Nodal and systemic recurrence following observation of a positive sentinel lymph node in melanoma.

BACKGROUND: Two RCTs found no survival benefit for completion lymphadenectomy after positive sentinel lymph node biopsy compared with observation with ultrasound in patients with melanoma. Recurrence patterns and regional control are not well described for patients undergoing observation alone. METHODS: All patients with a positive sentinel node biopsy who did not have immediate completion lymphadenectomy were identified from a single-institution database (1995-2018). First recurrences were classified as node only, local and in-transit (LCIT) only, LCIT and nodal, or systemic. Regional control and factors associated with recurrence survival were analysed. RESULTS: Median follow-up was 33 months. Of 370 patients, 158 (42·7 per cent) had a recurrence. The sites of first recurrence were node only (13·2 per cent), LCIT only (11·9 per cent), LCIT and nodal (3·5 per cent), and systemic (13·8 per cent). The 3-year postrecurrence melanoma-specific survival rate was 73 (95 per cent c.i. 54 to 86) per cent for patients with node-only first recurrence, and 51 (31 to 68) per cent for those with initial systemic recurrence. In multivariable analysis, ulceration in the primary lesion (hazard ratio (HR) 2·53, 95 per cent c.i. 1·27 to 5·04), disease-free interval 12 months or less (HR 2·38, 1·28 to 4·35), and systemic (HR 2·57, 1·16 to 5·65) or LCIT and nodal (HR 2·94, 1·11 to 7·79) first recurrence were associated significantly with decreased postrecurrence survival. Maintenance of regional control required therapeutic lymphadenectomy in 13·0 per cent of patients during follow-up. CONCLUSION: Observation after a positive sentinel lymph node biopsy is associated with good regional control, permits assessment of the time to and pattern of recurrence, and spares lymphadenectomy-related morbidity in patients with melanoma.

A phase I multi-institutional study of systemic sorafenib in conjunction with regional melphalan for in-transit melanoma of the extremity.

BACKGROUND: Isolated limb infusion with melphalan (ILI-M) corrected for ideal body weight (IBW) is a well-tolerated treatment for patients with in-transit extremity melanoma with an approximate 29 % complete response (CR) rate. Sorafenib, a multi-kinase inhibitor, has been shown to augment tumor response to chemotherapy in preclinical studies. METHODS: A multi-institutional, dose-escalation, phase I study was performed to evaluate the safety and antitumor activity of sorafenib in combination with ILI-M. Patients with AJCC stage IIIB/IIIC/IV melanoma were treated with sorafenib starting at 400 mg daily for 7 days before and 7 days after ILI-M corrected for IBW. Toxicity, drug pharmacokinetics, and tumor protein expression changes were measured and correlated with clinical response at 3 months. RESULTS: A total of 20 patients were enrolled at two institutions. The maximum tolerated dose (MTD) of sorafenib in combination with ILI-M was 400 mg. Four dose-limiting toxicities occurred, including soft tissue ulcerations and compartment syndrome. There were three CRs (15 %) and four partial responses (20 %). Of patients with the Braf mutation, 83 % (n = 6) progressed compared with only 33 % without (n = 12). Short-term sorafenib treatment did alter protein expression as measured with reverse phase protein array (RPPA) analysis, but did not inhibit protein expression in the MAP kinase pathway. Sorafenib did not alter melphalan pharmacokinetics. CONCLUSION: This trial defined the MTD of systemically administered sorafenib in combination with ILI-M. Although some responses were seen, the addition of sorafenib to ILI-M did not appear to augment the effects of melphalan but did increase regional toxicity.

Phase II trial of neoadjuvant temozolomide in resectable melanoma patients.

