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Cutaneous melanoma of the head and neck
Cutaneous
Melanoma
of the Head and Neck
D. CATLIN, M.D., Nm
From the Head and Nem York, New York.
Neck
Service,
Memorial
Center,
URTHER STUDY of the
dreaded melanoma reveals that the cutaneous variety of the head and neck is not uniformly lethal; in overall perspective, it has a very respectable five year survival rate. It is true, however, that melanoma can frequently be completely unpredictable in its behavior. The following two cases illustrate this point.
F again
CASE REPORTS CASE I. A twenty-two year old white man presented with a slow-growing, small, black mole of over ten years’ duration in the center of his left cheek. A local excision was made and the histologic diagnosis was melanoma. The tumor recurred in six months and was re-excised, again being classified histologically as melanoma. The patient finally died of melanoma four years later. Autopsy disclosed a metastasis in the right frontal lobe of the brain. There was no evidence of residual melanoma in the left cheek or neck. Comment: According to the evidence presented here, this patient should have been cured; instead, he was dead of disseminated melanoma in four years. Such behavior gives the melanoma a very bad reputation, worse than it deserves. The other side of the coin is the history of the second patient.
York, New York
delivered of a normal baby and placenta, She has now been well and free of disease for over twelve years. Comment: One would think that this poorly treated, metastasizing melanoma in a young, pregnant woman would cause death quickly. However, it remained localized to regional lymph nodes and the patient was saved by adequate surgery. These two examples illustrate how difficult it is to anticipate the course of any melanoma and the importance of offering aggressive treatment even though the situation may be unfavorable at the start. The primary purpose of this report is to review in some detail our total experience with cutaneous melanomas of the head and neck at Memorial Center. The head and neck are known to be common areas for melanoma [l-3]. My report made in 1954 was of 106 patients treated on the Head and Neck Service only [4]. The present series is larger and includes all patients seen at the Center regardless of the Service giving treatment. CLINICAL MATERIAL During the twelve year period of 194’7 through 1968, 179 patients were examined and most of them treated at Memorial Center; 129 patients were treated in the Head and Neck Service, and the remaining fifty were private patients of surgeons on other Services. One hundred seventeen patients were men and sixty-two were women, a ratio of almost 2 to 1 in favor of men; all these patients were white. We have seen no true Negro with a melanoma in the skin of the head and neck. It has been noted elsewhere that melanoma of the skin does occur in Negroes in other areas such as the palms of the hands, soles of the feet, and in the subungual region [5,61. The curve illustrated in Figure 1 shows that 73 per cent of these melanomas occurred in patients from thirty to seventy years of age; also, melanoma
CASEII. A twenty-five year old white housewife complained of recent growth in a ten year old black mole on the left lower part of the neck. Before referral to us, this skin tumor was excised and somewhat later a left cervical lymph node was removed; the histologic diagnosis for both specimens was melanoma. This patient was four months pregnant on her admission to Memorial Hospital, A left radical neck dissection including wide excision of the scars of previous surgery was performed; several cervical lymph nodes contained metastatic melanoma, Five months after this operation she was 512
American
Journal
of Surgery
Cutaneous
Melanoma
irl more younger Ijatients than are other more common iorms of head and neck cancer. The youngest patients were two nineteen year old girls. One had a melanoma on the cheek and the other on the is found
3 13
of Head and Neck 40
neck. Both were “cured” by local excision in the outpatient department. iYot a single case of prepubertal melanoma of childhood was seen. The oldest patient was a ninety-nine year old man with a melanoma of the cheek which was excised in the hospital
operating room. This patient died twenty-two months later of cardiac disease without further evidence of melanoma. During this study five patients with metastatic neck nodes only and one patient with a metastatic parotid nodule were encountered in whom no primary melanoma was ever found. Four of these patients were dead of disseminated melanoma within two to seventeen months. One patient clinically free of further melanoma died of a heart attack four years and ten months after radical neck dissection. In the patient with metastasis in the parotid gland further melanoma developed in the neck eleven years after parotidectomy. Since these patients (five men and one woman) do not fit in with or belong to the group with melanoma of the skin, their cases will not be analyzed further in this report. They seemed of sufficient interest to at least record and are known to carry a poor prognosis [7]. F.%CTORS RELATED
TO PROGNOSIS
Histopathology. A pathologic tissue diagnosis of melanoma was obtained in all cases. Our pathologists made no qualifying statements except in the cases of a few elderly patients with superficial lesions in which a favorable outcome was suggested ; in each instance such comment proved to be clinically correct. Size of Lesion. The size of the primary melanoma on admission was recorded with a somewhat varying degree of accuracy. It is noteworthy that seventy-four melanomas (41 per cent of the group) were less than 2 cm. in diameter. This rather large number of small primary lesions was undoubtedly due to their dark pigmentation and their location on a prominently exposed part of the body. Any change in color or size of these lesions could be quickly noted by the patient or the family. This conjecture is supported by the finding that only six melanomas were larger than 5 cm. Color. With respect to color fifty-two melanomas were black, twenty-two brown, five pink, and three were colorless. Thirtythree melanomas were ulcerated and seventyseven presented with satellites. In ninety-three patients there was no visible evidence of priVol. 112, Octobev
1966
Agein years FIG. 1. Age incidence in Ii9 melanomas of the skin of the head and neck. This curve indicates that melanoma tends to appear at an earlier age in patients than the more common epidcrmoid carcinoma.
mary melanoma due to local excision elsewhere before admission. Duration. The duration of these melanomas is also interesting and characteristic of this form of skin cancer. Sixty-seven patients (32 per cent) were known to have had their pigmented lesions for ten years or longer. Twenty patients had moles from six to twelve months. Only one patient had noted his melanoma for less than one month. These findings confirm the old observation that melanomas frequently arise in previously existing pigmented moles which were thought to be harmless and benign. Previous Treatment. Previous treatment (if any) of our group of patients with melanoma was for the most part surgical. One hundred thirty patients (72 per cent) had either local excision or excisional biopsy only. Four patients received more extensive surgery and forty patients were referred without any treatment. Five patients received some x-ray treatment ; two patients had x-ray therapy alone and three patients had x-ray therapy plus limited surgery. In none of these five patients was the disease ultimately controlled. Site of Origin of the Primary Melanoma. Table I lists the site of origin of our 179 melanomas in their order of decreasing frequency. The skin of the cheeks and neck accounted for 114 melanomas (75 per cent). The nose and chin were the two sites least commonly involved. For convenience and clarity a column has been added to the right edge of this table to
Catlin TABLE I SITE OF ORIGIN OF PRIMARY MELANOMAOF THE SKIN
Anatomic Location
No. of Patients
Cheek Neck Scalp Ear Forehead Eyelid (lower) Chin Nose Total
63 51 28 16 13 4 2 2
No. of Patients without Evidence of Disease at Five Years 27 20 11 9 3 1
179
1 72
show the number of patients free of melanoma at five years in relation to the anatomic site of the primary lesion. More than one half of the cures (65 per cent) occurred in cases of melanoma of the cheek and neck. It should be noted also that eleven of the twenty-eight patients with melanoma of the scalp did well even though this area is reported as unfavorable [8]. There was a single incidence of possible “spontaneous” destruction of a primary melanoma. An occasional report on this unusual phenomenon can be found [9]. Our episode is based on a presumably accurate history but was not confirmed histologically. A sixty year old man was referred shortly after excision of a left spinal accessory lymph node of six months’ duration. The histologic diagnosis was metastatic melanoma. For more than a year this patient had noted a coal black mark on the posterior surface of the left ear. Recently this lesion disappeared without any incidence of trauma. A small oval area of pale scarring with a suggestion of pigmentation at the superior margin remained. Our treatment consisted of wide excision of the scarred portion of the left ear combined with a left neck dissection. examination of the surgical Pathologic specimen showed one nodule of metastatic melanoma in the posterior triangle of the left neck contents. The specimen from the left ear revealed focal hyperpigmentation with scattered nevus cells but no residual melanoma. The patient has remained well for over five years and no other deposit of melanoma has ever been found. Stage of Disease on Admission. A detailed staging of the exact size and extent of the primary melanoma together with the
