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BACKGROUND Thickness is known to be an important survival prognosticator for cutaneous melanoma, but controversy exists as to whether Clark level of invasion retains prognostic significance once thickness has been accounted for. A recent proposal to eliminate Clark level from the staging system for melanoma of the American Joint Committee on Cancer (AJCC) prompted the authors to investigate whether level adds useful prognostic information to Breslow thickness. They used the data base of the New York University Melanoma Cooperative Group (NYU-MCG) Registry. METHODS The analysis was based on 919 patients with AJCC Stage I or II melanomas diagnosed between 1972 and 1982 and followed for an average of 10.9 years. Melanoma thicknesses were divided into 4 categories (≤0.75, 0.76–1.50, 1.51–4.00, and >4.00 mm). Patients were cross-classified according to tumor thickness and Clark level (II–V). For each combination of thickness and level, the Kaplan–Meier survival curve and 10-year survival proportion were computed, using death from melanoma as the outcome. The impact of Clark level on survival was evaluated for each of the thickness categories. The Cox proportional hazards model was used to assess the simultaneous effect of thickness and level on survival while controlling for other important prognostic factors, i.e., age, tumor location, and presence or absence of ulceration. RESULTS Level of invasion was a significant predictor of death from melanoma in each of the four thickness categories. Likewise, in the Cox analyses, level was a significant prognostic variable, even after thickness was included in the model and regardless of whether thickness was treated as a categoric or a continuous variable. CONCLUSIONS These results confirm that both tumor thickness and level of invasion are important independent prognostic factors in AJCC Stage I and II melanomas. The authors recommend that Clark levels be kept as criteria in the AJCC staging system and be included in pathology reports. [See editorial on pages 491–6, this issue.] Cancer 2000;88:589–95. © 2000 American Cancer Society.

BACKGROUND Recently, the Pigmented Lesion Group at the University of Pennsylvania described a 4-variable model for predicting 10-year survival for patients with primary cutaneous melanoma. The variables are tumor thickness, anatomic site of the lesion, age, and gender. The objective of the current study was to test the validity of this model, employing the large data base of the New York University Melanoma Cooperative Group. METHODS The predicted probabilities of 10-year survival for 780 patients with primary cutaneous melanoma were determined by multivariate logistic regression, using the 4 variables. RESULTS The overall 10-year survival rate of the current study group was 78.4%. Of the four variables, tumor thickness, anatomic site of the lesion, and age were found to be independent predictors of survival. Although survival was better for women, gender was not a statistically significant factor in predicting 10-year survival when entered into the multivariate logistic regression model. In the current study, the probability of 10-year survival of patients with melanomas < 0.76 mm ranged from 93-99%, depending on the age and primary site. Age and site had more impact on the prognosis of intermediate and thick melanomas than on thin melanomas. Thus, for melanomas 0.76-1.69 mm, 1.70-3.60 mm, and thicker than 3.60 mm, the probabilities of survival ranged from 70-94%, 39-82%, and 23-68%, respectively. CONCLUSIONS The wider ranges in survival rates for thicker melanomas, depending on the other variables, emphasize the importance of including variables in addition to tumor thickness in a prognostic model. Using a large data base from a medical center, the current study supports the prognostic multivariate model of the Pigmented Lesions Group of the University of Pennsylvania; however, the authors of the current study did not find gender to be statistically significant in this multivariate model. Cancer 1997; 80:1426-31. © 1997 American Cancer Society.

Background. This study was designed to determine the risk of developing malignant melanoma (MM) in patients with a history of basal cell and/or squamous cell skin cancer (BCC/SCC) and to determine whether surveillance efforts can be directed toward these patients for the detection of early MMs. Methods. The study cohort was followed by annual total cutaneous examination (TCE). Controls consisted of individuals from the United States population matched for age, sex, and length of follow-up. The anatomic locations of the study cohorts'newly diagnosed MMs were plotted on an anatomic chart. The setting was a private dermatology practice. Two hundred, ninety consecutive white patients with a history of BCC/SCC but with no personal or family history of MM were followed by annual TCEs. The main outcome measures were the relative risk of developing MM and their prognosis. Results. Ten of the 290 patients developed an MM within an average of 109 months of follow-up (range, 317 years). All MMs were less than 0.70 mm in Breslow thickness and 80% occurred on usually clothed cutaneous sites. The expected number of MMs in the control population was 0.59 (P=0.006), resulting in a relative risk of 17. Conclusion. Patients with BCC/SCC skin cancer are at substantial increased risk for developing MM. Regular and life-long surveillance TCE is an inexpensive and effective method for detecting curable MMs in such patients

