Tumor growth rate as a prognostic factor of acral melanoma in a Korean population

Rapid growth of cutaneous melanoma is associated with aggressive histopathologic features and poor prognosis. However, the impact of growth rate (GR) in acral melanoma (AM) remains largely unknown.We performed this study to identify the impact of GR on lymph node metastasis and survival in AM.We analyzed cases of invasive AM diagnosed at our institution between 1998 and 2017. We investigated the impact of GR on the prognosis of AM.A total of 126 cases of invasive AM were included. Log (GR) was significant associated with lymph node metastasis in the univariate logistic regression analysis (P = .005). The log-rank test revealed statistically significant differences in disease-free survival (DFS) and disease-specific survival (DSS) among the GR quartiles. In the Cox regression analysis, log (GR) was an independent predictor for DFS (P = .041), but not for DSS in multivariate analysis. In the subgroup analysis, log (GR) was an independent predictor for early-stage (≤2A) AM (DFS, P = .002; DSS, P = .004).The limitations of this study include the retrospective design of the study and possible recall bias.Our results suggest that GR is an important prognostic factor for DFS and DSS in AM patients and an independent predictor for early-stage AM.

Acral lentiginous melanoma: a skin cancer with unfavourable prognostic features. A study of the German central malignant melanoma registry (CMMR) in 2050 patients

BACKGROUND

Acral lentiginous melanoma (ALM) is one of the four major subtypes in cutaneous melanoma (CM). Although ALM has a poorer prognosis than other CM subtypes, the prognostic factors associated with ALM have only been verified in small-sized cohorts because of the low incidence of ALM worldwide.

OBJECTIVES

To investigate the clinical characteristics of ALM and to evaluate their prognostic values based on a large dataset from the Central Malignant Melanoma Registry (CMMR) of the German Dermatologic Society.

METHODS

The Kaplan-Meier method was used to estimate the potential influence of clinical and histological parameters on ALM disease-specific survival (DSS) curves, which were compared using the log-rank test. A Cox proportional hazards model was used to identify independent prognostic factors for DSS.

RESULTS

In total, 2050 patients with ALM were identified from 58 949 patients with CM recorded by the CMMR with follow-up data. In multivariate analyses, age (P = 0·006), ulceration (P = 0·013), tumour thickness (P < 0·001) and tumour spread (P < 0·001) turned out to be significant prognostic factors for DSS in ALM whereas sex, nevus association and level of invasion were not independent factors.

CONCLUSIONS

ALM has the same prognostic factors as other subtypes of melanoma. Unfavourable prognosis probably derives from the delay in diagnosis in comparison with other melanoma subtypes.

Insulin-Like Growth Factor II mRNA-Binding Protein 3 Expression Correlates with Poor Prognosis in Acral Lentiginous Melanoma

Insulin-like growth factor-II mRNA-binding protein 3 (IMP-3) is an RNA-binding protein expressed in multiple cancers, including melanomas. However, the expression of IMP-3 has not been investigated in acral lentiginous melanoma (ALM). This study sought to elucidate its prognostic value in ALMs. IMP-3 expression was studied in 93 patients diagnosed with ALM via immunohistochemistry. Univariate and multivariate analyses for survival were performed, according to clinical and histologic parameters, using the Cox proportional hazard model. Survival curves were graphed using the Kaplan-Meier method. IMP-3 was over-expressed in 70 out of 93 tumors (75.3%). IMP-3 expression correlated with thick and high-stage tumor and predicted poorer overall, melanoma-specific, recurrence-free and distant metastasis-free survivals (P = 0.002, 0.006, 0.008 and 0.012, respectively). Further analysis showed that patients with tumor thickness ≤ 4.0 mm and positive IMP-3 expression had a significantly worse melanoma-specific survival than those without IMP-3 expression (P = 0.048). IMP-3 (hazard ratio 3.67, 95% confidence intervals 1.35-9.97, P = 0.011) was confirmed to be an independent prognostic factor for melanoma-specific survival in multivariate survival analysis. Positive IMP-3 expression was an important prognostic factor for ALMs.

Prognostic indicators of poor outcome in horses with laminitis at a tertiary care hospital

This retrospective study investigated the factors associated with a poor outcome (death by euthanasia or from other causes) in horses treated for laminitis at a tertiary care hospital. Cases (n = 247) were defined as patients with laminitis that were euthanized or that died of other causes during hospitalization. Controls (n = 344) were patients with laminitis that survived to be discharged from the hospital. In the final multivariate analysis, the factors significantly associated with an increased risk for death and their respective odds ratios (OR) were as follows: Thoroughbred (OR = 1.57); racehorse (OR = 1.76); treatment with flunixin meglumine (OR = 1.76); vascular pathology (OR = 2.12); distal displacement of the third phalanx (OR = 2.68); pneumonia (OR = 2.87); and lameness of Obel grade II (OR = 2.99), grade III (OR = 9.63), or grade IV (OR = 20.48). The use of glue-on shoes significantly reduced the risk for death (OR = 0.36).