size, number, and distribution of its regional metastasis (if any) seems of questionable value. It is unlikely that any two examiners would arrive at precisely the same evaluation if a detailed clinical impression was attempted for factual classification. Therefore it seems prudent to settle for a broader classification in which both clinical error can be minimized and agreement on the extent of the disease simplified. This principle has been advocated by others for staging melanoma [10,11]. Utilizing this principle, we have grouped all of our cases as localized melanoma (stage I), melanoma with regional metastases (stage II), and generalized melanoma (stage III) as listed in Table II. In the right hand column of this table is recorded the five year cure rate. As would be expected, localized melanoma carries twice as good a prognosis as melanoma with metastases to the regional nodes [11]. There was no five year survival for patients with generalized melanoma. ADDITIONAL FACTORS RELATED TO PROGNOSIS
Several other factors commonly thought to be related to prognosis are listed in Table III and have been commented on by others [I 1 ,121, Melanoma is a rare form of cancer and consequently many of the following subgroups contain only a few cases. Small numbers limit statistical significance but are of interest as a factual record of an actual experience. Determinate five year cure rates only are listed since these results are clinically the most significant and useful. Size of Primary Melanoma. It is commonly believed that a large primary lesion carries a poorer prognosis than a small one, but this study does not validate such a conclusion. Seventeen of the melanomas were 3 to 5 cm. in diameter; the five year cure rate in these patients was 35 per cent. Six of our patients had melanomas from 5 to 10 cm. in size; the five year cure rate here was 30 per cent. This experience suggests that the size of a melanoma is less ominous than its ability to metastasize to regional lymph nodes. Ulceration and Satellites. If the primary melanoma is ulcerated or surrounded with pigmented satellites, the prognosis is commonly thought to be poor. Thirty-one patients presented with ulcerated melanomas; the five year cure rate was 38 per cent, only slightly less than the cure rate for the whole group. Eleven paAmerican
Journal of Surgery
Cutaneous
Melanoma
of Head and Neck
TABLE II STAGE OF
DISEASE
ON ADMISSION
TABLE AND
FIVE
YEAR
CURE
FACTORS
INFLUEPiClNG
RATE
Stage of Disease
I. Local disease only II. With cervical metastases to the lymph nodes III. With distant genmetastasis; eralized disease Total
No. and Percentage of Patients
58
(39%)
III
PROGNOSIS
IN DETERILIINATR
CASES
No. and Percentage of Patients without Evidence of Disease at Five Years
31
(53%)
75
(50%)
19
(25%)
16
(11%) 149* (100~~)
0
(0%) 50 (34%)
* There were an additional thirty patients who were without evidence of disease on admission after local excision elsewhere (see text).
tients had satellites around the primary melanoma; the cure rate here was 63 per cent in this small group. In our experience neither ulceration nor satellites worsen the prognosis to any significant degree; the presence of either of these two findings should not deter aggressive treatment aimed at control. Previous Treatment Elsewhere. It is a well known truism that the first “crack” at any cancerous lesion should be the most effective one. Subsequent operations are usually compromised due to scarring and tissue distortion resulting from the initial surgery. In this series over three times as many patients had previous treatment as those referred with no treatment. Some form of local excision was the commonest type of previous treatment. In the 129 patients who had undergone some surgery before referral, the five year cure rate was 42 per cent. In the thirty-three patients with no previous treatment, our cure rate was 57 per cent, a seemingly significant improvement. The best results of all were in the thirty patients who came to us clinically free of melanoma with a history of recent local excision elsewhere. In twenty-seven patients a reexcision at the site of previous operation was made. In only one patient was melanoma found and the pathologist was somewhat hesitant to state if this residual tumor was primary or a metastasis. Twenty-two of the patients remained well for a determinate five year cure rate of 88 per cent. This experience confirms Vol. IIZ, October 1966
5 1.;
Factor
Size of melanoma 3-5 cm. 5-10 cm. Ulceration Satellites Previous treatment Yes NO Patients clinically without evidence of disease after local excision &33Vllere
Sex Male Female Pregnancy
No. of Patients (Total 162)
-Five Year Cures--No. of Percentage Patients (Total 43.8’,&) (Total T3)
:<
li 6 31 11
6 3 12 i
:x5. 50.0 38.8 63.6
129 33
54 19
41.8 57.F)
26
22
84.4
107 55 9
37 36 5
34.5 65.4 55.5
again the value of an adequate initial operation. Sex. An interesting and surprising prognostic factor in our patients was their sex. In 107 men the five year cure rate was 34 per cent. In fifty-five women the cure rate was 65 per cent. Melanomas in our series were found twice as commonly in men but the cure rate was twice as good in women. Further study revealed that more women received treatment in an earlier stage of their disease than did the men. Forty-five per cent of the women had stage I melanoma on admission as compared to 25 per cent for men. Of the stage II melanomas, 47 per cent were in men and only 29 per cent in women. This distribution suggests that women, in general being more fastidious and observant than men, sought treatment sooner. Pregnancy. The coexistence of pregnancy with any form of cancer has been thought to have a deleterious effect on the outcome of the disease [13-153. The gravid condition has been blamed for stimulating the malignancy of a lesion, particularly in respect to melanoma. In this study there were nine women who were pregnant at some time during the course of their treatment for melanoma. A brief review of these cases seems in order. Five of these patients completed their pregnancies and were free of disease for five years or longer. One of these five died of metastasis to the brain seven years after wide excision of a melanoma in the skin of the left upper part of the neck. Another patient completed a normal pregnancy after an excision of a melanoma from her left cheek. She
Catlin
516
died of generalized disease six years later. A sixth patient completed her pregnancy and lived over nine years with disease before dying from generalized metastases. There were two patients in whom pregnancy seemed to relate to the fatal growth of melanoma. In one patient a “mole” on the left forehead grew rapidly and ulcerated four months after her second pregnancy. She died from metastases to the lung in four months. In the other patient metastasis to the cervical nodes appeared during pregnancy and three years after the excision of a melanoma in the right cheek. She died from generalized disease in sixteen months. The ninth and final patient had a melanoma in the left temporal scalp and was three months pregnant. An elective total hysterectomy was performed in addition to radical surgery to the left part of the scalp and neck. She was dead from melanoma in seven months. From this limited experience, there is no conclusive evidence that melanoma is made more malignant by pregnancy. There seems to be no valid indication for therapeutic abortion. The determinate cure rate for the nine pregnant patients (55.5 per cent) is better than for the entire group of patients with melanoma of the head and neck (43.8 per cent). TREATMENT
Surgery has proved to be the only effective treatment for melanoma at Memorial Center and most other places [4,5,13,16-201. Occasionally control of the disease by irradiation was noted but this occurs too rarely to be of any real significance. In the present study roentgen rays, radon seeds, and chemotherapy were used sparingly and then mostly in stage III cases. &&&ion l’herapy. There were only two cases in which x-ray treatment apparently destroyed the primary melanoma. A twentynine year old woman had a tiny melanoma on the left cheek treated with roentgen rays and a single application of radium. She has been well for over eight years with no recurrence or spread of melanoma. A sixty-five year old man received radical surgery for a melanoma of the left ear with a metastatic node in the left part of the neck; recurrent melanoma (proved by biopsy) developed at the site of the left neck dissection. High voltage x-ray treatment caused complete disappearance of this new mass in the