Skin cancers are the most common cancers in humans. The American Cancer Society estimates that in the United States more than 700,000 new skin cancers are diagnosed annually. Although the majority of nonmelanoma skin cancers occur on visibly exposed anatomic areas, most malignant melanomas occur on body sites obscured by clothing. The high mortality associated with advanced melanomas emphasizes the importance of performing regular total cutaneous examinations in all patients to detect early, easily curable lesions. A number of techniques aid in these examinations: (1) physical and psychologic preparation of the patient; (2) appropriate lighting and a suitable examination table; (3) when indicated, use of Wood's light, dermoscopy, and photography. In addition, any suspicious lesion should be biopsied promptly either in parte or in toto. Lastly, the patient should be educated about the signs and symptoms of skin cancer, the role of sunlight in causing skin cancer, and the need for sun avoidance and/or protection. By heightening public awareness of the high incidence of cancers of the skin and by emphasizing the need for routine examination of the entire cutaneous surface, most cutaneous malignancies can be diagnosed early when they can be cured by simple surgical procedures.

The objective of follow-up examinations of patients who have had Stage I invasive malignant melanoma is the early detection of local recurrences, metastases, and new primary melanomas. Model schedules for follow-up intervals were developed based on a survey of eight physicians. These melanoma experts agree that regular follow-up examinations are indicated and that the time intervals between examination vary according to the thicknesses of the melanomas. The patient follow-up schedule derived is: for melanomas up to 0.75-mm thick, every 6 months for years 1 and 2, and annually for years 3, 4, and 5; for melanomas 0.76-1.50 mm thick, every 3 months for years 1 and 2, semi-annually for years 3, 4, and 5; and for melanomas > 1.50 mm thick, every 3 months for years 1, 2, and 3, and semi-annually for years 4 and 5. After the fifth year, the recommendation is to examine all patients annually for life because of the continued risk for recurrences and new primary melanomas. For those individuals at especially high risk for developing multiple primary melanomas more frequent examinations may be appropriate.

This is the second article in a series that reviews the experience in the Skin and Cancer Unit, from 1955 through 1982, with the treatment of basal cell carcinomas (BCCs). This report deals with 2314 previously untreated (primary) BCCs removed by curettage-electrodesiccation. Multivariate analysis showed that increasing lesion diameter (P less than .001), high-risk anatomic sites (nose, paranasal, nasal-labial groove, ear, chin, mandibular, peri-oral, and peri-ocular areas) (P less than .001), middle-risk anatomical sites (scalp, forehead, pre- and post-auricular, and malar areas) (P less than .001), and time-span treated (1955 to 1963) (P = .012) were independent risk factors for high recurrence rates. The patient's age, sex, and lesion duration before treatment did not affect the recurrence rates. In order to best illustrate our current experience with BCCs, the last time-span (1973 to 1982) was examined in detail. For the low-risk sites (neck, trunk, and four extremities), BCCs of all diameters responded well to curettage-electrodesiccation with an overall 5-year recurrence rate of 3.3% (SE = 1.5%) determined by the modified life-table method. In the middle-risk sites BCCs less than 10 mm in diameter had a recurrence rate of 5.3% (SE = 2.7%). Finally, in the high-risk sites, lesions less than 6 mm in diameter had a recurrence rate of 4.5% (SE = 2.6%). Thus, BCCs less than 6 mm in diameter, regardless of anatomic site, as well as selected larger BCCs depending on their anatomic site, are effectively treated by currettage-electrodesiccation.