Effect of Lameness on Culling in Dairy Cows

The purpose of this study was to assess the effect of lameness on dairy cow survival. Cox's proportional hazards regression models were fitted to single-lactation data from 2520 cows in 2 New York State dairy herds. Models were controlled for the time-independent effects of parity, projected milk yield, and calving season, and for the time-dependent effects of lameness and culling. Other common diseases were found to be nonconfounding and so were not included in any of the final models. Survival was measured as the time from calving until death or sale. Cows were censored if they reached the start of the next lactation or end of the study, whichever occurred first. All models were stratified by herd. For all lameness diagnoses combined, survival in the herd decreased for those cows becoming lame during the first half of lactation, with a hazard ratio of up to 2 times that of a nonlame cow. Foot rot diagnosed during the second or third months of lactation decreased survival during the same time period (hazard ratio=5.1; 95% confidence interval=1.6 to 16.2). Sole ulcers diagnosed in the first 4 mo of lactation decreased survival in several subsequent periods in which the strongest association was between diagnosis in the third and fourth months of lactation and exit from the herd during that same period (hazard ratio=2.7; 95% confidence interval=1.3 to 6.0). Foot warts were not associated with decreased survival in this analysis. Lameness was never associated with increased survival in any of the models.

Distal lower extremity sarcomas: frequency of occurrence and patient survival rate

BACKGROUND

Primary sarcomas in the distal leg, tibia, fibula, ankle, and foot are uncommon and are believed to be less malignant than those that arise in other sites, but only limited information is available to support this contention.

METHODS

Using a computerized system containing extensive information regarding over 14,000 patients, mostly with tumors treated by our center over a 25-year period, 175 sarcomatous lesions with MSTS stage I, II, and III were located in the distal lower extremity. These were compared with 2367 lesions of similar diagnoses in other body parts. The principal studies included diagnostic distribution and outcome (recorded as death as a result of disease). Data were compared for diagnosis, gender, age, Musculoskeletal Tumor Society (MSTS) stage, anatomic site, and treatment methods and evaluated statistically by chi-square methods.

RESULTS

The most frequent distal lower limb tumors were synovial cell sarcoma, osteosarcoma, and Ewing's tumor and the percentage distribution of the various tumors for that site as compared with the rest of the body was quite different. Of even more importance was the remarkable difference in outcome with the death rate for the lower limb tumors set at 10%, while the same tumors at other sites had a death rate of 27% (p <.000002). Furthermore, gender, stage, age, and the type of operative procedure showed highly significant differences between the tumors of the lower leg and those of the remainder of the body.

CONCLUSIONS

On the basis of these data, it is evident that far fewer sarcomas occur in the lower leg, tibia, fibula, ankle, and foot than in other body sites and that their diagnostic distribution is different. Of perhaps greater interest is the fact that the rate of metastasis and death is markedly reduced for this site as compared with others. The authors speculate on the causes of this remarkable alteration in numbers and outcome.

Survival of patients with primary pedal melanoma

Malignant melanoma is increasing at a rate faster than any other cancer in the United States. Location of the primary tumor on the foot is associated with poorer prognosis. This study evaluates a cohort of 148 patients with melanoma of the lower extremity (37 foot or ankle and 111 leg, knee, or thigh) diagnosed at a university medical center during a 32-year period. The mean follow-up for the foot/ankle patients was 44 months. The overall 5-year survival rate was 52% for patients with a primary melanoma of the foot/ankle compared with 84% for patients with a primary melanoma elsewhere on the lower extremity. Although the study period extended over 32 years, nearly 65% of the foot/ankle patients were diagnosed in the last decade. This increase is most likely because of the documented increase in incidence of melanoma in the United States and an increasing referral pattern at our institution.

Hyperthermic isolated limb perfusion with tumor necrosis factor-alpha and melphalan in patients with locally advanced soft tissue sarcomas: treatment response and clinical outcome related to changes in proliferation and apoptosis

Hyperthermic isolated limb perfusion with tumor necrosis factor-alpha and melphalan (HILP-TM) with or without IFN-gamma is a promising local treatment in patients with locally advanced extremity soft tissue sarcomas (STSs), with response rates of up to 84%. The mechanisms of the treatment response are poorly understood. Here, we determined the HILP-TM-induced changes in mitotic activity, proliferation, and apoptosis in 37 STSs; the additional effect of IFN-gamma; and the association of HILP-TM with treatment response and clinical outcome. On archival material, obtained before and 6-8 weeks after HILP-TM with (n = 15) or without (n = 22) IFN-gamma, the number of mitoses was counted, and the proliferation fraction was determined by immunohistological staining for the proliferation associated Ki-67 antigen (MIB1). Apoptosis was visualized by enzymatic detection of DNA fragmentation (terminal deoxynucleotidyl transferase-mediated nick end labeling method). Clinical and histological response, follow-up status, and survival were recorded. The number of mitoses dropped 57% and proliferation rate decreased with 40% after HILP-TM, whereas the amount of apoptosis after HILP-TM more than doubled as before HILP-TM. The addition of IFN-gamma to HILP-TM did not influence the changes in tumor parameters and did not affect treatment response. A better clinical response to HILP-TM was correlated with high mitotic activity and low amount of apoptosis in tumor samples before HILP-TM. Patients with highly proliferative STS before and after HILP-TM had a relatively poor prognosis. Furthermore, patients who developed distant metastases after HILP-TM had a relatively high number of dividing cells in the tumor remnants after treatment.