neck. This man has now been well for over fourteen years. Seven other patients received some form of irradiation during their treatment; six of these patients are dead from melanoma. The seventh patient returned to Africa, was lost track of shortly after treatment, and is probably dead from disease. X-ray therapy has been reported to be of palliative value in the treatment of metastases to the bone from melanoma [21] ; we observed only a single example. Back pain due to lumbosacral metastasis was greatly relieved by 2 mev. x-ray therapy although this thirty-five year old male patient soon died of disseminated disease. Chemotherapy. Several chemical agents (HNZ [mechloroethamine], OPDA [orthophenylenediamine], DON [norleukine], TEM [triethylene melanine], Meticorten@, methyl metomycin, etc.), rabies vaccine, desiccated thyroid, and 101 Egypt virus were used in six patients all of whom had advanced, widespread melanoma. No palliation or regression of disease was noted in this small number of patients. These experimental drugs were not used in more favorable cases. Surgery. Wide excision of the melanoma including its regional metastases, when present, was carried out in almost all situations in which resection was possible. Excision of the primary melanoma only was the commonest operation and constituted our initial treatment in seventy-one patients. Twenty-five of these operations were performed with local anesthesia in the outpatient department. (Fig. 2.) Sixteen of these patients are without evidence of disease for five years or longer for a determinate ’ cure rate of 76 per cent. Only four patients died of melanoma, three with distant metastases only, and the other with disease in the neck as well. Four patients died of other causes and were free of melanoma. There were only three instances of local recurrence and one of these was controlled by re-excision in the operating room. Only one patient had a neck dissection three years after local surgery and is now well for over ten years. It can be seen that small, localized melanomas suitable for excision in the outpatient department carry a good prognosis and rarely metastasize to regional nodes. It would seem that an elective neck dissection is seldom indicated in these early cases. The prognosis is American
Jouvnal
of Surwy
Cutaneous
Melanoma
particularly favorable in elderly patients with superficial melanomas which are longstanding, aptly called “congenital” in type [16]. There were thirty patients referred to us who in each case had undergone local excision of a “benign mole” which on histologic examination showed melanoma. The referring surgeon was usually doubtful about the adequacy of his opcration. In twenty-eight of thethirtypatientswe performed a wider excision at the site of previous surgery and in a few cases even included a 11f2ck dissection. In only one instance was residual melanoma found and even here the evidence was clouded. Our pathologist was uncertain whether the residual melanoma was primary or a small metastasis. Twenty-two of these patients remained well. Only three patients died of melanoma. The determinate 5 year cure rate of S-l per cent was the best for all sub&Toups. Of the seventy-one patients whose melanomas were locally excised initially, skin grafts were used in only thirty-six of the operations (50 per cent); Figure 3 illustrates such a case. However, a skin graft is not necessarily a good index by which to judge a wide excision. The skin of the neck and cheeks is usually abundant and freely movable. Primary closure is often possible and prtferablc. Rotated flaps of adjacent skin favor prompt healing as well as being cosmetically acceptable (Fig. 4.) Free xrafts, especially of the split thickness variety, seldom look well on the face since both their color and texture do not match the surrounding normal skin. The defects of the scalp, orbit, and forehead were mostly grafted since the skin in these areas is not readily mobile. The same principle holds true for the upper part of the neck in the postauricular area. Split thickness skin grafts were favored and were used in SO per cent of the cases. They are easily cut with a good dermatome and take with greater certainty than does full thickness skin. (Fig. 5.) In brief our policy is to widely excise the primary melanoma without any preconceived emphasis on closure. The resulting defect is closed directly or with a rotated skin flap when needed. :1 graft is used only when neither of these two methods is feasible. The determinate five year cure rate for our thirty-six patients with grafts is 5-i per cent, a somewhat better figure than for our over-all control and is not surprising in such a small, selected group. Vol. II;‘.
Cklolrer IY66
of Head and Neck
517
Neck Dissection. The generally accepted treatment for metastases to the cervical lymph nodes from melanoma is the classical, complete neck dissection as described by Martin in his book on surgery [ZZ]. The extent of this radical operation is rarely modified and is used by us in all resectable cases. When metastatic nodes are present clinically, a neck dissection is in order. In the absence of clinically significant findings in the neck, the question of an “elective” neck dissection comes up. T\;o clear-cut answer to this situation is available; the problem has been much discussed elsewhere without any uniform consensus [2,5,13,17,20,23-251. It will be further dtalt with herein in some detail. In recent years the importance of making the regional lymph node dissection “in continuity” with the excision of the primary melanoma has been stressed [2,26]. In the head and neck region such an operation is frequently not practical. For example, it would require an unusual and probably impractical technic to combine neck dissection in continuity with excision of a melanoma of the skin of the nose, forehead, parietal scalp, tip of ear, etc. Our policy is to carry out an in continuity operation only when the location of the primary melanoma lends itself to the procedure. Thus, it would apply to lesions arising in the skin of the neck, lower part of the cheek (Fig. G), postauricular scalp (Fig. 7). and so forth. At some point during the treatment of this study group, IOX neck dissections were performed on 100 patients; bilateral neck dissections in stages were performed on three patients. Two of thcsc patients are dead from melanoma; the third patient is living and well for over ten years. Eighty-six neck dissections were part of our initial treatment; fifty-nine of these operations (i0 per cent) included excision of the primary melanoma. Seventeen neck dissections ir’erc performed during subsequent treatment; four of these operations included excision of recurrent primary melanoma. Eighty-three of the neck dissections were carried out on patients who had either clinical or histologic evidence of metastatic disease in the neck; these operations, therefore, were not “elective.” In evaluating the effectiveness of our eighty-three definitive neck dissections, the eighty patients concerned were studied. Our operations were locally successful in forty-six instances (57 per cent) in that further melanoma in the dissected neck never developed
Catlin
FIG. 4. A, melanoma of left cheek; arrow points to a satellite. B, postoperative view. Cheek defect closed with skin flap rotated from the neck. Neck dissection was negative for metastases.This sixtyeight year old woman died two years later of metastases to the brain.
in these patients. In addition twenty-six of these patients (32 per cent) were free of melanoma for five years or longer. One of these patients underwent staged bilateral neck dissections. From this experience it can be seen that neck dissection is the most effective known treatment for metastatic melanoma in cervical lymph nodes. The over-all five year survival rate of one third of these patients compares favorably with similar treatment for the more common cancer of the tongue [26]. It is encouraging to know that an aggressive surgical attack on melanoma is as rewarding as in other forms of cancer of the head and neck. Elective Neck Dissection. The use of a radical regional lymph node dissection in the
absence of positive clinical findings in the neck has been a much debated subject [13,16,18,24, 25,271. No really clear-cut course of action can be advocated on the evidence produced so far. Our own experience with melanomas of the head and neck is of interest although it fails to supply a definitive answer to this elusive problem. In our management of 179 patients with melanoma, we performed twenty neck dissections in cases in which clinically there was no evidence of abnormal cervical lymph node enlargement. From a strictly literal viewpoint, these operations can be called “elective” in nature. Why did our surgeons choose to dissect these necks in which there was no clinical American Journal of Surgery
Cutaneous
Melanoma
of Head and Neck
5 I9
FIG. 5. A, diffuse melanoma of the left parietal scalp in a thirty-eight
left neck dissection.
