Historical Overview of Melanoma G. RODERICK McLEOD, AO, MB, BS, FRCS (EDIN), FRCS (ENG), FRACS NEVILLE C. DAVIS, AO, MD, HONDS, FRCS, FRACS, FACS
his consideration of the development of knowledge about malignant melanoma is confined to the period from the late 18th to the early 20th century. It was in this period that the first descriptions of melanoma as a disease entity were published, and the foundation of the principles of management was established.
T
John Hunter In the Hunterian Museum of the Royal College of Surgeons of England can be found specimen 219. This specimen was collected by John Hunter (1728 - 1793) in 1787. The accompanying description of the specimen gives details on the patient, a 35-year-old man, in whom a mass that had been excised 3 years previously from behind the angle of the mandible recurred. The recurrent mass had enlarged slowly until it was injured in a drunken fight, when it began to grow rapidly over the next few weeks. Hunter excised the mass, which he described as a “cancerous fungous excrescence.“ It has more recently been reexamined and confirmed to be melanoma.’
Red
Theophile
Laennec
Although Hunter was the first to describe a patient with metastatic melanoma and preserve a specimen, it was Reni Theophile Laennec (1781-1826) who first described melanoma as a disease entity. Laennec combined his study of the signs and symptoms of disease in patients in the wards with the subsequent study of the anatomic appearance in the mortuary. Laennec presented an unFrom the Queensland Melanoma Project, Princess Alexandra Hospital, Brisbane, Australia. Address correspondence to G. Roderick McLeod, Queensland Melanoma Project, Princess Alexandra Hospital, Wolloongabba, Brisbane 4102, Australia.
0 1992 by Elsevier Science Publishing
Co., Inc.
l
0738-081x/92/$5.00
published memoir to the Facultg de Mhdecine de Paris in 1806, in which he described melanoma as a disease entity. He first used the word melanosis in 1812 in the Bulle-
fins de la Faculfe’ de Me’decine de Paris2 William Norris In 1820, William Norris (1792 - 1877), a general practitioner in Stourbridge, England, gave the first description of a case of melanoma in the English literature.3 He called it a “case of fungoid disease,” but the description was of a patient who died from disseminated melanoma. Norris subsequently wrote that this was “the first genuine general good case” of melanoma. His description, which follows, clearly substantiates the claim. Mr. D., aged 59 years, of light hair and fair complexion presented to Dr. Norris on February 6,1817 with a tumour of his abdominal wall midway between umbilicus and pubes. There had always been a mole on this position but nine months previously, it began to grow and tumour developed. It was half the size of a hen’s egg, of a deep brown colour, of a firm and fleshy feel, ulcerated, and discharging a highly foetid ichthorous fluid. The apex of the tumour was broader than its base. Some months after the tumour appeared, several distinct brown nodules sprang up around it. The primary tumour was removed by the knife but then recurred in the scar in less than six weeks. The glands of the groin were swollen and slightly tender to the touch. In spite of the disseminated nature of the tumour the general health of the patient was not so much impaired as to interfere with his exercise or business. Multiple subcutaneous deposits developed with a distressing cough and dyspnoea before he died.4
Norris’ description of the autopsy findings demonstrated the overall body distribution of the metastatic disease. In 185 7, Norris published a paper in which he gave a very complete description of the case he had reported in 1820 and of two other cases, with brief notes on five more patients. Norris must have been a fine example of the
5
6
Clinics in Dermatology
MCLEOD AND DAVIS
1992;10:5- 7
interested, observant general practitioner. His observations included a number of findings that have become accepted as tenets in the study of melanomas. Some findings had appeared in papers published previously by others, but Norris’ report related to his own work. He described several epidemiologic features: (1) Melanoma often arises in preexisting moles. (2) Melanoma is more commonly seen in industrial rather than rural workers. (3) Patients more often have fair skin and light-colored hair. (4) Melanoma occurs in families and may be hereditary. (5) Trauma may aggravate the tumor and increase its rate of growth. Two clinical features he noted were that patients are more often males and tend to be heavy smokers, and despite widespread metastatic disease, there is little effect on physical ability until the late stages. With respect to pathologic features, Norris reported the following: (1) Melanoma is not always black and can be amelanotic. (2) The tumor is sometimes characterized by pigment spreading about it, but is sometimes nodular or polypoid. (3) Satellite deposits may develop about the primary melanoma. (4) Widespread subcutaneous deposits may develop. (5) Dissemination is possible to every site in the body. In noting the results of treatment, Norris found that limited local excision may lead to local recurrence, wide excision of the primary and surrounding clear skin can give good results, and disseminated disease does not respond to available methods of treatment.
