Douglas J. Pritchard

Lymphadenectomy in the Management of Stage I Malignant Melanoma: A Prospective Randomized Study

A prospective randomized study was initiated at our institution in 1972 to determine the efficacy of routine elective lymphadenectomy in localized (stage I) melanoma. Included in the study were 171 patients, 62 of whom had no lymphadenectomy, 55 of whom had delayed lymphadenectomy, and 54 of whom had immediate lymphadenectomy. No significant difference was found among the three treatment groups with respect to survival or metastasis-free survival. Multifactorial analysis indicated that the level of invasion and the thickness of the lesion were the most important prognostic factors, followed by age (60 years or older), site (legs), and tumor type (nodular). A prognostic index based on these variables was highly predictive of metastasis or death. Even when this score was considered, no significant variation was noted among the three treatment groups. More subsequent complications of melanoma, however, occurred in the group with no lymphadenectomy--36 in this group but only 19 in each of the other treatment groups. This finding was not statistically significant but does indicate that a few additional problems may be associated with leaving regional nodes intact. Further studies are needed, and indeed are being conducted, to determine whether elective lymphadenectomy improves survival sufficiently to offset the costs and the complications associated with this approach.

Ewing's sarcoma. A clinicopathological and statistical analysis of patients surviving five years or longer

Of 229 patients with primary Ewings sarcoma of bone, thirty-seven survived five years or longer. When the patients who survived five years or longer were compared with the 192 who did not, two factors associated with longer survival were identified in this retrospective study: location of the primary tumor within an extremity and inclusion of surgery as part of the initial treatment. The probability of five-year survival for all 229 patients with primary Ewings sarcoma was 16 per cent. For those seen since 1950, this probability was 18 per cent, and for patients without metastasis, it was 22 per cent.

Osteosarcoma of the spine.

Primary osteosarcoma of bone has originated in the spine in only a few patients. This report concerns twenty-seven of thirty patients who had the original diagnosis made and surgical treatment, if any, performed at the Mayo Clinic. The patients ages ranged from eleven to eighty years. Pain in the area of involvement was the first symptom in all patients. In addition, nineteen patients (70 per cent) had neurological symptoms and signs when they were first seen. All patients had a surgical biopsy of the lesion, often combined with decompressive laminectomy. Twenty-one of the twenty-seven patients received postoperative radiation therapy in various dosages. Only five patients received adjunctive chemotherapy. All but one patient died of the disease, with a median length of survival of ten months (range, one to thirty-eight months). Although rare, osteosarcoma of the spine can usually be suspected on roentgenograms, and then the most aggressive therapy is justified.

Trends and Variability in Survival Among Patients With Osteosarcoma: A 7-Year Update

This report is an update of a 1978 article on osteosarcoma in Mayo Clinic patients. It includes additional follow-up on previously reported cases and incorporates new cases treated since the time of that original study. From 1963 through 1981, 336 patients with classic, previously untreated osteosarcoma received their first definitive treatment at our institution. Survival of these patients was studied in detail. The most significant result was that survival in the 1960s was much worse than that in the 1970s. The first evidence of improvement in survival was noted in 1969; subsequently, further improvement occurred but was not consistent. This finding prevailed with respect to duration of survival to death, survival to detection of metastasis, and survival from occurrence of metastasis to death. On the basis of detailed regression analysis, several variables had independent prognostic value. From these findings, a prognostic score was developed, which was based on the number of the following unfavorable characteristics: age younger than 10 years, male sex, tumor diameter more than 15 cm, cell type osteoblastic or chondroblastic, duration of symptoms 2 months or less, and involvement of the femur or humerus. Patients with five or six of these unfavorable characteristics had a very poor survival; in contrast, patients with only one or two characteristics had a good outcome. Even when these scores were fairly constant, however, the calendar period had a strong influence on survival. Likewise, when treatment was considered and adjustments by score were made, no significant differences could be found between those patients treated by amputation only and those treated by amputation supplemented with chemotherapy or radiotherapy.