BACKGROUND: We treated melanoma patients with temozolomide (TMZ) in the neoadjuvant setting and collected cryopreserved tumor samples before and after treatment. The primary objective was to determine whether the response proportion was higher than previously reported in widely metastatic patients. A secondary objective was to test the feasibility of obtaining adequate tissue before and after treatment for genetic testing. MATERIALS AND METHODS: Chemotherapy-naive melanoma patients who were candidates for surgical resection were eligible. TMZ was administered orally at 75 mg/m(2)/day for 6 weeks of every 8-week cycle. Cycles were repeated until complete response (CR), progression, or stable disease (SD) for two cycles. RESULTS: Of 19 assessable patients, 2 had CRs and 1 had partial response. Four patients had SD; 12 progressed. Tumor O-6-methylguanine-DNA methyltransferase (MGMT) promoter was unmethylated in all nine patients analyzed including from the two CR patients. Pretreatment tumor microarray results were obtained in 16 of 19 patients. CONCLUSIONS: The response proportion to TMZ in the neoadjuvant setting was 16%, not different than in the metastatic setting. Responses were seen even in tumors with a methylated MGMT promoter. Pretreatment cryopreserved tumor adequate for microarray analysis could be obtained in most, but not all, patients. Post-treatment tumor was unavailable in complete responders.

Preperitoneal repair of inguinal hernia at open radical prostatectomy.

PURPOSE: Patients undergoing prostatectomy for cancer are at risk for onset/worsening of inguinal hernia (IH). Preperitoneal inguinal hernia repair (IHR) concurrent with radical prostatectomy (RP) should be considered. Dissection of the preperitoneal space at RP provides an ideal opportunity for the repair of inguinal hernia. We describe our efforts with patients undergoing RP and IHR to determine whether this approach is safe. METHODS: Records of patients undergoing RP and simultaneous IHR were identified from a prospective prostatectomy database from 1995 to 2007. Clinical hernia presentation, repair techniques, operative time, and complications were recorded. RESULTS: During the study period, 4,311 RPs were performed at our institution. Of these, 108 patients (2.5%) had 141 simultaneous IHRs. The mean patient age was 61 years (range 45-79), with an average body mass index (BMI) of 27.5 (range 19-37.6). Most patients underwent repair of a unilateral IH (n = 75; 69%) and 33 patients (31%) had a bilateral repair. The operative time was a median of 224 min in patients undergoing simultaneous IHR compared with 180 min in patients undergoing RP only. Records of the time required for IHR were available for 21 patients undergoing unilateral repair and for 18 patients undergoing bilateral repair. The median times for unilateral and bilateral IHR were 42 and 33 min, respectively. Only one patient had postoperative complications (perineal discomfort, bilateral neuralgia/paresthesia) possibly related to IHR. There were no wound infections in patients undergoing simultaneous hernia repair. Of the 141 IH repairs, four recurrent hernias (2.8%) required reoperation at a median of 16 months following initial repair. CONCLUSIONS: In our experience, preperitoneal IHR at the time of RP should be strongly considered, as it is not associated with an increased risk of complications and adds less than an hour of additional operative time to RP alone.

Microscopic satellitosis in patients with primary cutaneous melanoma: implications for nodal basin staging.

BACKGROUND: Microscopic satellitosis in melanoma is uncommon. The role of regional basin staging/therapy in patients with this high-risk feature has not been well defined. METHODS: Patients presenting from 1996 to 2005 with clinically localized melanoma containing microscopic satellitosis were identified from a prospective, single-institution database. Multiple factors were analyzed to determine their predictive value for recurrence. The management of the draining nodal basin was evaluated to determine its impact on recurrence and survival. RESULTS: Thirty-eight patients presented to our institution during this time period with clinically localized melanoma containing microscopic satellitosis. The 5-year overall and disease-free survivals in these patients were 34% and 18%, respectively. Sixty-eight percent had pathologically involved regional nodal metastases. With median follow-up of 21 months, 68% recurred, with a median time to recurrence of 9 months. Lymphovascular invasion (LVI) (p = 0.01), tumor regression (p = 0.04), and positive regional lymph nodes (p = 0.02) were associated with an increased risk of recurrence. Of the 31 patients who underwent sentinel lymph node (SLN) biopsy, 22 had metastasis in the SLN (71%). Fifteen of these patients underwent completion lymphadenectomy (CLND) and seven were observed. There was no difference in disease-free survival (DFS), disease-specific survival (DSS), or overall survival (OS) between these groups (p = 0.42). CONCLUSIONS: Pathological lymph node metastases were more prevalent (68%) than in any group previously defined. Regional nodal status predicted recurrence but not nodal recurrence. In SLN-positive patients, CLND did not improve DFS, DSS, or OS, although the number of patients was small. Further studies are needed to determine the utility of regional nodal staging/therapy in these high-risk patients.

