Desmoplastic melanoma: patterns of recurrence.

Desmoplastic melanoma is a rare type of malignant melanoma, recognized since 1971. Other variants of desmoplastic melanoma include neural transforming melanoma and neurotropic melanoma. The pathology and clinical features of 58 patients whose tumor had the features of desmoplastic melanoma, neural transforming melanoma, and neurotropic melanoma, either separately or in combination, were examined to assess patterns of recurrent disease. The tumor was situated on the head and neck in 41% of patients and was amelanotic in 71% of patients. There was an associated superficial melanoma in 48% of patients. There was a combination of the 3 histologic patterns, commonly found in the 1 melanoma. Local recurrence occurred in 29% of patients and malignant cranial neuropathies were documented in 4 patients. Nineteen percent of patients have died from disseminated disease. Neurotropic melanomas had a lower incidence of visceral recurrence. Desmoplastic and neural transforming melanomas had similar rates of local and visceral recurrence. When this specific variant of melanoma is compared with larger series of malignant melanoma in general, they appear to be more advanced locally, with a higher incidence of local recurrence. When considered in relation to the thicker nondesmoplastic melanomas, the survival is no worse and may be more favorable. Surgeons should excise the primary tumor and local recurrences with wide margins and adopt close follow-up. On the head and neck, symptoms and signs relating to trigeminal or facial nerve innervation may herald a developing malignant cranial neuropathy.

Desmoplastic, neural transforming and neurotropic melanoma: a review of 45 cases.

An analysis of the clinicopathological features of 45 cases of desmoplastic, neural transforming and neurotropic melanoma assessed by a single pathologist are reported. The age range of 27 males and 18 females was 17-88 years. Twenty primary lesions (44%) were on the head and neck and fourteen (31%) were on the trunk. Thirty lesions (67%) were amelanotic. The initial clinical diagnosis was incorrect for 16 patients. Mean thickness was 4.5 mm. Recurrence occurred in 17 patients (38%). Local recurrence has occurred in 12 patients. This was related to a primary where: pathological diagnosis was incorrect; excision was less than 1 cm; the site was on the head and neck; Clarke level was V; and Breslow thickness was greater than 4 mm. Four patients had cranial nerve neuropathies due to recurrent neurotropic melanoma. Four patients are alive with inoperable disease and five have died from disseminated melanoma. These tumours can be difficult to recognize clinically and pathologically, with poor results if not adequately treated primarily. Therefore, the need for surgeons to be aware of this tumour and its clinicopathological features is important. Close follow-up is essential.

Adenovirus replication as an in vitro probe for drug sensitivity in human tumors.

The feasibility of using adenovirus 5 as an in vitro probe for chemosensitivity in short-term cultures of human tumors was evaluated using human melanoma cell lines and primary cultures of melanoma biopsies. A convenient immunoperoxidase method was developed for quantitating viral replication 2 days after infection. Two different approaches were explored: the host cell reactivation assay (HCR) using drug-treated virus; and the viral capacity assay using drug-treated cells. The HCR assay detected sensitivity to 5-(3-methyl-1-triazeno)imidazole-4-carboxamide (MTIC) in Mer- (methyl excision repair deficient) cell lines as decreased ability of the cells to replicate MTIC-treated virus. This test should be applicable to DNA-damaging agents and repair-deficient tumors. Adenovirus replicated readily in nonproliferating primary cultures of melanoma biopsies; application of the HCR assays to this material identified one Mer- sample of 11 tested. Herpes viruses were not suitable for use in HCR because herpes simplex virus type 1 failed to distinguish Mer- from Mer+ melanoma cells; and nonproductive infection of MTIC-sensitive lymphoid cells with Epstein-Barr virus yielded an MTIC-resistant cell line. The second assay (viral capacity) involved determination of the inhibition of replication of untreated virus in treated cells. This approach correctly predicted sensitivity to hydroxyurea and deoxyadenosine in melanoma cell lines when compared with clonogenic survival assay. Viral capacity was also inhibited by cytosine arabinoside, fluorouracil, vincristine, adriamycin, 6-mercaptopurine and ionising radiation, and may therefore be useful for detecting sensitivity to a wide range of antitumor agents.