This is a study of factors associated with late recurrence (i.e. 10 or more years after definitive surgery) of cutaneous malignant melanoma (MM). Four factors were evaluated: Breslow thickness, site of the primary MM, age of the patient at initial treatment for MM, and gender. These factors were compared between two groups: (1) Stage I cases in the New York University Melanoma Cooperative Group (NYU-MCG) database that had 'early recurrence' (less than 10 years) of MM, and (2) cases in the literature with late recurrence of MM plus five new cases reported here. Compared to the group of patients with 'early recurrence' of MM, the group of patients who had late recurrence of MM were found more likely to have thinner primary melanomas (p less than 0.001), to be younger (p less than 0.001), to be female (p = 0.001), and, for females, to have the MM located on an extremity (p = 0.017). Because late recurrence does occur and because the risk of developing a new primary MM is increased in MM patients, any patient who has had a MM should be followed for life.

This is the fourth report in a series that reviews the experience in the Skin and Cancer Unit, from 1955 through 1982, with the treatment of basal cell carcinomas (BCCs). It concerns 862 primary (previously untreated) BCCs irradiated by a "standardized" x-ray therapy schedule. The overall 5-year recurrence rate for these lesions, as determined by the modified life-table method, was 7.4%. This rate was not significantly different from that experienced with 211 recurrent (previously treated) BCCs with a re-recurrence rate of 9.5% (P = .552). For the primary BCCs, multivariate analysis showed that increasing BCC diameter was the only independent risk factor for high recurrence rates (P = .003). The patient's age or sex, the duration of the BCC, the anatomic site of the BCC, or time-span treated (1955-1963, 1964-1972, 1973-1982) did not significantly affect the recurrence rate. Additional analysis showed that BCCs on the head less than 10 mm in diameter had a 5-year recurrence rate of 4.4% whereas those 10 mm or greater in diameter had a rate of 9.5%. Lastly, the proportion of recurrence-free treatment sites with a good or excellent long-term cosmetic outcome after x-ray therapy (63%) was lower than previous reports in this series with curettage-electrodesiccation (91%) and surgical excision (84%). Thus, if the long-term cosmetic outcome after treatment is not an overriding concern to the patient, x-ray therapy is an effective modality for many primary and recurrent BCCs.

This is the first article in a series reviewing the extensive experience of the Oncology Section of the Skin and Cancer Unit, from 1955 through 1982, with 5755 basal cell carcinomas (BCCs) treated by curettage-electrodesiccation, surgical excision, or x-ray therapy. Recurrence rates were calculated by three methods for each of the treatment modalities: 1) by the raw recurrence rate method; 2) by the "strict" 5-year recurrence rate method; and 3) by modification of the life-table method. Our analyses show that the last method best approximates the true recurrence rate. Primary (previously untreated) BCCs had a 5-year recurrence rate of 10.6% (standard error 0.6%), and previously treated BCCs had a rate of 15.4% (standard error 1.3%) (P = .0002). The greatest risk for recurrence of treated primary BCCs occurred 1 to 4 years after therapy. It is concluded that recurrence rates of primary BCCs should be reported separately from those of previously treated BCCs and that the modified life-table method is best suited to calculate 5-year recurrence rates.

A total of 357 white patients who had melanocytic nevi that fulfilled the clinical criteria for the "classic" atypical-mole (dysplastic-nevus) syndrome (100 or more melanocytic nevi; one or more melanocytic nevi 8 mm or larger in diameter; and, one or more melanocytic nevi with atypical features) were followed for the development of cutaneous malignant melanomas. Seventeen patients (4.8%) developed malignant melanomas during an average follow-up period of 49 months. One patient developed two malignant melanomas. Eight of the malignant melanomas detected were in situ and ten were invasive melanomas (less than 0.86 mm in Breslow thickness), implying an excellent prognosis. The number of malignant melanomas detected in these patients exceeded significantly the number expected to occur in age- and sex-matched white controls. All groups were shown to have an increased risk for the development of malignant melanomas. Total-body photographs were helpful in detecting changes in size, shape, and color that led to the diagnosis of malignant melanoma. These data support the concept that patients with this readily regionalized clinical presentation of classic atypical-mole syndrome are at an increased risk for malignant melanomas and, therefore, should be examined regularly.

In order to determine the prevalence of key features concerning nevocytic nevi (NN) in 150 consecutive Caucasian patients with dysplastic nevi (DN), total-body photographs were reviewed that revealed the following: 74% had greater than or equal to 100 NN, 73% had NN 8 mm or more in diameter, and 81% had atypical NN. The patients were then divided into two subsets, those with a personal and/or family history of malignant melanoma (MM) and those without, to see if the proportion of these three features differed in these two groups. There were no statistically significant differences between the MM-history-positive and MM-history-negative subsets.