Multifactorial analysis of the survival of patients with distant metastasis arising from primary extremity sarcoma

BACKGROUND

Despite optimal multimodality limb-sparing therapy for extremity soft tissue sarcoma (STS), a significant number of patients develop distant metastasis. The objective of this study was to analyze patterns of metastatic disease and define prognostic factors for survival in a large group of patients followed prospectively at a single institution.

METHODS

Between July 1, 1982, and June 30, 1996, all adult patients admitted to the Memorial Sloan-Kettering Cancer Center with primary extremity sarcoma were treated and prospectively followed. Patients who developed distant metastases constituted the study group. Prognostic factors were analyzed for postmetastasis survival. These included both factors related to the primary tumor and factors related to the pattern of metastasis. Postmetastasis survival was modeled using the Kaplan-Meier method. Statistical significance was evaluated using the log rank test for univariate analysis and the Cox proportional hazards model for multivariate analysis.

RESULTS

During the study period, the authors admitted and treated 994 patients with primary extremity STS. The median follow-up was 33 months. Distant metastasis developed in 230 patients (23%). Median survival after distant metastasis was 11.6 months. The lungs were the first metastatic site in 169 patients (73%). Other first sites of metastasis included the skin and soft tissues of the head and neck, trunk, and extremities. There was no statistically significant difference in survival between patients with pulmonary and those with nonpulmonary metastatic disease. In multivariate analysis, resection of metastatic disease, the length of the disease free interval, the presence of a preceding local recurrence, and patient age > 50 years all were significant predictors of postmetastasis survival. Other factors that defined the primary tumor, including histologic grade, depth, and microscopic margins, were not associated with postmetastasis survival.

CONCLUSIONS

Despite optimal multimodality therapy, 23% of the patients in this series with primary extremity sarcoma developed distant metastasis. Median survival after metastasis was approximately 1 year. After metastasis, the independent favorable factors that are associated with patient survival include resection of the metastases, a long disease free interval, the absence of preceding local recurrence, and patient age < 50 years. Although a definitive conclusion regarding the benefit of resection can be made only with a randomized clinical trial, these data suggest that resection of metastatic STS may contribute to patient survival, which in some cases may be long term.

Survival of patients with melanoma of the lower extremity decreases with distance from the trunk

BACKGROUND

Early stage melanoma of the lower extremity is generally associated with a favorable prognosis. However, several retrospective studies have suggested that melanoma on the foot portends poor survival. The authors hypothesized that the region of the lower extremity has prognostic importance.

METHODS

Between January 1, 1971, and December 31, 1991, 652 patients were seen at the John Wayne Cancer Institute for a primary melanoma on the foot (92 patients), calf (336 patients), or thigh (224 patients). All patients had clinically or histopathologically negative regional lymph nodes. The duration of follow-up after first diagnosis was 9 -302 months, with a minimum of 6 years for survivors. Survival curves were estimated by the Kaplan-Meier method. Pearson chi-square test was used to test differences associated with the regional site of the lower-extremity melanoma. The log rank test was used for univariate analysis, and Cox proportional hazards regression was used for multivariate analysis.

RESULTS

Univariate analysis identified regional site, gender, Breslow depth, Clark level, and age at diagnosis as significant for both overall survival (OS) and disease free survival (DFS) (P = 0.0001). Multivariate analysis confirmed regional site as an independent prognostic variable for OS (P = 0.0002) and DFS (P = 0.0005). Ten-year rates of OS and DFS were 71% and 66%, respectively, for patients with foot melanomas, compared with 92% and 87% for those with calf melanomas and 95% and 94% for those with thigh melanomas.

CONCLUSIONS

The prognosis for patients with primary melanoma of the lower extremity is affected by the distance of the lesion from the trunk. Thus, distal (foot) lesions carry a higher risk than thigh lesions. This difference should be considered as a covariate when stratifying patients in clinical trials.

Clinical outcomes of localized melanoma of the foot: a case-control study

The controversy over whether melanoma of the foot has a poorer prognosis than melanoma of the leg remains unresolved. This investigation used a case-control design to address this issue. This design consisted of a survival analysis of 119 cases with localized melanoma of the foot and 238 controls with localized melanoma of the leg that were matched on prognostic factors including tumor thickness, ulceration, surgical treatment, gender, year of diagnosis, and age. There was a statistically significant difference between the survival rates of cases and controls. The 5-year survival rate for cases was 74.3% compared to 85.2% for controls. At 10 years, the survival rate was 63.6% for cases and 77.2% for controls. Cases experienced a higher percentage of distant recurrences than controls. These results imply that patients with melanoma of the foot have a poorer survival than patients with melanoma of the leg after controlling for prognostic factors.

Angiomatoid malignant fibrous histiocytoma: report of an unusual case with highly aggressive clinical course

The authors report a case of angiomatoid malignant fibrous histiocytoma (AMFH), affecting a 9-year-old girl, with a highly aggressive clinical course. The tumor, noticed by the patient as a painless nodule in the dorsum of her left foot for 12 months, recurred 8 months after initial excision, and despite wide local reexcision, metastasized 4 months later to the liver and lung, where it grew at an alarming rate, to the extent of occupying the entire left hemithorax in a period of 10 weeks and killed the patient 14 months after initial excision. Review of the literature showed that the culminated rates of recurrence, metastasis, and mortality for AMFH were 23.2%, 8.7%, and 4.3%, respectively, indicating that it is definitely a malignant neoplasm with a potentially fatal outcome.

