Surgical standards in the primary care of melanoma patients.

Excisional biopsy is recommended as the procedure of choice whenever there is suspicion of malignant melanoma. There are only few indications for incisional biopsies, which--in contrast to former opinions--do not worsen the prognosis. For nearly 70 years the debate about the optimal resection safety margin around the primary tumor was influenced by historical case reports and paradigms. Recently, controlled clinical studies provided new insights. Accumulating evidence over the past two decades showed that narrower surgical margins do not have any influence on the rate of advanced metastatic disease. Local recurrence is rare (approximately 0.1%) when primary tumors are thin and is seen more often (approximately 10%) in primary tumors of greater thickness (>4 mm). Analysis of the overall survival in randomized trials shows equal prognosis for malignant melanoma for narrow and wide resection margins. Due to these findings in-toto excisional biopsy for in-situ melanoma, a resection margin of 1 cm for primary tumors with a tumor thickness up to 2 mm and a resection margin of 2 cm for primary tumors greater than 2 mm appears sufficient. By this procedure primary closure of wounds will be possible in nearly all cases, morbidity and costs of surgical approaches will be reduced. For a long time it has been discussed whether prophylactic removal of lymph nodes ('elective lymph node dissection') is of benefit for melanoma patients. More recently 'selective' lymphadenectomy ('sentinel node biopsy', SNB) has been proposed to evaluate the status of the first draining lymph node ('sentinel node') of the regional basin. Several studies now demonstrate that the sentinel node evaluation for underlying metastatic disease reflects the status of the entire lymph node region and is therefore a useful prognostic factor superior to measurement of tumor thickness in primary melanoma. However, it is unclear whether sentinel node biopsy is of benefit for a better survival in affected patients.

[Temozolomide as therapeutic option for patients with metastatic melanoma and poor prognosis]. / Temozolomid als Therapieoption bei Patienten mit fernmetastasiertem Melanom und ungünstiger Prognose.

BACKGROUND AND OBJECTIVE: Stage IV melanoma patients with a very advanced disease are usually excluded from clinical trials. We treated 25 stage IV patients with temozolomide - a cytostatic drug with 100% oral bioavailability and considerable penetration of CNS tissue. PATIENTS/METHODS: 25 patients (17 female, 8 male) between 24 and 82 years (mean: 55.5 years) were included in this retrospective study. 19 patients had received at least one and up to four previous chemotherapy regimens during the course of stage IV disease. 11 (44%) patients showed cerebral metastases prior to therapy with temozolomide. 200 mg/m2 temozolomide were given orally at home on day 1 to 5 in week 1 and in week 5, respectively. RESULTS: Out of 23 evaluable patients 2 (8.7%) showed a partial remission, 2 (8,7%) a minor response, 6 (26.1%) had stable disease, 1 (4,3%) a mixed response, and 12 (52.1%) patients experienced disease progression. Sites of remission included brain, lung, liver, lymph nodes and muscle. Two patients interrupted therapy due to severe leuko- and thrombocytopenia (WHO grade 3 and 4). All other patients tolerated treatment with temozolomide well and no dose reduction was necessary. The median overall survival was 7 months (2-28+ months) since beginning of therapy and 15 months (4-63+ months) since onset of stage IV disease. CONCLUSION: Temozolomide represents a safe treatment option in patients with metastatic melanoma and poor prognosis.

[Lipoma of the lip. A rare differential diagnosis]. / Das Lipom der Lippe. Eine seltene Differenzialdiagnose.

We report on a 49 year-old female patient with a cherry-sized tumor of the lower lip, which over several years had steadily increased in size. The patient was psychologically affected by the appearance of the tumor and had difficulties to eat. We excised the tumor in local anaesthesia. Histology confirmed the clinical suspicion of lipoma. A total of four lipomas at this location have been reported world-wide.

Complete remission of a radio-resistant cutaneous angiosarcoma of the scalp by systemic treatment with liposomal doxorubicin.