This report verifies the ability of a Prognostic Index (PI) to accurately predict 5-year survival rates for 879 Stage I cutaneous malignant melanoma (MM) patients seen at New York University Medical Center. The PI used in this study was first reported from Munich, West Germany, and is calculated from standard histologic sections by multiplying the MM thickness in millimeters (Breslow method) by the number of MM mitoses per square millimeter. A PI value of less than 19 versus greater than or equal to 19 was found to be a significant and independent prognostic variable for Stage I MM when compared with seven other predictive variables (including Breslow thickness). These PI intervals identified a subgroup of patients with MM of intermediate thicknesses (1.50-3.49 mm) whose significantly worse survival would not have been anticipated if prognosis were determined by Breslow thickness alone. For example, patients with MM 1.50 to 2.49 mm thick have a 5-year survival rate of 84.1% determined by Breslow thickness alone; however, among these patients exists a subgroup with PI greater than or equal to 19 whose survival rate is only 57.6%. This study verifies the additive usefulness of the PI in predicting survival rates of patients with Stage I cutaneous MM.

The immune system is believed to influence tumor growth; and, ionizing radiation has an immunosuppressive potential. However, investigators have come to conflicting conclusions regarding the effect of localized radiation therapy on both the immune system and on distant tumor growth. This report describes two murine models. In the first, B-16 malignant melanoma was implanted simultaneously into the left groin and right axilla. In the second model, in order to immunize the mouse, B-16 melanoma was implanted into the left groin 1 week before implanting melanoma into the right axilla. In both models, 600 rad caudal hemibody irradiation was given in a single fraction with a 4 MeV linear accelerator. Significant decrease in the growth of irradiated groin tumors occurred. Unirradiated axillary tumors did not demonstrate increased growth. We conclude that, at least in these models, high dose, wide-field irradiation does not augment the growth of unirradiated tumors in the same host.

Data concerning risk factors for the development of cutaneous malignant melanoma (MM) were abstracted from published case-control studies. Relative risks (more appropriately "odds ratios") and 95% confidence intervals were quoted or calculated for each risk factor in each study. Those risk factors that were reported to be significant in over half of the studies include: phenotypic factors (blue eyes, blond or red hair, light complexion, freckles, sun sensitivity, and inability to tan); personal history of non-melanoma cutaneous cancer or precancer; higher socioeconomic status; increased numbers of nevocytic nevi; and bursts of sun exposure. Further study is needed on family history and personal history of MM; these were not found to be significant risk factors in over half the reviewed case-control studies. This review leaves out other undoubtedly important risk factors such as dysplastic nervus syndrome and race, which need investigation by the case-control method. Determination of risk factors allows the identification of that subset of the population most at risk for the development of MM. Given the continued increase in the incidence of MM, these data can help to focus preventive measures on the more susceptible subgroups of the population.

The results of treatment of 42 cases of lentigo maligna and 16 of lentigo maligna melanoma at the New York University Medical Center was reviewed. The recurrence rate after surgical excision of 22 lesions of lentigo maligna was 9% (2/22), but after treatment of 20 such lesions with destructive techniques (X rays, curettage-electrodesiccation, cryosurgery), it was 35% (7/20). Of 11 cases of lentigo maligna melanoma that were excised, none recurred locally, but fatal metastases ensued in one case. Five patients who were eventually classified as having lentigo maligna melanomas had been treated by destructive techniques. In four of them there were local recurrences and in two, metastases as well; the fifth patient had metastases without local recurrence. On the basis of this review of these 58 cases, we conclude that surgical excision and careful histologic study of step sections through the entire lesion insure accurate diagnosis and provide the highest cure rates for lentigo maligna and lentigo maligna melanoma.

