Prevention of malignant melanoma

Dermatologists and physicians of other specialties, as well as other health professionals have made tremendous efforts to improve the public education (primary prevention) and early detection (secondary prevention) of cutaneous malignant melanoma (CMM) especially during the last decade. In Australia, the country with the highest incidence of CMM in the world, the first public and effective campaigns were already carried out in the sixties. Through the public campaigns, the knowledge increased about skin cancer, and the attitude and behavior toward sun exposure changed in the population. In the USA and Great Britain too, effective public campaigns were carried out in great numbers and extensive experience was acquired. In Germany, prevention campaigns were first run in regional areas. In 1989, the Commission of Early Detection and Prevention of Melanoma of the German Dermatological Society launched nation-wide campaigns. These activities were complemented by regional campaigns in the 1990s. The analysis of previous campaigns demonstrates that single activities are less effective and repeated campaigns are necessary to increase knowledge about skin and to change attitudes and behavior towards UV-exposure. In addition, the development of sun protective clothing and structural changes, e.g. creation of shady places around open-air swimming pools, should be aimed for. Physicians of other specialties and other health professionals should also be included in prevention campaigns.     

Primary malignant melanoma of the vagina

We report two cases of primary malignant melanoma of the vagina explaining the essential clinical pathological and therapeutic features. They themselves, added those represented in literature, might constitute a further contribution to best definition of the unusual genital pathology, especially as regards prognostic and therapeutic aspects.     

Primary malignant melanoma of the oesophagus

We report the case of a 74-year-old female patient in whom a primary malignant melanoma of the oesophagus was detected at the time of investigation of phlebothrombosis. Therapy of choice for this extremely rare tumour is radical surgical resection of the oesophagus. Even after surgical resection, primary oesophageal melanomas have a very poor prognosis. According to the present state of knowledge, it remains unclear to what extent the prognosis could be improved by adjuvant therapeutic procedures with radiotherapy or chemotherapy and immunostimulation.     

Primary bilateral malignant melanoma of the choroid (author's transl)

Report on an extremely rare case of primary bilateral malignant melanoma of the choroid with histological verification of both tumors. The patient was a 54-year-old woman; the presumptive clinical diagnosis was a primary bilateral melanoblastoma. A thorough general examination did not reveal any metastases. Six months later the patient underwent surgery. The left eye, in which the tumor was larger, was enucleated and a B-type malignant melanoma of the choroid with invasion of the sclera was diagnosed histologically. Two months later the patient died of a lung embolism. Histological verification of the tumor of the right eye led to the same diagnosis as in the left eye, but without invasion of neighbouring structures. No distant metastases were found at autopsy. A thin layer of slender spindle nevus cells was found between the tumor and the sclera during the histological study. The author agrees with Yanoff and Zimmerman (1967) that this may be regarded as the origin of the malignant tumor.     

Primary malignant melanoma of the vagina: a report of 22 cases

In this paper, 22 patients from 1973 through 1994 with primary malignant melanoma are retrospectively analyzed. Vaginal bleeding, discharge and a tumor mass were the chief complaints. The most common site of the tumor origin was the lower third of the anterior and postrior vaginal wall. The 5-year survival rate of 18 previously untreated patients was 11% (2/18). Of the 18 patients, 9 in stage I treated by surgery and postoperative chemothreoapy and/or radiotherapy survived for an average of 33 months. Two of the 9 patients receiving radical surgery survived for more than 5 years. None of the remaining 9 patients in stage II-IV treated with chemotherapy and/or radiotherapy survived longer than 2 years. The survival time differed significantly in patients with and without pelvic lymph node metastasis (7 versus 41 months) and in those with and without vascular tumor thrombi (13 versus 43 months). Mitotic index of tumor cells and lymphocytic infiltration were of no prognostic value.     

Prognosis in malignant melanoma

A uniform and practical classification and staging system for melanoma must exist and be widely adopted if useful comparisons between different treatment centers and databases are to be made. This article reviews the 1992 American Joint Committee on Cancer pTNM staging system. In this classification, localized disease without regional nodal involvement is defined as stage I or II, depending on the tumor thickness of the primary melanoma. Regional lymph node involvement and/or in-transit metastasis is defined as stage III, and systemic metastatic disease is defined as stage IV.     