Other 19th~Century Writers on Melanoma In 1825 Sir Andrew Halliday described the autopsy findings on a patient who had small black deposits of melanoma on the skin, in the viscera, and on the dura mater.5 David Williams, in 1834, described a primary melanoma that appeared as a dark spot on the shoulder and increased in area, later developing a nodule in its substancee6 This description suggests a superficial spreading melanoma proceeding through a horizontal growth phase and then developing vertical growth. Isaac Parrish (1811- 1852), in the American Journal of Medical Science in 1837, gave what is believed to be the first case report of a melanoma in North America.’ The tumor was located on the foot, but whether it arose in plantar or dorsal skin is unclear. Robert Carswell (1793 - 1857) described melanoma in 1838 in his book illustrations of the Elementary Forms of Disease.* In his paper of 18574 Norris expressed some regret that “It is singular that Cullen, Carswell and Fawdington, should have written on the disease some years after I first published, and never alluded to my case.” 4 Samuel Cooper, in 1840, described the “black cancer” we11.9 He remarked that “the only chance for benefit de-
pends upon the early removal of the disease by operation, when the situation of the part affected will admit of it.”
James Paget Knowledge about melanoma was becoming organized when Sir James Paget (18 14 - 1899) published his work in 1853,‘O which included a report of 25 cases of “melanoid cancer.” He clearly described the development of what we call superficial spreading melanoma and its change to vertical growth.
Oliver Pemberton In 1858, Pemberton described the changes that occur as primary melanoma develops.” In describing the color changes, he included the slate color often seen in early change in a nevus. He collected a series of 60 cases, including a case of plantar melanoma in a black man from Madagascar, the first report of melanoma in a black person. He reported poor survival rates and expressed the view that the treatments available at that time were inadequate.
Jonathan Hutchinson Sir Jonathan Hutchinson (1828- 1913) first reported subungual melanoma in 1857,‘* in the same year a description of the condition was published by Fergusson.13 But the reason Hutchinson’s name is linked with malignant melanoma is his description of Hutchinson’s melanotic freckle in 1892.14 He described, in a 56-year-old man, “a large black stain on his left cheek, present for many years but increasing in size of late.” He went on to describe the occurrence of melanoma in the lesion.
More 19th-Century Descriptions Many other papers were published in the late 19th century, covering various aspects of melanoma. In 1885, two papers on the subject appeared in an issue of the Glasgow Medical Journal. Tennent described melanuria.15 Norris had described changes in the urine in his first patient, writing, “The urine sometimes resembled porter, and deposited a lateritious sediment.” 4 Tennent believed the unusual greenish-black color of the urine was probably caused by the absorption of melanin. In the other paper, Joseph Coats recommended wide excision of the primary lesion.16 In 1892, Snow considered excision of the primary lesion as sole treatment to be futile, recommending “the perfect eradication of those lymph glands which will nec-
Clinics in Dermatology 1992;10:5- 7
essarily be first infected; before enlargement takes place, radical removal . . . is a safe and easier measure.” l7
Frederick Eve Frederick Eve, a surgeon at London Hospital in 1903, presented a lecture about a hospital series of 45 patients seen over 20 years. is He wrote that although it was generally accepted that melanoma was “the most malignant of all tumours,” there were “certain remarkable exceptions.” He supported the use of wide excision and elective regional node dissection in all cases.
William Sampson Handley At London Hospital Frederick Eve and William Sampson
Handley (1872- 1962) worked in association. Sampson Handley based two Hunterian Lectures*9 on the findings made at autopsy in one of Eve’s patients. He recommended, and included a figure as demonstration, that the melanoma be excised about an inch from the edge of the tumor, down to subcutaneous fat, and that the excision of subcutaneous fat then be extended by undermining the skin for about 2 in. in all directions, including the deep fascia and some of the muscle. This was based on the patient in whom deposits of metastatic melanoma were situated on the deep fascia below the primary tumor. This case of melanoma was at least stage II, with in-transit and regional node involvement. These lectures laid a strong foundation for the radical excisions and routine elective dissections that were the basis of treatment of melanoma over the next 60 years. As a large proportion of patients presented in that time with locally advanced disease, this approach to management was probably appropriate. Renewed interest in the study of melanoma since 1960, with emphasis on early diagnosis, has led to questioning of the radical management recommended through the 19th and early 20th century.
Conclusions Through their careful observations, physicians have added greatly to our understanding of malignant melanoma since those early descriptions nearly 200 years ago. Much of modern-day care is based on their work. Although much progress has been made since 1960, we still
MCLEOD AND DAVIS
7
OVERVIEW OF MELANOMA
owe much to the pioneer students of malignant noma.
mela-
References 1. Bodenham DC. A study of 650 observed malignant melanomas in the southwest region. Ann R Co11 Surg Engl 1968;43:218. 2. Laennec RTH. Sur les melanoses. 1812;1:2.
