Long Term Results of Surgical Treatment of Melanoma of the Limbs

Stage I Melanoma of the Limbs: Assessment of Prognosis by Levels of Invasion and Maximum Thickness

The prognostic significance of 2 histological parameters, level of invasion and maximum thickness is evaluated in 248 cases of malignant melanoma of the limbs staged T1–3, N0 M0 which were collected for Trial No. 1 of the W.H.O. Collaborating Centres for the Evaluation of Methods of Diagnosis and Treatment of Melanoma between September 1967 and December 1974. There is a linear relation of tumor thickness to mortality with a high statistical significance (P = 0.0002). Mortality also increases with progression of the level of invasion. The incidence of occult metastases to the regional lymph nodes increases with increasing thickness or level of invasion. Moreover the age and sex corrected survival curves are also dependent on both parameters. The comparison of the 2 methods revealed that maximal tumor thickness is a more powerful measure of prognosis than is the determination of the level of invasion.

Stage I Melanoma of the Limbs. Immediate versus Delayed Node Dissection

553 patients with stage I malignant melanoma of the limbs entered a prospective randomized clinical trial carried out by the W.H.O. Collaborating Centres for Evaluation of Methods of Diagnosis and Treatment of Melanoma from September 1967 to January 1974. 286 patients were submitted to wide excision of primary and node dissection at the time as appearance of regional lymph node metastases and 267 to wide excision and immediate node dissection. Survival was identical in the 2 groups. Different subsets of patients were evaluated to assess whether some groups of patients may benefit from immediate node dissection. As regards sex, females and a significantly higher survival rate than males (p < 0.05), but results were not improved by immediate node dissection. Maximum diameter and elevation of primary melanoma were significantly related to survival but also in these cases immediate node dissection did not achieve better results. 63 patients had an excisional biopsy of their melanoma within 4 weeks before final treatment. This procedure did not worsen survival and also in this case immediate node dissection did not improve survival. 273 cases were classified according to histologic type: survival of superficial spreading and nodular melanoma was not different at a statistically significant level after the 2 treatment modalities. 325 cases were considered classifiable according to Clark's levels, out of these 165 were submitted to immediate node dissection. Neither level III nor level IV cases showed higher survival rate after immediate node dissection. Maximum tumor thickness according to Breslow was evaluated in 338 cases: 188 were submitted to wide excision and immediate node dissection. In no clusters of thickness did the enlarged surgical procedure achieve better results. The authors conclude that there is good evidence that in stage I melanoma of the extremities delayed dissection is as effective as the immediate one in the control of the disease if the patient can be kept under strict clinical control. Immediate node dissection is advisable if the quarterly follow-up is not guaranteed, at least for melanomas thicker than 2 mm.

Prognostic factors for stage I melanoma of the skin: a review

The prognosis of melanoma of the skin has been investigated in many studies. In this report papers on the prognosis of stage I melanoma published since 1975 in the leading oncology journals have been reviewed. Further the data collected by the WHO Collaborating Centre for Evaluation of Methods of Diagnosis and Treatment of Melanoma are analysed, and the results compared with those of other series. Three factors emerge as clearly influencing prognosis: sex, maximum tumour thickness and ulceration. The role of other factors and particularly that of an interaction between tumour thickness and ulceration conjectured by some authors remains questionable.

[Surgical treatment of malignant melanomas of the skin]

The authors report on the most important problems of surgical treatment in primary melanomas. Great importance should be attributed to surgery especially in I. stage melanomas, just because it might influence further development of the disease--they accentuate. This argument will justify the performance of an elective lymphonodal dissection if there are some risk factors (e.g. depth of invasion, tumour thickness, exulceration, anatomic subsites, etc.) suggesting the possible presence of microscopic regional metastases. Within the frame of a clinical study a large number of literary data are also discussed.

