apparent paradox, we analyzed the relationship between age and other major prognostic factors.

METHODS

The Sunbelt Melanoma Trial is a prospective, randomized study with 79 institutions involving SLN biopsy for melanoma. Eligible patients were 18 to 70 years old with melanoma of > or = 1.0-mm Breslow thickness and clinically N0 regional lymph nodes. SLNs were evaluated by serial histological sections and immunohistochemistry for S-100 protein.

RESULTS

A total of 3076 patients were enrolled in the study, with a median follow-up of 19 months. Five age groups were examined: 18 to 30, 31 to 40, 41 to 50, 51 to 60, and 61 to 70 years. Trends between age and several key prognostic factors was identified: as age group increased, so did Breslow thickness (analysis of variance; P <.001), the incidence of ulceration and regression, and the proportion of male patients (each variable: chi2, P <.001). The incidence of SLN metastasis, however, declined with increasing age (chi2; P <.001).

CONCLUSIONS

As age increases, so does Breslow thickness, the incidence of ulceration and regression, and the proportion of male patients-all poor prognostic factors. However, the frequency of SLN metastasis declines with increasing age. It is not known whether this represents a decreased sensitivity (higher false-negative rate) of the SLN procedure in older patients or a different biological behavior (hematogenous spread) of melanomas in older patients.

Cutaneous melanoma in the Florentine area, Italy: incidence, survival and mortality between 1985 and 1994

In recent decades, the increase in incidence of melanoma (MM) and the consequent mortality pointed to the concept of a 'melanoma epidemic'. More recently, the mortality has been slowly declining in many countries. This study is aimed at evaluating the incidence, mortality and survival in the Florentine area of Italy, using registry-based information. Between 1985 and 1994, 997 cases were notified with a survival of 713 patients (1985-92) and 316 deaths. Age-adjusted incidence, mortality rates and 95% confidence interval were calculated by period, gender and Breslow thickness. The relative survival rates were calculated and the effects of prognostic factors were evaluated using multivariate analysis. The incidence of MM increased during this period. This result referred only to 'thin melanomas', while the incidence rate for melanomas thicker than 1.00 mm remained unchanged both in young and old individuals. The mortality rate remained stable. The 5-year survival rate increased between 1985 and 1992. The inclusion of Breslow thickness in the multivariate model caused a reduction of the period effect. In conclusion, a changing pattern of MM epidemiology is being observed, with increase of 'thin' forms and a tendency for mortality to decline. The increasing awareness of population about MM prevention may partially explain these findings.

Randomized, placebo-controlled, phase III surgical adjuvant clinical trial of megestrol acetate (Megace) in selected patients with malignant melanoma

A randomized, double-blind, placebo-controlled phase III clinical trial was performed to assess megestrol acetate (Megace) as a postsurgical adjuvant therapy for patients with locally advanced malignant melanoma. Patients whose tumors were greater than 1.7 mm thick and had no regional lymph node involvement and patients with regional lymph node involvement were randomized to receive either 160 mg twice per day oral suspension of megestrol acetate or placebo. Treatment was administered for a maximum of 2 years or until disease progression. The study accrued 262 eligible patients. All but two patients were followed until death or a minimum of 4.5 years. Disease progression was documented in 156 patients. Neither progression-free survival (PFS) nor overall survival (OS) was found to differ between the treatments. The median PFS was 2.4 years in the megestrol acetate arm and 2.3 years in the placebo arm. Multivariate analysis revealed a significantly decreased PFS for patients with four or more positive regional lymph nodes and metachronous nodal disease. Median OS was 5.3 years in the megestrol acetate arm and 3.9 years in the placebo arm. Multivariate analysis revealed that OS was significantly decreased for patients 70 years of age or older with four or more positive lymph nodes. Adjuvant therapy with megestrol acetate oral suspension administered at a dose of 160 mg twice a day for 2 years was not found to be effective in prolonging PFS or OS in patients with surgically resected, locally advanced melanoma.

Prognostic factors

The American Joint Committee on Cancer has recently revised the staging system for melanoma. In this article, prognostic factors for melanoma are discussed in order of significance as outlined by the new staging system. In addition, other historically relevant prognostic factors are reviewed. The article concludes with a discussion of new technology, which may aid in the future staging of melanoma patients.