Patient
has
FIG. 7. A, melanoma with satellites in right postauricular area. Arrows point to enlarged lymph nodes. B, neck dissection was in.. r . ., 1 . .,
j
I
evidence of disease? The most common reason was that in thirteen of the twenty patients the primary melanoma arose in the skin of the neck under consideration for surgery. Eleven of these patients had limited excisions of their melanomas before coming to us. In each of these eleven patients the examining surgeon could not be certain that the previous local excision had been adequate; the referring surgeons were equally uncertain. It was therefore elected to perform a more radical excision and include neck dissection at the same time. Any scarring produced by the re-excision in the neck would Vol. 112, October 1966
prevent a satisfactory dissection at a later date. It seems almost misleading to call a neck dissection carried out under these conditions truly elective even though lymph nodes were histologically positive in only one of the eleven operations. In the other two patients with no previous treatment, neck dissections were performed for the same reason of surgical entry into the neck. It might be more accurate to say that anatomic and technical considerations were the deciding factors for neck dissection in these thirteen patients. Six patients with melanomas on the cheek
Catlin TABLE IV STATUS AND END RESULTS FOR PATIESTS AT FIVE YEARS
Result No evidence of disease Dead of disease Living with melanoma Lost track of, status unknown Dead of other causes, no evidence of disease No treatment at Memorial Center Total NOTE:
Absolute
No. of Patients 73 71 7 11 13 4 179
five year cure rate (seventy-three
of
179 patients), 40.7 per cent; determinate five year cure rate (seventy-three of 162 patients), 43.8 per cent.
patient with melanoma on the ear were also subjected to elective neck dissections. The lymph nodes were histologically negative in all of them. To summarize then, in twenty elective neck dissections positive lymph nodes were found in only one instance. That patient remained free of melanoma only to die from a cardiovascular accident two years later. Fourteen patients were free of melanoma at five years; four patients died from melanoma, three of them from distant metastases and one from local recurrence in the neck. One patient was lost track of free of disease three years after surgery. From our experience it seems reasonable to conclude that an elective neck dissection is advisable only when it can be readily performed in conjunction with the excision of the primary melanoma even though in most instances the lymph nodes will be histologically negative for metastases. The psychological impact of a negative neck dissection on both the patient and the surgeon is not to be lightly disregarded. Clear lymph nodes indicate stage I disease with the best prognosis. Such knowledge provides optimism for both patient and surgeon. If an unsuspected metastasis is discovered by neck dissection, this indicates that the correct operation was made at the correct time. The patient received the best known treatment for a stage 11lesion. and one
END RESULTS
The five year results of our experience with all cases compare favorably with the reports of others [2,3,5,11,18,20,23] and are summarized in Table IV. The relationship of cure rate
to stage of disease on admission is tabulated in Table II and to the site of origin of the melanoma in Table I. The determinate five year cure rate shows improvement over our 1954 report [4]. A satisfactory explanation for this improvement is not apparent. Seventy-one of our patients were without evidence of disease at five years after treatment. At ten years an additional nine patients were dead from melanoma, demonstrating the ability of this lesion to become lethal after long delay. CONCLUSION
Actually it is the unpredictable behavior of melanoma which gives it such a bad reputation. The ability of this “black” cancer to metastasize by the blood stream can defeat the success of an otherwise splendid local control. Lethal distant metastases developed in seven of our patients more than five years after successful Iocal surgery. In the skin of the head and neck area, the knowledge that the five year cure rate for melanoma compares favorably with most of the more common epidermoid carcinomas of the mouth, pharynx, and larynx encourages a bold surgical attack. No other form of treatment is curative except in very isolated instances. Survival in the stage I cases (53 per cent) is approximately double that obtained in stage II (25 per cent). It is not the age, sex, or pregnant state of the patient or the size, ulceration and, satellite formatian of the primary melanoma which determines the outcome but rather the insidious ability of this lesion to metastasize widely and at any time. Inasmuch as it can be extremely difficult to determine just how “early” and localized a melanoma is, the emphasis on prompt, adequate excision cannot be overstressed. It has already been clearly pointed out [16,19] that it is impossible to foretell when or why a quiescent cutaneous “mole” will suddenly explode and become wildly malignant. A prompt and generous excision of any primary melanoma is always mandatory. A neck dissection should be included whenever there is a reasonable clinical or anatomic indication for doing so. REFERENCES 1. PACK, G. T., LENSON, Regional distribution
N., and GERBER, D. M. of moles and melanomas.
Arch. Surg., 65: 862, 1952. Awican
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Cutaneous 2.
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Melanoma
G. ‘f. End results in the treatment of malignant melanoma Surgery, 46: 44i. 1959. WATSON, E, C. Melanoma. -4 ten-year rctrospective survey in New Zealand. Australian & New Zealand J. Surg., 33: 31, 1963. OATLIN, D. Melanomas of the skin of the head and neck. d nn. Sury., 140: 796, 1954. MEYER, H. W. and GUMPORT, S. L. Malignant melanoma. .4nn. Surg., 138: 643, 1953. MORRIS, G. C. and HORN, R. C., JR. Malignant melanoma in the Negro. Surgery, 29: 223, 1951. DAS GUPTA, T. and BOWDEN, L. Malignant melanoma of unknown primary origin. Surg. Gynec. b Obst., 117: 341, 1963. CONLEY, J. J. Malignant tumors of the scalp: 58 cases of melanoma. Plast. 6 Reconstruct. Surg., 33: 163, 1964. SUMNER, W. C. Spontaneous regression of melanoma. Cancer, 6: 1040, 1953. GEORGE, P. A., FORTNER, J. G., and PACK, G. T. Melanoma with pregnancy. Cancer, 13: 854, 1960. MCNEER, G. and DAS GUPTA, T. Prognosis in malignant melanoma. Surgery, 56: 512, 1964. FORTNER, J. G. Factors in treatment of melanoma. M. Clin. North America, 45: 643, 1961. GUMPORT, S. L. and MEYER, H. W. Treatment of 126 cases of malignant melanoma. Ann. Surg., 150: 989, 1959. PACK, G. T. and SCHARNAGEL,I. M. The prognosis for malignant melanoma in pregnant women. Cancer, 4: 324, 1951. SHOCKET,E. C. and FORTNER, J. G. Melanoma and pregnancy an experimental evaluation of a clinical impression. S. Forum, 9: 6i, 1959. PACK,
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of Head and Se&
521
16. MCSEER, G. The clinical behavior and managenicnt of malignant melanoma. J.A. 11f..4,, 176: 1, 1961. 17. MCNEER, G. ;\ curable form of cancer: melanoma. J1. Sri.. 16: 55, 1965. 18. MCS~AIS, B.. KIDDELL, D. H., RICHIE, Ii. E., and CKUCKER. E. F. Treatment of malignant melanoma. .lnn. Surg., 159: 967, 1964. 19. PACK, G. T. The pigmented mole and the malignant melanoma. Virginia M. Monthly, 84: 111, 1957. 20. SOUTHU’ICK, H. W., SLAUGHTER, D. P., and HINKAMP. J. F. Malignant melanoma of the head and neck. .-1nz. J. Surg., 106: 852, 1963. 21. HILARIS, B. S., RABEN, M., CALABRESE, A. S., PHILLIPS, R. F., and HENSCHKE, N. K. Value of radiation therapy for distant metastases from malignant melanoma. Cancer, 16: 765, 1963. 22. MARTIN, H. Surgery of Head and Neck Tumors. New York, 1957. Paul B. Hoeber, Inc. 23. KRAGH, L. V. and ERICH, J. B. Malignant melanomas of the head and neck. Ann. Surg., 151: 91, 1960. 24. PRICE, W. E. and DUVAL, M. K., JR. Regional lymph node dissection and malignant melanoma. Arch. Surg., 87: 59, 1963. 25. SOUTHWICK, H. W., SLAUGHTER, D. P., HINKAMP, J. F., and JOHNSON, F. E. The role of regional node dissection in the treatment of malignant melanoma. ilrch. Surg., 85: 63, 1962. 26. FRAZELL, E. L. and LUCAS, J. C., JR. Cancer of the tongue. Cancer, 15: 1085, 1962. 27. Gums, L. W. and MACDONALD,I. The role of radical lymphadenectomy in treatment of melanoma. An?. J. Surg., 104: 135, 1962.