Soft tissue sarcomas of the hand and foot: management and survival

BACKGROUND

Soft tissue sarcomas of the hands and feet present a challenge for limb-preserving resections.

METHODS

A retrospective review of 19 patients with sarcomas of the hand or foot was done. Wide or local excision was performed in 14 patients (74%), and amputation in 5 patients (26%). Of the latter group, three amputations involved a digit or toe, and two (10%) were major amputations (one Syme amputation and one below-knee amputation). When the minimum surgical margin was narrow (1 to 2 mm), adjuvant radiation was given postoperatively (n = 4).

RESULTS

Local recurrence was observed in four patients (21%). Two of these required an amputation for local control. Local recurrence was observed in one of four patients (25%) treated with marginal resection and radiation and three of 15 (20%) of those with resection alone.

CONCLUSIONS

A sizable percentage (37%) of patients with soft tissue sarcomas of the hand and foot ultimately required an amputation, although often the amputation was a minor one involving only a toe or a digit. Limb preservation was successful in the majority of patients (63%). The local recurrence rate was 21%, which may be improved with more frequent use of adjuvant therapy. The 5-year survival rate was 82%, which is better than that usually quoted for overall extremity soft tissue sarcomas.

Tumors of the foot and ankle: analysis of 196 cases

A retrospective assessment was performed on 196 tumors of the foot and ankle [out of 1786 bone and soft tissue tumor cases, (10.9%)] between March 1986 and March 1996 in the Ankara University Department of Orthopedics and Traumatology Tumor Section. Mean age was 28 years (range 3 to 75 years). Of the 196 foot and ankle tumor cases, 171 (87.2%) were benign, and 25 (12.8%) were malignant. One hundred ninety-four (98.9%) were primary tumors and 2 (1.1%) were metastatic tumors. One hundred thirty-six (69.4%) originated from bone, whereas 60 (30.6%) originated from soft tissue. The most frequent foot and ankle tumors were osteosarcoma among malignant osseous tumors, squamous cell carcinoma among malignant soft tissue lesions, solitary exostosis among benign osseous tumors, and xanthoma and giant cell tumor among benign soft tissue tumors. Mean follow-up time was 21.3 months (12 to 90 months). One hundred forty (71.4%) of the patients underwent various operations while the remaining 56 (28.6%) were treated conservatively. Of the 140 surgical cases, 13 (9.3%) had a recurrence, 3 (2.1%) died, and 124 (88.6%) had a clinical cure. For most of the patients who required surgery, nonaggressive procedures were sufficient while amputations were required for 14 patients.

Incidence and risk factors for bumblefoot (pododermatitis) in rehabilitated raptors

A retrospective cohort study was conducted on 821 raptors of 12 representative species, admitted to the California Raptor Center (CRC), during 1980-1990. The incidence rate for bumblefoot was 52 cases per 100 bird-years at risk. Eagles and hawks (buteos) were more likely to develop bumblefoot, and did so earlier during their captivity than other species. Also, raptors admitted with a limb fracture had the greatest risk (OR = 4.2) of developing bumblefoot than any other condition on entry. Median time from admission to development of bumblefoot was 52 days, and median duration of bumblefoot was 23 days.

Minor amputations on the feet after revascularization for gangrene. A consecutive series of 95 limbs

A consecutive series of 89 patients (95 limbs) with gangrene were operated on with amputation of toes or some distal part of the foot after arterial reconstruction. 43 patients had diabetes. Healing was achieved in 81/82 feet when the reconstruction was open. Amputation below or above the knee was required in 4/5 limbs when the reconstruction failed. 8 patients died before healing. The median time to healing was 30 (17-452) days, after a single amputation, and 115 (36-466) days, when more than one procedure had been necessary. We concluded that amputations on the feet for gangrene usually heal after arterial reconstruction, in patients with diabetes as well as in those with arteriosclerosis. No weight bearing and control of infection are important during the early postoperative period.

Melanoma of the foot in white South Africans

There have been few studies that have compared the outcome of treatment of melanoma on the sole and dorsum of the foot or defined their prognostic factors. We describe 44 white patients (30 women and 14 men, mean age 53 years) with melanoma on the foot (sole, n = 25, dorsum, n = 19) seen over a 15 year period. Forty patients presented with stage I, two with stage II, one with stage III, and one with stage IV disease. The median Breslow depth of penetration was 2.8 mm (sole 3.3, dorsum 2.3). Of the 40 patients with stage I disease, 34 patients (17 dorsum, 17 sole) were treated by wide local excision (2 cm or more) and none developed local recurrence. Six patients (five sole, one dorsum) who had narrow excision margins (less than 1 cm, stage I disease) developed local recurrences. Ten patients underwent prophylactic hyperthermic limb perfusion. Sixteen patients with stage I disease (10 sole, six dorsum) developed metastases in the inguinal nodes. All 16 underwent block dissection of the nodes and five are alive. The overall survival for both dorsum (73%) and sole (66%) (stage I disease) was similar at 60 months. Both patients with stage II disease were alive at the time of writing, but the two patients with stage III and IV disease had died. The foot is an anatomical subsite associated with a poor prognosis for melanoma. There is little difference in prognostic factors and outcome between the sole and dorsum.