Malignant melanoma mortality rates in Chile (1988-98)

BACKGROUND

Malignant melanoma (MM) mortality has increased in the Caucasian population many fold over the past several decades. In this study, we analyzed the Chilean-specific, age-adjusted MM mortality rates per 100,000 population during the decade 1988-98 in order to establish changes in that period.

METHODS

We analyzed all death certificates from the Chilean Death Registry Office (1988-98) and retrieved the deaths attributed to MM. The data were categorized according to sex and age group. The annual age-adjusted and sex-specific rates of MM mortality per 100,000 population were calculated.

RESULTS

Chilean MM mortality rates increased by 14% between 1988 and 1998. The relative risk for males vs. females was 1.3 with a tendency to rise, showing an increase of 30%. The relative risk of dying from MM in Chile increased linearly with age. An individual of 75 years or older had a 44.24 times greater risk of dying of MM than an individual in the 0-44-year age group. The rates in the > 75-year age group also showed a tendency to rise over the decade, with an increase of 64% (1988-98).

CONCLUSIONS

The Chilean MM mortality rates are lower than the world standardized rates. The total Chilean MM mortality rates showed an increase over the decade 1988-98, mainly due to MM mortality in males. The MM mortality in Chilean females was lower than that in males, and was unchanged over the decade; this is in agreement with the results reported in other countries. This is one of the first studies of MM mortality in the Chilean population. The results are important when the geographic location of Chile is considered.

Absence of type I estrogen receptors in choroidal melanoma: analysis of Collaborative Ocular Melanoma Study (COMS) eyes

PURPOSE

To evaluate choroidal melanomas in enucleated eyes for the presence of type I estrogen receptors.

METHODS

Fourteen consecutive eyes with large choroidal melanomas (defined as >16-mm basal diameter and >8 mm thickness) from 14 patients (eight women and six men with a mean age of 57 years; range, 25--74 years) enucleated in accordance with the Collaborative Ocular Melanoma Study (COMS) protocol were investigated. Immunohistochemical techniques were employed to label the choroidal melanomas for the presence of type I estrogen receptors. Each specimen was then evaluated in a masked fashion by an experienced ophthalmic pathologist for positive nuclear staining.

RESULTS

No tumors showed immunohistochemical evidence of a type I estrogen receptor.

CONCLUSION

Type I estrogen receptors are not present in choroidal melanoma. Estrogens are not likely to influence choroidal melanoma growth through traditional receptors.

Malignant melanoma: clinical variants and prognostic indicators

The four main clinicopathological subsets of melanoma are described and the arguments for their retention in a research setting presented. Further additional subsets are described, including partly regressed primary melanoma, melanoma arising in a congenital naevus and multiple primary tumours. Pathological prognostic indicators are discussed and the pre-eminent significance of tumour thickness and its interaction with ulceration described. The need for accurate personal predictive profiles as distinct from those relevant to populations is discussed, as is the need for a molecular marker of metastatic potential.

Current therapy of cutaneous melanoma

Melanoma is a growing public health problem. Optimal care of the melanoma patient is multidisciplinary, but plastic surgeons and other surgical specialties play a central role in the management of these patients. Although surgery remains the mainstay of therapy for melanoma, several recent clinical studies have helped to clarify the biology of the disease and have changed the patterns of care for patients with melanoma. The advent of lymphatic mapping for interrogation of regional lymph nodes and interferon as the first effective postsurgical adjuvant therapy have had a major impact on the care of melanoma in the United States and elsewhere. This article will review the current clinical approach and therapy for cutaneous melanoma. The diagnosis, prognostic variables, staging evaluation, current surgical and medical treatment, and follow-up guidelines for patients with all stages of melanoma are reviewed. Recent studies, controversies, and directions of future investigational therapies will be discussed.

