A clinicopathological study of 30 melanomas of the vulva.

Thirty cases of malignant melanomas of the vulva were studied for prognostic factors. Ulceration, tumor thickness, and positive inguinal lymph nodes were the most important prognostic factors. Morphometry did not demonstrate any prognostic meaning. Traditionally a radical vulvectomy and bilateral inguinal lymph node dissection were the therapy of choice, but this treatment modality did not show a better survival than less radical treatment. A low-risk and a high-risk group of patients have been identified for recurrence. The low-risk patient has a nonulcerative tumor, less than 3 mm thick, without clinical evidence of inguinal lymph node metastases, and should be treated by local excision with a 2- to 3-cm margin. The high-risk patient has a tumor which is ulcerative and/or more than 3 mm thick and should also be treated by local excision without elective inguinal node dissection. If clinical suspicion of inguinal lymph node metastases exists, an inguinal node dissection is advocated for better local control of the disease.

Temporal change in diagnostic criteria as a cause of the increase of malignant melanoma over time is unlikely.

To assess whether the increase in malignant melanoma incidence could be due, at least in part, to changes in histological criteria of malignancy, pathologists in Australia, France, Italy, New Zealand, Norway, Sweden, the United Kingdom, the United States and the USSR reviewed diagnoses of 50 consecutive pigmented naevi (40 junctional and compound; 10 intradermal) and 20 consecutive malignant melanomas made in each participating centre around 1930, around 1955 and around 1980. Collaborating pathologists re-read the material, 2,665 cases in all, either from the original slide (82%) or from a recut block (17%), gave their diagnosis and indicated whether the lesion was benign (B), dubious benign (DB), dubious malignant (DM) or malignant (M). As the distribution of review diagnoses was much the same whether the original slide or one made from a recut block was read, the material was pooled. Overall, 2.8% of cases originally reported as B/DB were reviewed as DM/M, while 4.4% of the DM/M diagnoses were held to be B/DB. The shifts between categories were greatest around 1955 and least around 1980, suggesting increasing uniformity of interpretation. All available blocks were recut and sections sent to IARC for review: 1.7% (22) of 1293 B/DB diagnoses were considered to be DM/M and 3.3% (18) of 551 DM/M diagnoses were considered to have been B/DB. The consistently low frequency of shift in diagnostic category, whether the material was reviewed in the collaborating laboratories or by one pathologist at IARC, in a study designed to give maximum attention to those lesions--the junctional and compound naevi--in which a change in opinion as to malignancy would be most likely to arise, suggests that pathologists, irrespective of geographical location, are using common criteria. These findings argue against changes in histological interpretation as being responsible for more than a small portion of the continuous increase of some 3% to 8% per annum observed in malignant melanoma incidence. Other explanations, such as an increase in the frequency or potential for malignant transformation of precursor lesions, must be sought. The anatomical distribution of the malignant melanomas examined followed the usual site pattern by sex, and their thickness was observed to decrease over the period of the study in most centres.

Results of radical dissection of the groin in patients with stage II melanoma and histologically proved metastases of the iliac or obturator lymph nodes, or both.

In order to determine the value of the pelvic part of the radical dissection of the groin, the histories of 23 patients with Stage II (UICC) melanoma with histologically proved metastases of the iliac or obturator lymph nodes, or both, were studied. Histologically proved primary melanomas were found in 19 patients, 18 were localized on the leg and one on the trunk. In four patients, the primary melanoma was unknown. Seven patients had received adjuvant radiotherapy. The time between node dissection and the moment of analysis was two years for 17 patients, five years for 11 patients and ten years for ten patients. Calculated actuarially, 42 per cent of the patients were still without distant metastasis after two years and 32 per cent after five and ten years. At the time of the analysis, ten patients were alive, nine without evidence of disease and three having survived for more than five years. Remarkably, the primary tumor of all three patients was "unknown" and they had all had adjuvant radiotherapy. In pooling the data of this series with those from the literature, it appears that, of 78 patients with Stage II melanoma and deep node involvement, 12 had a disease-free survival time of more than five years after therapeutic radical groin dissection. Involvement of deep nodes does not always seem to equate with systemic disease. We think that, when there is an indication for a therapeutic groin dissection, an en bloc superficial and deep lymph node dissection is warranted.

To perfuse or not to perfuse? A retrospective comparative study to evaluate the effect of adjuvant isolated regional perfusion in patients with stage I extremity melanoma with a thickness of 1.5 mm or greater.

The use of isolated regional perfusion in an adjuvant setting for stage I melanoma of the extremity continues to be controversial. The present retrospective study evaluates the past 20 years' experience by comparing 227 perfused patients from Groningen with 238 matched controls from five hospitals in The Netherlands and Westphalia (a region of West Germany bordering the Netherlands). All patients underwent wide local excision for a primary extremity melanoma of 1.5 mm or greater in thickness. A proportional hazards regression analysis for recurrence of disease and survival identified the significant prognostic factors, of which tumor thickness was the most important. Corrected for these factors, it was not possible to demonstrate a statistically significant effect for perfusion in terms of time to limb recurrence (P = .61), time to regional lymph node metastasis (P = .11), time to distant metastasis (P = .73), disease-free interval (P = .42), and survival (P = .90). No statistically significant differences were seen for adjuvant perfusion in any of the subgroups.

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.

