A retrospective study of 275 cases of cutaneous malignant melanoma in the East Midland region

British Journal of Plastic Surgery (1982) 35, 6042 0 1982 The Trustees of British Association of Plastic Surgeons

0007-1226/82/0287-0060

$02.00

A retrospective study of 275 cases of cutaneous malignant melanoma in the East Midland region MICHAEL

Y. BOS and MALCOLM

DEANE

Department of Plastic and Reconstructive Surgery, City Hospital, Nottingham

Summary-A study of 275 cases of cutaneous malignant Nottingham has shown no significant changes in survival figures 13 years ago. Early excision of a suspicious tumour is still the best approach and was found to be a reliable malignancy in a pigmented lesion. A large percentage of patients with malignant melanoma after the initial treatment. Therefore, the routine follow-up melanoma should be continued for at least 10 years.

Introduction Malignant melanoma is a relatively rare skin tumour best treated in a regional centre. Nottingham receives patients from the East Midland Region and malignant melanoma cases are treated by a single integrated team. This team includes chemotherapists, radiotherapists, pathologists and plastic surgeons. Over a ten year period 275 primary malignant melanomata were referred for treatment. The data presented here have been compiled and grouped according to Clark’s classification (1969). Between 1969 and 1978, 275 patients with primary cutaneous malignant melanoma were treated in the Department of Plastic Surgery at Nottingham. All lesions with a firm clinical diagnosis of malignant melanoma were excised under general anaesthesia and the defect splitskin grafted, usually by the delayed exposure technique. A margin of 5cm of skin around the tumour was included in the specimen with subcutaneous tissue down to the underlying fascia. Where this was not possible for anatomical reasons, for example on the face, a lesser margin was accepted. The skin margin was usually increased to 1Ocm around melanomata arising on the trunk. In those cases where there was some clinical doubt of the diagnosis the lesion was submitted for frozen section prior to the wider removal being carried out (McGovern, 1967; Little and Davis, 1974; McGovern et al., 1973). This biopsy was an “excisional biopsy”, fusiform in shape with a margin of normal skin of at least 0.5 cm. 60

melanoma treated in one centre at rates since Bodenham published his followed by immediate frozen section way of confirming the diagnosis of develop their first metastases 5 years of patients with cutaneous malignant

The accuracy of immediate frozen section diagnosis compared with the final paraffin section has been high and no false positive results have so far been encountered. On a few occasions a definite answer could not be given, but those were confined mainly to lesions showing early superficial malignant change in a junctional naevus. It is the policy in this unit not to carry out a prophylactic lymph node dissection in the absence of clinically involved regional nodes, unless the primary tumour is situated in or very close to the groin or axilla. However, each patient is followed up carefully and at the first sign of clinical lymph node involvement a radical block dissection is carried out. A small group of patients with metastases have received radiotherapy with temporary relief in a few cases only. The remainder of the patients with disseminated metastases were treated with chemotherapy or immunotherapy. The results of a controlled trial of active immunotherapy carried out in Nottingham in 1977 have already been published (McIllmurray et al, 1977).

The study Nottingham serves an area of approximately 1.2 million people. Each year an ave&ge of 25 new cases of malignant melanoma have been treated. This incidence of 2 per 100,000 inhabitants is compared with that reported in other series (Table 1). Malignant melanoma has been seen

STUDY OF MALIGNANT

MELANOMA

IN THE EAST MIDLAND

more often in women, with a sex ratio of 1.6: 1 (Table 2). Bodenham (1968) in his study drew attention to the high incidence of malignant melanoma on the female leg. This has been confirmed in our study with 53% of malignant melanomata in females occurring on the leg, compared with only 36% in males. In males, the most common site was the trunk (35”,@,closely followed by the face (31%) (Table 3). Table 1 United