Influence of epidermal growth factor and insulin-like growth factor 1 on nuclear maturation and fertilization of buffalo cumulus oocyte complexes in serum free media and their subsequent development in vitro.

The in vitro maturation, fertilization and development of Indian water buffalo (Bubalus sp.) cumulus oocyte complexes (COCs) to blastocysts were studied during culture, either in serum free tissue culture medium 199 (TCM 199) or Waymouth MB (WM). Based on different supplements added to these media, the experimental groups included: (a) no supplement (control); (b) hormones (FSH, LH and oestradiol) (c) Epidermal growth factor (EGF); (d) IGF-1; and (e) EGF + IGF-1. Experiments were conducted to note three end points: (1) nuclear maturation 24 h after culture (eight replicates); (2) fertilization 24 h after insemination (10 replicates); (3) development to blastocysts (nine replicates). The oocytes were cultured in groups of up to five per drop. Using a two-way (5 x 2) factorial model with interactions, the results were compared using generalized linear models with binomial errors and the logit link function. In experiment 1, the proportion of oocytes reaching metaphase II was higher for all the supplement treatments than the control treatment (t = 3.68, p < 0.0001). The proportion of oocytes reaching metaphase II was 74.7, 63.2, 64.7 and 81% with hormone (chi2 = 17.23, p < 0.0001), EGF (chi2 = 7.07, p = 0.007), IGF-1 (chi2 = 19.21, p = 0.002) and EGF + IGF-1 (chi2 = 33.04, p < 0.0001) supplementation, respectively, compared to 46.6% in the control (no supplement) group. Media did not have an effect on outcome. In experiment 2, the proportion of oocytes fertilized was significantly higher with hormones (31.0%, chi2 = 12.5, p = 0.0004), IGF-1 (35.7%, chi2 = 20.53, p < 0.0001), and the EGF + IGF-1 combination (49.7%, chi2 = 51.35, p < 0.0001) compared to control (16.2%). No significant effect of media was seen. In experiment 3, the proportion of oocytes that cleaved at 48 h after culturing was significantly higher for all supplement treatments compared to control. IGF-1 supplementation was the only treatment that did not produce a significantly higher rate of progression to blastocysts compared to the control. Once again, media had no effect on outcome. It was concluded that maturation, fertilization and development of buffalo oocytes were enhanced by all supplements tested. Enhancement was maximal with the combination of EGF+IGF-1. In contrast, no significant differences were found between the two types of media used.

Estimating the relative risk of developing melanoma in INK4A carriers.

Estimation of the relative risk of cancer due to rare germline mutations using population-based epidemiological techniques is challenging, since studies with very large numbers of subjects are required. In this pilot study using a novel study design, we evaluated the role of INK4A mutations in melanoma by comparing patients with multiple primary melanomas to those with single primaries. Patients were ascertained from the Surgery and Dermatology Clinics at Memorial Sloan-Kettering Cancer Center and at the Yale University Pigmented Lesion Clinic. Subjects completed a questionnaire covering risk factors for melanoma and were tested for INK4A mutations. Five (8%) of 65 patients with multiple primaries had a mutation, compared with none of 88 patients with single primaries (P=0.03). Examination of other factors, such as number of nevi on the arms of the patients, fair skin, hair and eye colour, and other phenotypic characteristics associated with the risk of melanoma, demonstrates that these factors exhibit higher prevalence in the multiple primary cases than in the single primaries. These results provide evidence of the utility of the new study design in evaluating the impact of rare but highly penetrant cancer risk factors.

