T1 and T2 squamous cell carcinoma of the oral tongue: prognostic factors and the role of elective lymph node dissection

BACKGROUND

The management of micrometastatic disease from squamous cell carcinoma (SCC) of the oral tongue remains controversial. This study describes prognostic factors in the disease and reviews the role of elective neck dissection (END).

METHODS

A retrospective analysis of all patients undergoing definitive surgical treatment of T1 and T2 SCC of the oral tongue between 1956 and 1994 at the University of Alabama at Birmingham was performed.

RESULTS

Patient, disease, and treatment variables were compiled for 169 patients. Multivariate analysis showed age (p = .02), sex (p = .02), disease differentiation (p = .0003), and palpable lymphadenopathy (p = .02) to be significant prognostic variables. Fifteen patients underwent END and 6 were shown to have micrometastatic disease (40.0%). There were no neck recurrences in these patients, but END was not shown to improve survival.

CONCLUSIONS

The presence of poorly differentiated disease gave the worst prognosis in this population of patients with T1 and T2 SCC of the oral tongue. A high incidence of nodal micrometastatic disease and the absence of recurrent disease after END suggest that END is appropriate therapy for these patients.

Prognostic factors in minor salivary gland cancer

BACKGROUND

Minor salivary gland cancer occurs infrequently and presents a diagnostic and therapeutic challenge. The purpose of this study was to determine prognostic factors for this disease.

METHODS

The medical records of 95 patients diagnosed and treated at the University of Alabama at Birmingham over a 35-year period were reviewed. Information concerning patient, disease, and treatment characteristics was compiled for each case. Multivariate analysis was conducted using a rank regression procedure.

RESULTS

State I or II cancer (p = .022), the absence of cervical lymph node metastases (p = .001), and surgical margins which were free of cancer (p < .001) were predictive of increased 4-year disease-free survival by multivariate analysis.

CONCLUSION

Our findings emphasize the need for detection of early-stage disease combined with complete surgical extirpation of the cancer, which provide the patient with the best chance for locoregional control and long-term survival.

Needle-localization biopsy of the breast: impact of a selective core needle biopsy program on yield

PURPOSE

To determine the effect of a selective core biopsy program on the yield at needle-localization biopsy (NLB) of nonpalpable lesions.

MATERIALS AND METHODS

Two hundred consecutive core biopsy samples of the breast were evaluated in an ongoing consecutive series of 1,172 NLB samples.

RESULTS

Before implementation of the core biopsy program, the yield at NLB improved from 21% at 100 cases to 35% just before the introduction of core biopsy. After implementation, the yield increased gradually to 55% at 200 cases. The yield in masses increased from 21% at 100 cases to 43% just before the initiation of the core biopsy program and then increased dramatically to 72% at 200 cases. The percentage of small lesions detected did not change with implementation: 88% of invasive cancers measured less than 1.5 cm and 60% measured less than 1 cm in the last 100 cases.

CONCLUSION

Appropriate selection of cases for core biopsy can more than double the yield of cancer in NLB samples without a decrease in the percentage of small cancers detected.

Melanoma recurrence surveillance. Patient or physician based?

OBJECTIVE

The authors determined the roles of the physician and the patient in melanoma recurrence detection.

METHODS

The University of Alabama Melanoma Registry, consisting of 1475 patients surgically treated for cutaneous melanoma from 1958 to 1984, was searched to find 195 evaluable cases of melanoma recurrence. Patients were grouped by the type of return visit. Group I returned on a previously determined date, whereas group II returned before the scheduled visit.

RESULTS

Symptoms of recurrence were present in 90% of group I patients and 93% of group II and correlated with the site of recurrence in more than two thirds of cases. Recurrence sites were local, regional, and distant in 35%, 31%, and 29% of group I, respectively, and 42%, 25%, and 29% of group II. The median interval to recurrence was 24.2 months in group I and 37.7 months in group II (p = 0.059). Median overall survival was 57 months in group I and 62 months in Group II (p = 0.210).

CONCLUSIONS

Symptoms are present in 90% of the patients with recurrent melanoma and accurately predict the site of recurrence. Overall survival is not affected by the type of patient return visit.

Paragangliomas of the Neck

Between 1967 and 1990 inclusive, 28 patients with paragangliomas of the neck were diagnosed at the University of Alabama at Birmingham Affiliated Hospitals. There were 11 men and 17 women, whose ages ranged from 12 to 76 years (mean, 47 years). Tumor locations included the carotid bodies (19 cases), the vagus nerves (three), supraglottic larynx (two), the left lateral pharyngeal wall (one), posterior to the right jugular vein (not otherwise defined) (one), subcutaneous neck tissue (one), and a cervical lymph node with unknown primary (one). Diagnostic workup included angiography (23 cases) with preoperative embolization (three), computed tomography (one), magnetic resonance imaging (two), and urinary catecholamine assay (four). All 28 patients underwent resection of the lesions. Cranial nerve damage occurred in 11 patients (39%). There were no perioperative deaths or cerebrovascular accidents, although one of two saphenous vein grafts became thrombotic after carotid body tumor resection.

Histopathological prognostic factors of certain primary oral cavity cancers

The TNM classification of cancers arising in the upper aerodigestive tract is a generally useful and widely applied method for estimating prognosis and planning therapy. In two retrospective reviews of patients with oral cavity cancers, we identified additional histopathological characteristics that were significantly related to treatment outcome. A study of 136 patients with squamous cell carcinoma of the anterior tongue (without clinical metastases) demonstrated, in a multifactorial analysis, three factors associated with a high risk of occult metastases: Clinical size of the primary tumor, presence of perineural invasion, and male gender. In a second analysis, of 89 patients with squamous cell carcinoma of the buccal mucosa, many pathologic and clinical parameters were related to prognosis using single-factor analysis. However, in multifactorial analysis only tumor thickness and vascular invasion were predictive of outcome.