In a prospective study of 455 consecutive patients with superficial spreading malignant melanomas entered into the data base of the Melanoma Cooperative Group of New York University Medical Center, it was found by linear-regression analysis that there is a statistically significant (p = 0.005) positive correlation between the ages of the patients and the thicknesses of their lesions. Although the reasons for the correlation between ages and thicknesses are not certain, several possible explanations were considered, namely: (1) the greater prevalence of superficial spreading malignant melanomas in the aged on the lower limbs where thicker lesions were present in our patients, (2) the altered skin of the elderly, which may favor deeper penetration by these neoplasms, (3) impaired immunologic responses in the aged, (4) the delay in diagnosis of malignant melanomas in the elderly because of obscuration of them by numerous benign pigmented lesions that frequently develop with aging, and (5) lesser concern of the elderly with their physical appearances in particular and medical problems in general.

A case of giant keratoacanthoma of the nose and paranasal areas is presented. Following a prolonged and stormy course, the tumor eventually involuted spontaneously, leaving in its wake significant destruction of an ala nasi. This report illustrates the problems of attempting to predict the natural history of a particular keratoacanthoma and the difficulties in managing an agressive-type tumor of this type.

Although thin malignant melanomas, i.e., those less than 0.76 mm in thickness, of the skin generally do not metastasize, it has been recently reported that when histologic regression is present, such lesions may then have a greater propensity for dissemination. However, this was not apparent in this study in which only one melanoma metastasized in a consecutive series of 41 thin lesions which were step-sectioned and had evidence of regression histologically. Possible explanations for this discrepancy are the failure of other authors to include only step-sectioned specimens of the primary melanomas in their material and/or geographic differences in the biologic behavior of this malignant neoplasm.

Malignant melanomas are not very radiosensitive neoplasms. Therefore, the prime management of such lesions is surgical. However, there are certain circumstances in which radiation therapy has been used and should be considered as useful. This article provides an overview of the literature on radiotherapy of primary and metastatic malignant melanomas in man. In addition, some unconventional methods like the use of radiation sensitizers, oxygen-independent radiation therapy, radiation combined with hyperbaric oxygen, and high-dose-per-fraction irradiation are discussed. The beneficial responses to radiation that have been reported in the literature and that we have personally observed suggest that a prospective study to determine the proper role of radiation therapy in the management of all forms and stages of malignant melanomas is warranted.

General principles of biopsy technique of cutaneous malignancies are given and specific techniques are described in detail for lesions of different types. Schematic drawings further elucidate subtleties not easily put into words.

A primary cutaneous myxosarcoma of the skin developed at the site from which an epithelial cyst had been excised. Following this surgical excision a "keloid" developed which was injected with intralesional corticosteroids. At this site an enlarging tumor developed which was initially thought to be myxoma on the histologic examination but subsequently gave rise to a solitary lymphnode metastasis. Wide local excision of the primary lesion with skin graft and radical axillary lymphadenectomy resulted in cure. Now, nine years post surgery the only problem that remains is repeated bouts of acute cellulitis in the slightly lymphe dematous upper extremity. Myxosarcomas of the skin are rare tumours. Metastases from such lesions are exceedingly rare.

Excision, as well as curettage and electrodesiccation, both have important places in the treatment of basal-cell carcinomas by the dermatologist, who should be knowledgeable concerning all available methods for treating this malignancy. In this paper we discuss factors which help one select excision or curettage and electrodesiccation for the treatment of a particular basal-cell carcinoma, rather than one of the other methods available such as x-radiation, Mohs' surgery or cryosurgery. We further discuss factors which could influence the choice between excision and curettage and electrodesiccation.

When first seen in May, 1974, this 7-week-old child presented a rapidly enlarging hemangioma involving her face, scalp, oral mucous membranes and pharynx. Because of the development of stridor and complete closure of the eyelids of one eye by the hemangioma, the child was placed on systemic corticosteroid therapy. This was continued for a three-month period at which point it was discontinued. There was unquestionalbe shrinkage of the tumor during therapy. The stridor disappeared and the eyelids opened within a few days. Within six days of discontinuation of the corticosteroids, there was sudden enlargement of the lesion and reappearance of stridor which again subsided after a six-week course of systemic corticosteroids. Currently, the child is still under observation. It is anticipated that further spontaneous resolution will take place but that she will require plastic surgery for some of the residual deformities. The questions of ocular involvement, cardiac enlargement, occlusion of the pharyngeal airway, and arteriovenous anastamoses were raised in this child. Newer treatments including embolization treatments and cryotherapy were considered for this child but were not pursued since the growth of the hemangioma came to a virtual standstill and the child is otherwise thriving.