Primary Epithelioid Sarcoma of the Hand and Forearm: A Review Of Thirteen Cases

Of eighty-five primary soft-tissue and sixteen primary bone sarcomas involving the hand and forearm, thirteen were epithelioid sarcomas, making this lesion third in frequency after fibrosarcoma and rhabdomyosarcoma in the whole series and first in frequency in the hand. In all thirteen patients the initial diagnosis was misleading; and recurrence, metastasis, or both occurred in all but the one patient who had primary forearm amputation. Primary en bloc excision and midforearm amputation are recommended if the lesion recurs.

Aggressive thoracotomy for pulmonary metastatic osteogenic sarcoma in children and young adolescents

During a 6-yr period, 57 children and young adults less than 21 yr of age underwent 111 thoracotomies for pulmonary metastatic osteogenic sarcoma. Follow-up after the initial thoracotomy averaged 36.8 no and ranged from 1 to 78 mo. Twenty-eight patients (49%) underwent more than one thoracotomy--the number of multiple thoracotomies averaged 2.9 and ranged from two to eight. Twenty-six of the 57 patients are currently alive, and 25 of these are free of disease. Median survival was 36 mo. Actuarial survival curves demonstrated a 5-yr survival of approximately 40%. Seventy-one percent of patients who had a tumor-free interval of greater than 1 yr are currently alive, compared with 39% of patients who had a tumor-free interval of less than 1 yr. Patients with disease confined to one lobe at the initial thoracotomy had a better survival (64%) than patients with diffuse or bilateral disease (41%). An aggressive surgical approach toward osteogenic sarcoma with pulmonary metastasis thus appears to be justified.

Magnetic Resonance Imaging of Aneurysmal Bone Cyst

A case of aneurysmal bone cyst is presented, and the radiographic, computed tomographic, and magnetic resonance imaging findings are discussed. The potential advantages of magnetic resonance imaging compared with those of computed tomography are explained. The case is presented to illustrate the potential value of magnetic resonance imaging in the evaluation of bone and soft tissue tumors.

Is the BANS concept for malignant melanoma valid

In this study of 427 patients with stage I malignant melanoma seen at the Mayo Clinic between 1973 and 1981, only those patients with complete data with respect to thickness and level of penetration of lesion, morphologic type, and anatomic site were included. Although supporting the widely accepted concept of the prognostic importance of thickness of the lesion, the level of penetration was of much lesser significance in our series, and prophylactic node dissection could not be shown to be of significant benefit. Likewise, the BANS concept proposed by Day et al [1] was not corroborated. The reasons for these discrepancies are not fully apparent, although a preponderance of thin and intermediate thickness lesions in our patients may have had some influence on our results.

Surgical Management of Malignant Melanoma of the Trunk and Extremities

The surgical management of newly diagnosed melanoma should be tailored to the characteristics of the individual lesion. The actual thickness of the lesion is the main consideration in planning surgical treatment. Prophylactic lymphadenectomy is no longer routinely recommended. For early detection of clinically suspicious nodes, however, close follow-up of the patient is necessary so that therapeutic lymphadenectomy can be accomplished. Surgical intervention plays a limited role in the management of disseminated melanoma.

The Use of Extracortical Implant Fixation to Reconstruct Large Bony Defects

To improve the long-term prognosis of custom-designed implants for the reconstruction of large bony defects after tumor resection or failed total joint arthroplasty, the concept of extracortical bone bridging was developed at the Mayo Clinic. This report summarizes the results of 24 operations with a minimum of 2 years’ follow-up (mean 56 months). The mean length of resection or bone loss was 163 mm. Eight knee joint arthrodeses and seven segmental diaphyseal resections of either the femur or the tibia were performed. Five and three resections of the ends of the femur were performed with replacement of the hip and knee joint, respectively. There was also one proximal humeral resection which involved the shoulder joint. Two implants had to be removed because of infection or stem fracture. Two cases of implant loosening could be salvaged by refixation and bone grafting. Extracortical bone bridging was uniformly achieved with a 70% coverage of the effective zones of bone bridging. Overall functional results were good or excellent in 70%, fair in 10%, and poor in 20%. For the evaluation of the devices, 75% were classified as good and excellent, whereas 12.5% each were classified as fair and poor.