Cutaneous angiosarcoma of the breast 7 years after lumpectomy and radiation therapy

A case of angiosarcoma of the skin of the breast is described in a woman 7 years after a primary breast carcinoma was treated by means of lumpectomy and irradiation. On mammograms, the angiosarcoma showed redevelopment of skin thickening and increase in breast density. Clinically, the skin showed patchy discoloration. Although there is an established association of angiosarcoma with lymphedema and therapeutic irradiation, there have been few other reports of this rare complication of local therapy for breast carcinoma. Recognition of the mammographic and clinical manifestations may help in the earlier diagnosis of additional cases.

Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction

Immediate breast reconstruction using the transverse abdominal myocutaneous island (TRAM) flap was performed in 54 patients over the past 3 years at our institution. This represented approximately 59 percent of patients undergoing all types of immediate breast reconstruction. In 10 patients, the abdominal island flap was transferred as a free flap based on the deep inferior epigastric pedicle. These patients were compared with the other 44 patients, in whom the flap was transferred using the conventional technique. The TRAM flap is well suited for immediate breast reconstruction because the procedure can be carried out simultaneously with mastectomy using separate operating teams and instruments. The operation is safe and relatively free of complications. The free TRAM group compared favorably with the conventional group in terms of complications, operating time, estimated blood loss, hospitalization, and return to functional baseline. The free TRAM flap appears to be as safe as the conventional technique with the advantages of a more limited rectus muscle harvest, improved medial contour of the breast due to the lack of tunneling, and perhaps a healthier flap because of the large donor vessels.

Proliferative disease and atypia in biopsies performed for nonpalpable lesions detected mammographically

A recent study of risk factors for breast cancer indicated elevated risks of 5.3 and 1.9 times, respectively, for women with biopsy specimens showing atypical hyperplasia (AH) and proliferative disease without atypia. These risks increase to 11 and 3.2 times, respectively, in women who also have a family history of breast cancer. This study reviews lesions detected mammographically in a series of patients with documented risk factors. The pathologic specimens of 100 consecutive localization breast biopsies performed for nonpalpable abnormalities detected mammographically were reviewed and classified according to the criteria of Dupont and Page in order to determine the incidence of AH and proliferative breast disease. The mammographic characteristics and historical risk factors of these women also were correlated. Twenty percent of the biopsy specimens showed carcinomas, 55% of which were noninvasive. AH was found in an additional 10% of the biopsy specimens, whereas proliferative disease without atypia occurred in 21% of the biopsy specimens. Forty-nine percent of the biopsy specimens showed nonproliferative changes. This study demonstrated that mammography, in addition to its ability to detect small nonpalpable cancers, identifies a high percentage (31% in this series) of women with pathologic lesions known to have an elevated risk for subsequent breast cancer. The current impetus for large-scale mammographic screening of asymptomatic women mandates the development of rational therapeutic protocols to accommodate the widening spectrum of high-risk pathologic lesions found in these selected populations.

Total pharyngeal reconstruction using a pectoralis major myocutaneous tunnel

Total pharyngeal reconstruction was performed using a pectoralis major myocutaneous flap. In this technique, the posterior wall of the neopharynx consists only of the prevertebral tissue, while the flap forms the anterior and lateral walls. The posterior wall heals by reepithelialization of the prevertebral fascia. Clinical experience with seven patients has shown that this technique provides a wide conduit and is not prone to develop stenosis.

Does radical mastectomy still have a place in the treatment of primary operable breast cancer?

This study (Alabama Breast Cancer Project) reports the ten-year surgical results of a prospective randomized trial comparing Halsted radical mastectomy (RM) with modified radical mastectomy (MRM) for breast cancer. We entered 311 patients in the study between 1975 and 1978. Patients with histologically positive axillary lymph nodes were randomized after operation to receive melphalan or intermittent intravenous cyclophosphamide, methotrexate, and fluorouracil for one year. After a median follow-up of ten years, there was no significant difference in the survival of the two groups (RM, 71%; MRM, 64%). Local recurrence after RM was significantly lower than after MRM. A subset of patients with more advanced cancers (T3 and T2 with clinically positive axillary nodes) experienced significantly better survival at ten years following RM compared with MRM (59% vs 38%, respectively). These results indicate that overall survival is similar for patients treated by either RM or MRM. However, there is subset of patients with more advanced cancers whose ultimate survival can be favorably influenced by RM.

Squamous cell carcinoma of the buccal mucosa: analysis of prognostic factors

Although the TNM system is the accepted standard for head and neck tumor classification, there are often discrepancies between tumor size and survival. This retrospective analysis of 89 patients with squamous cell carcinoma of the buccal mucosa was carried out to evaluate tumor thickness and depth of invasion as prognostic variables and to compare them to the standard parameters. Recurrence rates increased with tumor size, clinical stage, thickness, and depth of invasion. In univariate analysis, sex, clinical stage, thickness, and depth of invasion were significantly related to survival (p less than 0.10). Multivariate analysis revealed that only thickness was an independent variable (p less than 0.0001). Patients with tumors less than 6 mm in thickness had a significantly better survival rate compared with those patients with tumors greater than 6 mm in thickness, regardless of the tumor stage. Measurement of tumor thickness should be included in estimating prognosis, planning therapy, and comparing results in patients with squamous cell carcinoma of the buccal mucosa.