Bull Fat Med Paris
3. Norris W. Case of fungoid disease. Edinburgh Med Surg J 1820;16:562. 4. Norris W. Eight cases of melanosis with pathological and therapeutical remarks on that disease. London: Longman, Brown, Green, Longman, and Roberts, 1857. 5: Halliday A. Case of melanosis. 1823;19:442.
Lond Med Repository
6. Silvers DN. On the subject of primary cutaneous melanoma: An historical perspective. In: Fenoglio CM, Wolff M, editors. Progress in surgical pathology. New York: Masson, 1982;Iv:277. 7. Parrish I. Case of melanosis. Am J Med Sci 1837;20:266. 8. Carswell R. Illustrations of the elementary forms of ‘disease. London: Longman, Orme, Brown, Green and Longman, 1838. 9. Cooper S. First lines of the theory and practice of surgery. 7th ed. London: Longman, Orme and Co, 1840. 10. Paget J. Lectures on surgical pathology. London: Longman, Brown, Green and Longman, 1853;2:639. 11. Pemberton 0. Observations on the history, pathology and treatment of cancerous diseases. London: J Churchill, 1858;8. 12. Hutchinson J. Melanotic disease of the great toe, following a whitlow of the nail. Trans Path01 Sot Lond 1857;8:404. 13. Under the care of Mr. Fergusson. Lancet 1857;1:289. 14. Hutchinson J. Lentigo melanosis. Arch Surg 1894;5:253256. 15. Tennent
GP. On a case of multiple melanotic sarcoma.
Glasgow Med J 1885;24:81. 16. Coats J. On a case of multiple melanotic sarcoma. Glasgow Med J 1885;24:92. 17. Snow H. Melanotic cancerous disease. Lancet 1892;2:872. 18. Eve F. A lecture on melanoma. Practitioner 1903;70:165. 19. Handley WS. The pathology of melanotic growths in relation to their operative treatment. I. Lancet 1907;1:927. 20. Handley WS. The pathology of melanotic growths in relation to their operative treatment. Lancet 1907;1:996.
his consideration of the development of knowledge about malignant melanoma is confined to the period from the late 18th to the early 20th century. It was in this period that the first descriptions of melanoma as a disease entity were published, and the foundation of the principles of management was established.
T
John Hunter In the Hunterian Museum of the Royal College of Surgeons of England can be found specimen 219. This specimen was collected by John Hunter (1728 - 1793) in 1787. The accompanying description of the specimen gives details on the patient, a 35-year-old man, in whom a mass that had been excised 3 years previously from behind the angle of the mandible recurred. The recurrent mass had enlarged slowly until it was injured in a drunken fight, when it began to grow rapidly over the next few weeks. Hunter excised the mass, which he described as a “cancerous fungous excrescence.“ It has more recently been reexamined and confirmed to be melanoma.’
Red
Theophile
Laennec
Although Hunter was the first to describe a patient with metastatic melanoma and preserve a specimen, it was Reni Theophile Laennec (1781-1826) who first described melanoma as a disease entity. Laennec combined his study of the signs and symptoms of disease in patients in the wards with the subsequent study of the anatomic appearance in the mortuary. Laennec presented an unFrom the Queensland Melanoma Project, Princess Alexandra Hospital, Brisbane, Australia. Address correspondence to G. Roderick McLeod, Queensland Melanoma Project, Princess Alexandra Hospital, Wolloongabba, Brisbane 4102, Australia.
0 1992 by Elsevier Science Publishing
Co., Inc.