Necrotizing fasciitis

Necrotizing fasciitis is a rapidly progressing soft-tissue infection characterized by extensive necrosis of subcutaneous fat and fascia. It is frequently accompanied by moderate to severe systemic toxicity and can be fatal without prompt recognition and aggressive surgical treatment. The podiatric physician must be aware of these infections because the extremities are common sites of involvement. Necrotizing, fasciitis must be treated as a medical emergency calling for prompt surgical intervention and high doses of broad-spectrum antibiotics.

Evaluation of dogs with digit masses: 117 cases (1981-1991)

Medical records of 117 dogs with digit masses were reviewed. Of 124 digit masses, 76 (61%) were malignant neoplasms, 25 (20%) were benign neoplasms, and 23 (19%) were pyogranulomatous inflammation. Of 29 digits with radiographic evidence of bone lysis, 24 (83%) were affected by malignant masses, whereas only 5 of 29 (17%) digits with radiographic evidence of bone lysis were affected by benign or pyogranulomatous masses. Only 1 of 19 (5%) dogs with melanoma had radiographic evidence of lysis, but 20 of 25 (80%) dogs with squamous cell carcinoma had radiographic evidence of bone lysis. Thoracic radiographs of 95 dogs were available. Six of 19 (32%) dogs with melanoma had radiographic evidence of pulmonary metastasis at the time of diagnosis, whereas 3 of 24 (13%) dogs with squamous cell carcinoma had radiographic evidence of pulmonary metastasis at the time of diagnosis. Twenty-nine digit neoplasms were squamous cell carcinoma, and 19 of 29 (66%) arose from the subungual epithelium. Of 19 dogs with squamous cell carcinoma originating from the subungual epithelium, 18 (95%) survived for at least 1 year, whereas only 6 of 10 (60%) dogs with squamous cell carcinoma originating in other parts of the digit survived for at least 1 year. Furthermore, of 19 dogs with squamous cell carcinoma originating from the subungual epithelium, 14 (74%) survived at least 2 years, whereas only 4 of 9 (44%) dogs with squamous cell carcinoma originating in other parts of the digit survived for 2 years. Dogs with melanoma of the digits had a median survival time of 12 months, with 10 of 24 (42%) alive at 1 year and 3 of 23 (13%) alive at 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)

The characteristics and causes of sheep losses in the Victorian Mallee

The extent and causes of sheep losses in the semi-arid Mallee region of north-western Victoria were assessed by interviewing the owners of 79 randomly selected farms running 241 flocks in 1987/88 and 245 flocks in 1988/89. Mean annual losses were higher in ram flocks (21%) than in ewe flocks (7%), in flocks of non-Merino sheep (rams 24%, ewes 11%, weaners 5%) than in Merino (rams 11%, ewes 6%, wethers 4%, weaners 4%) and in ewe flocks 3 or more years old (10%) than in young ewe flocks (3.5%). In flocks where losses exceeded 5%, the causes most often reported by farmers were blowfly strike (especially in Merino sheep and weaners), ewe losses in autumn close to lambing, and heliotrope (Heliotropium europaeum) poisoning. Heliotrope poisoning was considered by the authors to be the main reason for the higher losses in old ewes than in young ewes and in non-Merino sheep than in Merino sheep. Losses of ewes associated with pregnancy and lambing were considered by the authors to be often predisposed by liver damage caused by heliotrope poisoning, and high losses in non-Merino ram flocks were attributed to both heliotrope poisoning and their ability to escape through boundary fences. Reasons for continuing high losses due to enterotoxaemia are discussed. Losses due to gastro-intestinal parasites, footrot and foot abscess were low.

Malignant melanoma of the foot and ankle

The records of sixty patients who had a malignant melanoma of the foot or ankle were reviewed retrospectively to determine the clinical features, prognostic factors, and distinguishing characteristics. Fifty-seven patients were white and three were black. There were forty-two women and eighteen men (a female-to-male ratio of 2.3 to 1). The mean age at the time of presentation was fifty-seven years (range, twenty-two to eighty-three years). The most common site of involvement was the plantar aspect of the foot. The mean duration of follow-up was forty-five months (range, three to 144 months). Kaplan-Meier life-table analysis revealed an over-all five-year survival rate of 63 per cent and an over-all ten-year survival rate of 51 per cent. The mean duration of survival for the patients who had a plantar or subungual lesion was significantly shorter than that for the patients who had a lesion at another site on the dorsal aspect of the foot or on the ankle (forty-seven compared with seventy-two months) (p = 0.02). The mean depth of the lesion, according to the criteria of Breslow, was 3.03 millimeters, and the mean level, according to the classification of Clark et al., was IV. According to the classification of the American Joint Commission on Cancer, forty-three patients had stage-I or II (local) disease, thirteen had stage-III disease (nodal or in-transit disease, defined as cutaneous or subcutaneous metastases more than two centimeters from the primary tumor but not beyond the regional lymph nodes), and four had stage-IV disease (distant visceral metastases) at the time of presentation. Lesions at plantar and subungual sites were also associated with a higher prevalence of clinical misdiagnosis compared with lesions on the dorsal aspect of the foot or on the ankle (p = 0.02). The misdiagnoses included a benign nevus (one patient), a paronychia (one patient), a pyogenic granuloma (two patients), a plantar wart (three patients), a ganglion cyst (one patient), a blister (two patients), and a traumatic lesion (five patients).(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of misdiagnosis and delay in diagnosis on clinical outcome in melanomas of the foot

BACKGROUND

Melanoma of the foot is often discussed as an uncommon tumor which, when it occurs, presents in nonwhite races.

