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Acral Lentiginous Melanoma:
This study is based on material from Charity Hospital of New Orleans, La., and the material dates from the 1950’s and early to mid 1960’s. It includes material that has been previously reported. The earlier studies did not include measurements by Breslow’s criteria. The material dates from a time when wide local excision were usually accompanied by local perfusion with chemotherapeutic agents. In the time-period of the study, acral lentiginous melanoma had not been defined as a separate entity. Later after the first description of ALM, there was controversy surrounding the identity of a melanoma, as a separate entity, in the acral sites.
In the late 1980’s, Dr. John Olivier collected this material with the intention of making a modified review; an attempt to correlate prognosis with the vertical dimensions of the lesions (Breslow’s criteria) was the object. The histologic material had been prepared without attention to the need for a measurement of vertical dimensions. In fact, many of the lesions were so “thick” that a measurement of the gross dimensions would have been appropriate; many of the lesions were too thick to be completely represented on a histologic slide.
I recently found this material while working in my storeroom; it was in a brown grocery bag from Schwegmann”s Giant Super Market.
Dr Olivier”s results (the brown study):
Material from thirty-eight cases was available. Measurements of vertical dimensions (Breslow’s criteria) were attempted. In addition, lesions were classified with regard to different histologic parameters. Status of regional lymph nodes (inguinal for foot lesions, and axillary for hand lesions) was evaluated; lymph node status was either positive or negative for metastasis, or unknown.
Patient outcome with respect to the melanoma was classified as good (no evidence of melanoma at time of last follow-up, or at death), poor (metastases beyond regional lymph nodes, or melanoma listed as cause of death), indeterminate (melanoma confined to regional nodes, or one extremity at last follow-up, or death), and unknown (poor or ambiguous follow-up). Also therapy was listed as E (excision of lesion), A (amputation), P (regional perfusion), ND (lmyph node dissection), and C (chemotherapy).
Regional node status vs. Breslow’s measurement:
Overall, patients with positive regional nodes tended to show higher measurements.
Positive nodes: 16 patients; mean Breslow measurement * = 5.96 mm; lowest Breslow measurement = 2.64 mm.
Negative nodes: 10 patients; mean Breslow measurement = 3.16 mm; highest Breslow measurement = 6.24 mm.
(*Note: This measurement is the mean for 9 of 16 patients who had defined limits of their tumors. Two of 16 had melanomas for which slides did not allow orientation of tumor. Five of 16 had tumors extending to the deep margins of tissue as represented on a slide (Patient #1 equal or greater than 2.64 mm, patient #9 = or > than 2 mm, patient #25 = or >7.2 mm, patient #27 = or > 12 mm, and patient #38 + or > 2.04 mm)
Regional lymph node statue vs. patient outcome:
Regional lymph node status did not significantly affect the incidence of eventual poor outcome. Of patients with adequate follow-up, 9 of 15 * (60%) patients with positive nodes eventually showed poor outcome while 5 of 9 ** (56%) patients with negative nodes showed poor outcome with respect to melanoma. Negative nodes, however, did correlate with the incidence of prolonged survival. Four of 9 (44%) patients with negative nodes survived at least 5 years with no subsequent evidence of disease compared to 1 of 15 (6.7%) patients with positive nodes. Six of 9 (67%) patients with negative nodes survived at least 5 years with 2 having eventual tumor death compared to 1 of 15 with positive nodes. The reason for the lack of correlation with good outcome is the number of patients with positive nodes who had indeterminate outcome.
(Note: * Of 16 patients with positive nodes, one had poor follow-up, 3 had indeterminate outcome; ** of 10 patients with negative nodes, one had poor follow-up.)
As noted previously, patients with positive nodes tended to have higher Breslow measurements. None of those patients with positive nodes in this study had Breslow measurements below 2.64 mm, while 5 patients with negative nodes had measurements = or < 1.80 mm. Therefore, it might be suggested that the apparent longer survival associated with negative regional lymph nodes could be related to lower vertical dimensions. Four patients with negative nodes had measurements greater than 2.64 mm, and it is noted that all four had eventual poor outcome. However, two of these four did survive 5 years, but with subsequent death due to melanoma. As noted above, one of 15 patients with positive nodes, and adequate follow-up survived 5 years. This patient had no subsequent disease. Also, a second patient with positive nodes survived 4 years and 6 months, and was then lost to follow-up. Even if this last mentioned patient did represent a 5 year survivor, the frequency of 5 year survivors in patients with negative nodes and higher Breslow measurements was higher than in those with positive nodes; although, the former group showed subsequent disease and poor outcome.
Therapy:
One of the weaknesses of this study is that different therapeutic methods were employed for different patients, but not in a controlled, randomized fashion. To the extent that these selections affected patient outcome, some of the above data may be compromised. Because of the limitations, efficacy of therapy cannot be judged. Comparisons of outcomes for different therapeutic groups are listed below. It is noted that none of the patients who recieved chemotherapy, and none of the patients who were untreated met with good outcome. Also, 10 of 11 patients (91%) who survived at least 5 years received node dissection, regional perfusion, or both (28 of the total 38 patients [74%] received node dissection, regional perfusion, or both). However, patient selection may have influenced these results.
Two patients received no treatment; one of these two had a poor outcome, and for the other, the outcome was indeterminate.
Six patients had an amputation or excision. In this group, there was one good outcome, one poor outcome, one indeterminate outcome, and 3 with poor follow-up.
Eight patients had amputation, or excision, with dissection of regional lymph nodes. There were 2 patients who survived 5 years with no subsequent evidence of disease. There were 3 patients with good outcome, and 5 with poor outcome.