Hyperthermic adjuvant perfusion chemotherapy for Stage I malignant melanoma of the extremity with literature review

Thirty-nine patients with clinical Stage I malignant melanoma of the extremities were treated with hyperthermic perfusion chemotherapy using melphalan followed by excision or wide re-excision of the area and regional lymph node dissection. Four patients with positive lymph nodes, on histologic examination, were considered pathologic Stage II. Seventy-two patients with clinical Stage I extremity melanomas, who were treated by conventional surgical methods, served as concurrent controls, and were comparable in the distribution of their various pretreatment characteristics. The actuarial survivals for clinical Stage I perfusion patients calculated by the life-table method at 5, 10, and 15 years were 91%, 86%, and 77%, respectively, and disease-free survivals were 85%, 80%, and 80%, respectively. These figures were significantly better than controls. A Breslow depth of invasion of greater than 1.5 mm showed a significant difference in both clinical and pathologic Stage I disease as compared with the controls. Similarly, perfused patients aged less than or equal to 50 years survived significantly better than controls in both clinical and pathologic Stage I disease. The literature has been reviewed.

Delayed regional lymph node dissection in stage I melanoma of the skin of the lower extremities

Results of a prospective randomized clinical trial conducted by the WHO Collaborating Centers for the Evaluation of Methods of Diagnosis and Treatment of Melanoma are reported. Five-hundred-fifty-three Stage I patients whose limbs were affected entered the study; 267 were submitted to wide excision and immediate node dissection and 286 had wide excision and node dissection at the time clinically positive nodes were detected. Survival curves of the two treatment groups could be superimposed. No subsets of patients benefitted from immediate node dissection. The authors conclude that delayed node dissection is as effective as the immediate dissection in Stage I melanoma of the extremities if the patient can be checked every three months. If the quarterly follow-up is not guaranteed, immediate node dissection is advisable, at least for melanomas thicker than 2 mm.

Malignant melanoma patients with positive nodes and relatively good prognoses: microstaging retains prognostic significance in clinical stage I melanoma patients with metastases to regional nodes

Fifteen variables were tested for their value in predicting recurrent disease in 46 clinical Stage I melanoma patients with metastases to regional nodes. A stepwise proportional hazards general linear model (Cox multivariate analysis) separated these melanoma patients with regional node metastases into at least two risk groups. Twenty patients in the relatively low-risk group had a five-year disease-free survival of 80% (in spite of having nodal metastases). This compares to a five-year disease-free survival of 17.5% for 26 patients in the high-risk group (P less than 0.001, Lee-Desu Statistic). Criteria for the high-risk group required that a patient have only one of the following two values: (1) The number of regional lymph nodes that contained tumor divided by the total number of nodes removed x 100% (percentage of positive nodes) greater than or equal to 20%; or (2) a primary tumor thickness of greater than 3.5 mm (regardless of node percentage). Conversely, patients in the low-risk group had neither of the above features. The high-risk group could further be stratified by the lymphocytic response at the base of the tumor. These findings have direct immediate application to the elective regional node dissection controversy and to adjuvant therapy studies containing these patients.

Malignant melanoma of the upper extremities

There were 487 patients treated for malignant melanoma of the upper extremities at the Pack Medical Group in New York City between 1939 and 1967 inclusive, fourth in frequency (14.7%) of total malignant melanomas treated here, being exceeded by malignant melanoma of the trunk (34%), head and neck (23%), and the lower extremities (20%). A 10-year survival rate of 342 determinate patients was 63%. Fourteen percent of the patients who died of melanoma died between the fifth and tenth years, indicating the need to report survival at the 10-year span. Survival was equal for the sexes (61% male and 64% female). The majority of the patients had infiltrating melanomas (Clark's Level 4 and 5) with a survival rate of 62%. Ten patients with superficial spreading melanomas (Clark's Level 2 and 3) and juvenile melanomas enjoyed a 100% 10-year survival. The worst prognosis was for six patients with amelanotic melanoma in that only two of ten survived ten years or longer. The question of elective axillary dissection remains elusive. In 106 patients classified as clinical Stage I, elective axillary dissection was performed in 55 instances, and 26 patients had microscopic evidence of metastases. Their 10-year survival rate was 65%, slightly higher than 16 patients in whom no elective axillary dissection was performed, among whom six later developed evidence of metastases, underwent therapeutic node dissections, and had a 10-year survival of 56%. Radical amputation is occasionally indicated with great palliation and often prolongation of life.