Pharyngoesophageal diverticulum complicated by squamous cell carcinoma

Pharyngoesophageal (Zenker's) diverticulum is a relatively common acquired condition that may cause dysphagia and regurgitation of food. Squamous carcinoma may develop in such a diverticulum, but this complication is exceedingly rare and may not be suspected preoperatively. This report describes a case in which the diagnosis of squamous carcinoma was made after regurgitation of malignant tissue from a radiographically proven pharyngoesophageal diverticulum. The patient was treated by simple diverticulectomy and postoperative radiation therapy.

Cystic epithelial-stromal tumor of the seminal vesicle

A cystic tumor composed of atypical glands in a cellular stroma arose in the pelvis of a 49-year-old man. Two years later an identical tumor was again excised from the pelvis. Morphologic, immunohistochemical and ultrastructural studies indicate that this neoplasm arose in the seminal vesicle, possibly from a seminal vesicle cyst. The tumor did not involve the prostate gland, and immunohistochemical stains for prostate-specific antigen and prostatic acid phosphatase were negative. Ultrastructural study showed that both the glandular and mesenchymal components of the tumor recapitulated features of normal seminal vesicle, further establishing origin from this site. This tumor resembles the rare cystadenoma of the seminal vesicle, yet the cytologic atypia suggests low grade malignant potential. Following the second excision, the patient has had a disease-free interval of 18 months. Long term follow-up and recognition of additional cases is necessary to define the biologic potential of this unusual tumor.

Is modified radical neck dissection only a staging procedure?

This retrospective study evaluates the clinical benefit of modified radical neck dissection among patients with squamous carcinoma of the upper aerodigestive tract. Ninety-eight modified neck dissections were performed in 86 patients over a 5-year period. The procedure entailed removal of the submaxillary and jugular chain nodes while the posterior triangle was not dissected. Thirty-two patients received postoperative radiotherapy. Lymph nodes were histologically positive in 55 of 98 dissections (56%). Among 72 determinate patients, recurrence in the dissected neck occurred in 8 of 38 with positive nodes and none of 34 with negative nodes (P less than 0.05). These recurrences occurred in patients who had clinically palpable nodes preoperatively. Postoperative radiotherapy did not significantly alter the overall recurrence rate or survival of patients with positive nodes. Cumulative disease-free survival at 5 years was 70% overall. It is concluded that the modified neck dissection described is appropriate in the clinically negative neck or when regional disease is early (i.e., N1) and located in the submandibular triangle. Postoperative radiotherapy should be given if more than one node is involved histologically or if extracapsular spread is present.

Modified radical neck dissection. Terminology, technique, and indications

The terminology relating to the various modifications of radical neck dissection is loose and confusing. A simple system of nomenclature has been suggested which allows specification of the node levels dissected and the structures preserved. A technique of modified neck dissection, which excludes dissection of the posterior triangle and spares the sternocleidomastoid muscle and spinal accessory nerve, has been described. We believe this operation is appropriate when local disease is advanced and clinically uninvolved neck nodes are likely to harbor occult metastatic disease, when resection of the primary tumor is through the neck, or when clinical disease in the neck is minimal. Patients with multiple palpable nodes, patients with nodes larger than 3 cm in diameter, patients with disease in the posterior triangle, and patients in whom radiotherapy to the neck has failed may be better served by radical neck dissection.

Malignant salivary tumors--analysis of prognostic factors and survival

A group of 113 patients with malignant salivary gland tumors was retrospectively reviewed to analyze the association of clinical and histologic factors with survival. These factors were patient sex and age, tumor site, clinical stage, histologic diagnosis, tumor grade, and whether or not final surgical margins were clear. There were 57 parotid, 40 minor salivary, and 16 submandibular gland cancers. The histologic groups were mucoepidermoid carcinoma (49 patients), adenoid cystic carcinoma (31), adenocarcinoma not otherwise specified (18), acinic cell carcinoma (7), malignant mixed tumor (5), squamous cell carcinoma (2), and undifferentiated carcinoma (1). Univariate analysis of clinical factors showed that age and clinical stage significantly influenced survival. At 10 yr the predicted cumulative survival rates for Stage I, II, III, and IV tumors were 74%, 56%, 32%, and 10%, respectively. Tumor grade was the only significant histologic factor. This was most obviously reflected among patients with mucoepidermoid carcinomas. Cumulative survival at 5 yr was 94% for those with low-grade tumors and 26% for high-grade tumors. By multivariate analysis, clinical stage, age, and tumor grade remained highly significant. Analysis of patients with only Stage I and II disease demonstrated that the significant factors were patient age, tumor site, tumor grade, and whether or not surgical clearance was achieved. These results suggest that clinical stage should not be the exclusive determinant of the extent of surgery and that the selection of patients, for adjuvant therapy may be improved by an awareness of these prognostic factors.

Neck dissection with and without radiotherapy: prognostic factors, patterns of recurrence, and survival

A group of 179 patients who had 205 neck dissections between 1979 and 1984 has been reviewed to assess the influence of adjuvant radiotherapy on survival. Lymph nodes were histologically involved in 91 of 107 radical neck dissections (85 percent) and 55 of 98 modified neck dissections (56 percent). Eighty-two patients received adjuvant radiotherapy of 5,000 rads or more. Patients with involved nodes had significantly lower survival rates than those with uninvolved nodes. Among patients with involved nodes, survival was significantly lower when two or more nodes were involved, when there was nodal involvement at multiple levels, or when extracapsular spread was present. Adjuvant radiotherapy was associated with a reduced recurrence rate in the ipsilateral neck but the incidence of distant metastases was higher. When patients with involved nodes were subgrouped according to prognostic factors, the survival of irradiated patients was improved only in the highest risk group, but this was not statistically significant. When radiotherapy is added to neck dissection for treatment of cervical metastases it can be expected to reduced ipsilateral neck recurrence and prevent relapse in the contralateral neck. Improved survival may depend on an ability to detect and treat occult distant metastases.