FDG-PET in the staging of malignant melanoma

Positron emission tomography (PET scanning) is a useful tool in staging of malignant melanoma. A radiolabelled glucoseanalogue can demonstrate changes in metabolism and thus identify malignancy in macroscopic unchanged structures. It is a non-invasive, fast method to identify especially visceral, still symptomless metastases. The patient can often be spared from mutilating surgery.     

Immunology of malignant melanoma

Traditionally a homograft valve is used as a pulmonary replacement device for the Ross operation. Right ventricular outflow tract reconstruction during aortic valve replacement with an autograft was performed with stentless xenograft valves in nine patients. Hemodynamic performance is satisfying, but, long term evaluation is needed.     

Biochemistry of malignant melanoma

The biochemistry of malignant melanoma is reviewed. The biosynthesis of melanin from tyrosine is described and the role of tyrosinase and other enzymes in melanoma considered. Detailed methods for the assay of free catechols, their metabolites and urinary indole melanogens are included. Normal values for these constituents and their significance in the evaluation of melanoma patients are discussed.     

Chemotherapy of malignant melanoma

Previous studies have shown the kidney to be an important site for the catabolism of secretin. We have investigated possible sites within the kidney for secretin uptake in four intact anesthetized dogs. The disappearance half-time of an intravenous infusion of secretin, measured by a sensitive and specific ratioimmunoassay in four intact anesthetized dogs was 2.84 minutes. After ureteral ligation (to arrest glomerular filtration), the half-time of a similar intravenous dose of secretin was 2.78 minutes. Finally, the renal vascular pedicles were ligated to totally exclude the kidneys from the circulation and the half-time was found to be 5.43 minutes. These findings demonstrate that the efficient renal mechanisms for secretin degradation are not dependent upon glomerular filtration but upon some other mechanism, presumably located in renal tubular cells.     

Extremity perfusion in malignant melanoma

The Drosophila giant lens (gil) gene encodes a secreted molecule which if absent leads to the recruitment of additional ommatidial cells normally eliminated by apoptosis. Heat induced ectopic gil expression leads to a reduction of ommatidial cells suggesting that gil is secreted by differentiating cells to prevent the development of an excess of cells of a given ommatidial cell type. A second important defect is the misrouting of photoreceptor axons in gil mutants. However, gil function is not required in photoreceptor axons for the establishment of proper connections. We propose that gil acts on the development of lamina cells preventing the correct differentiation of the target region of photoreceptor axons and therefore leading to an axon guidance phenotype.     

Conjunctival malignant melanoma in children

The first case concerns a 14-year-old girl with a brown conjunctival mass temporally in her right eye which was excised and diagnosed as active conjunctival melanotic lesion. Five years later, a malignant melanoma of the right lacrimal sac and orbit led to general metastatic spread. The second case demonstrates a conjunctival brown mass temporally in the left eye of a 3-year-old boy which enlarged over 4 years. The excision revealed a melanotic lesion which was of uncertain histological dignity. The third case occurred in a 4-year-old boy with a conjunctival glassy tumor temporally in his right eye which after excision led to controversial discussions concerning benign nevus or malignant melanoma.     

Tamoxifen in metastatic malignant melanoma

Eight patients with advanced metastatic malignant melanoma were treated with tamoxifen at a dose of 10 mg orally twice a day for a minimum of 4 weeks. There was one complete response of skin disease occurring over a period of 40 weeks. This patient has remained disease-free for 8+ weeks. Two other patients demonstrated a partial but brief (4 weeks) shrinkage of gross subcutaneous disease. Three patients exhibited no response to the drug, but two patients had rapid acceleration of disease between the second and fourth weeks of treatment. Further exploration of the basis for these favorable and adverse responses is being pursued.     

Prognostic factors in malignant melanoma

The clinical spectrum and biologic behavior of melanoma are heterogeneous. Several clinical factors may include sex, location, and age. Histologic prognostic factors may include tumor type, tumor thickness, and mitotic index in relationship to the primary tumor. With respect to metastatic melanoma, the prognostic factors may include lymph node status, number of lymph nodes, and extracapsular extension. Cytogenetic and molecular determinants of progression of melanoma may aid the current prognostic factors when they are established more firmly. Current surgical treatment is determined by the clinical and histologic factors.