Annual

States of America

Queensland. South

incidence

Australia

West Region,

UK

Denmark East Midlands

Region,

Table 2

Reported female: male

UK

of malignant

melanoma

4.2 per 100,000 population (Kopf et al., 1972) 16.0 per 100,000 population (Smith, 1979) 3.5 per 100,000 population (Bodenham, 1968) 2.5 per 100,ooO population (Clemmesen, 1960) 2.0 per 100,000 population (Nottingham series)

sex ratio

of malignant

I:1 I:1

Raven (1950) Allen and Spitz (1953) White (1959)

1.3:l 2.5: 1 IS:1 1.6:1

Bodenham (196X) Ciemmesen (1960) Nottingham series

Table 3 malignant

Anatomical melanoma

melanoma,

distribution by sex

of

cutaneous

SilC

Females

Mu/es

Face Head/Neck Upper limb Hand/Wrist Trunk Thing Lower leg Foot/Ankle Eyelids and conjunctiva

7% 4”’ /0 15%

21”;

Mortality

2% 18% 7% 33% 13% 1%

1oo/:, 2O’ /” 4”’ 355: 39’ 119: 12% 2”’ ,”

and survival rate

From the total of 275 cases, 171 could be followed over a period of 5 years. Disregarding the site of the tumour and the level of invasion, the 5 year survival rate was 67% (Table 4). Bodenham’s (1968) figures showed 60% survival rate over the same period.

Table 4 melanoma:

61

REGION Five year survival (all cases)

rate for treated

Peterson et al. (1962) Lehman et al. (1966)

malignant

58% 430,; 60% 67”; 67”;,

Bodenham (1968) Cutler et al. (1975) Nottingham series

Several writers have reported the more favourable prognosis of slow growing malignant melanoma on the lower limb. We have achieved a 5 year survival rate of 81% for melanoma on the female leg. However, an interesting finding was the even better behaviour of those lesions presenting on the upper limb in women. Twentythree out of 25 females were still alive after 5 years giving a survival rate of 91% (Table 5). Five male patients had a malignant melanoma on an arm. Three died within 5 years giving a survival rate of 40;:. Whereas the location of the tumour, to a great extent, determines the prognosis, the level of invasion of malignant cells is also highly significant. Clark et al. (1969) reported a direct relationship between survival rates and levels of invasion, the survival rate being inversely related to the level of tumour invasion. Table 5

Five year survival to anatomical site and sex

Lower leg Trunk Foot/Ankle Face Upper limb (including hand and wrist) Head/Neck *In parentheses

rate of melanoma

related

Females

Mllk.Y

81% 76% 63% 75% 91%

50”,, 56”. (44%)* 88”,, ( 5 I %)* 73”,, (779<)$ 40”,,

(78%)* (54%)* (48%)* (79%)*

86”,,

80%

are Bodenham’s

figures (1968)

More recently, Breslow (1970) also has shown a link between prognosis and thickness of the tumour (which includes the tumour raised above the skin surface). Of 275 primary cutaneous malignant melanomata, 220 were available for histological review and classified according to Clark et al. (1969). This classification was accepted by the International Cancer Conference in Sydney, the Australia, as a method of correlating thickness of primary malignant melanoma with survival of the patient.

62

BRITISH JOURNAL

In Nottingham, there would appear to be a relatively high proportion of nodular type melanoma. In our series 33% of the tumours were classified as nodular. The 5 year survival rate for this type of melanoma is 32% in our series (Table 6).

OF PLASTIC SURGERY

References A. C. and Spitz, S. (1953). Malignant melanoma: a clinico-pathological analysis of the criteria for diagnosis and prognosis. Cancer, 6, 1. Bodenham, D. C. (1968). A study of 650 observed malignant melanomas in the Southwest Region. Annals of the Royal

Allen,

College of Surgeons of England, 43, 218.

Breslow, A. (1970). Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma.