The classification of malignant melanoma, its histological reporting and registration: a revision of the 1972 Sydney classification.

A group of pathologists with an interest in malignant melanoma met in Sydney in 1982 to update the classification of melanoma formulated in Sydney in 1972. The group recommended that malignant melanoma be classified as follows: malignant melanoma with an adjacent component of superficial spreading type, malignant melanoma with an adjacent component of lentigo maligna type, malignant melanoma with an adjacent component of acral lentiginous type, malignant melanoma with an adjacent component of mucosal lentiginous type, malignant melanoma with no adjacent component, malignant melanoma of unclassifiable histogenetic type. The data recorded in the surgical pathology report should include: diagnosis of primary malignant melanoma, histogenetic classification, presence/absence of ulceration, micrometer-measured thickness, microanatomical level, mitotic rate/mm2, presence/absence of vascular invasion, presence/absence of regression, completeness of resection. The recommendations for the examination of specimens and the recording of data for research purposes and for tumour registries are described.

Laryngeal edema as a complication of chemical peel.

Laryngeal edema is a rare complication in patients undergoing chemical face peels. Symptoms of stridor, hoarseness, and tachypnea developed within 24 hours after peeling and subsided within another 24 hours after inhalation therapy with heated aerosol mist was begun. All patients who developed this complication were heavy smokers. A possible mechanism by which this complication was produced is discussed and experience with a drug regimen to prevent its occurrence is presented.

The diagnosis of Hutchinson's melanotic freckle (lentigo maligna) in Queensland.

Following an increase in the reported incidence of melanoma of Hutchinson's melanotic freckle type (HMFM) in Queensland, a review of its histological diagnosis was undertaken. Ninety-nine pigmented lesions reported by 13 different pathology laboratories throughout Queensland as having an in-situ component of Hutchinson's melanotic freckle (HMF) were reviewed by 2 pathologists with an interest in malignant melanoma. This diagnosis was confirmed in 76 cases while in a further 3 the reviewers regarded the in-situ component as indeterminate. It would seem that the level of agreement among pathologists reporting HMF(M) should be considered in any assessment of incidence patterns of melanoma.

International pathologists congruence survey on quantitation of malignant melanoma.

A congruence survey of pathologists in Brisbane, Adelaide, Oslo and Paris on classifying and grading histological features such as dermal invasion, cross-sectional profile, mitotic activity and lymphocytic infiltrate was done on 147 cutaneous melanomas. The overall agreement was about 70%, about one pathologist in three or four disagreeing on each feature. Taking into acount also the considerable number of slides in which agreement was less, the results are considered unsatisfactory. Agreement was highest in cross-sectional profile and least in level of invasion. It is evident that the gradings are subjective and indicate the need for detailed histological description in making the criteria and the necessity of collaboration between pathologists to study slides and clarify problems. Experience is important and the slides must be of high technical excellence. Comparisons of results between different pathologists on the histological quantitations of malignant melanoma should take note of the degree of congruence achievable.

Changing epidemiology of malignant melanoma in Queensland.

Information provided by Queensland pathology laboratories shows that the annual incidence of cutaneous malignant melanoma in Queensland has doubled from 16 per 100 000 population in 1966, to 32.7 per 100 000 in 1977. The incidence in males, and the males to females ratio have increased. The major sites of the tumour remain the same, except possibly for a reduction in the number of leg tumours in females in tropical Queensland. More tumours with an in-situ component of Hutchinson's melanotic freckle type are being diagnosed. The tumours diagnosed in 1977, compared with those in the Queensland Melanoma Project files from 1963 to 1969, are more superficial (Level 1 or Level 2), with nonelevated profile and smaller diameter. The findings suggest that the disease is being diagnosed and treated earlier.

Retinal detachment following phacoemulsification.