Randomized, placebo-controlled trial of dietary supplementation of alpha-tocopherol on mutagen sensitivity levels in melanoma patients: a pilot trial.

We evaluated the effects of vitamin E (dl-alpha-tocopherol) on mutagen sensitivity levels in a randomized placebo-controlled pilot trial. In brief, a dietary supplement of 1000 mg/day vitamin E or a placebo was randomly administered for 3 months to melanoma outpatients clinically free of the disease. Plasma vitamin E and mutagen sensitivity levels were measured at baseline and at the end of the trial after 3 months. At baseline, we found no significant differences in plasma vitamin E and mutagen sensitivity levels between the two groups. We also measured dietary intake at baseline and found dietary vitamin E to be a poor predictor of plasma levels of vitamin E. After 3 months of supplementation, we found that plasma levels of alpha-tocopherol increased significantly (P = 0.0005) in the vitamin E compared to the placebo group. We also found a non-significant, but consistent decrease in plasma gamma-tocopherol concentrations in the vitamin E supplemented compared to the placebo group. We did not find any significant difference between the vitamin E and placebo groups in mutagen sensitivity levels either at baseline or after 3 months of supplementation. We conclude that short term vitamin E supplementation, although it causes increased blood levels of alpha-tocopherol, does not provide protection against bleomycin-induced chromosome damage.

Mutagen sensitivity as an indicator of soft tissue sarcoma risk.

The etiology of soft tissue sarcoma is poorly understood. Exposure to environmental chemicals may play a role, but the data are not clear. We compared a group of soft tissue sarcoma patients with healthy controls to determine whether the mutagen sensitivity assay, a simple chromosome aberration assay using the radiomimetic bleomycin, might be useful to identify patients at risk for soft tissue sarcoma. Patients with a diagnosis of soft tissue sarcoma at Memorial Sloan-Kettering's outpatient clinic signed informed consent and donated 30 ml of blood. Controls were selected from the general population of Connecticut by random digit dialing. Unrepaired DNA damage was assessed for 100 metaphase spreads for each individual, with the number of breaks in chromatids being counted as breaks per cell (b/c). The 20 cases with soft tissue sarcoma had 1.03 mean b/c and the controls had 0.88 b/c (P = 0.16). Patients with soft tissue sarcoma were 5.7 times more likely to be mutagen sensitive than controls (P = 0.01), as determined after dividing subjects into sensitive or not sensitive groups based on the median b/c among controls. As mutagen sensitivity has been shown to be associated with a number of cancers and appears to reflect genetic susceptibility, this assay may be an appropriate biomarker for radiation sensitivity or it may be a marker of susceptibility to soft tissue sarcoma. Larger studies should be undertaken to assess these possibilities.

Early recurrence after lymphatic mapping and sentinel node biopsy in patients with primary extremity melanoma: a comparison with elective lymph node dissection.

INTRODUCTION: Although sentinel node biopsy with completion lymphadenectomy in node-positive patients (SLND) has been widely adopted in the management of patients with early stage melanoma, reports detailing the outcome of patients after SLND are limited. To address this issue, we analyzed our experience with SLND and provided a comparison to patients treated with elective lymph node dissection (ELND). METHODS: All patients who underwent SLND (1991-1998) and ELND (1974-1994) were identified from single institution melanoma databases. RESULTS: A total of 152 and 329 patients with early-stage melanoma of the extremity underwent SLND and ELND, respectively. Nodal metastases were present in 44 of 329 ELND patients (13%) and in 31 of 152 SLND patients (20%). Early relapse-free and disease-specific survivals were similar for the entire population, although in patients at higher risk for recurrence (age >50 years, thickness >3.0 mm), there was an increased rate of relapse in the SLND group (P = .04). Among all sites of early recurrences, locoregional sites were more common in patients undergoing SLND (72%) compared with ELND (39%, P < .01). SLN-negative patients with nodal recurrence had evidence of metastases on retrospective enhanced pathologic analysis in four of seven cases. CONCLUSIONS: Although overall relapse-free and disease-specific survivals are similar, there is a higher rate of relapse in a subset of SLND node-negative patients who are at high risk for nodal metastases. ELND and SLNB should not be thought of as equivalent approaches until studies with longer follow-up are available.