We report an 80-year-old man suffering from an angiosarcoma of the scalp. Because of the wide extent of the lesions, surgery was not performed. Instead, the patient was treated with electron-beam radiation. Later, the patient failed to benefit from radiotherapy demonstrated by a local relapse and new malignant lesions. Additionally, a cervical lymph node metastasis appeared for the first time. Subsequently, we successfully administered liposomal doxorubicin (Caelyx(R)). Shortly after administration of two cycles the scalp angiosarcoma showed a clear regression. Following six cycles, the patient clinically showed a complete remission of all skin lesions and the cervical lymph node; metastasis was confirmed by histology and fine needle aspiration, respectively. Liposomal and pegylated doxorubicin, a cytostatic drug belonging to the anthracyclines, has already shown to be effective and mostly well tolerated in the therapy of acquired immune deficiency syndrome-related Kaposi's sarcoma and very recently in cutaneous T-cell lymphoma, too. Caelyx(R) appears to be a promising alternative to conventional treatment of cutaneous angiosarcoma.

[Congenital cerebriform nevus cell nevus on the occiput. Removal after tissue expander implantation]. / Zerebriformer kongenitaler Nävuszellnävus am Kapillitium. Entfernung nach Expanderimplantation.

A 26 year old man presented with a giant cerebriform nevus on the occiput. Clinical appearance of the nevus, maceration within the folding and risk of malignancy prompted us to perform a complete excision. The scalp defect was closed with a rotation flap following an implantation of a tissue expander.

[Safety margins in the excision of primary malignant melanoma. Proposals based on controlled clinical trials]. / Sicherheitsabstände bei der Exzision des primären malignen Melanoms. Diskussionsvorschläge aufgrund von Ergebnissen aus kontrollierten klinischen Studien.

Excisional biopsy is recommended as the procedure of choice whenever there is suspicion of malignant melanoma. Incisional biopsies are only rarely indicated. For nearly seventy years the debate about the optimum resection safety margin around the primary tumor was influenced by historical case reports and paradigms. Recently, controlled clinical studies have provided new insights. Accumulating evidence over the last two decades shows that narrower surgical margins influence neither the rate of satellites or in-transit-metastases nor the occurrence of advanced metastatic disease. Local recurrence is rare (approx. 0.1%) when primary tumors are thin and is seen more often (approx. 10%) in primary tumors of greater thickness (> 4 mm). Analysis of the overall survival in randomized trials shows equal prognosis for malignant melanoma for narrow and wide resection margins. Due to these findings in-toto excisional biopsy for in-situ melanoma, a resection margin of 1 cm for thin primary tumors (< 1 cm tumor thickness) and a resection margin of 1 to 2 cm for primary tumors greater than 1 mm appears sufficient. With these recommendations, primary closure of wounds will be possible in nearly all cases, reducing surgical costs and morbidity. This article should serve as a basis of discussion for the proposed revision of the current guidelines of the German Dermatologic Society (DDG) on the primary surgical care of melanoma patients.

[Surgical and adjuvant drug therapy in head and neck cutaneous melanoma]. / Operative und adjuvante medikamentöse Therapie des kutanen Melanoms im Kopf-Hals-Bereich.

The rapid incidence rise of cutaneous melanoma resulted in an increasing interest in this particular tumor. During the last years public prevention campaigns enlarged the awareness of melanoma, subsequently as a direct effect the mean tumor thickness of melanoma, the most predictable prognostic factor, decreased. Moreover, the biology of melanoma initiation and metastasis has been studied extensively with special interest in molecular biology. Controlled clinical studies answered several critical questions in respect to the standard care of surgery in melanoma. Yet, the guidelines for the surgical treatment of head and neck melanoma are in accordance to that of other localisations with reduced safety margins around the primary tumor. Elective (prophylactic) lymph node dissection (ELND) of regional lymph nodes is no more considered as a standard tool. Moreover, ELND has been given up by most melanoma centers, since it is known that prospective-randomized trials were not able to demonstrate an increase of overall survival for patients with ELND compared with untreated patients. Instead of this potentially aggressive treatment modality the examination of the first draining regional lymph node, sentinel node biopsy (SNB), has been introduced some years ago. Recently, a large clinical trial demonstrated that the SNB status reflects the most valuable prognostic factor for primary melanoma known so far. First studies in head and neck melanoma figured out that this technique is more complex in this special localisation, but produced comparable results. Systemic adjuvant (prophylactic) therapy of high-risk melanoma should preferentially be applied within controlled clinical trials. Most attractive candidates for an effective treatment are interferons. Several studies ruled out that interferon alpha-treated melanoma patients demonstrate an extended disease-free survival. Adjuvant chemotherapy has not shown a clinically relevant benefit. Thus, patients should preferentially be treated within controlled clinical trials.