Petra Büttner

Primary cutaneous melanoma : identification of prognostic groups and estimation of individual prognosis for 5093 patients

Background. Numerous investigations have examined prognostic factors for patients with primary cutaneous melanoma. However, only a few studies have been published on the definition of prognostic groups. The first aim of the present study was to determine the relative importance of different prognostic factors in a large collective study. The second aim was to define prognostic groups of patients based on combinations of prognostic factors and to define a model that allows the estimation of individual survival probability.

Primary Cutaneous Melanoma. Optimized Cutoff Points of Tumor Thickness and Importance of Clark's Level for Prognostic Classification.

Background. Maximum tumor thickness and level of invasion are known to be the most important prognostic factors for patients with primary cutaneous melanoma. However, the classification of tumor thickness and the question of whether the combination of tumor thickness and level of invasion provides a better prognostic classification than tumor thickness alone are still matters of debate. The present study examined the relationship between tumor thickness and survival probability to define cutoff points of tumor thickness. Secondly, it investigated the prognostic value of the combination of tumor thickness and level of invasion as proposed in the current TNM classification system.

Epidemiologic evidence for the role of melanocytic nevi as risk markers and direct precursors of cutaneous malignant melanoma: Results of a case control study in melanoma patients and nonmelanoma control subjects

BACKGROUND Melanocytic nevi (MN) are markers of melanoma risk, but their potential role as precursors of cutaneous malignant melanoma (CMM) is still controversial. OBJECTIVE The overall and site-specific relative risk (RR) of developing CMM was evaluated according to site-specific MN counts. METHODS MN prevalence by anatomic site and by age was compared in 200 CMM patients and in 200 nonmelanoma control subjects; RRs were calculated. RESULTS In CMM patients both MN and CMM were mainly found on the legs in women and on the posterior trunk in men, whereas in the control subjects most MN were found on the arms. MN counts on the trunk in men and on the legs in women were best predictors of the overall CMM risk (RR: 33-fold and 15-fold, respectively, for greater than 20 vs up to 4 MN). For both genders combined, the RR for CMM developing on the trunk and legs (predominant CMM locations) was best predicted by MN counts in the respective body region (RR: 24-fold and 27-fold, respectively). MN prevalence peaked in the fourth to fifth decade of life and most CMM were diagnosed during the fifth and sixth decades. CONCLUSION The site-specificity of melanoma risk found for high MN counts on the trunk and the legs and the close similarities in age distribution suggest that the role of MN as direct precursors of CMM has been underestimated and exceeds the number of histologically evident MN associated with CMM.

The German Melanoma Registry and Environmental Risk Factors Implied

There is no nationwide, population-based cancer registry in the Federal Republic of Germany (FRG). Only the cancer registry of the federal state of Saarland, a region with about 1 000 000 inhabitants bordering on France, has reliably documented the incidence of malignant melanoma in western Germany. The annual incidence of melanoma registered for this region in the mid-1980s was 6/10 0000 inhabitants for both sexes (age-adjusted for the European standard population) (Garbe et al. 1986). The increase in the incidence of melanoma in the 1970s documented by the Saarland cancer registry suggested that the incidence would double every 15 years (Garbe et al. 1986). This rate of increase is in good agreement with data from the two internationally longest existing cancer registries in Denmark and Connecticut (USA) (Houghton et al. 1980). However, the question arises whether the data from the Saarland cancer registry and the melanoma incidence derived from this more rural area are representative for the entire FRG. Another drawback of the Saarland cancer registry is that only the diagnoses were registered, without detailed information on histologic subtypes and other histologic or prognostic parameters and without documentation of possible risk factors for developing melanoma.