Site-specific risk of cutaneous malignant melanoma and pattern of sun exposure in New Zealand

The site-specific relationship between melanoma and sun exposure was investigated in the high-risk region of New Zealand. Age and latitude of residence were used as biological and geographical proxy measures of exposure for the 16,117 newly incident cases and 3,150 death records reported between 1968 and 1993. Age-standardized rates were the highest for the trunk in males and for the lower limbs in females, but once body surface area was accounted for, highest rates were found on fully exposed sites, particularly the ears in men. Melanomas occurred at a substantially younger age on intermittently exposed sites than chronically exposed ones (difference of about 13 and 27 years for men and women, respectively, between the trunk and the face). Age and latitude were found to influence melanoma rates in a sex- and site-specific fashion. For heavily exposed body areas, incidence rates increased more modestly with age before age 50 than after. In contrast, sharp increases in risk occurred from early age for episodically exposed sites with a reversal of trend observed among the elderly. For males, the magnitude of the latitude gradient was about 65% (incidence) and 50% (mortality) greater for body areas most intermittently exposed compared with those with a least intermittent pattern of exposure. The latitude gradient was steeper for males than females and for incidence than mortality, regardless of the pattern of site exposure. Sex- and age-specific differences in risk were largely explained by the varying patterns of exposure. These results confirm that intermittent exposure is probably more effective than continuous exposure in producing an early onset of melanoma. Reducing the episodes of acute exposure remains a paramount aspect to melanoma prevention strategies.

Changing epidemiology of anorectal melanoma

PURPOSE

We reviewed 117 cases of anorectal melanoma to better define epidemiologic and survival characteristics of this rare neoplasm.

METHODS

The National Cancer Institute Surveillance, Epidemiology, and End Results database covering the period 1973 through 1992 was used. This represents 9.5 percent of the United States population. Melanoma arising in the anorectum was identified using International Classification of Diseases for Oncology codes. Two-tailed Student's t-test, chi-squared, and Wilcoxon's tests were used for comparisons of means, proportions, and actuarial survival rates, respectively.

RESULTS

One hundred seventeen cases of anorectal melanoma were identified, representing 0.048 percent of all colorectal malignancies in the database. The male-to-female ratio was 1:1.72. The mean age was 66 +/- 16 years. Mean age by gender, however, was lower for males (57 years) then for females (71 years; P < 0.001). The age difference represents an increased incidence of anorectal melanoma in males younger than the age of 45 years. Furthermore, the incidence of anorectal melanoma in young males ages between 25 to 44 years tripled in the San Francisco area when compared with all other locations (14.4 vs. 4.8 per 10 million population; P = 0.06). Males have a survival advantage over females (62.8 percent vs. 51.4 percent 1-year and 40.6 percent vs. 27.7 percent 2-year; P < 0.01).

CONCLUSIONS

The overall incidence of anorectal melanoma continues to rise and survival rates remain poor. A new trend toward bimodal age distribution was observed. There is indirect evidence that implicates human immunodeficiency virus infection as a risk factor. Survival rate is better in young patients aged 25 to 44 years.

Investigation of female survival benefit in metastatic melanoma

Epidemiological studies show female survival benefit in advanced metastatic melanoma. In investigating a possible mechanism for this female survival benefit, we have previously reported that the female steroid 17beta-oestradiol significantly reduces invasion of a human melanoma cell line (A375-SM cells) and ocular melanoma cells through fibronectin. Neither cell type was found to possess oestrogen receptor-alpha. The aim of the current study was to obtain further information on the extent to which progression of cutaneous melanoma might be sex steroid sensitive by (a) examining the relationship between circulating sex steroids, sex hormone binding globulin and disease progression; (b) examining the relationship between sex steroid structure and the ability of steroids to reduce invasion of a melanoma cell line in vitro; and (c) examining the effects of sex steroids on proliferation of these cells in vitro. We report a significant reduction in circulating oestrone with disease progression in male but not female patients. Examining steroids for their ability to inhibit invasion of A375-SM cells through fibronectin in vitro, oestrogenic compounds (17beta-oestradiol and oestrone) were found to inhibit invasion; in this respect, oestrone was approximately 50 times more potent than 17beta-oestradiol; steroids lacking the benzene ring structure did not inhibit invasion, indeed dehydroepiandrosterone (DHEA) which acts as a precursor to androgenic steroids significantly enhanced invasion. Proliferation of A375-SM cells was unaffected by 17beta-oestradiol, oestrone or dihydrotestosterone when cells were cultured on plastic; in contrast, all three steroids induced modest proliferation of cells when grown on fibronectin with dihydrotestosterone the most mitogenic of the three steroids. These data are consistent with sex steroids playing a role in melanoma progression.