Surgical treatment of early-stage carcinoma of the oral tongue--wound adjuvant treatment be beneficial?

A group of 97 patients with clinical stage I and stage II squamous carcinoma of the oral tongue, treated by partial glossectomy alone, has been reviewed to define prognostic indicators. Sixty-seven patients were staged T1N0 and 30 were T2N0. Disease recurred in 28 patients (27%) and the most common site of failure was the ipsilateral neck (21%). The incidence of initial recurrence did not vary significantly with patient age, sex, T-stage, or when tumor size was examined in other subdivisions. The presence of perineural invasion significantly increased recurrence rate (P = 0.003) and decreased survival (P = 0.002). Disease-free survival at 5 yr was 73% for patients with T1 tumors, and 62% for T2 tumors. This difference was not significant. In this low-risk patient population with early stage carcinoma of the oral tongue, partial glossectomy is adequate treatment in most cases. However, we recommend postoperative radiation therapy to the primary site and ipsilateral neck for patients with perineural invasion. No evidence could be found to support adjuvant local therapy or elective neck treatment in the remaining patients.

Predicting the risk of abdominal disease in Hodgkin's lymphoma. A multifactorial analysis of staging laparotomy results in 255 patients

There were 425 consecutive patients treated for Hodgkin's disease at this Medical Center from 1943 to 1983. Of these, 255 patients underwent a staging laparotomy and had complete preoperative clinical records. Overall, 35% had a change in stage (24% were upstaged, 11% downstaged). Twenty-nine per cent of clinical stage I patients were upstaged; 31% of stage II patients were upstaged, while less than 1% were downstaged; and four per cent of stage III patients were upstaged while 44% were downstaged. The diagnostic laparotomy yielded involvement in the spleen in 71% of patients with abdominal involvement, in the periaortic lymph nodes in 41%, in the liver in 11%, and the bone marrow in seven per cent. Only 12% of the 135 patients with negative laparotomies subsequently relapsed in the abdomen after a mean follow-up of 4.8 years. A multifactorial analysis was performed to identify dominant factors predicting the risk for abdominal disease. The factors best predicting abdominal involvement in stage I and II patients were: antecedent symptoms (greater than or equal to 2, 1, 0; p less than 0.00001), histological type [nodular sclerosing (NS) less than lymphocyte-predominant (LP) less than mixed cellularity (MC) less than lymphocyte-depleted (LD); p = 0.0009], and sex (females less than males, p = 0.01). The clinical stage (I vs. II), the site of lymphoma presentation, and the age and race of the patient did not have significant predictive value for the risk of abdominal disease after the other factors were accounted for. A mathematical model was derived for identifying dominant prognostic factors for predicting the risk of abdominal disease in an individual patient setting. The lowest risk patients were asymptomatic females with NS histology (6%) or LP histology (8%), while the highest risk patients were men with multiple symptoms and either MC histology (85%) or LD histology (93%). This information can be useful in making clinical decisions in Hodgkin's lymphoma patients, especially those at an increased risk for surgery.

The influence of surgical margins and prognostic factors predicting the risk of local recurrence in 3445 patients with primary cutaneous melanoma

Risk factors associated with local recurrences were analyzed from a series of 3445 clinical Stage I melanoma patients. In single-factor analysis, tumor thickness, ulceration, and increasing age were highly significantly predictive of recurrence (p less than 0.00001). After 5 years of follow-up, local recurrence rates were 0.2% for tumors less than 0.76 mm thick, 2.1% for tumors 0.76 to 1.49 mm thick, 6.4% for tumors 1.5 to 3.99 mm thick, and 13.2% for tumors 4.0 mm or greater in thickness. Ulcerated melanomas recurred more often than nonulcerated lesions (11.5% versus 1.9%). When analyzed as a continuous variable, increasing age increased the risk of local failure. In multifactorial analysis, all of these three factors remained independently predictive of local recurrence. Recurrences were more common with nodular melanomas (5.6%) compared to superficial spreading (2.5%) or lentigo maligna melanoma (2.5%), but this difference did not reach statistical significance (P = 0.115). Lower extremity (4.7%) and head and neck lesions (4.4%) recurred more frequently than upper extremity (1.6%) or trunk (1.2%) melanomas (P = 0.0217). The highest recurrence rates were observed in patients with melanomas located on the foot (11.6%) and hand (11.1%). The safety of conservative margins for the excision of low-risk melanomas was demonstrated in a review of 1151 consecutive patients with melanomas less than 1 mm thick where only one local recurrence was observed. Sixty-two percent of these patients had resection margins of 2 cm or less. In 95 patients local recurrence developed as the first site of relapse and were treated with surgical excision. The median survival for this group was 3 years, whereas 20% of this group survived 10 years. These data demonstrate that: (1) the risk of local recurrence rises with increasing tumor thickness, presence of ulceration, and age; (2) melanomas less than 1 mm thick have a very low local recurrence rate, even when excised with margins of 2 cm or less; and (3) local recurrence is a poor prognostic sign because regional and systemic metastases subsequently develop in many patients.