STUDY DESIGN

The tumor registry of a 650 bed community teaching hospital and the Connecticut Tumor Registry were retrospectively reviewed for the nine-year period from July 1980 to July 1989. Patient age, race, sex, incidence of misdiagnosis, and delay until definitive therapy were recorded. Tumor location, size, staging, follow-up, recurrence, and disease-free survival rates were also recorded and correlated with initial disease, stage, and misdiagnosis or delay.

RESULTS

Twenty-six cases were identified at Bridgeport Hospital, and 140 cases were identified in the Connecticut Tumor Registry. Significant delay in diagnosis occurred in 68 percent of the cases from the hospital and at least 16 percent of the cases in the state tumor registry. Regardless of stage, melanoma of the foot had a worse prognosis than melanoma of the thigh and lower leg. Delays in diagnosis had no demonstrable effect on clinical outcome.

CONCLUSIONS

Melanoma of the foot is not as rare as commonly suspected, and constituted 3 percent of the 4,562 melanomas reported in the state tumor registry for the nine-year period. The majority were in fair-skinned individuals, and misdiagnosis was common. It is the inherent aggressiveness of the tumor rather than the delay in diagnosis that accounts for the poor clinical outcome.

Melanoma of the foot

We performed a prospective study of the results of treatment of primary cutaneous melanoma of the foot in 282 patients to determine if there were any factors that could predict survival. These patients were part of a group of 1018 patients who had primary cutaneous melanoma affecting the lower extremity. We found that 184 (65 per cent) of the 282 patients had a tumor that extended into the reticular dermis or subcutaneous tissue (a Level-IV or V lesion according to the system of Clark et al.). Sixty-three patients (22 per cent) had evidence of local, regional, or distant metastatic disease at the time of presentation. Location of the melanoma on the plantar aspect of the foot was found to be an independent variable that was associated with a poorer rate of survival (56 per cent at five years and 46 per cent at ten years) compared with a dorsally located melanoma (80 per cent at five years and 67 per cent at ten years). Subungual lesions were associated with an extremely low rate of survival (17 per cent at ten years); however, because of the small number of subungual lesions that were followed, the difference in survival between the patients who had a plantar lesion and those who had a subungual lesion was not significant (p = 0.52). Variables, in order of decreasing importance, that had independent prognostic significance for survival of patients who had a melanoma of the foot were the clinical stage of the lesion at the time of presentation (p < 0.001) and the age of the patient (p < 0.03), as determined by multivariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of the effects of intra-arterial and intravenous cisplatin on foot tumors and survival of rats bearing lung metastases

The therapeutic efficacy on intra-arterial (IA) and intravenous (IV) cisplatin on both foot tumors and lung metastases of transitional cell carcinoma RBT-1 in rats was compared. 5 mg/kg of either IA or IV cisplatin was administered to rats bearing both a foot tumor and pulmonary metastases. The antitumor effects on foot tumors were evaluated by changes in paw volume, foot weight and tumor area, and on lung metastases by a prolongation in life span after the amputation of the affected limb. IA cisplatin had remarkable therapeutic efficacy on the foot tumor as compared with IV cisplatin. Life span prolongation was obtained by both the IA and IV infusion. However, there was no significant difference between the survival of the rats given IV and those given IA cisplatin. These results indicate that IA cisplatin is more effective than IV cisplatin on primary tumors, and the effects of IA and IV cisplatin on lung metastases and survival are similar.

Association of high molecular weight melanoma-associated antigen expression in primary acral lentiginous melanoma lesions with poor prognosis

In a recent study we detected marked differences in the antigenic profile of acral lentiginous melanoma (ALM) and nodular melanoma lesions. Furthermore, we showed that the human high molecular weight melanoma-associated antigen (HMW-MAA) is expressed with a significantly higher frequency in metastatic than in primary ALM lesions. Because of the potential role of HMW-MAA in the metastatic process of melanoma cells, in the present investigation we tested whether HMW-MAA represents a useful prognostic marker in ALM. Primary ALM lesions removed from 32 patients were stained with anti-HMW-MAA monoclonal antibody (mAb) in an immunoperoxidase reaction. The results were correlated with the expression of other markers defined by mAb, with clinical parameters of the disease, and with histopathological characteristics of the lesions. Only 9 of the 32 primary ALM lesions tested were stained by anti-HMW-MAA mAb. Expression of HMW-MAA was the only variable associated with patients' survival and disease-free survival. Both were significantly shorter in patients with HMW-MAA expression in their primary lesions. These results suggest that HMW-MAA may represent a novel prognostic marker in ALM, since phenotyping of primary ALM lesions with anti-HMW-MAA mAb may provide information about the prognosis of the disease which cannot be obtained with known prognostic parameters.