Elektive Lymphknotendissektion bei primärem malignen Melanom

ZusammenfassungDie Rolle der elektiven Lymphknotendissektion (ELND) in der Behandlung des malignen Melanoms wird kontrovers diskutiert. Ziel der vorliegenden Untersuchung war eine Analyse des Einflusses der ELND bezüglich Überlebenszeit und rezidivfreier Zeit bei malignen Melanomen an Rumpf und Extremitäten. Mittels eines Matched-pair-Verfahrens wurden 375 Patienten, die mit weiter lokaler Exzision (WLE) und ELND behandelt wurden, einem gleich großen Vergleichskollektiv mit alleiniger WLE gegenübergestellt. Es fanden sich keine Unterschiede der Gesamtüberlebenszeit zwischen beiden Kollektiven, jedoch war das rezidivfreie Intervall im Kollektiv WLE+ELND signifikant verlängert (p<0,05). Höhere Überlebensraten fanden sich nach WLE+ELND bei den mittleren Tumordicken, wenngleich nicht statistisch signifikant (p=0,14), jedoch wurde auch hier der günstige Einfluß auf das rezidivfreie Überleben evident (p<0,001). Im Geschlechtervergleich zeigte sich ein größerer Nutzen der ELND bei männlichen Patienten mit Melanomen mittlerer Tumordicken. Unsere Ergebnisse stehen in Einklang mit zahlreichen Daten der Literatur, aus denen eine prognostische Begünstigung durch eine elektive Lymphknotendissektion in der Primärbehandlung des malignen Melanoms mittlerer Tumordicke hervorgeht.SummaryThe role of elective lymph node dissection (ELND) in primary malignant melanoma is controversial. Our purpose was to evaluate the benefit of ELND regarding survival and disease-free survival in malignant melanoma of the trunk and extremities. By matched-pair analysis, 375 patients treated by wide local excision (WLE) plus ELND were compared to 375 patients treated by WLE only. There was no difference in survival between the two treatment groups; however, the disease-free interval was significantly higher in the collective treated by WLE plus ELND (P<0.05). Increased survival rates were noted for intermediate tumor thickness of 1.51–4.0 mm for the WLE+ELND group although the difference was not significant (P=0.14), and disease-free survival was significantly improved in this group (P<0.001). ELND elicited a higher benefit in male patients with intermediate thickness melanoma. Our results confirm the findings of several studies that ELND improves the outcome after primary treament of malignant melanoma of intermediate tumor thickness.

Dysplastic Nevi-Dysplastic Nevus Syndromes: Clinical Features and Genetic Aspects

The incidence of cutaneous malignant melanoma (MM) is rising tremendously worldwide in white populations. The reasons for the dramatic increase are not entirely known. A number of factors have been linked etiologically with melanoma, including host factors such as skin complexion, hair and eye color, and number of melanocytic nevi and environmental factors such as sunlight exposure and a positive family history of malignant melanoma. The last mentioned risk factor was recognized in 1978 when the groups of Clark and Lynch simultaneously reported an inherited syndrome characterized by atypical moles and melanomas. Clark et al. (1978) termed this syndrome BK mole syndrome, using the initials of his affected families, while Lynch et al. (1978) called it FAMMM (familial atypical multiple mole melanoma) syndrome. The very exciting clinical feature of these families was the finding that in affected individuals, those with atypical or dysplastic nevi, the risk for developing melanoma approached 100%. The atypical nevus therefore was regarded as the putative precursor for MM. In the following years observations on atypical moles in melanoma-prone families were generalized and applied to individuals who had no family history of the tumor. The term dysplastic nevus syndrome (DNS) was first used for this condition by Elder et al. (1980) and is now widely accepted. Since then, however, many epidemiologic studies have demonstrated a significant lower melanoma risk for these individuals compared with the classic BK mole patients. Therefore, it is now commonly accepted that dysplastic nevi are both a risk indicator and possible precursors of malignant melanomas (Elder 1988).

Role of elective lymph node dissection in stage I malignant melanoma: evaluation by matched pair analysis.

The role of elective lymph node dissection (ELND) in clinical stage I malignant melanoma continues to be controversial. We present a matched pair analysis of 375 patients treated in the Department of Dermatology in Kassel between 1979 and 1991 by wide local excision (WLE) plus ELND. Multivariate analysis revealed tumor thickness, level of invasion, age, sex, and localization as independent prognostic factors, and 375 patients treated by WLE alone were matched as controls to the patients treated by ELND and WLE, There was no significant benefit from WLE plus ELND compared to WLE alone in the total group as shown by the 5-year survival rates (87.3% versus 86.4%) and 10-year survival rates (80.1% versus 77.82%). Increased survival rates were noted for tumor thicknesses 1.51–4.0 mm for the WLE plus ELND group, as shown by the 10-year survival rates of 73.1% versus 60.3%. However, these data were not significant (p = 0.14). Disease-free survival rates were significantly higher in the group treated by additional ELND for all tumor thicknesses (p < 0.05) and even more in intermediate tumor thicknesses of L51–4.0mm (p < 0.001). A significant benefit of elective lymph node dissection was detected for malignant melanoma of the trunk (all tumor thicknesses), as shown by the 5-year survival rates of 92.0% versus 79.7% and 10-year survival rates of 80.4% versus 45.16% (p < 0.05). Malignant melanoma of the extremities revealed no significant differences in survival rates. We conclude that there is a certain benefit from ELND in clinical stage I malignant melanoma for tumor thicknesses of 1.51–4.00 mm. Especially in malignant melanoma of the trunk, WLE plus ELND was more beneficious than WLE alone.