Melanoma
of the Head and Neck
D. CATLIN, M.D., Nm
From the Head and Nem York, New York.
Neck
Service,
Memorial
Center,
URTHER STUDY of the
dreaded melanoma reveals that the cutaneous variety of the head and neck is not uniformly lethal; in overall perspective, it has a very respectable five year survival rate. It is true, however, that melanoma can frequently be completely unpredictable in its behavior. The following two cases illustrate this point.
F again
CASE REPORTS CASE I. A twenty-two year old white man presented with a slow-growing, small, black mole of over ten years’ duration in the center of his left cheek. A local excision was made and the histologic diagnosis was melanoma. The tumor recurred in six months and was re-excised, again being classified histologically as melanoma. The patient finally died of melanoma four years later. Autopsy disclosed a metastasis in the right frontal lobe of the brain. There was no evidence of residual melanoma in the left cheek or neck. Comment: According to the evidence presented here, this patient should have been cured; instead, he was dead of disseminated melanoma in four years. Such behavior gives the melanoma a very bad reputation, worse than it deserves. The other side of the coin is the history of the second patient.
York, New York
delivered of a normal baby and placenta, She has now been well and free of disease for over twelve years. Comment: One would think that this poorly treated, metastasizing melanoma in a young, pregnant woman would cause death quickly. However, it remained localized to regional lymph nodes and the patient was saved by adequate surgery. These two examples illustrate how difficult it is to anticipate the course of any melanoma and the importance of offering aggressive treatment even though the situation may be unfavorable at the start. The primary purpose of this report is to review in some detail our total experience with cutaneous melanomas of the head and neck at Memorial Center. The head and neck are known to be common areas for melanoma [l-3]. My report made in 1954 was of 106 patients treated on the Head and Neck Service only [4]. The present series is larger and includes all patients seen at the Center regardless of the Service giving treatment. CLINICAL MATERIAL During the twelve year period of 194’7 through 1968, 179 patients were examined and most of them treated at Memorial Center; 129 patients were treated in the Head and Neck Service, and the remaining fifty were private patients of surgeons on other Services. One hundred seventeen patients were men and sixty-two were women, a ratio of almost 2 to 1 in favor of men; all these patients were white. We have seen no true Negro with a melanoma in the skin of the head and neck. It has been noted elsewhere that melanoma of the skin does occur in Negroes in other areas such as the palms of the hands, soles of the feet, and in the subungual region [5,61. The curve illustrated in Figure 1 shows that 73 per cent of these melanomas occurred in patients from thirty to seventy years of age; also, melanoma
CASEII. A twenty-five year old white housewife complained of recent growth in a ten year old black mole on the left lower part of the neck. Before referral to us, this skin tumor was excised and somewhat later a left cervical lymph node was removed; the histologic diagnosis for both specimens was melanoma. This patient was four months pregnant on her admission to Memorial Hospital, A left radical neck dissection including wide excision of the scars of previous surgery was performed; several cervical lymph nodes contained metastatic melanoma, Five months after this operation she was 512
American
Journal
of Surgery
Cutaneous
Melanoma
irl more younger Ijatients than are other more common iorms of head and neck cancer. The youngest patients were two nineteen year old girls. One had a melanoma on the cheek and the other on the is found
3 13
of Head and Neck 40
neck. Both were “cured” by local excision in the outpatient department. iYot a single case of prepubertal melanoma of childhood was seen. The oldest patient was a ninety-nine year old man with a melanoma of the cheek which was excised in the hospital
operating room. This patient died twenty-two months later of cardiac disease without further evidence of melanoma. During this study five patients with metastatic neck nodes only and one patient with a metastatic parotid nodule were encountered in whom no primary melanoma was ever found. Four of these patients were dead of disseminated melanoma within two to seventeen months. One patient clinically free of further melanoma died of a heart attack four years and ten months after radical neck dissection. In the patient with metastasis in the parotid gland further melanoma developed in the neck eleven years after parotidectomy. Since these patients (five men and one woman) do not fit in with or belong to the group with melanoma of the skin, their cases will not be analyzed further in this report. They seemed of sufficient interest to at least record and are known to carry a poor prognosis [7]. F.%CTORS RELATED
TO PROGNOSIS
Histopathology. A pathologic tissue diagnosis of melanoma was obtained in all cases. Our pathologists made no qualifying statements except in the cases of a few elderly patients with superficial lesions in which a favorable outcome was suggested ; in each instance such comment proved to be clinically correct. Size of Lesion. The size of the primary melanoma on admission was recorded with a somewhat varying degree of accuracy. It is noteworthy that seventy-four melanomas (41 per cent of the group) were less than 2 cm. in diameter. This rather large number of small primary lesions was undoubtedly due to their dark pigmentation and their location on a prominently exposed part of the body. Any change in color or size of these lesions could be quickly noted by the patient or the family. This conjecture is supported by the finding that only six melanomas were larger than 5 cm. Color. With respect to color fifty-two melanomas were black, twenty-two brown, five pink, and three were colorless. Thirtythree melanomas were ulcerated and seventyseven presented with satellites. In ninety-three patients there was no visible evidence of priVol. 112, Octobev
1966
Agein years FIG. 1. Age incidence in Ii9 melanomas of the skin of the head and neck. This curve indicates that melanoma tends to appear at an earlier age in patients than the more common epidcrmoid carcinoma.
mary melanoma due to local excision elsewhere before admission. Duration. The duration of these melanomas is also interesting and characteristic of this form of skin cancer. Sixty-seven patients (32 per cent) were known to have had their pigmented lesions for ten years or longer. Twenty patients had moles from six to twelve months. Only one patient had noted his melanoma for less than one month. These findings confirm the old observation that melanomas frequently arise in previously existing pigmented moles which were thought to be harmless and benign. Previous Treatment. Previous treatment (if any) of our group of patients with melanoma was for the most part surgical. One hundred thirty patients (72 per cent) had either local excision or excisional biopsy only. Four patients received more extensive surgery and forty patients were referred without any treatment. Five patients received some x-ray treatment ; two patients had x-ray therapy alone and three patients had x-ray therapy plus limited surgery. In none of these five patients was the disease ultimately controlled. Site of Origin of the Primary Melanoma. Table I lists the site of origin of our 179 melanomas in their order of decreasing frequency. The skin of the cheeks and neck accounted for 114 melanomas (75 per cent). The nose and chin were the two sites least commonly involved. For convenience and clarity a column has been added to the right edge of this table to
Catlin TABLE I SITE OF ORIGIN OF PRIMARY MELANOMAOF THE SKIN
Anatomic Location
No. of Patients
Cheek Neck Scalp Ear Forehead Eyelid (lower) Chin Nose Total
63 51 28 16 13 4 2 2
No. of Patients without Evidence of Disease at Five Years 27 20 11 9 3 1
179
1 72
show the number of patients free of melanoma at five years in relation to the anatomic site of the primary lesion. More than one half of the cures (65 per cent) occurred in cases of melanoma of the cheek and neck. It should be noted also that eleven of the twenty-eight patients with melanoma of the scalp did well even though this area is reported as unfavorable [8]. There was a single incidence of possible “spontaneous” destruction of a primary melanoma. An occasional report on this unusual phenomenon can be found [9]. Our episode is based on a presumably accurate history but was not confirmed histologically. A sixty year old man was referred shortly after excision of a left spinal accessory lymph node of six months’ duration. The histologic diagnosis was metastatic melanoma. For more than a year this patient had noted a coal black mark on the posterior surface of the left ear. Recently this lesion disappeared without any incidence of trauma. A small oval area of pale scarring with a suggestion of pigmentation at the superior margin remained. Our treatment consisted of wide excision of the scarred portion of the left ear combined with a left neck dissection. examination of the surgical Pathologic specimen showed one nodule of metastatic melanoma in the posterior triangle of the left neck contents. The specimen from the left ear revealed focal hyperpigmentation with scattered nevus cells but no residual melanoma. The patient has remained well for over five years and no other deposit of melanoma has ever been found. Stage of Disease on Admission. A detailed staging of the exact size and extent of the primary melanoma together with the