Head and neck melanoma in 534 clinical Stage I patients. A prognostic factors analysis and results of surgical treatment

Single and multifactorial analyses were used to evaluate prognosis and results of surgical treatment in 534 clinical Stage I patients with head and neck cutaneous melanoma treated at the University of Alabama in Birmingham (U.S.A.) and the University of Sydney (Australia). This computerized data base was prospectively accumulated in over 90% of cases. Melanomas were about equally distributed between men and women. They were located on the skin of the face in 47%, neck in 27%, scalp in 13%, and the ear in 13% of patients. Both the results of the prognostic factors analyses and the surgical treatment demonstrated that lentigo maligna melanoma (LMM) was distinct from the other two growth patterns, superficial spreading melanoma and nodular melanoma (SSM and NM). In a multifactorial analysis of the 453 patients with SSM and NM, the dominant prognostic variables were tumor thickness (p less than 0.00001), anatomic subsite (p = 0.0213), and ulceration (p = 0.0289). Patients with melanomas on the scalp or neck subsites fared worse than those with tumors located on the face or ear. The results differed for LMM, where thickness was not a significant predictor of survival, and the most dominant prognostic variable was ulceration (p = 0.0042). Local recurrence rates were low, being 2.4% for tumors less than 2.5 mm in thickness, but were 12.3% for tumors greater than or equal to 4.0 mm in thickness. Patients with SSM and NM lesions located on the head and neck had a lower survival rate than those with extremity melanomas in every tumor thickness category, although only those in the 0.76 to 1.49 mm thickness subgroup were significantly different (p = 0.0007). After 5 years of follow-up, patients who underwent an elective lymph node dissection for SSM and NM with a thickness range of 1.5 to 3.99 mm had a better survival (72%) than patients with melanomas of equivalent thickness whose initial treatment was wide excision alone (45%). LMM had a less aggressive biologic behavior compared to SSM or NM and was treated more conservatively. Thus, LMM lesions had an 85% 10-year survival rate with wide excision only, and there was no significant improvement in survival with ELND. Growth patterns, tumor thickness, ulceration, and anatomic subsites should be considered when evaluating risk factors and when making treatment decisions in head and neck melanoma patients.

Hayes Martin lecture. Vicissitudes of head and neck cancer

In this study 136 of 167 patients (81 percent) with squamous cell carcinoma of the anterior tongue had no clinically evident neck node metastases. In 92 patients who received no elective treatment to the neck, 8 percent had recurrences at the primary site and 25 percent had recurrences in the neck with the primary site controlled. Three factors identify those patients at highest risk for harboring occult metastases: clinical size of the primary tumor, the presence of perineural invasion, and the sex of the patient (men fare worse). Patients with primary tumors of 1 cm or less in greatest diameter should not have elective treatment to the at-risk neck, patients with tumors greater than 3 cm in greatest diameter should receive treatment to the at-risk neck, and patients with cancer demonstrating perineural invasion should receive treatment to the at-risk neck. In the future, randomized controlled trials evaluating the efficacy of elective treatment to the at-risk neck should include only those patients at intermediate risk for harboring occult neck node metastases (that is, primary tumors 1 to 3 cm in greatest dimension without perineural invasion). Careful retrospective multifactorial analysis of the natural history and prognosis should always precede prospective, randomized trials to prevent the randomization of patients whose outcome can be predetermined on the basis of clinical and histologic characteristics.

Metastases to the upper levels of the axillary nodes in carcinoma of the breast and its implications for nodal sampling procedures

An axillary lymphadenectomy is important for the staging and treatment of metastatic disease in patients with carcinoma of the breast, especially since the nodal status is a primary criterion for using systemic adjuvant chemotherapy. As more conservative operations combined with radiation therapy have been increasingly used for selected patients with carcinoma of the breast, an axillary node sampling instead of a complete axillary dissection has been advocated by some oncologists. However, the possibility exists that node "sampling" understages patients who would otherwise have received adjuvant chemotherapy to improve their chances for cure. We retrospectively examined this hypothesis in a group of 72 patients with documented nodal metastases who had a radical mastectomy (modified or Halsted). Overall, 18 of 72 patients (25 per cent) had metastatic involvement confined to the upper axillary nodes (Levels II and III). Of the patients with no clinically palpable nodes, 32 per cent had metastatic nodal involvement confined to the upper nodes. Medial quadrant lesions exhibited this tendency more than lateral quadrant lesions (50 versus 20 per cent). Larger primary tumors were associated with an increasing likelihood of involved nodes; however, even 14 per cent of the smallest primary lesions of the breast (less than 2 centimeters) had metastases exclusively to the upper axillary region. Since approximately 40 per cent of the patients with carcinoma of the breast have nodal metastases and since 25 per cent of these metastases are confined to the upper portion of the axilla, it is estimated that at least 10 per cent of all women with carcinoma of the breast (25 X 40 per cent) would be understaged by an axillary node sampling procedure.

Changing trends in cutaneous melanoma over a quarter century in Alabama, USA, and New South Wales, Australia

Clinical and pathologic characteristics of melanoma were compared among 1647 clinical Stage I patients treated at the University of Alabama in Birmingham (USA) and The University of Sydney (Australia) between 1955 and 1980 to determine what changes occurred over a quarter century. Over this period, the number of patients treated annually has increased substantially. There was a steady increase in the proportion of patients presenting with localized disease (clinical Stage I). Melanomas became thinner, less invasive, less ulcerative and thus more curable. They also exhibited more of a radial growth phase. The median thickness of melanomas decreased in Australia from 2.5 mm prior to 1960 to 1.1 mm during the period 1976 to 1980, while in Alabama it has decreased from 3.3 to 1.4 mm. There was a significant increase in melanomas located on the trunk in males and a corresponding decrease in male head and neck melanomas. No significant change in the site distribution was observed for any major anatomical area on female patients. There were minimal differences in the incidence of both clinical and pathologic parameters among melanoma patients in Alabama, USA and in New South Wales, Australia even when accounting for their year of diagnosis. Long-term survival rates in patients with localized disease were found to increase slightly during the 25 year time frame of this analysis. The changes that have occurred are likely due to earlier diagnosis and changes in the biological nature of the disease.