Primary genitourinary melanoma.

OBJECTIVES: To describe the presentation, management, and clinical outcome of patients with genitourinary melanoma. METHODS: We identified 14 patients with genitourinary melanoma treated at Memorial Sloan-Kettering Cancer Center, New York and Tripler Army Medical Center, Honolulu, Hawaii. The presentation, surgical treatment, disease progression, and outcome of these patients were reviewed. Survival was analyzed, using the Kaplan-Meier product limit method. RESULTS: The presentation and management of patients with genitourinary melanoma were varied. Overall, the prognosis was poor, with a median survival of 43 months, and only 3 patients were alive, without disease, at last follow-up. Our findings confirm a poor prognosis in patients with this rare disease. CONCLUSIONS: Genitourinary melanoma is a rare form of the disease with an unfavorable clinical outcome. Less than one third of patients survive long term, although patients with scrotal melanomas may have a better prognosis.

Sentinel lymph node biopsy in the management of patients with primary cutaneous melanoma: review of a large single-institutional experience with an emphasis on recurrence.

OBJECTIVE: To analyze the authors' experience with sentinel lymph node biopsy (SLNB) and the subsequent incidence and pattern of recurrence in patients with positive and negative nodes. SUMMARY BACKGROUND DATA: Lymphatic mapping with SLNB has become widely accepted in the management of patients with melanoma who are at risk for occult regional lymph node metastases. Because this procedure is relatively new, the pattern of recurrence after SLNB is not yet clear. METHODS: All patients with primary cutaneous melanoma who underwent SLNB from 1991 through 1998 were identified from a prospective single-institution melanoma database. RESULTS: Three hundred fifty-seven consecutive patients with localized primary cutaneous melanoma who underwent SLNB were identified. The sentinel node was identified in 332 patients (93%) and was positive in 56 (17%). Fourteen percent of patients had developed a recurrence at a median follow-up of 24 months. The median time to recurrence was 13 months. The 3-year relapse-free survival rates for patients with positive and negative nodes were 56% and 75%, respectively. SLN status was the most important predictor of disease recurrence. The site of first recurrence in patients with negative and positive nodes was more commonly locoregional than distant. Reexamination of the SLN in 11 patients with negative nodes with initial nodal and in-transit recurrence showed evidence of metastases in 7 (64%). CONCLUSIONS: Patients with positive sentinel nodes have a significantly increased risk for recurrence. The early pattern of first recurrence for patients with negative and positive results is characterized by a preponderance of locoregional sites, similar to that reported in previous series of elective lymph node dissection. These data underscore the need for careful pathologic analysis of the SLN as well as a careful, directed locoregional physical examination in the follow-up of these patients.

Giant cellular blue nevus of the anterior chest wall mimicking metastatic melanoma to the breast: a case report.

BACKGROUND AND OBJECTIVES: Blue nevi are benign pigmented dermal lesions that can mimic cutaneous melanoma in appearance. Cellular components may infiltrate subcutaneous tissue. We present a complex case of cellular blue nevus (CBN) to demonstrate the ambiguous clinical appearance of these lesions and to provide an approach for management of such cases. METHODS: We report an extraordinary case of CBN mimicking metastatic melanoma to the breast. A 53-year-old female with an acquired giant blue nevus of the chest wall was found to have two new breast nodules suspicious for malignancy on routine mammography. These were biopsied and interpreted as consistent with metastatic melanoma vs. CBN. The patient underwent complete excision of the chest wall nevus and modified radical mastectomy. RESULTS: Pathologic evaluation of the chest wall specimen revealed numerous collections of deeply pigmented melanocytes scattered throughout the breast parenchyma and embracing ductal structures. No mitoses or nuclear polymorphism were seen. The diagnosis of CBN involving the chest, breast tissue and axillary lymph nodes was made. CONCLUSION: Giant blue nevi overlying the breast can develop cellular components that infiltrate subcutaneous and breast tissue resulting in the appearance of breast nodules on mammography. A generous excision biopsy inclusive of the overlying nevus and breast component may be required to establish the dignity of the lesion.