Importance of diabetic foot admissions at Middlemore Hospital

AIMS

To investigate the costs and mortality associated with admission for diabetic foot problems.

METHODS

Identification of patients by codes for diabetes and peripheral vascular disease from routinely collected hospital discharge data. Information was collected retrospectively from charts. Post discharge outcome was assessed by discussion with general practitioners.

RESULTS

357 patients accounted for 503 admissions. 11-15% of patients (n = 49) were admitted for diabetic foot problems. Patients with type 1 diabetes had shorter lengths of stay than those with type 2 diabetes, were more likely to be admitted with chronic renal failure and less likely to be admitted with ischaemic heart disease. Maori and Pacific Island patients with type 2 diabetes were admitted at a younger age than Europeans (53 (SD12) vs 56 (11) vs 69 (13) years respectively, p < 0.001). Admissions for diabetic foot problems resulted in the longest hospital stay in comparison with other causes (19 (1-184) days vs 8 (1-116)) days. Average cost per diabetic foot admission was $12,500 with a total annual cost of over $600,000.

CONCLUSION

The diabetic foot is expensive and yet these costs are largely avoidable with improvement in patient education, motivation, monitoring and earlier intervention. It would be better to have in place improved community and hospital care before the predicted growth in the diabetic population associated with ageing.

Improvement in survival rate of patients with acral melanoma observed in the past 22 years in Sendai, Japan

While the incidence of malignant melanoma is much lower in Japanese than in Caucasians, the commonest site of melanoma in Japanese has been reported to be the acral regions of the limbs. The survival rate for acral and nodular melanoma observed at the Department of Dermatology, Tohoku University Hospital in Sendai, Japan from 1969 to 1990 was reviewed. Among 150 melanoma patients 125 (83%) and 17 (11%) had primary cutaneous melanoma and mucous membrane melanomas, respectively. Frequent sites for cutaneous melanomas were the sole (31%) and subungual regions (15%). Comparison of the stages of plantar melanoma at diagnosis showed that the proportion of stages III and IV decreased after 1980 with a corresponding increase in those with a tumour thickness of less than 4 mm (stage II). Concurrently, the prognosis of plantar melanoma has improved; the 5-year survival rate in each of the three periods 1969-75, 1976-80 and 1981-85 was 21, 70 and 90%, respectively. This was also the case with subungual melanoma. Such improvements in the prognosis are thought to be mainly due to early detection through the growing public awareness of this life-threatening disease. By contrast cases of nodular melanoma increased sharply after 1980. Among these, the high proportion of patients in advanced stages (stages III and IV) remained static even after 1980, with a resultant low 5-year survival rate in the above mentioned periods of 33, 38 and 18%, respectively.

A retrospective evaluation of laminitis in horses

Case records of 202 horses treated for laminitis were reviewed with the intent of determining the long-term outcome and correlating this with digital radiographic findings and with the degree of pain associated with the laminitis. At long-term follow-up 57 horses had returned to athletic soundness (Group 1), 20 horses were intermittently lame (Group 2), 19 horses had permanent severe lameness (Group 3), 97 were dead (Group 4), and 9 were lost to follow up. Using simple regression analysis, functional outcome did not correlate with the degree of rotation (R2 = 0.004) or the presence of distal displacement (R2 = 0.139). Functional outcome did correlate with the clinical grade of laminitis (R2 = 0.504). Horses in Group 1 had significantly less distal phalangeal rotation (5.89 +/- 6.48 degrees) than did horses in Group 2 (11.10 +/- 8.19) and Group 3 (14.50 +/- 10.80), but were not significantly different from Group 4 horses (7.49 +/- 6.57). Of 96 surviving horses, 23 had evidence of distal displacement compared with 54 of 97 non-survivors. Based on these results, horses that develop distal displacement of the distal phalanx are more likely to die than are horses without distal displacement; however, the presence or absence of distal phalangeal displacement and the degree of distal phalangeal rotation cannot be used to predict the outcome of a horse with laminitis. Clinical assessment is a more reliable means of determining the final outcome and should be given precedence over radiographic findings.

The current management and prognosis of acral lentiginous melanoma

A computer-aided retrospective analysis was performed on 359 patients with stage I and II melanoma at the time of diagnosis (disease confined to the primary melanoma), at the University of South Florida (Tampa, FL). Eighteen patients were identified with primary melanoma in acral locations, most being acral lentiginous melanoma. A comparison of actuarial survival curves of patients with melanoma in four different locations (acral, head and neck, trunk, and other extremity site) was performed. The patients with melanoma in acral locations did not have a statistically different actuarial survival than those with primary melanoma in other sites. When actuarial disease-free survival curves were constructed, however, acral primary melanoma had a shorter interval to recurrence than those located on the trunk or other extremity sites. Differences between actuarial disease-free survival for the head and neck and for acral primary sites were not significant. To identify prognostic factors responsible for the decreased disease-free survival of the acral lentiginous population, a regression analysis was performed. Three prognostic factors were analyzed for stage I and II melanoma, including Breslow tumor thickness, ulceration of the primary lesion, and primary site location. In the univariate analysis, with each prognostic factor acting independently, tumor thickness (p less than 0.01) and ulceration (p = 0.02) were significant variables influencing the disease-free interval. Primary site did not, however, add prognostic information to the model (p = 0.54). A stepwise multivariate analysis confirmed this finding.