size, number, and distribution of its regional metastasis (if any) seems of questionable value. It is unlikely that any two examiners would arrive at precisely the same evaluation if a detailed clinical impression was attempted for factual classification. Therefore it seems prudent to settle for a broader classification in which both clinical error can be minimized and agreement on the extent of the disease simplified. This principle has been advocated by others for staging melanoma [10,11]. Utilizing this principle, we have grouped all of our cases as localized melanoma (stage I), melanoma with regional metastases (stage II), and generalized melanoma (stage III) as listed in Table II. In the right hand column of this table is recorded the five year cure rate. As would be expected, localized melanoma carries twice as good a prognosis as melanoma with metastases to the regional nodes [11]. There was no five year survival for patients with generalized melanoma. ADDITIONAL FACTORS RELATED TO PROGNOSIS
Several other factors commonly thought to be related to prognosis are listed in Table III and have been commented on by others [I 1 ,121, Melanoma is a rare form of cancer and consequently many of the following subgroups contain only a few cases. Small numbers limit statistical significance but are of interest as a factual record of an actual experience. Determinate five year cure rates only are listed since these results are clinically the most significant and useful. Size of Primary Melanoma. It is commonly believed that a large primary lesion carries a poorer prognosis than a small one, but this study does not validate such a conclusion. Seventeen of the melanomas were 3 to 5 cm. in diameter; the five year cure rate in these patients was 35 per cent. Six of our patients had melanomas from 5 to 10 cm. in size; the five year cure rate here was 30 per cent. This experience suggests that the size of a melanoma is less ominous than its ability to metastasize to regional lymph nodes. Ulceration and Satellites. If the primary melanoma is ulcerated or surrounded with pigmented satellites, the prognosis is commonly thought to be poor. Thirty-one patients presented with ulcerated melanomas; the five year cure rate was 38 per cent, only slightly less than the cure rate for the whole group. Eleven paAmerican
Journal of Surgery
Cutaneous
Melanoma
of Head and Neck
TABLE II STAGE OF
DISEASE
ON ADMISSION
TABLE AND
FIVE
YEAR
CURE
FACTORS
INFLUEPiClNG
RATE
Stage of Disease
I. Local disease only II. With cervical metastases to the lymph nodes III. With distant genmetastasis; eralized disease Total
No. and Percentage of Patients
58
(39%)
III
PROGNOSIS
IN DETERILIINATR
CASES
No. and Percentage of Patients without Evidence of Disease at Five Years
31
(53%)
75
(50%)
19
(25%)
16
(11%) 149* (100~~)
0
(0%) 50 (34%)
* There were an additional thirty patients who were without evidence of disease on admission after local excision elsewhere (see text).
tients had satellites around the primary melanoma; the cure rate here was 63 per cent in this small group. In our experience neither ulceration nor satellites worsen the prognosis to any significant degree; the presence of either of these two findings should not deter aggressive treatment aimed at control. Previous Treatment Elsewhere. It is a well known truism that the first “crack” at any cancerous lesion should be the most effective one. Subsequent operations are usually compromised due to scarring and tissue distortion resulting from the initial surgery. In this series over three times as many patients had previous treatment as those referred with no treatment. Some form of local excision was the commonest type of previous treatment. In the 129 patients who had undergone some surgery before referral, the five year cure rate was 42 per cent. In the thirty-three patients with no previous treatment, our cure rate was 57 per cent, a seemingly significant improvement. The best results of all were in the thirty patients who came to us clinically free of melanoma with a history of recent local excision elsewhere. In twenty-seven patients a reexcision at the site of previous operation was made. In only one patient was melanoma found and the pathologist was somewhat hesitant to state if this residual tumor was primary or a metastasis. Twenty-two of the patients remained well for a determinate five year cure rate of 88 per cent. This experience confirms Vol. IIZ, October 1966
5 1.;
Factor
Size of melanoma 3-5 cm. 5-10 cm. Ulceration Satellites Previous treatment Yes NO Patients clinically without evidence of disease after local excision &33Vllere
Sex Male Female Pregnancy
No. of Patients (Total 162)
-Five Year Cures--No. of Percentage Patients (Total 43.8’,&) (Total T3)
:<
li 6 31 11
6 3 12 i
:x5. 50.0 38.8 63.6
129 33
54 19
41.8 57.F)
26
22
84.4
107 55 9
37 36 5
34.5 65.4 55.5
again the value of an adequate initial operation. Sex. An interesting and surprising prognostic factor in our patients was their sex. In 107 men the five year cure rate was 34 per cent. In fifty-five women the cure rate was 65 per cent. Melanomas in our series were found twice as commonly in men but the cure rate was twice as good in women. Further study revealed that more women received treatment in an earlier stage of their disease than did the men. Forty-five per cent of the women had stage I melanoma on admission as compared to 25 per cent for men. Of the stage II melanomas, 47 per cent were in men and only 29 per cent in women. This distribution suggests that women, in general being more fastidious and observant than men, sought treatment sooner. Pregnancy. The coexistence of pregnancy with any form of cancer has been thought to have a deleterious effect on the outcome of the disease [13-153. The gravid condition has been blamed for stimulating the malignancy of a lesion, particularly in respect to melanoma. In this study there were nine women who were pregnant at some time during the course of their treatment for melanoma. A brief review of these cases seems in order. Five of these patients completed their pregnancies and were free of disease for five years or longer. One of these five died of metastasis to the brain seven years after wide excision of a melanoma in the skin of the left upper part of the neck. Another patient completed a normal pregnancy after an excision of a melanoma from her left cheek. She
Catlin
516
died of generalized disease six years later. A sixth patient completed her pregnancy and lived over nine years with disease before dying from generalized metastases. There were two patients in whom pregnancy seemed to relate to the fatal growth of melanoma. In one patient a “mole” on the left forehead grew rapidly and ulcerated four months after her second pregnancy. She died from metastases to the lung in four months. In the other patient metastasis to the cervical nodes appeared during pregnancy and three years after the excision of a melanoma in the right cheek. She died from generalized disease in sixteen months. The ninth and final patient had a melanoma in the left temporal scalp and was three months pregnant. An elective total hysterectomy was performed in addition to radical surgery to the left part of the scalp and neck. She was dead from melanoma in seven months. From this limited experience, there is no conclusive evidence that melanoma is made more malignant by pregnancy. There seems to be no valid indication for therapeutic abortion. The determinate cure rate for the nine pregnant patients (55.5 per cent) is better than for the entire group of patients with melanoma of the head and neck (43.8 per cent). TREATMENT
Surgery has proved to be the only effective treatment for melanoma at Memorial Center and most other places [4,5,13,16-201. Occasionally control of the disease by irradiation was noted but this occurs too rarely to be of any real significance. In the present study roentgen rays, radon seeds, and chemotherapy were used sparingly and then mostly in stage III cases. &&&ion l’herapy. There were only two cases in which x-ray treatment apparently destroyed the primary melanoma. A twentynine year old woman had a tiny melanoma on the left cheek treated with roentgen rays and a single application of radium. She has been well for over eight years with no recurrence or spread of melanoma. A sixty-five year old man received radical surgery for a melanoma of the left ear with a metastatic node in the left part of the neck; recurrent melanoma (proved by biopsy) developed at the site of the left neck dissection. High voltage x-ray treatment caused complete disappearance of this new mass in the