A randomized prospective trial of radical (Halsted) mastectomy versus modified radical mastectomy in 311 breast cancer patients

This study reports the results of a prospectively randomized trial for treatment of carcinoma of the breast comparing standard (Halsted) radical mastectomy to a modified radical mastectomy. Three hundred eleven patients with primary operable carcinoma of the breast were entered in a surgical and adjunctive chemotherapy trial in Alabama between 1975 and 1978. A total of 91 surgeons participated (all Diplomats of the American Board of Surgery and Members of the American College of Surgeons). All operative reports, pathology and therapy were reviewed by referees. Histologically node positive patients were randomized after operation to receive melphalan or C.M.F.(cytoxan, methotrexate, and 5-FU) for 1 year. After a median follow-up of 5.5 years, there was no significant difference in disease-free survival or in overall survival between the two groups. There was a trend toward improved 5-year survival rates in the radical mastectomy group compared to the modified radical mastectomy group (84% vs. 76%, p = 0.14). There was also an increased incidence of local wound recurrence in those patients receiving modified radical mastectomy, but the differences were not statistically significant (p = 0.09). Longer follow-up will be necessary to evaluate these results more fully.

Patient risk factors and surgical morbidity after regional lymphadenectomy in 204 melanoma patients

A series of 204 melanoma patients were studied six months or longer after regional lymph node dissection of the neck (N = 48), axilla (N = 98) and groin (N = 58) in order to determine the degree of morbidity and analyze for risk factors associated with these procedures. Only one-quarter of the patients experienced wound-related, short-term complications that were common at all sites; however, these rarely resulted in long-term functional deficits. Seromas (22%), temporary nerve dysfunction or pain (14%), and wound infections (6%) were the most frequent short-term complications. Wound complications extended the mean hospital stay by 0.6 to 4.8 days. Residual lymphedema of the leg was measurable in 26% of groin dissection patients after six months or longer; most of the edema was confined to the thigh. Only 8% of patients had significant functional deficit from lymphedema. The risk of developing at least one complication for all patients was increased for obese patients (P = 0.05) and increasing age (P = .01). These risk factors should be considered when evaluating melanoma patients for regional lymph node dissection.

A multifactorial analysis of melanoma. IV. Prognostic factors in 200 melanoma patients with distant metastases (stage III)

A multifactorial analysis of 200 cutaneous melanoma patients with distant metastasis (stage III) was performed on 13 clinical and pathological factors using the Cox regression analysis. There were only three dominant prognostic variables that independently predicted the patient's clinical course: (1) number of metastatic sites (1 vs. 2 vs. greater than or equal to 3, p less than 0.00001), (2) remission duration (less than 12 mo vs. greater than or equal to 12 mo, p = 0.0186), and (3) the location of the metastases (visceral vs. nonvisceral vs. combined, p = 0.0192). Factors that were not significant in the multifactorial analysis included the patients' age and sex, the site of the primary melanoma, the sequence of metastases, and all histopathological features of the primary melanoma (thickness, level of invasion, ulceration, growth pattern, pigmentation, and lymphocyte infiltration). For a single metastatic site, the 1-yr survival rate was 36%, while it was only 13% for 2 sites, and 0% for greater than or equal to 3 sites (p less than 0.00001). The 1-yr survival for patients was 40% for nonvisceral sites (skin, subcutaneous, distant lymph nodes) compared to only 11% for visceral metastases and 8% for combined sites (p less than 0.00001). Pulmonary metastases were associated with a significantly higher survival rate than metastatic melanoma in any other visceral site. The most common first site of distant metastases (either alone or in combination) was skin (38%), lung (36%), liver (20%), and brain (20%). The skin, subcutaneous and distant lymph node group was the first site of metastases in 59% of patients. This finding emphasizes the importance of careful physical exams in routine metastatic evaluations. Only a minority (25%) of stage I patients progressed to stage III disease after a median interval of 2.8 years. In contrast, the majority (75%) of melanoma patients with nodal metastases (stage II) progressed to stage III disease after a median duration of only 11 mo. Of the patients who eventually developed stage III disease, 95% of those who initially presented with stage II disease progressed within 3 yr, while stage I patients who progressed to stage III did not reach a 95% cumulative incidence until 8 yr.

A comparison of prognostic factors and surgical results in 1,786 patients with localized (stage I) melanoma treated in Alabama, USA, and New South Wales, Australia

Twelve clinical and pathologic parameters were compared in two series of Stage I melanoma patients treated at the University of Alabama in Birmingham, USA (676 patients) and at the University of Sydney in New South Wales, Australia (1,110 patients). Actuarial survival rates were virtually the same at the two institutions over a 25-year follow-up period. The incidence of thin melanomas (less than 0.76 mm) was also similar at both geographic locations (25% vs. 26%). Other similarities of these two patient populations included the following: 1) tumor thickness (Breslow Microstaging). 2) level of invasion (Clark Microstaging), 3) surgical results, 4) sex distribution, and 5) age distribution. The greatest differences between the two patient populations were their 1) anatomic distribution, 2) growth pattern, and 3) incidence of ulceration. The trunk was the most common site of melanoma, and occurred more frequently among Australian patients (37% vs. 28%). A multifactorial analysis (Cox's regression model) was then performed that included a comparison of the two institutions as a variable (Alabama vs. Australia). The dominant prognostic factors (p less than 0.0001) were 1) ulceration, 2) tumor thickness, 3) initial surgical management (wide excision +/- node dissection), 4) anatomic location, 5) pathologic stage (I vs. II), and 6) level of invasion. The benefit of elective lymph node dissection was demonstrated in both series for patients with intermediate thickness melanoma (0.76 to 3.99 mm.) For melanomas ranging from 0.76 to 1.5 mm in thickness, the benefit of node dissection was primarily in male patients. Survival rates for melanoma at the two institutions were not significantly different in the multifactorial analysis, even after adjusting for all other variable. Thus, the biologic behavior of melanoma in these two different parts of the world was virtually the same, with only minor differences that did not significantly influence survival rates. Long-term follow-up exceeding eight to ten years after surgery is critical in the interpretation of these prognostic factors and the surgical results.