Comparative live year survival rate in relation to level of invasion in three series of patients

Table 6

with malignant

melanoma

Superficial spreading Nodular type

Clark (1969)

Bodenham (1968)

Nottingham Series

69% 44%

74% 21%

70% 32%

Annals of Surgery, 172, 902. Clark, W. H., From, L., Bernardino, E. A. and Mihm, M. C. (1969). The histogenesis and biologic behaviour of primary human melanomas of the skin. Cancer Research, 29, 705. Clemmesen, J. (1960). Statistical studies in the aetiology of malignant neoplasms. I Acta Pathologica Microbiologica Scandinauica (Suppl), 174, 411.

Cutler, S. J., Myers, M. H. and Green, S. B. (1975). Trends in survival rates of patients with cancer. New England Journal of Medicine. 293, 122.

Kopf, A. W., Bart, R. S. and Rodrigues-Sains, R. S. (1972). Malignant melanoma. The Journal of Dermatologie Surgery and Oncology, 3, 42. Lehman, J. A. ,Jr., Cross, F. S. and Richey, W. G. (1966).

A lentigo maligna is usually found on the sunexposed surfaces of the body, especially the face, in elderly people. In this series there were only 8 tumours diagnosed as lentigo maligna. Two of these patients died of metastases. Of the tumours which were available for reexamination 63% were classified as a superficial spreading type of malignant melanoma. Of this group 70% were still alive after 8 years. The 5 year survival rate related to anatomical site in Bodenham’s series and the Nottingham series is compared in Table 5. Although one may be tempted to think of 5 year cure rates, it is important to realise that about 20% of patients destined to have recurrent melanoma develop it after the 5th year. In this study it was found that 9% of the patients in the superficial spreading group developed metastases after 5 years; in the nodular group 34% of patients did so. It is this unpredictable behaviour of the malignant melanoma that makes it obligatory to extend the follow-up period to 10 years or more.

Clinical study of forty-nine melanoma. Cancer, 19, 611.

patients

with

malignant

Little, J. H. and Davis, N. C. (1974). Frozen section diagnosis of suspected malignant melanoma of the skin. Cancer, 34, 1163. McGovern, V. J., Mihm, M. C., Bailly, C. et al. (1973). The

classification of malignant melanoma and its histologic reporting. Cancer, 32, 1446. McGovern, V. J. (1967). Malignant melanoma with particular reference to diagnosis by frozen section. Bulletin of the Post-Graduate Committee in Medicine, University of Sydney, 23, 58. McIllmurray, M. B., Embleton, M. J., Reeves, W. G., Langman, M. J. S. and Deane, M. (1977). Controlled trial of active immunotherapy in management of stage IIB malignant melanoma. British Medical Journal, 1, 540. Peterson, N. C., Bodenham, D. C. and Lloyd, 0. C. (1962).

Malignant melanoma of the skin. A study of the origin, development, aetiology. spread, treatment and prognosis. British Journal of Plastic Surgery, 15, 45. Raven, R. W. (1950). The properties and surgical problems of malignant melanoma. Annals of Royal College of Surgeons of England, 6, 28. Smith, T. (1979). The Queensland melanoma project: An exercise in Health Education. British Medical Journal, 1, 253. White, L. P. (1959). Studies on melanoma. The New England Journal of Medicine, 260, 789.

The Authors Michael Y. Bns, MD,

Acknowledgements We are most grateful to Mr D. Wynn-Williams, who allowed us to study his patients and to Mr L. Sully for his assistance. Also to Dr M. Wroughton of the Department of Dermatology, Queens Medical Centre, Nottingham. Her precise recording of the cases was a great help. We would like to thank Dr R. S. Reeve of the Department of Pathology of the City Hospital, Nottingham, who retrospectively classified all the microscopical specimens.

Consultant

Plastic

Surgeon,

Arnhem,

in Plastic

Surgery, Nottingham. Malcolni Deane, FRCS, Consultant Plastic Surgeon, Department of Plastic and Reconstructive Surgery, City Hospital, Nottingham. The

Netherlands,

formerly

Registrar

Requests for reprints to: Malcolm Deane, FRCS, Department of Plastic and Reconstructive Surgery, City Hospital, Nottingham NG5 IPD.