Ralph L. Corsetti

Thin <= 1 mm level III and IV melanomas are higher risk lesions for regional failure and warrant sentinel lymph node biopsy

Background: Thin melanomas have become increasingly prevalent, and lesions 1 mm or less in thickness are frequently diagnosed. They are considered highly curable when treated with wide local excision alone with reported 5-year disease free survivals of 95% to 98%. However, thin Clark level III and IV melanomas may have an increased potential for metastasizing and late recurrence because of dermal lymphatics located at the interface of the papillary and reticular dermis. We have addressed this controversial area by reviewing the outcomes of patients with invasive thin (# 1.0 mm thick) melanomas.Methods: We reviewed 415 invasive melanomas from 1983–1995 in the Rhode Island tumor registries which kept records of both tumor thickness and Clark levels. Sixty-eight (16.4%) of the 415 invasive melanomas were thin (# 1.0 mm in thickness) and were treated by wide local excision only. In situ lesions were excluded. Thirty-eight (56%) of the 68 thin melanomas were either Clark level III or IV.Results: Seven (18.4%) of the 38 level III and IV thin melanomas had a recurrence at a minimum follow-up of 36 months. Median time to recurrence was 52 months, and the average measured depth of tumor thickness was 0.84 mm. Only one (3.3%) of 30 level II melanomas recurred (P < .05).Conclusions: Thin level III and IV melanomas are at increased risk for late recurrence when compared with all thin melanomas. Because there is effective adjuvant therapy with alpha interferon for patients with stage III melanoma to treat regional and systemic disease, and because sentinel lymph node biopsy (SLNB) offers minimal morbidity, we suggest using SLNB to accurately stage and treat all patients with thin melanoma that are high Clark levels that are at increased risk for metastases.

The evolution in management of patients with subcentimeter, node-negative, triple-negative breast cancer.

BACKGROUND The aim of this study was to determine the evolution in treatment recommendations and outcomes for patients with subcentimeter, node-negative, triple-negative disease. METHODS Patients were divided into a remote (diagnosed from 1997 to 2003) and a recent (diagnosed from 2004 to 2011) group. Demographics, tumor size, surgical treatment, use of adjuvant chemotherapy, survival, and disease recurrence were evaluated. RESULTS Thirty patients were placed in the remote group and 31 in the recent group. Demographics, tumor sizes, and surgical treatment were similar between groups. The use of adjuvant chemotherapy increased from 7% to 42% in the recent group (P < .002). Disease-free survival and recurrence (7%) was not influenced by the use of chemotherapy. CONCLUSIONS This study demonstrates that adjuvant chemotherapy is increasingly used in patients with the triple-negative phenotype, regardless of other favorable prognostic variables. The value of adjuvant chemotherapy for the subgroup of patients in our study is unclear and mandates further investigation.

A Potential Additional Variable to Consider in the Surgical Treatment of Ductal Carcinoma in Situ

Background HER2/neu is a potentially interesting variable that has been demonstrated to have a profound impact on the management of invasive breast carcinoma, and we performed this study to evaluate the differences between HER2-positive and HER2-negative ductal carcinoma in situ. The impetus for this study was our poor recruitment to the National Surgical Adjuvant Breast and Bowel Project Protocol B-43 trial that was designed to evaluate the potential role of trastuzumab in breast conservation therapy for patients with HER2-positive ductal carcinoma in situ. Methods All patients with ductal carcinoma in situ and an assessment for the HER2/neu receptor were identified. Patients with HER2-positive and HER2-negative ductal carcinoma in situ were compared to determine differences in demographic, hormone receptor status, nuclear grade, presence of necrosis, surgical procedure (lumpectomy or mastectomy), tumor size, and extent of margins. Quantitative variables were analyzed with t test, and nominal variables were assessed by chi square analysis. Results A total of 177 patients were identified with a mean age of 61.0 years. A total of 101 patients (57.1%) were treated with lumpectomy, and 76 had mastectomy (42.9%). Forty-four (24.9%) patients were positive, and 133 (75.1%) were negative for the HER2/neu receptor. HER2-positive tumors were larger (23.6 vs 13.8 mm, P=0.001) and more likely to undergo mastectomy (61.4% vs 36.8%, P=0.01). Conclusion Based on these results, an HER2-positive ductal carcinoma in situ is likely to be larger than an HER2-negative tumor, leading to more frequent use of mastectomy. This finding would explain our poor recruitment to the National Surgical Adjuvant Breast and Bowel Project Protocol B-43 trial.