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

Abstract

Italian

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

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References

Balch

M.C.

Murad

Soong

Ingalls

A.L.

Richards

P.C.

Maddox

W.A.

: Tumor thickness as a guide to surgical management of clinical stage I melanoma patients. Cancer, 43: 883–888, 1979.

Block

G.E.

Hartwell

S.W.

Jr. : Malignant melanoma a study of 217 cases. Part I: Epidemiology, Parte II: Treatment effect. Ann. Surg. (Suppl.), 154: 74–101, 1961.

Bodenham

D.C.

: Basic principles of surgery - Malignant melanomas. In: Melanoma and skin cancer. pp. 375–387, McCarthy

W.H.

(ed.), Proc. Intern. Cancer Conf., VCN Blight Government Printer, Sydney, 1972.

Breslow

: Tumor thickness, level of invasion and node dissection in stage I cutaneous melanoma. Ann. Surg., 182: 572–575, 1975.

Breslow

Cascinelli

Van der Esch

E.P.

Morabito

: Stage I melanoma of the limbs: Assessment of prognosis by levels of invasion and maximum thickness. Tumori, 64: 273–284, 1978.

Breslow

: The surgical treatment of Stage I cutaneous melanoma. Cancer Treat. Rev. (in press), 1979.

Cade

: Malignant melanoma. Ann. R. Coll. Surg. Engl., 28: 331–366, 1961.

Cascinelli

Balzarini

G.P.

Fontana

Morabito

Orefice

: Long term results of surgical treatment of melanoma of the limbs. Tumori, 62: 233–242, 1976.

Clark

W.H.

Jr. , From

Bernardino

E.A.

Mihm

M.C.

Jr. : The histogenesis and biologic behavior of primary human malignant melanomas of the skin. Cancer Res., 29: 705–727, 1969.

10.

Davis

: Elective node dissection: Yes or no? In: Melanoma and skin cancer. pp. 407–416. McCarthy

W.H.

(ed.), Proc. Intern. Cancer Conf., VCN Blight Government Printer, Sydney, 1972.

11.

Eve

F.A.

: A lecture on melanoma. Practitioner, 70: 165, 1903.

12.

Goldsmith

H.S.

Shah

J.P.

Kim

D.H.

: Prognostic significance of lymph node dissection in the treatment of malignant melanoma. Cancer, 26: 606–609, 1970.

13.

Gumport

S.L.

Meyer

H.W.

: Treatment of 126 cases of malignant melanoma. Long term results. Ann. Surg., 150: 989–992, 1959.

14.

Gutterman

J.U.

Mavligit

Gottlieb

J.A.

Burgess

M.A.

McBride

C.E.

Einhorn

Freireich

E.J.

Hersh

E.M.

: Chemoimmunotherapy of disseminated malignant melanoma with dimethyl triazeno carboxamide and Bacillus B Calmette-Guérin. N. Engl. J. Med., 291: 592–597, 1974.

15.

Handley

W.S.

: The pathology of melanotic growths in relation to their operative treatment. Lancet, April 6, p. 1927, 1907.

16.

Hersh

E.M.

Gutterman

J.U.

Mavligit

G.M.

: BCG as adjuvant immunotherapy for neoplasia. Ann. Rev. Med., 28: 489–515, 1977.

17.

Lejeune

F.J.

: Efficacy of elective regional lymph node dissection on primary (stage I) malignant melanoma. In: Controversies in Cancer - Design of Trials and Treatment - Tagnon

H.J.

Staquet

M.J.

(eds.), Masson, New York, 1980.

18.

McGovern

V.J.

: The classification of melanoma and its relationship with prognosis. Pathology, 2: 85–89, 1970.

19.

McNeer

Das Gupta

: Prognosis in malignant melanoma. Surgery, 56: 512–518, 1964.

20.

Mundth

E.D.

Guralnick

E.A.

Raker

J.W.

: Malignant melanoma: A clinical study of 427 cases. Ann. Surg., 162: 15–28, 1965.

21.

Pack

G.T.

Scharnagel

Morfit

: The principle of excision and dissection in continuity for primary and metastatic melanoma of the skin. Surgery, 17: 849, 1945.

22.

Pemberton

: Observations on the history, pathology and treatment of cancerous diseases. J. Churchill, Vol. 8, London 1858.

23.

Pringle

J.H.

: Operation in melanotic tumors of the skin. Edinburgh M.J., 23: 496, 1908.

24.

Sim

F.H.

Taylor

W.F.

Ivins

J.C.

Pritchard

D.J.

Soule

E.H.

: A prospective randomized study of the efficacy of routine elective lymphadenectomy in management of malignant melanoma. Cancer, 41: 948–956, 1978.

25.

Southwick

H.W.

Slaughter

D.P.

Hinkamp

J.F.

Johnson

F.E.

: The role of regional node dissection in the treatment of malignant melanoma. Arch. Surg., 85: 63–68, 1962.

26.

TNM classification of malignant tumors. UICC, Geneva 1978.

27.

Veronesi

Cascinelli

Balzarini

G.P.

Preda

: Treatment of regional node metastases. In: Melanoma and skin cancer. pp. 417–423. McCarthy

W.H.

(ed.), Proc. Intern. Cancer Conf., VCN Blight Government Printer, Sydney, 1972.

28.

Veronesi

Bajetta

Cascinelli

Clemente

Rilke

: New trends in the treatment of malignant melanoma. Int. Adv. Surg. Oncol., 1: 113–156, 1978.

29.

Veronesi

Adamus

Bandiera

D.C.

Brennhovd

I.O.

Caceres

Cascinelli

Claudio

Ikonopisov

R.L.

Javorskj

V.V.

Kirov

Kulakowski

Lacour

Lejeune

Mechl

Morabito

Rode

Sergeev

van Slooten

Szczygiel

Trapeznikov

N.N.

Wagner

R.I.

: Inefficacy of immediate node dissection in stage I melanoma of the limbs. N. Engl. J. Med., 297: 627–630, 1977.

30.

Wanebo

H.J.

Fortner

J.G.

Woodruff

Mac Lean

Binkowski

: Selection of the optimum surgical treatment of stage I melanoma by depth of microinvasion: Use of the combined microstage technique (Clark-Breslow). Ann. Surg., 182: 302–313, 1975.

31.

Wanebo

H.J.

Woodruff

Fortner

J.G.

: Malignant melanoma of the extremities. A clinicopathologic study using levels of invasion (microstage). Cancer, 35: 666–676, 1975.