[Intraepidermal melanocytic proliferation. A practical guide to the classification of ambiguous melanotic skin lesions and of possible precursors of malignant melanomas]. / Les prolifeérations mélanocytaires intra-épidermiques. Guide pratique de classification des lésions mélaniques cutanées ambigués et de quelques précurseurs possibles des mélanomes malins.

A group of senior Pathologists engaged in review work on international randomized trials for the W.H.O and/or the E.O.R.T.C., propose a new simplified classification of melanocytic lesions with an intra-epidermal component, applicable in routine. This classification attempts to introduce standards to permit morphological identification of a large group of intra-epidermal melanocytic proliferations with three classes of atypia (slight, mild, severe) and group of malignant melanomas especially those without dermal invasion. The new definitions and objective criteria (at cytological and architectural level) of diagnosis are given with examples of equivalence between some established entities and this new universal terminology.

Punch biopsy of melanoma.

A 46-year-old albino woman is described with a melanoma on the leg from which a punch biopsy specimen was inadvertently taken. In the reexcision specimen, two biopsy wounds were recognized that were filled with tumor. The initial level III lesion had to be subsequently reported as a deep level IV amelanotic melanoma with an increased thickness. It is emphasized that in places where the subcutaneous fat is absent, punch or incision biopsy may thwart proper secondary excision.

Contrasting incidences along with descriptive markers in the epidemiology of melanoma.

The four volumes of "Cancer Incidences in Five Continents" provided the data for studying the geographical differences in melanoma incidence. The cancer cumulative incidence rate was used, along with other descriptive markers: sex ratio, age group distribution and sub-site distribution. The incidence of melanoma was correlated with other sites of cancer across populations for both sexes separately, showing a high correlation with ovarian cancer. The regions used for the main comparison were Miyagi Prefecture, Japan, Alberta, Canada and Norway. An answer was sought to the question as to whether or not the (basic) low incidence is mainly determined by endogenous factors while the (superimposed) high incidence arises under the influence of an environmental cause. Cohort studies and studies of migrant populations offer data which suggest that ultraviolet exposure is among the causal environmental factors. The correlation study emphasizes the importance of the endogenous factors. The observations on the behaviour of the descriptive markers are used to give an outline for further research using descriptive and analytical epidemiological methods.

Biopsy and survival of malignant melanoma.

Primary excisional biopsy is recommended as the procedure of choice whenever there is any suspicion of malignant melanoma. Evaluation of the total architecture of the lesion is necessary to make a satisfactory pathologic diagnosis and prognosis. Moreover, the risk of local tumor recurrence and metastatic potential can be increased by incisional procedures. Awareness of these potential hazards should provoke reappraisal of management of primary melanomas.

Chemosensitivity of human melanoma xenografts in immunocompetent mice and its histological evaluation.

In the subrenal capsule assay, the immuno-competent mice used have a host immune response to the graft which may introduce a bias in the determination of tumour size. A study was therefore conducted to verify the quality of the correlation that could exist between "macroscopical" and "microscopical" evaluation. A histological study of 12 different tumours treated with cis-Pt, L-PAM, DTIC, vindesine, BCNU or TGU demonstrated that a cellular host immune response was observed in 11 out of the 12 control groups and was uneven in the treated groups. The "microscopical" and "macroscopical" evaluations of tumour-take were 100 and 95% respectively. Although there was a fair correlation between the "microscopic" and "macroscopic" parameters, tumour variations in absence of host reaction--which reflect pure chemosensitivity of the treated tissue--could be measured in 50% of the cases. It was possible to determine a base-line for rejection of the test results when the control group showed a decrease in mean tumour size exceeding 20% of its initial size on day 0. If the decrease is less than 20%, then the histological evaluation appears to be of considerable additional value.

Mucosal melanomas of the head and neck.

Mucosal melanoma of the head and neck is a rare condition. This study presents a review of 26 patients with such tumors, followed up at a minimum of 5 years. The 5-year survival rate in this group was 38%. Recurrences with a fatal outcome, however, have been encountered up to 12 years after initial diagnosis. Primary radical surgery offers the best chance for local control. Nasal-cavity lesions seem to be associated with a better prognosis than oral-cavity tumors. Analysis of pathologic features by microstage measurement showed that the majority of tumors were of considerable thickness. This factor may partially explain the poor prognosis associated with mucosal melanomas in comparison to their cutaneous counterparts. Local recurrences and distant metastases were the principal causes of treatment failure. A persistent treatment policy, however, may still substantially prolong survival in such cases. Regional lymph-node metastasis did not pose a significant problem in the management of these tumors. Recognition of the nature and significance of the appearance of oral melanosis is stressed.

Stage I melanoma of the limbs: assessment of prognosis by levels of invasion and maximum thickness.

The prognostic significance of 2 histological parameters, level of invasion and maximum thickness is evaluated in 248 cases of malignant melanoma of the limbs staged T1-3NoMo which were collected for Trial No. 1 of the W.H.O. Collaborating Centres for the Evaluation of Methods of Diagnosis and Treatment of Melanoma between September 1967 and December 1974. There is a linear relation of tumor thickness to mortality with a high statistical significance (P = 0.0002). Mortality also increases with progression of the level of invasion. The incidence of occult metastases to the regional lymph nodes increases with increasing thickness or level of invasion. Moreover the age and sex corrected survival curves are also dependent on both parameters. The comparison of the 2 methods revealed that maximal tumor thickness is a more powerful measure of prognosis than is the determination of the level of invasion.