Eight patients had amputation, or excision, with dissection of regional lymph nodes and regional perfusion. There were 3 patient who survived 5 years with no subsequent evidence of disease. One patient survived 5 years with subsequent evidence of disease. For 4 patients the outcome was good; for 3 patients the outcome was poor; for one patient the follow-up was poor.
Five patients had an amputation, or excision, with perfusion and chemotherapy. There were 2 patients who survived 5 years with subsequent evidence of disease. For 4 patients the outcome was poor and for one patient follow-up was poor.
Three patients had excision with perfusion. There were 2 patients who survived 5 years with no subsequent evidence of disease. Two patients had a good outcome, and one patient had a poor outcome.
Others: Patient 35 underwent biopsy (assumed to be excisional) at another hospital. There was no further treatment. Patient 35 survived 5 years with no subsequent evidence of disease. Patient 7 had chemotherapy alone, and met with a poor outcome. Patient 30 had excision, dissection of nodes, and chemotherapy; his outcome was of indeterminate type. Patient 10 had amputation, perfusion, and chemotherapy. Follow-up was poor. Patient 29 had perfusion alone. The outcome was poor. Patient 34 had excision, perfusion, ? node dissection, and ?chemotherapy. Follow-up was poor.
For lesions less than 1 mm in vertical dimensions, there was one patient and the outcome was good. In the range of 1-1.5 mm, there were 3 patients; all 3 survived 5 years with no evidence of disease. For the range 1.5-2, there were 2 patients; one was a 5 year survivor with no subsequent evidence of disease; one had a good outcome; one a poor outcome. For the range 2-2.5 mm, there were no patients. For the range 2.5-3, there were 2 patients; one was a survivor at 5 years with no subsequent evidence of disease; one had a good outcome, and one had poor follow-up. There were no cases in the range 3-3.5 mm. For the range 3.5-4, there were 4 patients; there was one survivor at 5 years with subsequent evidence of disease; there were 3 patients with poor outcome, and one patient with indeterminate outcome. There were no patients in the range 4-4.5 mm. In the range 4.5-5 mm, there were 3 patients. There was one good outcome, one poor outcome, and one poor follow-up. In the range 5-6mm there were 4 patients. Two patients had a poor outcome, and two had poor follow-up. In the range 6-7, there were 2 patients. There was one 5 year survivor with subsequent evidence of disease. There was one good outcome, and one poor outcome. In the range 7-8 mm, there were 3 patients. Three patients had a poor outcome. In the range 8-9 mm, there were 2 patients. There was one 5 year survivor at 5 years with no subsequent evidence of disease; there was one poor follow-up. There were no patients in the range 9-10 mm. In the range greater than 10 mm, there were 4 patients. There was one 5 year survivor with subsequent evidence of disease. For one patient, outcome was good; for 2 patients, outcome was poor; and for one patient, outcome was indeterminate.
Seven patients were not categorized in the above presentation due to difficulty in determining tumor measurements. Eight patients survived five years or more without subsequent evidence of melanoma. The full Breslow measurement could be obtained for seven of these, and the adverage measurement was 2.39 mm (not included in this average is a patient whose measurement was equal to, or greater than, 2.61 mm). For patients who had a poor outcome, and whose full measurement could be obtained, the average was 5.35 mm. Only one patient whose tumor measured greater than 2.64 mm survived 5 years without subsequent evidence of melanoma. * For this study, Breslow measurements between 2.52 and 2.64 mm represent an interval below which patients show a good prognosis with a prolonged disease-free survival, and above which there is greatly reduced chance of good prognosis. Also for measurements greater than 2.64 mm, no significant correlation could be seen between increasing size of tumor, and prognosis, whether judged by number of patients with good outcome, poor outcome, or 3 year or 5 year survival. The measurements for five year survivors without subsequent disease are listed below:
1.04, 1.50, 1.80, 2,64, 1.08, 2.61, 0.67, 8.00 mm.
* For 3 patients who survived 5 years without evidence of disease, but who subsequently had a death related to tumor the measurements were:
6.24, 3.72, and > 11 mm. One patient was disease free when lost to follow-up at 4 years and 6 months; the measurement of this lesion was 4.68 mm.
Microscopic observations:
Inflammation:
nflammation within the tumor was graded for each case as mild, mild to moderate, moderate, moderate to heavy, and heavy. Correlation with outcome was as follows:
In the mild category, there were 20 patients. There was one 5 year survivor with no subsequent evidence of disease; 3 with subsequent disease. For one patient, outcome was good; for 12, poor; and for 2, indeterminate. For 5 patients, follow-up was poor.
In the mild-moderate category, there were 5 patients. There was one survivor at 5 years with no subsequent evidence of disease. Outcome for 2 was good; for 3, poor.
In the moderate category, there were 9 patients. There were three 5 year survivors with no subsequent evidence of disease; and 3 survivors at 5 years with subsequent evidence of disease. For 5 patients, outcome was good; for one, poor, and for one, indeterminate. For 2 patients, follow-up was poor.
In the moderate-moderately heavy category, there were 2 patients. There was one 5 year survivor with no subsequent evidence of disease. For one patient, outcome was good; for one patient, outcome was poor.
In the heavy category, there were 2 patients. There were two 5 year survivors with no subsequent evidence of disease. For 2 patients, outcome was good.
While estimation of the degree of inflammation was objective, there does appear to be improved chance of 5 year disease-free survival, and good outcome with higher degrees of inflammation.
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