A controversial treatment for melanoma, elective lymph node dissection (ELND), has again been shown to provide important prognostic information, according to a study presented at the 65th Annual Meeting of the American Society of Plastic and Reconstructive Surgeons (ASPRS) held in Dallas, Texas. Although the retrospective study did not demonstrate that ELND makes a difference in patient survival, it indicated that the information gained from the removal and testing of the lymph nodes could be crucial in predicting the patient's prognosis.
"Melanoma has clinical characteristics that require observation over a long period of time for an accurate picture of what ultimately will happen to patients," said plastic surgeon William J. Kane, md, assistant professor of plastic and reconstructive surgery, Mayo Graduate School of Medicine, Mayo Clinic, Rochester, Minnesota, one of the clinical investigators. "Since reliable curative adjunct therapies beyond surgery do not currently exist, the main value in looking at the lymph nodes probably is the prognostic information that they provide for the patient. From this, we are able to determine how well the patient will do in the future. Once more reliable immune or chemotherapeutic therapies are developed, this information may have value in deciding which patients should receive it based on a high-risk for recurrent disease."
Elective lymph node dissection is the removal of lymph nodes immediately surrounding the melanoma and takes place at the same time as removal of the tumor. If malignant cells are detected in the removed lymph nodes, this has significant ramifications for the patient's prognosis. The surgeon generally determines whether ELND will be included with therapy based on factors inherent to the tumor and the patient.
The retrospective study included 424 patients with clinical stage I melanoma of the head and neck treated at the Mayo Clinic for the 20-year period between 1970 and 1990. In all, 42% (180) of the patients underwent ELND as part of their initial treatment, and testing revealed malignancy in the lymph nodes of 83%. Initial treatment failed in 36% (152) of patients because of distant metastasis.
Although the study showed no survival or disease control benefit for ELND, information resulting from tests of the removed lymph nodes had significant prognostic value. The remarkable long-term survival rates are likely due to early detection of the disease in this particular group of patients, with 82% surviving after 5 years and 75% surviving after 10 years. No patients were known to have died of their disease 15 years after initial treatment. Ongoing multi-institutional prospective studies investigating the therapeutic efficacy of ELND in treating melanoma are now underway.
"Unfortunately, we now are seeing an unprecedented number of people in their 20's with melanoma," said Dr. Kane. "There is no question that the number of primary diagnosed cases in this age group is on the rise and many of these are people who have been going to tanning booths."
Some people have a genetic predisposition to melanoma, according to Dr. Kane, and overexposure to ultraviolet light exacerbates that problem. Melanoma can even occur in the sinus cavities and under the tongue, places that sunlight never touches. However, early detection and surgical removal is still the best treatment for melanoma, and the prognosis for people whose disease is caught early remains reasonably good.
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
