Malign melanom

Editor's Notes

1. % 7,5 abcde uymuyor Autosomal dominantly inherited mutations in melanoma susceptibility genes are responsible for only a small proportion of cutaneous melanomas, probably less than 1 to 2 percent [37]. Mutations in two genes, CDKN2A and CDK4, have been identified in melanoma-prone families [38]. Features associated with the presence of familial melanoma include multiple cases of cutaneous melanoma on the same side of the family, multiple primary cutaneous melanomas in the same individual, early age of onset of cutaneous melanoma, and multiple nevi. Approximately 20 to 40 percent of families with three or more affected first-degree relatives have mutations in the CDKN2A gene; this drops to less than 5 percent in families with two affected members [39]. Mutations are found in approximately 15 percent of patients with multiple primary melanomas
2. WHO rezeksiyonlar arasında fark olmamasına ragmen 1cm i sadece 1mm altındaki lezyonlarda öneriyorlar
3. 8 yıllık takip sağkalım farkı yok
4. Fark yok
5. Rezeksiyon sınırının rekürenste etkili olduğunu gösteren tek çalışma Yazarlar 2mm altına 1cm, 2mm üstüne 1cm üzerinde rezeksiyon sınırı önermekte Sağkalıma etkisi yok 2mm altı 1cm 2mm üzeri 1cmden geniş cerrahi sınırla çıkartmayı öneriyorlar Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0 to 4.0 mm). Intergroup Melanoma Surgical Trial. AUBalch CM; Soong S; Ross MI; Urist MM; Karakousis CP; Temple WJ; Mihm MC; Barnhill RL; Jewell WR; Wanebo HJ; Harrison R SOAnn Surg Oncol 2000 Mar;7(2):87-97.   BACKGROUND: Ten- to 15-year survival results were analyzed from a prospective multi-institutional randomized surgical trial that involved 740 stages I and II melanoma patients with intermediate thickness melanomas (1.0 to 4.0 mm) and compared elective (immediate) lymph node dissection (ELND) with clinical observation of the lymph nodes as well as prognostic factors that independently predict outcomes. METHODS: Eligible patients were stratified according to tumor thickness, anatomical site, and ulceration, and then prerandomized to either ELND or nodal observation. By using Cox stepwise multivariate regression analysis, the independent predictors of outcome were tumor thickness (P < .001), the presence of tumor ulceration (P < .001), trunk site (P = .003), and patient age more than 60 years (P = .01). RESULTS: Overall 10-year survival was not significantly different for patients who received ELND or nodal observation (77% vs. 73%; P = .12). Among the prospectively stratified subgroups of patients, 10-year survival rates favored those patients with ELND, with a 30% reduction in mortality rate for the 543 patients with nonulcerated melanomas (84% vs. 77%; P = .03), a 30% reduction in mortality rate for the 446 patients with tumor thickness of 1.0 to 2.0 mm (86% vs. 80%; P = .03), and a 27% reduction in mortality rate for 385 patients with limb melanomas (84% vs. 78%; P = .05). Of these subgroups, the presence or absence of ulceration should be the key factor for making treatment recommendations with regard to ELND for patients with intermediate thickness melanomas. CONCLUSIONS: These long-term survival rates from patients treated at 77 institutions demonstrate that ulceration and tumor thickness are dominant predictive factors that should be used in the staging of stages I and II melanomas, and confer a survival advantage for these subgroups of prospectively defined melanoma patients.  
6. Prospektif randonmize çalışma yok
7. İlk 5 yıl içinde lokal rekürens çıkar.1- 2mm altı lezyonlarda 9/6 da 5 ve üzerindeki yıllarda, 2mm üzerindeki lezyonlarda 8/6 da ilk 4 yılda lokal rekürens Risk faktörleri: Cerrahi çıkartım genişliği Primer tm kalınlığı Ülserasyon Anotomik yerleşim lokal rekürens proksimal ekstremite%1,1 Gövde %2,7 Distal üst ekst %3,1 Distal alt ekst %6,3 Baş boyun 9,4 Desmoplastik histoloji pozitifse lokal rekürens %48 Nodal metastaz
8. 1395 hasta 3,9 yıl izlem intransit metastaz %6,6
9. BCG — Response rates of 50 to 100 percent for BCG-injected lesions have been reported, and this therapy may also result in a systemic anti-neoplastic effect, with up to 21 percent of the non-injected lesions showing a response [32]. IFNa — The efficacy of intralesional injection of IFNa was shown in a study of 51 patients with at least one skin metastasis from melanoma who received 10 MU of recombinant IFNa or 6 MU of highly purified natural IFNa three times weekly [33]. There were 24 complete or partial local responses, the duration of which ranged from 2 to 18 months. Similar to the experience with BCG, systemic anti-neoplastic responses were observed in a few patients (n = 9), with documented responses in lung and non-injected soft tissues. IL-2 — High-dose systemic IL-2 represents the current standard of care for patients with disseminated malignant melanoma. At least some data supports a possible benefit for intratumoral injection of a limited number of melanoma metastases, with significantly less toxicity. In one study, 24 patients with primary melanoma and a single or multiple cutaneous or soft tissue metastases received intralesional injections (from 0.6 to 6 x 10(6) IU per dose, depending upon lesion size) two to three times weekly [34]. A complete response was seen in 209 of the 245 treated metastases, with a partial response in 21 others. Treatment was reasonably well tolerated. Cisplatin/epinephrine gel — Other investigators have injected local deposits with a gel consisting of cisplatin plus the vasoconstrictor epinephrine [35,36] in order to attempt to deliver high concentrations of the cytotoxic agent to the local area with minimal systemic leakage and toxicity. In one report of 28 patients with recurrent melanoma, this approach resulted in a complete response in 114 of 244 treated lesions, and a partial response in 16 [36]. Electrochemotherapy — A novel approach to intralesional delivery of dytotoxic agents is the use of electrochemotherapy, in which a small amount of an electric current is applied to a subcutaneous tumor deposit simultaneously with intralesional injection of a cytotoxic agent [37,38]. Drug delivery can be increased 100-fold by this electroporation method [39]. Although most studies have used bleomycin [37,38,40], cisplatin is also being used [41]. Response rates of up to 100 percent of the injected lesions have been noted, with no evidence of systemic antineoplastic toxicity.
10. Krementz, ET, Carter, RD, Sutherland, CM, et al. Regional chemotherapy for melanoma. A 35-year experience. Ann Surg 1994; 220:520. 294 hasta