Prognostic evaluation of cutaneous malignant melanoma: a clinicopathologic and immunohistochemical study

BACKGROUND AND OBJECTIVES

Depth of invasion and stage of the disease are established prognostic indicators in cutaneous malignant melanoma. The role of other parameters is still an open problem.

METHODS

In 93 consecutive patients with cutaneous malignant melanoma, the level of invasion, tumor thickness, ulceration, vascular invasion, lymphoplasmocytic infiltrates, and mitotic index were evaluated by histology. Expression of Ki-67 and PCNA proliferative antigens together with vimentin, S100, and HMB 45 proteins were assessed by immunohistochemistry.

RESULTS AND CONCLUSIONS

Disease-free and overall survival were correlated with tumor stage, tumor thickness, level of invasion, macroscopic pattern, ulceration, vascular invasion, expression of HMB 45, PCNA, and Ki-67/MIB1. Stage, HMB 45, and PCNA were independent prognostic factors for disease-free survival, whereas tumor stage, tumor thickness, and expression of both proliferative antigens influenced overall survival independently. The variables studied demonstrated reciprocal correlation; therefore, analysis of many prognostic parameters in malignant melanoma could be recommended.

Childhood melanoma survival

BACKGROUND

Melanoma in childhood is uncommon. Some believe that melanoma among children is associated with a better prognosis than among adults.

METHODS

The authors reviewed their institutional experience with melanoma in 40 patients younger than 18 years treated between 1950 and 1984. All slides were reviewed by a single dermatopathologist who was blinded to clinical outcomes. Long term follow-up was available for all but three patients.

RESULTS

There were 26 girls and 14 boys. The median age at diagnosis was 15 years (range, 3-17 years). Eleven patients (28%) were younger than 12 years. Fifteen patients (38%) had melanoma arise in a congenital nevus (2 had bathing trunk nevi. The most common site was the extremity (n = 23), followed by the trunk (n = 10) and the head and neck (n = 7). Seventeen patients (43%) initially were considered to have benign lesions, and 23 patients (57%) were diagnosed correctly with melanoma at initial presentation. Only 21 of 37 evaluable patients (57%) were alive at last follow-up with a median follow-up of 18 years (range, 2-48 years). Fifteen patients (41%) died of their disease, with a median survival of 12 months (range, 6-60 months). One patient died of breast carcinoma 14 years after treatment for melanoma. Disease free survival was 57% at 5 and 10 years. Of the 15 patients who died of disease, 12 were female (P = 0.09) and 10 had melanoma arising in a congenital nevus (P < 0.05). Five-year overall survival was 78% for patients who presented with localized disease (n = 23) and 30% for patients who presented with regional metastasis (n = 16, P < 0.001). There were no survivors among those who presented with systemic disease (n = 1).

CONCLUSIONS

Children with melanoma are at significant risk of dying of their disease. Survival is similar to that seen among adults and depends on stage at presentation. The survival advantage observed for adult females is not seen among children.

Superior survival of young women with malignant melanoma

BACKGROUND

The Commission on Cancer data from the National Cancer Data Base (NCDB) relating to patients with malignant melanoma are used to examine patterns of long-term survival by patient gender and age, stage of disease, disease morphology, and anatomic subsite.

METHODS

Five calls for data have yielded more than 3,700,000 cases of cancer for the years 1985 through 1993, including 23,341 cases of malignant melanoma between 1985 and 1989, from hospital cancer registries across the US, representing slightly less than a quarter of all melanoma cases diagnosed in the US between 1985 and 1989.

RESULTS

Three statements can be made from this data: (1) There is little difference in the frequency of malignant melanoma between men and women with respect to stage of disease or morphology. However, differences between the genders do appear with respect to the anatomic subsite of melanotic tumors. (2) Overall, young women (45 years of age and under) enjoy superior survival rates when compared with older women (55 years of age and older) and men of any age. (3) The survival advantage held by young women is particularly pronounced among patients diagnosed with advanced stage disease.