Patterns of detection in patients with cutaneous melanoma.

BACKGROUND: Despite the importance of early detection in preventing mortality from melanoma, little is known regarding how patients with the disease come to diagnosis. METHODS: The authors prospectively evaluated 471 newly diagnosed melanoma patients between 1995 and 1998. Patients completed a questionnaire that included 1) identification of the person who detected the lesion, 2) the anatomic location of the lesion, and 3) family history of melanoma. Logistic regression analysis was performed to examine the relation between detection patterns and lesion thickness, adjusting for age, gender, anatomic site of the primary lesion, and family history of melanoma. RESULTS: The majority of patients detected their own melanoma (n = 270; 57%). Females were more likely to self-detect than males (69% vs. 47%; P < 0.0001). Physicians detected the melanoma in 16% of patients (n = 74), followed by "spouse" in 11% of patients (n = 51). Within this group, detection by wives was 7.5 times more common than detection by husbands (P < 0.0001). Logistic regression analysis revealed that physicians were 3.6 times more likely to detect thin lesions (

Restoration of alloreactivity of melanoma by transduction with B7.1.

Melanoma cells are unusual because, unlike most epithelial tumors, constitutive expression of human leukocyte antigen (HLA) class II molecules is common. To elucidate the role of HLA class II expression in the immunopathogenesis of melanoma, the authors compared HLA class II+ melanoma cells to autologous B cells with respect to their ability to stimulate primary (naïve) histoincompatible lymphocytes and T-cell clones (antigen experienced). Using primary lymphocytes (peripheral blood lymphocytes [PBLs]), melanoma cells were nonstimulatory when compared to autologous B cells. To determine whether this was caused by defective antigen processing, the authors used alloreactive T-cell clones, which require alloantigen presentation by a histocompatible stimulator cell but not costimulation. Melanoma cells stimulated the alloreactive T-cell clones in two of three clones tested, indicating that they processed and presented alloantigen. To determine whether the failure of melanoma cells to stimulate primary lymphocytes was caused by their inability to costimulate the T cells, the authors transduced the melanoma cells with B7.1 and achieved stable expression in more than 95% of the cells. The transduced cells were highly stimulatory, eliciting a 17- to 25-fold increase in proliferation by the peripheral blood lymphocytes compared with controls. Indeed, B7-expressing melanoma cells were more stimulatory than autologous B cells, which elicited an 11- to 15-fold increase compared with controls. These data indicate that melanoma cells fail to stimulate primary lymphocytes because they do not deliver costimulatory signals. Engineering HLA class II+ melanoma cells to express high levels of B7.1 may provide a way to elicit primary T-cell responses to melanoma-associated antigens.

Pregnancy-associated melanoma occurring in two generations.

We report of a case of malignant melanoma occurring during pregnancy in a woman whose mother had a melanoma excised during pregnancy. There was no other family history of melanoma. To our knowledge, this has not been previously reported. A review of the recent literature suggests that pregnant women with melanoma do not have a worse prognosis when compared to matched controls, but may present with worse prognostic features.

CD4(+) T cells kill HLA-class-II-antigen-positive melanoma cells presenting peptide in vitro.

