Merle A. Legg

Changes in clinical presentation and management of malignant melanoma

Records of 147 patients with primary cutaneous malignant melanoma treated at the Lahey Clinic from 1955–1979 were reviewed. Complete clinical follow‐up data were obtained, and all pathologic material was reviewed. Proposed new risk categories based on a modification of the Clark and Breslow categorizations are outlined. The incidence of low‐risk melanoma has dramatically increased (from 23–53%) and that of high‐risk melanoma has decreased (from 34–10%) over the period of this study. Dermal punch biopsy gives accurate staging information and carries no increased risk of local recurrence, nodal metastases, or death from disease. Resection of a margin of clinically uninvolved skin measuring twice the diameter of the primary melanoma minimizes local recurrence (2.5% or less), does not adversely affect survival, and reduces the need for skin grafting. Arbitrary wide margins are not justified. Regional lymphadenectomy offers no improvement in survival in patients with low‐risk and moderate‐risk melanoma and can play only a minor role at most in improving survival for patients with high‐risk melanoma.

METASTASIS OF CANCER OF THE RECTUM AND SIGMOID FLEXURE.

SummaryAn autopsy series of 320 patients who had carcinoma of the rectum or sigmoid flexure has been reviewed and a pattern of metastasis plotted with reference to the duration of survival after operation. It is noteworthy that in many of these patients the tumor remained localized for long periods of time.Regional lymph-node metastasis did not significantly increase after the immediate postoperative period.Hematogenous metastatic spread rapidly increased during the early months after operation. Various factors which may play a part in hematogenous spread have been discussed and therapeutic implications suggested. Some of the clinical implications resulting from this autopsy study have been reviewed.

Human colon tumors. Enzymic and histological characteristics

In samples of colonic adenocarcinomas, the mean activities of thymidine kinase, glucose‐6‐phosphate dehydrogenase, phosphoserine phosphatase and pyrroline‐5‐carboxylate reductase were several fold higher than those of non‐neoplastic colon. The presence of considerable, told labile pyrroline‐5‐carboxylate reductase activity provided an additional criterion for distinguishing tumors from the control tissue. Deviations from the pattern of enzymes in normal colon were much more pronounced in the five moderately well‐differentiated than in the single well‐differentiated adenocarcinoma.

Percutaneous fine needle aspiration biopsy of pancreatic carcinoma

Carcinoma of the pancreas was diagnosed in 13 patients by percutaneous fine needle aspiration. The tumor was localized by angiography in eight, ultrasound in five, and endoscopic retrograde pancreatography in three patients. In four patients aspiration was performed using two of the three localizing techniquesCytological diagnosis of carcinoma of the pancreas can be made accurately by percutaneous fine needle aspiration of the tumor and operative intervention avoided in those patients who do not require operative bypass procedures. Percutaneous fine needle aspiration can be used with equal facility with arteriography, ultrasound, or endoscopic retrograde pancreatography. There have not been complications due to fine needle biopsy, and one can expect a 77–86% positive diagnostic yield.

Contemporary treatment of malignant melanoma

Abstract From 1949 to 1967, 176 cases of melanoma have been completely reviewed with a minimal follow-up period of six years including histologic reassessment, complete clinical evaluation, and current health or nature of death. With strict histologic criteria rather than clinical criteria, the incidence of lentigo maligna melanoma was 6 per cent; nodular melanoma, 20 per cent; and superficial spreading melanoma, 74 per cent. Compared with those of patients seen before 1949, the size and depth of invasion at diagnosis have improved greatly, and cure rate has more than doubled; current six year disease-free survival is 67 per cent. The current depth criteria of Clark are found to be unnecessarily complex and no more accurate in predicting survival than careful measurement of maximal diameter. Surgical therapy was conservative or radical primary resection and either observation or prophylactic resection or therapeutic resection for regional lymph nodes. No disadvantage in terms of cure or local recurrence was detectable using conservative local resections when reasonable criteria of local tissue sacrifice were observed. Several specific groups of patients could be defined by clinical and histologic criteria when there was potential benefit in prophylactic nodal resections. Thus, superficial spreading melanomas less than 1.5 cm in diameter or with level II depth of invasion or with 1+ mitotic rate constitute 50 per cent of all cases, yet they have less than a 10 per cent risk of nodal disease at any time in their clinical course whether cured or not. In contrast, with any melanoma of the leg and trunk, nodular melanoma in any location, or level V involvement in any clinical type, 30 per cent risk of regional nodal disease exists and prophylactic nodal resections are potentially useful. When prophylactic nodal resections are performed, conservative types of resections are the equivalent of radical resections and produce considerably less morbidity.

Pancreatic alpha cell tumors: Case report and review of the literature

Twenty‐eight cases of alpha cell tumors of the pancreatic islets have been reported. The clinical features include typical skin rash (termed migratory necrolytic erythema) and stomatitis with anemia, abnormal glucose tolerance, and weight loss. The time course of the disease is variable but the clinical syndrome may be present for up to 15 years (median five years) before discovery of the tumor. In 3 patients, cure was achieved by surgical resection, and in 17 patients in whom metastatic sites were evaluable, 16 involved the liver. Six patients have received chemotherapy: 4 with streptozotocin (STZ); 1 with dimethyl triazeno imidazole carboxamide (DTIC); and 2 with 5‐fluorouracil. All 4 patients receiving STZ responded to therapy with objective regression of the tumor and in 3 the dermatitis syndrome receded as well. The selectivity of the STZ for beta cells observed in animals is contrasted with the specific antitumor activity of STZ for alpha as well as beta and delta cell tumors in man.