In a consecutive series of 1,500 eyes in which phacoemulsification had been performed, the incidence of subsequent retinal detachment was 3.6%. Vitreous loss occurred in 4.2% (63) of the 1,500 cases, and in this group of eyes the incidence of retinal detachment was 14% (9). The characteristics of retinal breaks and the configurations of retinal detachments following phacoemulsification were in general similar to cases following intracapsular surgery. The surgical reattachment rates in these eyes compared favorably to previous reports on the repair of retinal detachments.

Secondary malignant melanoma in lymph nodes: incidence, time of occurrence, and mortality.

During a follow-up period of six to 12 years, 15.4% of patients in the Queensland Melanoma Project (Q.M.P.) developed histologically proven secondary deposits in lymph nodes. The incidence rate in males (21%) was twice that in females (11%), but the mortality rate was similar (M., 67%; F., 61%). Thirty-two patients (2%) had positive nodes with no known primary lesion. Metastases developed in males with lesions on the foot (50%), on the thigh (29%), and on the back (22%); and in females with lesions on the lower leg (9%) and thigh (20%). About one-half of the nodes were removed at the time of treatment of the primary growth or within two months. Three-quarters were removed in the first year. However, it was found that tumour could remain dormant for more than eight years. Dormant tumours behaved in a similar aggressive fashion on regrowth as non-dormant secondaries. Nodal metastases were present in 5% of patients at the time of their first presentation with primary melanoma. Elective node dissections were done in 6% of males and 11% of females.

Spindle and epithelioid cell nevi in children and adults. A review of 211 cases of the Spitz nevus.

A large series of 211 Spitz nevi is reviewed. 30% of the lesions were from patients 20 years of age and over. The trunk and lower extremity were most commonly involved. There were no significant histologic differences between cases from adults and children. Features which may help in differentiating atypical Spitz nevi from malignant melanoma include the presence of some nevus cell maturity at the base, an absence of atypical mitoses, no significant upward epidermal spread and the nuclear chromatin pattern.

Oncornavirus-like particles in malignant melanoma and control biopsies.

Tests for the presence of oncornavirus-like particles in human biopsies were made by the Spiegelman simultaneous assay for 70S RNA and RNA-dependent DNA polymerase and by detection of 600-900S particles, incorporating 3H-uridine, produced by cultured biopsy cells. Thirty-one malignant melanoma biopsies from 29 patients were studied. Using the simultaneous assay, evidence of virus-like particles was found in 15/26 (58%) of melanoma biopsies, 0/3 naevi pools, 1/4 samples of skin adjacent to melanoma, 0/3 samples of normal adult skin and 0/3 prepuces. The velocity sedimentation technique was shown to be a useful screening test for oncornaviruses in studies of two virus-producing mouse cell lines (TKL-5 and WEHI-22), and was positive with 7/9 melanoma biopsies. Overall, these results are compatible with the earlier findings of similar virus-like particles in malignant melanoma cell lines, but the exact nature of the particles remains to be defined.

Leukocyte adherence inhibition and specific immunoreactivity in malignant melanoma.

The leukocyte adherence inhibition (LAI) test has been used to assess specific anti-tumour immunoreactivity in 80 patients with malignant melanoma, 21 of whom had apparently been successfully treated by surgery, and 44 control subjects. Reaction with melanoma extracts in vitro enabled the activity of blood leukocytes to be detected by inhibition of their adherence to glass, while serum was tested for factors which modified this inhibition. Of the patients with tumours (ranging from primary melanoma in situ to advanced disseminated disease), 22/24 had active leukocytes and 50/58 has serum blocking factor; two of the sera, from patients with regressing tumours were unblocking. After surgery with no clinical recurrence, leukocytes continued to be active except when tested several years after operation. Blocking factor rapidly disappeared in 16/20 patients tested, and in several patients examined serially the serum became unblocking. In three cases, persistence of serum blocking was followed by clinical diagnosis of metastases. Leukocyte activity was nerver detected in control subjects (0/10), many of whom had other kinds of tumours or skin lesions. Blocking activity in serum was found in only 3/38 controls with no history of melanoma (1 had a fibrosing cellular blue naevus and 2 had liver disease). Thus the LAI test correlated well with clinical and pathological findings, and shows great promise for the reliable, rapid and specific immunodiagnosis of malignant melanoma.