Surgical management of regional lymph nodes in patients with melanoma. Experience with 4682 patients.

OBJECTIVE: The purpose of this study was to evaluate a large number of patients with cutaneous melanoma who had or who were at risk for lymph node metastases to contribute to the understanding of the behavior of and appropriate management of draining nodes. A major goal of the study was to reassess the clinical impact of elective lymph node dissections (ELND) in a large patient population. SUMMARY BACKGROUND DATA: Large retrospective studies suggest that ELND may improve the prognosis of patients with intermediate thickness melanomas; however, that improvement has not been observed in two randomized prospective controlled trials. METHODS: The charts of 4682 patients treated at a single institution for localized or regional disease were reviewed individually. The median follow-up was 4.7 years, with 814 patients followed more than 10 years. The data were tabulated and evaluated with the aid of a computer data base system. RESULTS: Among patients with nodal metastases, 10% of nodal metastases were to contralateral nodes, and 6% were to nodal basins that would not be predicted by classic models of lymphatic drainage; in 13% of patients, nodal metastases occurred to greater than one nodal basin (3% of the entire study group). For all thickness ranges, the incidence of nodal metastases was comparable to the incidence of distant metastases; intermediate-thickness lesions had no relative predilection for nodal metastases. At the initial evaluation, regional nodal basins were clinically negative in 3550 patients, of whom 911 (25.7%) underwent ELND. Stratified into five thickness groups (< 0.76 mm, 0.76 to 1.5 mm, 1.5 to 2.5 mm, 2.5 to 4 mm, and > 4 mm), pathologically positive nodes were identified in 0%, 5%, 16%, 24%, and 36%, respectively (16% overall). Among the 911 patients who underwent ELND, 214 (23%) had nodal metastases, 143 at the time of ELND and 71 at a later date. Of these 71 patients, 31 (44%) had nodal metastases in a previously dissected nodal basin, and 40 (56%) had them in basins not previously dissected. The survival of patients with clinically negative nodes treated with and without ELND were compared. The two groups were well matched for major prognostic factors. Stratified by Breslow thickness and primary site, no significant improvement in survival was observed with ELND. CONCLUSIONS: Because of the significant incidence of metastases to contralateral and atypical nodal basins, lymphoscintigraphy may be justified for the preoperative evaluation of patients for ELND. However, the therapeutic value of ELND is questionable as a result of (1) the finding that the risk of nodal metastases is not relatively more common than is that of distant metastases among patients with intermediate-thickness melanomas, (2) the fact that only 16% of ELND were positive, (3) the finding that ELND may not prevent recurrent nodal disease in the dissected basin, and (4) the absence of any apparent impact on survival among patients who underwent ELND.

Skin melanoma. Cured fraction and survival time as functions of thickness, site, histologic type, age, and sex.

BACKGROUND: Previously, nonparametric or semiparametric methods have been used to determine the relationship of various prognostic covariates with survival of skin cancer. Unfortunately, these methods do not readily distinguish between factors that modulate cure and those that modulate survival time among uncured patients. METHODS: The multivariate lognormal model can be used to detect the association of cured fraction and median survival time with specific prognostic covariates. This model was applied to survival data from 2004 patients with skin melanoma using the following prognostic covariates: thickness, site, and histologic type of the tumor and sex and age of the patient. RESULTS: This analysis revealed that a low cured fraction was associated with thick lesions and location other than trunk or extremity, whereas a short median survival time was associated with thick lesions and tumor located on the trunk. Advanced age was highly associated only with short median survival time. CONCLUSION: The lognormal survival model offers insight into the biology of skin melanoma by distinguishing the roles played by likelihood of cure and survival time. The differential associations of various covariates with these two parameters suggest that biologic mechanisms that govern cure are not identical to those that govern survival time.

The annual risk of melanoma progression. Implications for the concept of cure.