neck. This man has now been well for over fourteen years. Seven other patients received some form of irradiation during their treatment; six of these patients are dead from melanoma. The seventh patient returned to Africa, was lost track of shortly after treatment, and is probably dead from disease. X-ray therapy has been reported to be of palliative value in the treatment of metastases to the bone from melanoma [21] ; we observed only a single example. Back pain due to lumbosacral metastasis was greatly relieved by 2 mev. x-ray therapy although this thirty-five year old male patient soon died of disseminated disease. Chemotherapy. Several chemical agents (HNZ [mechloroethamine], OPDA [orthophenylenediamine], DON [norleukine], TEM [triethylene melanine], Meticorten@, methyl metomycin, etc.), rabies vaccine, desiccated thyroid, and 101 Egypt virus were used in six patients all of whom had advanced, widespread melanoma. No palliation or regression of disease was noted in this small number of patients. These experimental drugs were not used in more favorable cases. Surgery. Wide excision of the melanoma including its regional metastases, when present, was carried out in almost all situations in which resection was possible. Excision of the primary melanoma only was the commonest operation and constituted our initial treatment in seventy-one patients. Twenty-five of these operations were performed with local anesthesia in the outpatient department. (Fig. 2.) Sixteen of these patients are without evidence of disease for five years or longer for a determinate ’ cure rate of 76 per cent. Only four patients died of melanoma, three with distant metastases only, and the other with disease in the neck as well. Four patients died of other causes and were free of melanoma. There were only three instances of local recurrence and one of these was controlled by re-excision in the operating room. Only one patient had a neck dissection three years after local surgery and is now well for over ten years. It can be seen that small, localized melanomas suitable for excision in the outpatient department carry a good prognosis and rarely metastasize to regional nodes. It would seem that an elective neck dissection is seldom indicated in these early cases. The prognosis is American
Jouvnal
of Surwy
Cutaneous
Melanoma
particularly favorable in elderly patients with superficial melanomas which are longstanding, aptly called “congenital” in type [16]. There were thirty patients referred to us who in each case had undergone local excision of a “benign mole” which on histologic examination showed melanoma. The referring surgeon was usually doubtful about the adequacy of his opcration. In twenty-eight of thethirtypatientswe performed a wider excision at the site of previous surgery and in a few cases even included a 11f2ck dissection. In only one instance was residual melanoma found and even here the evidence was clouded. Our pathologist was uncertain whether the residual melanoma was primary or a small metastasis. Twenty-two of these patients remained well. Only three patients died of melanoma. The determinate 5 year cure rate of S-l per cent was the best for all sub&Toups. Of the seventy-one patients whose melanomas were locally excised initially, skin grafts were used in only thirty-six of the operations (50 per cent); Figure 3 illustrates such a case. However, a skin graft is not necessarily a good index by which to judge a wide excision. The skin of the neck and cheeks is usually abundant and freely movable. Primary closure is often possible and prtferablc. Rotated flaps of adjacent skin favor prompt healing as well as being cosmetically acceptable (Fig. 4.) Free xrafts, especially of the split thickness variety, seldom look well on the face since both their color and texture do not match the surrounding normal skin. The defects of the scalp, orbit, and forehead were mostly grafted since the skin in these areas is not readily mobile. The same principle holds true for the upper part of the neck in the postauricular area. Split thickness skin grafts were favored and were used in SO per cent of the cases. They are easily cut with a good dermatome and take with greater certainty than does full thickness skin. (Fig. 5.) In brief our policy is to widely excise the primary melanoma without any preconceived emphasis on closure. The resulting defect is closed directly or with a rotated skin flap when needed. :1 graft is used only when neither of these two methods is feasible. The determinate five year cure rate for our thirty-six patients with grafts is 5-i per cent, a somewhat better figure than for our over-all control and is not surprising in such a small, selected group. Vol. II;‘.
Cklolrer IY66
of Head and Neck
517
Neck Dissection. The generally accepted treatment for metastases to the cervical lymph nodes from melanoma is the classical, complete neck dissection as described by Martin in his book on surgery [ZZ]. The extent of this radical operation is rarely modified and is used by us in all resectable cases. When metastatic nodes are present clinically, a neck dissection is in order. In the absence of clinically significant findings in the neck, the question of an “elective” neck dissection comes up. T\;o clear-cut answer to this situation is available; the problem has been much discussed elsewhere without any uniform consensus [2,5,13,17,20,23-251. It will be further dtalt with herein in some detail. In recent years the importance of making the regional lymph node dissection “in continuity” with the excision of the primary melanoma has been stressed [2,26]. In the head and neck region such an operation is frequently not practical. For example, it would require an unusual and probably impractical technic to combine neck dissection in continuity with excision of a melanoma of the skin of the nose, forehead, parietal scalp, tip of ear, etc. Our policy is to carry out an in continuity operation only when the location of the primary melanoma lends itself to the procedure. Thus, it would apply to lesions arising in the skin of the neck, lower part of the cheek (Fig. G), postauricular scalp (Fig. 7). and so forth. At some point during the treatment of this study group, IOX neck dissections were performed on 100 patients; bilateral neck dissections in stages were performed on three patients. Two of thcsc patients are dead from melanoma; the third patient is living and well for over ten years. Eighty-six neck dissections were part of our initial treatment; fifty-nine of these operations (i0 per cent) included excision of the primary melanoma. Seventeen neck dissections ir’erc performed during subsequent treatment; four of these operations included excision of recurrent primary melanoma. Eighty-three of the neck dissections were carried out on patients who had either clinical or histologic evidence of metastatic disease in the neck; these operations, therefore, were not “elective.” In evaluating the effectiveness of our eighty-three definitive neck dissections, the eighty patients concerned were studied. Our operations were locally successful in forty-six instances (57 per cent) in that further melanoma in the dissected neck never developed
Catlin
FIG. 4. A, melanoma of left cheek; arrow points to a satellite. B, postoperative view. Cheek defect closed with skin flap rotated from the neck. Neck dissection was negative for metastases.This sixtyeight year old woman died two years later of metastases to the brain.
in these patients. In addition twenty-six of these patients (32 per cent) were free of melanoma for five years or longer. One of these patients underwent staged bilateral neck dissections. From this experience it can be seen that neck dissection is the most effective known treatment for metastatic melanoma in cervical lymph nodes. The over-all five year survival rate of one third of these patients compares favorably with similar treatment for the more common cancer of the tongue [26]. It is encouraging to know that an aggressive surgical attack on melanoma is as rewarding as in other forms of cancer of the head and neck. Elective Neck Dissection. The use of a radical regional lymph node dissection in the
absence of positive clinical findings in the neck has been a much debated subject [13,16,18,24, 25,271. No really clear-cut course of action can be advocated on the evidence produced so far. Our own experience with melanomas of the head and neck is of interest although it fails to supply a definitive answer to this elusive problem. In our management of 179 patients with melanoma, we performed twenty neck dissections in cases in which clinically there was no evidence of abnormal cervical lymph node enlargement. From a strictly literal viewpoint, these operations can be called “elective” in nature. Why did our surgeons choose to dissect these necks in which there was no clinical American Journal of Surgery
Cutaneous
Melanoma
of Head and Neck
5 I9
FIG. 5. A, diffuse melanoma of the left parietal scalp in a thirty-eight
left neck dissection.