CONCLUSIONS

These data suggest that factors present in younger women may be critical in the superior survival rates seen among premenopausal women and might be hormonal in nature.

Skin melanoma in Italy: a population-based study on survival and prognostic factors

Survival and prognostic factors of invasive cutaneous melanoma patients diagnosed in the province of Florence, Italy, were studied using a regression analysis of relative survival rates. The case series consisted of 428 patients reported by the Tuscany Cancer Registry between 1985 and 1989. The effect of gender, age, anatomical site, histological type and microstaging parameters upon relative survival were evaluated using an extension of the Cox proportional hazard model. Five-year relative survival was 70%; 8-year relative survival, referring to a subset of patients, was 67%. In univariate analysis, the following variables were significantly associated with better prognosis: female gender, age younger than 60 years, superficial spreading melanoma (SSM) compared with nodular melanoma (NM), location on the limbs, a thinner lesion according to Breslow, a shallower Clark level. Females had a clear-cut prognostic advantage over males in each category of the variables considered above. After simultaneous adjustment for all other variables, three factors continued to show an independent prognostic effect: age, gender and microstaging parameters (Breslow thickness and Clark level, separately fitted in the model). In the multivariate analysis, the prognostic advantage of females over males was specifically seen for lesions located on the trunk and for both SSM and NM histotype.

Tamoxifen, 17beta-oestradiol and the calmodulin antagonist J8 inhibit human melanoma cell invasion through fibronectin

Invasion through stromal extracellular matrix (ECM) is part of the complex, multistep process of tumour cell invasion and metastasis. Our group has previously demonstrated that calcium and calmodulin are important in another step in the metastatic cascade - that of attachment of cells to ECM. Interestingly, the non-steroidal anti-oestrogen tamoxifen (which also has calmodulin antagonist activity), used in the treatment of breast cancer and now in metastatic cutaneous melanoma, can inhibit the attachment of normal and neoplastic cells to ECM. In this study, we investigated whether such drugs, known to inhibit cell attachment, could also subsequently reduce their invasion through a layer of human fibronectin. We examined the ability of the specific calmodulin antagonist J8, tamoxifen and its two major metabolites, N-desmethyltamoxifen (N-des) and 4-hydroxytamoxifen (4-OH), as well as the pure anti-oestrogen ICI 182,780 and 17beta-oestradiol to inhibit invasion of the human cutaneous melanoma cell line, A375-SM, uveal melanoma cells and uveal melanocytes. A375-SM cells and uveal melanoma cells showed a high level of invasion (15.2% and 33.7% respectively) compared with melanocytes (around 5%) under the experimental conditions used. Submicromolar concentrations of N-des, tamoxifen, J8 and 17beta-oestradiol significantly reduced the invasiveness of the A375-SM cell line. The uveal melanoma cells also showed similar inhibition, although at higher concentrations of these agents. 4-OH and ICI 182, 780 had little or no effect on invasion of A375-SM cells (these were not tested on uveal melanoma cells). All cells used in this study were found to be negative for type I nuclear oestrogen receptors, reinforcing the possibility that tamoxifen and 17beta-oestradiol can act via mechanisms unrelated to binding to classical oestrogen receptors to inhibit tumour cell invasion.

Neoplastic progression and prognosis in melanoma

Most melanomas evolve through an initial stage known as radial growth phase (RGP), encompassing in situ and microinvasive malignancies in which the probability of cure approaches 100%. At the present time, despite a shift toward earlier recognition of melanoma, by the time of diagnosis roughly 70% of melanomas have evolved to a point, known as vertical growth phase (VGP) or tumorigenic melanoma, at which cure is not certain, and prognosis depends upon certain attributes of the neoplasm and the host. Attempts have been made to assemble these attributes into prognostic models to permit estimation of the probability of cure for individuals and for groups of patients. Attributes that have been identified as independent prognostic variables include thickness of the primary neoplasm, the numbers of mitotic figures, and the presence of tumor-infiltrating lymphocytes (TIL). Other biologically important prognostic variables are on the horizon, and some will likely be based on molecules (markers) expressed on neoplastic cells that show functional significance in mechanisms of metastasis.