PURPOSE: Most melanoma cell lines express HLA class II antigens constitutively or can be induced to do so with interferon gamma (IFNgamma). We have previously demonstrated that peptide-specific CD4(+) T cells proliferate in response to HLA-class-II-antigen-mediated peptide presentation by melanoma cells in vitro and produce interleukin-10 (IL-10) and (IFNgamma). We asked whether the responding T cells kill the tumor cells and, if so, whether direct cell contact was required. METHODS: Two HLA class II(+) melanoma cell lines derived from metastases were co-cultured with a human CD4(+) T cell clone specific for influenza hemagglutinin peptide (HA). T cells, melanoma, and HA were co-cultured for 48 h. Melanoma cells with and without HA and/or T cells served as controls. After 36 h, the medium was removed for cytokine analysis by enzyme-linked immunosorbent assay (ELISA). Twelve hours later non-adherent cells were washed away and the adherent melanoma cells were trypsinized and counted. Dual-chamber culture plates were used to determine whether cell contact and/or exposure to cytokine were required for tumor cell death. RESULTS: Melanoma cell counts were over 80% lower in wells containing T cells than in wells with melanoma and peptide alone (P < 0.05). ELISA of supernatants revealed production of IFNgamma and IL-10 by the responding T cells. Direct T cell contact with tumor cells was not required for tumor cell death, as melanoma cells were killed when they shared medium but had no contact with T cells responding to peptide presentation by HLA-class-II-antigen-positive melanoma cells in a separate chamber. Blocking antibody to IFNgamma but not IL-10 prevented melanoma cell death at levels of cytokine similar to that present in co-culture assays. CONCLUSIONS: Peptide-specific CD4(+) T cells kill melanoma cells in vitro when they recognize peptide presented by the tumor cell in the context of HLA class II antigen. Direct cell contact is not required, suggesting that it is a cytokine-mediated event. Immunotherapy, using primed CD4(+) T cells and peptide, may be beneficial in patients whose tumors express HLA class II antigens or can be induced to do so with IFNgamma.

Large plaque-type blue nevus with subcutaneous cellular nodules.

Unusual or atypical melanocytic nevi can be confused with malignant melanoma. The authors present two cases of an unusual variant of blue nevus that were misdiagnosed initially as malignancy. Both lesions were asymptomatic and characterized clinically by childhood onset, with slow enlargement during adolescence and subsequent nodule formation. One lesion, which measured 24 cm in greatest dimension, was located on the anterior chest wall of a 53-year-old woman. The other lesion, which measured approximately 15 cm in greatest dimension, was located on the lateral abdominal wall of a 20-year-old man. Both lesions were characterized by a multifocal dermal and subcutaneous proliferation of fusiform and dendritic pigmented melanocytes. The histologic appearance of individual foci ranged from dermal melanocytosis to common blue nevus and cellular blue nevus. The cellular foci were located in the subcutis and involved, in one patient, the stroma of the breast. The cells were immunoreactive for S-100 protein, gp100 (HMB-45), and Melan-A (A103). Ultrastructural analysis revealed melanocytes typical of blue nevus. The woman underwent complete excision of the lesion, and the man underwent only partial excision of the lesion. On clinical follow-up of 32 and 19 months, respectively, both patients are alive and well with no evidence of recurrence or progression. Because the lesions presented clinically as large plaques and were diagnosed histologically as blue nevi with subcutaneous foci of cellular blue nevus, we term this rare variant of blue nevus large plaque-type blue nevus with subcutaneous cellular nodules. Recognition of this lesion enhances our knowledge of the morphologic spectrum of melanocytic tumors and helps to avoid confusion with malignant melanoma.

Cytokine production by CD4+ T-cells responding to antigen presentation by melanoma cells.

Melanoma cells are unusual because, unlike most epithelial tumours, constitutive expression of HLA class II antigens is common. We have previously demonstrated that a peptide-specific CD4+ T-cell clone proliferates briskly in response to peptide and HLA class II expressing melanoma cell lines derived from metastases. Here we demonstrate that these CD4+ T-cells secrete large amounts of interferon-gamma (IFNgamma) and interleukin-10 (IL10), and insignificant quantities of IL2 or IL4, in response to peptide presentation by both melanoma and autologous B-cells. T-cells produced more IL10 when responding to peptide presentation by melanoma cells compared with B-cells, and less IFNgamma (P<0.01). Addition of IL12 did not alter the cytokines produced but increased the T-cell production of both, especially the production of IL10 in response to peptide presentation by melanoma cells. Our data suggest that differential cytokine production by CD4+ T-cells in response to peptide presentation by HLA class II expressing tumour cells may contribute to tolerance to tumour antigens.