Physiologic amputation for acute pedal sepsis

There are three options for management of pedal sepsis requiring lower extremity amputation: one-stage emergency, two-stage guillotine, or physiologic amputation. The excessive mortality usually ascribed to amputation surgery is basically derived from the selection of one of these options in emergency situations, with published mortalities of 10 per cent to 40 per cent being the norm. We have performed 465 lower-extremity amputations for vascular insufficiency for seven years, with overall 30-day operative mortalities of 0.5 per cent for below-knee amputations and 2.7 per cent for above-knee amputations. One hundred sixteen of these patients presented with acute pedal sepsis superimposed on significant medical disability, and were managed initially with physiologic amputation and intensive hemodynamic monitoring; the overall mortality for this select group was 5.1 per cent. An algorithm of management of patients presenting with acute pedal sepsis has thereby been derived, and is herein presented.

Kaposi's sarcoma of the foot. A review and report of 156 cases

The authors identify the incidence of Kaposi's sarcoma in the foot, and discuss the increasing incidence of AIDS-related cases, and the increasing chance of mortality when this lesion is seen in patients under the age of 50.

Factors affecting outcome of diabetic patients with foot ulcers or gangrene

This paper reports the outcome in 205 diabetic patients with foot ulcers or gangrene. The circulation to the foot was assessed using a radioisotope clearance test to measure the skin perfusion pressure (SPP) and skin vascular resistance (SVR) in the foot. Factors important in predicting initial healing were the age of the patient, SPP and SVR but not the ankle pressure index. The factors predicting death during 6-42 months follow-up were age and initial SPP; half the patients had died or under-gone amputation at 22 months. The information from the radioisotope clearance test is important in helping determine appropriate management for these patients and provides information not available from other methods, such as the ankle pressure measurement.

The influence of sepsis and ischemia on the natural history of the diabetic foot

One hundred seventeen diabetic patients with lesions involving 174 extremities were reviewed to evaluate the natural history of the problem and specifically those factors that influence its course both acutely and chronically. The extremities of diabetic patients with foot lesions can be categorized based on severity of infection and presence of ischemia. Half of these patients developed lesions in the contralateral extremity either concurrently (synchronous) (7%) or later (metachronous) (43%). Major amputation was required in 59 of the 174 extremities evaluated (34%). In patients with metachronous lesions, unilateral amputations were required in 28 per cent of patients and bilateral amputations in 26 per cent. Limb salvage by revascularization required 1.4 operations per extremity, carried 2 per cent operative mortality and was successful in 66 per cent. Although 24 per cent of these patients died within 5 years of the initial presentation of their foot lesions, these data suggest that limb salvage attempts are reasonably successful and relatively safe. The combination of extremity sepsis and ischemia in the diabetic adversely effects the survival of both the extremity and the patient.

A multivariate analysis of prognostic factors for melanoma patients with lesions greater than or equal to 3.65 mm in thickness. The importance of revealing alternative Cox models

Fourteen prognostic factors were examined in 79 patients with clinical Stage I melanoma greater than or equal to 3.65 mm in thickness. All nine patients with melanoma of the hands or feet died of melanoma. A Cox proportional hazards (multivariate) analysis of the remaining 70 patients showed that a combination of the following four variables best predicted bony or visceral metastases: 1) a nearly absent or minimal lymphocyte response at the base of the tumor, 2) histologic type other than superficial spreading melanoma, 3) location on the trunk, and 4) positive nodes or no initial node dissection. Ulceration and/or ulceration width were not useful in predicting outcome either singly or in combination with other variables. Patients with negative lymph nodes and primary tumors of the trunk, hands, and feet did not do better than patients with positive nodes at those sites. Conversely, non of 16 patients with negative lymph nodes and extremity melanomas (excluding the hands and feet) or head and neck melanomas developed visceral or bony metastases (i.e., five-year disease-free survival rate 100%).

Effects and dose--response relationships of skin cancer and blackfoot disease with arsenic

In a limited area on the southwest coast of Taiwan, where artesian well water with a high concentration of arsenic has been used for more than 60 years, a high prevalence of chronic arsenicism has been observed in recent years. The total population of this "endemic" area is approximately 100,000. A general survey of 40,421 inhabitants and follow-up of 1,108 patients with blackfoot disease were made. Blackfoot disease, so-termed locally, is a peripheral vascular disorder resulting in gangrene of the extremities, especially the feet. The overall prevalence rates for skin cancer was 10.6 per 1000, and for blackfoot disease 8.9 per 1000. Generally speaking, the prevalence increased steadily with age in both diseases. The prevalence rates for skin cancer and blackfoot disease increased with the arsenic content of well water, i.e., the higher the arsenic content, the more patients with skin cancer and blackfoot disease. A dose-response relationship between blackfoot disease and the duration of water intake was also noted. Furthermore, the degree of permanent impairment of function in the patient was directly related to duration of intake of arsenical water and to duration of such intake at the time of onset. The most common cause of death in the patients with skin cancer and blackfoot disease was carcinoma of various sites. The 5-year survival rate after the onset of blackfoot disease was 76.3%; the 10-year survival rate was 63.3% and 15-year survival rate, 52.2%. The 50% survival point was 16 years after onset of the disease.