Patient
has
FIG. 7. A, melanoma with satellites in right postauricular area. Arrows point to enlarged lymph nodes. B, neck dissection was in.. r . ., 1 . .,
j
I
evidence of disease? The most common reason was that in thirteen of the twenty patients the primary melanoma arose in the skin of the neck under consideration for surgery. Eleven of these patients had limited excisions of their melanomas before coming to us. In each of these eleven patients the examining surgeon could not be certain that the previous local excision had been adequate; the referring surgeons were equally uncertain. It was therefore elected to perform a more radical excision and include neck dissection at the same time. Any scarring produced by the re-excision in the neck would Vol. 112, October 1966
prevent a satisfactory dissection at a later date. It seems almost misleading to call a neck dissection carried out under these conditions truly elective even though lymph nodes were histologically positive in only one of the eleven operations. In the other two patients with no previous treatment, neck dissections were performed for the same reason of surgical entry into the neck. It might be more accurate to say that anatomic and technical considerations were the deciding factors for neck dissection in these thirteen patients. Six patients with melanomas on the cheek
Catlin TABLE IV STATUS AND END RESULTS FOR PATIESTS AT FIVE YEARS
Result No evidence of disease Dead of disease Living with melanoma Lost track of, status unknown Dead of other causes, no evidence of disease No treatment at Memorial Center Total NOTE:
Absolute
No. of Patients 73 71 7 11 13 4 179
five year cure rate (seventy-three
of
179 patients), 40.7 per cent; determinate five year cure rate (seventy-three of 162 patients), 43.8 per cent.
patient with melanoma on the ear were also subjected to elective neck dissections. The lymph nodes were histologically negative in all of them. To summarize then, in twenty elective neck dissections positive lymph nodes were found in only one instance. That patient remained free of melanoma only to die from a cardiovascular accident two years later. Fourteen patients were free of melanoma at five years; four patients died from melanoma, three of them from distant metastases and one from local recurrence in the neck. One patient was lost track of free of disease three years after surgery. From our experience it seems reasonable to conclude that an elective neck dissection is advisable only when it can be readily performed in conjunction with the excision of the primary melanoma even though in most instances the lymph nodes will be histologically negative for metastases. The psychological impact of a negative neck dissection on both the patient and the surgeon is not to be lightly disregarded. Clear lymph nodes indicate stage I disease with the best prognosis. Such knowledge provides optimism for both patient and surgeon. If an unsuspected metastasis is discovered by neck dissection, this indicates that the correct operation was made at the correct time. The patient received the best known treatment for a stage 11lesion. and one
END RESULTS
The five year results of our experience with all cases compare favorably with the reports of others [2,3,5,11,18,20,23] and are summarized in Table IV. The relationship of cure rate
to stage of disease on admission is tabulated in Table II and to the site of origin of the melanoma in Table I. The determinate five year cure rate shows improvement over our 1954 report [4]. A satisfactory explanation for this improvement is not apparent. Seventy-one of our patients were without evidence of disease at five years after treatment. At ten years an additional nine patients were dead from melanoma, demonstrating the ability of this lesion to become lethal after long delay. CONCLUSION
Actually it is the unpredictable behavior of melanoma which gives it such a bad reputation. The ability of this “black” cancer to metastasize by the blood stream can defeat the success of an otherwise splendid local control. Lethal distant metastases developed in seven of our patients more than five years after successful Iocal surgery. In the skin of the head and neck area, the knowledge that the five year cure rate for melanoma compares favorably with most of the more common epidermoid carcinomas of the mouth, pharynx, and larynx encourages a bold surgical attack. No other form of treatment is curative except in very isolated instances. Survival in the stage I cases (53 per cent) is approximately double that obtained in stage II (25 per cent). It is not the age, sex, or pregnant state of the patient or the size, ulceration and, satellite formatian of the primary melanoma which determines the outcome but rather the insidious ability of this lesion to metastasize widely and at any time. Inasmuch as it can be extremely difficult to determine just how “early” and localized a melanoma is, the emphasis on prompt, adequate excision cannot be overstressed. It has already been clearly pointed out [16,19] that it is impossible to foretell when or why a quiescent cutaneous “mole” will suddenly explode and become wildly malignant. A prompt and generous excision of any primary melanoma is always mandatory. A neck dissection should be included whenever there is a reasonable clinical or anatomic indication for doing so. REFERENCES 1. PACK, G. T., LENSON, Regional distribution
N., and GERBER, D. M. of moles and melanomas.
Arch. Surg., 65: 862, 1952. Awican
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4. 5. 6. 7.
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Melanoma
G. ‘f. End results in the treatment of malignant melanoma Surgery, 46: 44i. 1959. WATSON, E, C. Melanoma. -4 ten-year rctrospective survey in New Zealand. Australian & New Zealand J. Surg., 33: 31, 1963. OATLIN, D. Melanomas of the skin of the head and neck. d nn. Sury., 140: 796, 1954. MEYER, H. W. and GUMPORT, S. L. Malignant melanoma. .4nn. Surg., 138: 643, 1953. MORRIS, G. C. and HORN, R. C., JR. Malignant melanoma in the Negro. Surgery, 29: 223, 1951. DAS GUPTA, T. and BOWDEN, L. Malignant melanoma of unknown primary origin. Surg. Gynec. b Obst., 117: 341, 1963. CONLEY, J. J. Malignant tumors of the scalp: 58 cases of melanoma. Plast. 6 Reconstruct. Surg., 33: 163, 1964. SUMNER, W. C. Spontaneous regression of melanoma. Cancer, 6: 1040, 1953. GEORGE, P. A., FORTNER, J. G., and PACK, G. T. Melanoma with pregnancy. Cancer, 13: 854, 1960. MCNEER, G. and DAS GUPTA, T. Prognosis in malignant melanoma. Surgery, 56: 512, 1964. FORTNER, J. G. Factors in treatment of melanoma. M. Clin. North America, 45: 643, 1961. GUMPORT, S. L. and MEYER, H. W. Treatment of 126 cases of malignant melanoma. Ann. Surg., 150: 989, 1959. PACK, G. T. and SCHARNAGEL,I. M. The prognosis for malignant melanoma in pregnant women. Cancer, 4: 324, 1951. SHOCKET,E. C. and FORTNER, J. G. Melanoma and pregnancy an experimental evaluation of a clinical impression. S. Forum, 9: 6i, 1959. PACK,
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of Head and Se&
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16. MCSEER, G. The clinical behavior and managenicnt of malignant melanoma. J.A. 11f..4,, 176: 1, 1961. 17. MCNEER, G. ;\ curable form of cancer: melanoma. J1. Sri.. 16: 55, 1965. 18. MCS~AIS, B.. KIDDELL, D. H., RICHIE, Ii. E., and CKUCKER. E. F. Treatment of malignant melanoma. .lnn. Surg., 159: 967, 1964. 19. PACK, G. T. The pigmented mole and the malignant melanoma. Virginia M. Monthly, 84: 111, 1957. 20. SOUTHU’ICK, H. W., SLAUGHTER, D. P., and HINKAMP. J. F. Malignant melanoma of the head and neck. .-1nz. J. Surg., 106: 852, 1963. 21. HILARIS, B. S., RABEN, M., CALABRESE, A. S., PHILLIPS, R. F., and HENSCHKE, N. K. Value of radiation therapy for distant metastases from malignant melanoma. Cancer, 16: 765, 1963. 22. MARTIN, H. Surgery of Head and Neck Tumors. New York, 1957. Paul B. Hoeber, Inc. 23. KRAGH, L. V. and ERICH, J. B. Malignant melanomas of the head and neck. Ann. Surg., 151: 91, 1960. 24. PRICE, W. E. and DUVAL, M. K., JR. Regional lymph node dissection and malignant melanoma. Arch. Surg., 87: 59, 1963. 25. SOUTHWICK, H. W., SLAUGHTER, D. P., HINKAMP, J. F., and JOHNSON, F. E. The role of regional node dissection in the treatment of malignant melanoma. ilrch. Surg., 85: 63, 1962. 26. FRAZELL, E. L. and LUCAS, J. C., JR. Cancer of the tongue. Cancer, 15: 1085, 1962. 27. Gums, L. W. and MACDONALD,I. The role of radical lymphadenectomy in treatment of melanoma. An?. J. Surg., 104: 135, 1962.