Melanoma and stroma: an interaction of biological and prognostic importance

Stromal relationships are crucial to metastatic spread of solid malignancies. Some aspects of this stroma interaction are obviously associated with particular morphological features, which may carry prognostic significance. In cutaneous melanoma, level of invasion, arrangement of cells (horizontal or vertical growth phase), neovascularization, vessel invasion, architecture of the border, and inflammatory infiltrate have been examined. Expression of adhesion molecules, signalling factors, cytoskeletal components, extracellular matrix molecules and matrix-degrading enzymes have been assessed by immunohistology and in situ hybridization. Besides providing prognostic information, a thorough evaluation of stromal relationships may help to increase our knowledge about factors mediating the growth and metastatic spread of malignancies.

Endocrinology of melanoma

Melanoma has a better prognosis in women than in men, may be exacerbated by pregnancy, and has been to reported to respond to hormonal manipulations. Laboratory investigations have demonstrated that both animal and human melanomas may respond to changes in the hormonal milieu. Steroid hormone binding activity has been demonstrated in some human melanomas, but only a small percentage of melanomas respond to hormonal manipulation. Randomized trials suggest a possible role for tamoxifen in combination with chemotherapy for metastatic melanoma and for megestrol acetate as an adjuvant. Nevertheless, it appears that the use of steroid hormones in the management of melanoma is limited.

Management of patients with intermediate-thickness melanoma

It is important to understand the management of patients with melanoma because of a rising incidence of this cancer in the United States. The most important prognostic factor is tumor thickness. Patients with early melanoma (thickness < 1.0 mm) have an excellent prognosis and are effectively treated with narrow local excision (1-cm radius). Those with advanced melanomas (tumor thickness > 4.0 mm) have a high risk of metastases and are treated with a wider local excision (2-3 cm). Controversies surrounding the management of patients with intermediate-thickness melanoma (thickness 1-4 mm) center on the issues of local excision and management of regional lymph nodes. Randomized trials have shown that a 2-cm radius of excision will minimize the risk for local recurrence. Although retrospective analyses have indicated a survival advantage for elective regional lymph node dissection, two randomized trials have not shown a benefit for the early removal of lymph nodes. Two more randomized trials are in progress. Techniques are now available to identify the sentinel lymph node, which will help to limit lymph node dissections to those patients with nodal metastases. Postoperative surveillance for recurrence is most effectively performed with a combination of patient self-examination and regular physician examinations rather than frequent X-rays and laboratory tests. Adjuvant therapy has not been proven effective for melanoma patients; however, many investigational trials are available.

Anorectal melanoma. A 64-year experience at Memorial Sloan-Kettering Cancer Center

PURPOSE

Operative management of patients with anorectal melanoma is controversial. To formulate a rational approach to patients with this disease, we reviewed our experience from 1929 to 1993.

METHODS

Records of all patients treated at our center with anorectal melanoma from 1929 to the present were reviewed. Survival analyses were graphically displayed using the Kaplan-Meier product-limit method, and distributions were compared using the log-rank test. Fisher's exact test was used to compare groups with small sample sizes.

RESULTS

Survival for the entire group (n = 85) was poor, 17 percent at 5 years (median, 19 months). Among the 71 patients with resectable disease, the five-year, disease-free survival distribution of patients who underwent abdominoperineal resection (APR) was more favorable than that of patients who underwent local procedures only, although this was not statistically significant (27 percent vs. 5 percent, APR vs. local procedures, respectively; P = 0.11). However, those who had an APR were more likely to survive long term than those who did not (P < 0.05). All ten long-term survivors were women. Nine had undergone APR, and one had a wide local excision. Of the nine survivors following APR, eight had negative and one had positive mesenteric nodes. Median size of the primary tumor in survivors following APR was 2.5 cm, compared with 4.0 cm for patients who did not survive long term following APR.

CONCLUSIONS

APR should be considered in patients with localized anorectal melanoma, particularly those with smaller tumors and no evidence of nodal metastases.