Faculty Bibliography

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%)

Fourteen variables were tested for their ability to predict visceral or bony metastases in 177 patients with clinical Stage I melanoma of intermediate thickness (1.51 - 3.39 mm). A Cox multivariate analysis yielded a combination of four variables that best predicted bony or visceral metastases for these patients: 1) mitoses greater than 6/min 2 (p = 0.0007), 2) location other than the forearm of leg) p = 0.009, 3) ulceration width greater than 3 mm (p = 0.04), 4) microscopic satellites (p = 0.05). The overall prognostic model chi square was 32.40 with 4 degrees of freedom (p less than 10 (-5). Combinations of the above variables were used to separate these patients into at least two risk groups. The high risk patients had at least a 35% or greater chance of developing visceral metastases within five years, while the low risk group had greater than an 85% chance of being disease free at five years. Criteria for the high risk group were as follows: 1) mitoses greater than 6/mm 2 in at least one area of the tumor, irrespective of primary tumor location, or 2) a melanoma located at some site other than the forearm or leg and histologic evidence in the primary tumor of either ulceration greater than 3 mm wide or microscopic satellites. The low risk group was defined as follows: 1) mitoses less than or equal to 6/mm 2 and a location on the leg or forearm, or 2) mitoses less than or equal to 6/mm 2 and the absence in histologic sections of the primary tumor of both microscopic satellites and ulceration greater then 3 mm wide. The number of patients in this series who did not undergo elective regional node dissection (N = 47) was probably too small to detect any benefit from this procedure. Based on survival rates from this and other studies, it is estimated that approximately 1500 patients with clinical Stage I melanoma of intermediate thickness in each arm of a randomized clinical trial would be needed to detect an increase in survival rates from elective regional node dissection

Fourteen variables were tested for their prognostic usefulness in 203 patients with clinical Stage I melanoma and primary tumor 0.76-169 mm thick. Only two variables, primary tumor location and level of invasion, were useful in predicting death from melanoma for these patients. Of the 12 deaths from melanoma, 11 occurred in patients with primary tumors located on the upper back, posterior arm, posterior neck, and posterior scalp (=BANS). There has been only one death from melanoma in 136 patients with melanoma located at other sites (11/67 vs 1/136, p less than 0.0001 Fisher's Exact Test). Of the 67 BANS patients, 51 had level II or level III lesions and five (10%0 died of melanoma. This compared with six deaths from melanoma in 16 patients (37.5%) with level IV BANS lesions (5/51 vs 6/16, p = 0.01 Fisher's Exact Test). The relatively high incidence of both melanoma deaths and regional node metastases for the BANS group merits consideration for testing the efficacy of elective regional node dissection for these patients

In a prospective study of 178 patients with malignant melanoma, a subset of 33 patients (18.5%) was identified to be at significantly higher risk for developing metastatic disease based on history of cigarette smoking. Patients in this high-risk group (current smokers with a greater than 15 pack-years of smoking history) had two-year disease-free survival rates of 74.2%. versus 92.3% for the remaining patients (p = 0.008). A possible explanation of this phenomenon is that chronic smoking diminishes host defense mechanisms and results in an adverse affect on the biologic behavior of established malignant melanomas

Despite the high cure rate achieved for basal-cell carcinomas treated with microscopically controlled excision, recurrences do occur. To determine if lesions that are likely to recur may be predicted at the time of surgery, data from 5020 patients with 7010 basal-cell carcinomas treated with Mohs' technique were reviewed. Two thousand nine hundred sixty (2960) lesions with five-year follow-up were studied (overall recurrence rate = 2.6%). Sex and age of the patients, size and location of lesions, types of previous therapy, and the number of surgical stages of microscopically controlled excision were all found to correlate significantly with recurrence rate (p less than 0.01). Multiple regression analysis was performed to determine the relative contribution of each of these variables to predictability of recurrences by a weighted scoring system. The derived model delineated the lesions into no-risk, low-, medium-, and high-risk groupings (p less than 0.000001). Lesions in the high-risk group had a recurrence rate of 10.1%, almost four times greater than the average. More aggressive microscopically controlled excisions and closer follow-up care are indicated for those lesions that can be predicted to result in a high-risk score

From their experience in treating squamous-cell carcinomas by microscopically controlled surgery, the authors found that such lesions in men, particularly in young men, on the extremities and of sizes larger than 5 cm or requiring more than four stages of excision had highest recurrence rates. They recommend one more stage of excision beyond an apparent plane free of malignancy as an insurance in selected cases

Basal-cell carcinomas on covered, anatomically shielded, or otherwise unusual sites of the body are rare compared to the number on constantly exposed parts of the body, but since basal-cell carcinomas are so common, instances of the former sort are not infrequently encountered. Five such cases are described and illustrated

Computer analyses to identify correlations between thickness of primary superficial spreading malignant melanoma and eighteen variables previously reported to be related to prognosis were performed on a series of malignant melanomas. The variables that showed statistically significant (less than or equal to 0.05) direct relationships to thickness were level (Clark), elevation of lesion, age of patient, least and greatest diameters of lesion, history of bleeding, ulceration, clinical and histologic stage, anatomic location, pedunculation, and satellitosis. The variables that did not correlate with thickness were clinical diagnosis of regional lymphadenopathy, in-transit metastasis, duration of lesion, sex, history of a previous malignant melanoma, and history of a pre-existing lesion at the site of the development of melanoma. Multiple regression analysis of the factors that showed statistically significant correlation with thickness of the primary lesion revealed a subset of six dominant variables that were most predictive of thickness, namely, level, elevation, largest diameter of lesion, ulceration, histologic stage, and age of the patient