Favorable factors in the adjuvant therapy of breast cancer

One hundred seventy-one patients received one year of melphalan or intermittent cyclophosphamide, methotrexate, and fluorouracil after mastectomy for breast cancer with involved axillary nodes. Analysis with a median follow-up of three years indicates a favorable outcome only for patients with 1-3 positive nodes who were treated with melphalan and who experienced a leukocyte count less than 3,000/mm3 (3.0 X 10(9)/l). Tumor size, average percentage of dose received, menopausal status, and type of chemotherapy were not significant factors in recurrence of disease, after adjustment for the number of positive nodes and leukocyte count nadir during treatment based on a multifactorial analysis. These data suggest that administration of a dose of melphalan which does not produce a leukocyte count of less than 3,000/mm3 is ineffective in preventing early recurrence of disease. Since oral melphalan is known to be erratically absorbed, lack of hematologic toxicity may well be due to variable absorption of the drug on a fixed-dose region. Failure to prevent recurrence of disease in this and other trials using oral melphalan may be due to chemotherapy-related as well as disease-related factors.

A multifactorial analysis of melanoma: III. Prognostic factors in melanoma patients with lymph node metastases (stage II)

Twelve prognostic features of melanoma were examined in a series of 185 patients with nodal metastases (Stage II), who underwent surgical treatment at our institution during the past 20 years. Forty-four per cent of the patients presented with synchronous nodal metastases (substage IIA), 44% of the patients had delayed nodal metastases (substage IIB), and 12% of the patients had nodal metastases from an unknown primary site (substage IIC). The patients with IIB (delayed) metastases had a better overall survival rate than patients with IIA (synchronous) metastases, when calculated from the time of diagnosis. These differences could be explained on the basis of tumor burden at the time of initial diagnosis (microscopic for IIB patients versus macroscopic for IIA patients). Once nodal metastases became evident in IIB patients, their survival rates were the same as for substage IIA patients, when calculated from the onset of nodal metastases. The survival rates for both subgroups was 28% at five years and 15% for ten years. Substage IIC patients (unknown 1 degrees site) had better five-year survival rates (39%), but the sample size was small and the differences were not statistically significant. A multifactorial analysis was used to identify the dominant prognostic variables from among 12 clinical and pathologic parameters. Only two factors were found to independently influence survival rates: 1) the number of metastatic nodes (p = 0.005), and the presence or absence of ulceration (p = 0.0019). Additional factors considered that had either indirect or no influence on survival rates (p > 0.10) were: anatomic location, age, sex, remission duration, substage of disease, tumor thickness, level of invasion, pigmentation, and lymphocyte infiltration. All combinations of nodal metastases were analyzed from survival differences. The combination that showed the greatest differences was one versus two to four versus more than four nodes. Their five-year survival rates were 58%, 27% and 10%, respectively (p < 0.001). Ulceration of the primary cutaneous melanoma was associated with a <15% five-year survival rate, while nonulcerative melanomas had a 30% five-year survival rate (p < 0.001). The combination of ulceration and multiple metastatic nodes had a profound adverse effect on survival rates. While tumor thickness was the most important factor in predicting the risk of nodal metastases in Stage I patients (p < 10(-8)), it had no predictive value on the patient's clinical course once nodal metastases had occurred (p = 0.507). The number of metastatic nodes and the presence of ulceration are important factors to account for when comparing surgical results, and when analyzing the efficacy of adjunctive systemic treatments.

The prognostic significance of ulceration of cutaneous melanoma

Ulceration of a cutaneous melanoma on microscopic sections is an adverse prognostic finding. The five-year survival rate is reduced from 80% for non-ulcerated melanomas to 55% in the presence of ulceration for Stage I melanoma patients and from 53 to 12% for Stage II melanoma patients (P less than 0.001). As a group, ulcerated lesions are thicker and more likely to have a nodular growth pattern. However, survival rates were still worse for ulcerated melanomas when matched with nonulcerated lesions for thickness and stage of disease. The width but not the depth of surface ulceration significantly correlated with survival. The median ulcer depth was 0.08 mm (range 0.01-1.2 mm). In those few lesions with ulcer craters more than 0.2 mm in depth, the melanomas were so thick they had the same poor prognosis regardless of whether thickness was measured to the base of the ulcer or to the top of the lesion. The Breslow microstaging method of measuring thickness is therefore a valid prognostic indicator, even for ulcerated lesions. The incidence of ulceration for the entire patient group ranged from 12.5% for melanomas less than 0.76 mm thickness to 72.5% for melanomas greater than 4.0 mm thick (P of correlation = 0.0001); from 12% for Level II invasion to 63% for Level V lesions (P = 0.005); from 23% for superficial spreading growth patterns to 49% for nodular and 74% for polypoid lesions (P = 0.0001); and from 27% for lesions with a heavy lymphocyte infiltration to 60% for minimal or absent host response (P = 0.005). There was no significant correlation with anatomic location, pigmentation of the melanomas, or with the patient's age and sex. Since ulceration appears to have such an important influence on survival rates, this parameter should be considered as a stratification criterion in clinical trials and accounted for when analyzing results of melanoma treatment.