BACKGROUND: Melanoma may remain clinically dormant for years, and patients may have distant metastatic disease decades after the initial diagnosis is made. Because of this potential for late recurrence, the concept of "cure" for melanoma is not particularly meaningful. METHODS: To understand better the risks of future disease as a function of time elapsed after diagnosis, the clinical course of melanoma was reviewed in 5838 patients. Using conditional probability methods, the risk of recurrent disease and the risk of death were determined for 1-year and 5-year intervals during the first 15 years of follow-up. RESULTS: The estimated 5-year risk of recurrence declined from 44% at the time of diagnosis to 21% after 6 years. The 5-year risk of mortality decreased from 26% after 1 year to 16% after 9 years. Among patients with recurrent or metastatic disease, the annual risk of mortality was approximately 20% per year for 3 years; thereafter, the risk declined markedly. Among patients with thick primary lesions, the greatest risk was during the first few years after diagnosis, but in patients with thin lesions, the risk was distributed evenly over 15 years and did not decrease with time. CONCLUSIONS: Conditional probability methods permit estimation of future risks to address questions frequently asked by patients with cancer who want to know when they can be considered cured of cancer or when the risk of recurrent disease has decreased. These data on the future risk of recurrent disease and mortality can give a patient meaningful information on which to base life decisions.

Cerebral emboli from the 'stump' of a totally occluded carotid artery: surgical management.

The obstructing thrombus in a totally occluded internal carotid artery may act as a source of cerebral emboli. These emboli traverse the external carotid and ophthalmic arteries and enter the intracranial circulation via retrograde collateral pathways. Surgical treatment can result in complete abatement of symptoms in selected patients. The authors describe internal carotid "stump" syndrome in a 47-year-old man and discuss the options for surgical management.

Anomalous origin of the left main coronary artery from the right anterior aortic sinus.

Anomalous origin of the left main coronary artery from the right sinus of Valsalva is an uncommon problem, occurring in four distinct patterns. When the left main coronary artery passes between the aorta and the pulmonary trunk, acute myocardial ischemia or sudden death may occur. Angiography is required in establishing a diagnosis. Surgical correction or bypass surgery are sometimes indicated. The authors report two cases of anomalous origin of the left main coronary artery and discuss the anatomic variants, clinical significance, and technical considerations in both diagnosis and management.

Basal cell carcinoma treated with Mohs surgery. A comparison of 54 younger patients with 1050 older patients.

The average age of patients with basal cell carcinoma (BCC) is over 60 years, and fewer than 5% of patients with this tumor are under 30 years of age. A comparison of younger (15 to 30 years) and older (56 to 70 years) patients with BCC was conducted to identify specific tumor or host features associated with BCC occurring early in life. According to data collected over an 11-year period, 54 of 2728 (2%) BCCs occurred "de novo" in younger patients. In contrast to the predominantly male older group, most of the younger patients were female. An increased use of tanning booths and hair-dyes was associated with the younger patients (P less than .001). More overall sunlight exposure and actinic keratoses were associated with the older patients (P less than .01). Defect and lesion sizes were smaller (P less than .01) in the younger group. Location, histology, and clinical morphology did not differ appreciably between the two groups. De novo BCCs in younger and older patients are similar, although some differences do exist.

Acute pulmonary embolectomy with cardiopulmonary bypass support.

Deep venous thrombosis and pulmonary thromboembolism remain major sources of patient morbidity and mortality. The authors present the case of a 55-year-old man with a massive pulmonary embolism and subsequent hemodynamic decompensation who was successfully treated by open pulmonary embolectomy supported with cardiopulmonary bypass. Indications for embolectomy and patient selection as well as technical considerations are discussed.

Round atelectasis in a 20-year-old woman.

Round atelectasis is an unusual pulmonary pseudotumor often associated with primary pleural pathologic conditions or pleural effusion. We report the case of a 20-year-old woman who was found to have a large, circular pulmonary lesion demonstrated on both plain chest x-ray film and computed chest tomography. The patient underwent exploratory thoracotomy, at which time this uncommon entity was identified.