A multifactorial analysis of melanoma. II. Prognostic factors in patients with stage I (localized) melanoma

Stage I melanoma encompasses an extraordinary diversity of biologic behavior. In such a setting where numerous parameters appear to influence survival, a multifactorial analysis using Cox's regression model is a valuable statistical model. Using a computerized data base of 394 clinical stage I melanoma patients treated at this institution during the past 20 years, a multifactorial analysis was used to compare the relative prognostic strength of 11 parameters. Two pathological factors (tumor thickness and ulceration) and two clinial factors (initial surgical treatment and anatomic location) were identified as the dominant prognostic variables. Other factors examined simultaneously that did not provide additional predictive influence on survival included the level of invasion, pigmentation, growth pattern, lymphocyte infiltration, pathological state, sex, and age. Melanoma thickness was the most important factor for predicting survival in patients with stage I melanoma (P less than 10(-8). This parameter is easy to measure and provides a quantitative estimate of clinically occult regional and distant metastases. Contrary to other reports using single factor analysis, the type of initial surgical treatment, in fact, did influence survival after other variables were taken into consideration. Thus the multifactorial analysis supports the observation that patients with intermediate thickness melanoma thickness of 1.5 to 3.99 mm had a 78% 8-year survival rate with wide excision of the melanoma and elective node dissection, while none survived more than 8 years if a melanoma of the same thickness was only widely excised. Multifactorial analysis is a useful and important statistical method when comparing treatment alternatives and prognostic factors in patients with melanoma.

A multifactorial analysis of melanoma: prognostic histopathological features comparing Clark's and Breslow's staging methods

A multifactorial analysis was used to identify the dominant prognostic variables affecting survival from a computerized data base of 339 melanoma patients treated at this institution during the past 17 years. Five of the 13 parameters examined simultaneously were found to independently influence five year survival rates: 1) pathological stage (I vs II, p = 0.0014), 2) lesion ulceration (present vs absent, p = 0.006), 3) surgical treatment (wide excision vs wide excision plus lymphadenectomy, p = 0.024), 4) melanoma thickness (p = 0.032), and 5) location (upper extremity vs lower extremity vs trunk vs head and neck, p = 0.038). Additional factors considered that had either indirect or no influence on survival rates were clinical stage of disease, age, sex, level of invasion, pigmentation, lymphocyte infiltration, growth pattern, and regression. Most of these latter variables derived their prognostic value from correlation with melanoma thickness, except sex which correlated with location (extremity lesions were more frequent on females, trunk lesions on males). This statistical analysis enabled us to derive a mathematical equation for predicting an individual patient's probability of five year survival. Three categories of risk were delineated by measuring tumor thickness (Breslow microstaging) in Stage I patients: 1) thin melanomas (<0.76 mm) were associated with localized disease and a 100% cure rate: 2) intermediate thickness melanomas (0.76-4.00 mm) had an increasing risk (up to 80%) of harboring regional and/or distant metastases and 3) thick melanomas (>/=4.00 mm) had a 80% risk of occult distant metastases at the time of initial presentation. The level of invasion (Clark's microstaging) correlated with survival, but was less predictive than measuring tumor thickness. Within each of Clark's Level II, III and IV groups, there were gradations of thickness with statistically different survival rates. Both microstaging methods (Breslow and Clark) were less predictive factors in patients with lymph node or distant metastases. Clinical trials evaluating alternative surgical treatments or adjunctive therapy modalities for melanoma patients should incorporate these parameters into their assessment, especially in Stage I (localized) disease where tumor thickness and the anatomical site of the primary melanoma are dominant prognostic factors.

The logic of adjunctive therapy in surgical patients with resectable cancer

The principles and rationale of using multiple modalities (surgery, chemotherapy, radiotherapy, and immunotherapy) to treat solid malignancies is reviewed. Animal models of human tumors have clearly demonstrated the superiority of combining local treatment (eg, surgery) with systemic treatment (eg, chemotherapy). Although the results of many trials of adjunctive therapy in man are still preliminary, they warrant the caustious generalization that multiple modality therapy will increasingly become more effective than surgery alone for most types of solid tumors. Although the strategy of employing adjunctive therapy is rational, it must be emphasized that the therapeutic efficacy of specific drugs or agents for particular patients or tumor types has not always been satisfactory. Clinical trials now in progress may demonstrate more effective regimens. In the meantime, physicians should be cautious about using adjunctive therapy as standard treatment until long-term benefits and safety have been demonstrated. Participation in clinical trials is encouraged to verify the validity and application of this therapeutic approach.

The pathologic behavior of primary vaginal carcinoma and its relationship to cervical cancer

The surgical pathology files at the University of Alabama Medical Center for 1958 through 1973 contain records of 157 cases of vaginal carcinoma. Of the 141 patients on whom complete records are available, 37 had primary and 104 secondary vaginal carcinoma. Only 3 of the primary vaginal malignancies were adenocarcinoma; the rest were epidermoid. The microscopic appearance of these carcinomas was frequently lateral spreading or papillary, but in a few instances the growth pattern was submucosal. Prognosis appeared to be related to the stage of the disease. Vaginal carcinomas associated with cervical cancer clustered either within 1 year or 5 years after the therapeutic treatment. In this paper, the relationship between primary vaginal cancer and cervical cancer is discussed.