l
0738-081x/92/$5.00
published memoir to the Facultg de Mhdecine de Paris in 1806, in which he described melanoma as a disease entity. He first used the word melanosis in 1812 in the Bulle-
fins de la Faculfe’ de Me’decine de Paris2 William Norris In 1820, William Norris (1792 - 1877), a general practitioner in Stourbridge, England, gave the first description of a case of melanoma in the English literature.3 He called it a “case of fungoid disease,” but the description was of a patient who died from disseminated melanoma. Norris subsequently wrote that this was “the first genuine general good case” of melanoma. His description, which follows, clearly substantiates the claim. Mr. D., aged 59 years, of light hair and fair complexion presented to Dr. Norris on February 6,1817 with a tumour of his abdominal wall midway between umbilicus and pubes. There had always been a mole on this position but nine months previously, it began to grow and tumour developed. It was half the size of a hen’s egg, of a deep brown colour, of a firm and fleshy feel, ulcerated, and discharging a highly foetid ichthorous fluid. The apex of the tumour was broader than its base. Some months after the tumour appeared, several distinct brown nodules sprang up around it. The primary tumour was removed by the knife but then recurred in the scar in less than six weeks. The glands of the groin were swollen and slightly tender to the touch. In spite of the disseminated nature of the tumour the general health of the patient was not so much impaired as to interfere with his exercise or business. Multiple subcutaneous deposits developed with a distressing cough and dyspnoea before he died.4
Norris’ description of the autopsy findings demonstrated the overall body distribution of the metastatic disease. In 185 7, Norris published a paper in which he gave a very complete description of the case he had reported in 1820 and of two other cases, with brief notes on five more patients. Norris must have been a fine example of the
5
6
Clinics in Dermatology
MCLEOD AND DAVIS
1992;10:5- 7
interested, observant general practitioner. His observations included a number of findings that have become accepted as tenets in the study of melanomas. Some findings had appeared in papers published previously by others, but Norris’ report related to his own work. He described several epidemiologic features: (1) Melanoma often arises in preexisting moles. (2) Melanoma is more commonly seen in industrial rather than rural workers. (3) Patients more often have fair skin and light-colored hair. (4) Melanoma occurs in families and may be hereditary. (5) Trauma may aggravate the tumor and increase its rate of growth. Two clinical features he noted were that patients are more often males and tend to be heavy smokers, and despite widespread metastatic disease, there is little effect on physical ability until the late stages. With respect to pathologic features, Norris reported the following: (1) Melanoma is not always black and can be amelanotic. (2) The tumor is sometimes characterized by pigment spreading about it, but is sometimes nodular or polypoid. (3) Satellite deposits may develop about the primary melanoma. (4) Widespread subcutaneous deposits may develop. (5) Dissemination is possible to every site in the body. In noting the results of treatment, Norris found that limited local excision may lead to local recurrence, wide excision of the primary and surrounding clear skin can give good results, and disseminated disease does not respond to available methods of treatment.
Other 19th~Century Writers on Melanoma In 1825 Sir Andrew Halliday described the autopsy findings on a patient who had small black deposits of melanoma on the skin, in the viscera, and on the dura mater.5 David Williams, in 1834, described a primary melanoma that appeared as a dark spot on the shoulder and increased in area, later developing a nodule in its substancee6 This description suggests a superficial spreading melanoma proceeding through a horizontal growth phase and then developing vertical growth. Isaac Parrish (1811- 1852), in the American Journal of Medical Science in 1837, gave what is believed to be the first case report of a melanoma in North America.’ The tumor was located on the foot, but whether it arose in plantar or dorsal skin is unclear. Robert Carswell (1793 - 1857) described melanoma in 1838 in his book illustrations of the Elementary Forms of Disease.* In his paper of 18574 Norris expressed some regret that “It is singular that Cullen, Carswell and Fawdington, should have written on the disease some years after I first published, and never alluded to my case.” 4 Samuel Cooper, in 1840, described the “black cancer” we11.9 He remarked that “the only chance for benefit de-
pends upon the early removal of the disease by operation, when the situation of the part affected will admit of it.”
James Paget Knowledge about melanoma was becoming organized when Sir James Paget (18 14 - 1899) published his work in 1853,‘O which included a report of 25 cases of “melanoid cancer.” He clearly described the development of what we call superficial spreading melanoma and its change to vertical growth.
Oliver Pemberton In 1858, Pemberton described the changes that occur as primary melanoma develops.” In describing the color changes, he included the slate color often seen in early change in a nevus. He collected a series of 60 cases, including a case of plantar melanoma in a black man from Madagascar, the first report of melanoma in a black person. He reported poor survival rates and expressed the view that the treatments available at that time were inadequate.
Jonathan Hutchinson Sir Jonathan Hutchinson (1828- 1913) first reported subungual melanoma in 1857,‘* in the same year a description of the condition was published by Fergusson.13 But the reason Hutchinson’s name is linked with malignant melanoma is his description of Hutchinson’s melanotic freckle in 1892.14 He described, in a 56-year-old man, “a large black stain on his left cheek, present for many years but increasing in size of late.” He went on to describe the occurrence of melanoma in the lesion.
More 19th-Century Descriptions Many other papers were published in the late 19th century, covering various aspects of melanoma. In 1885, two papers on the subject appeared in an issue of the Glasgow Medical Journal. Tennent described melanuria.15 Norris had described changes in the urine in his first patient, writing, “The urine sometimes resembled porter, and deposited a lateritious sediment.” 4 Tennent believed the unusual greenish-black color of the urine was probably caused by the absorption of melanin. In the other paper, Joseph Coats recommended wide excision of the primary lesion.16 In 1892, Snow considered excision of the primary lesion as sole treatment to be futile, recommending “the perfect eradication of those lymph glands which will nec-
Clinics in Dermatology 1992;10:5- 7
essarily be first infected; before enlargement takes place, radical removal . . . is a safe and easier measure.” l7
Frederick Eve Frederick Eve, a surgeon at London Hospital in 1903, presented a lecture about a hospital series of 45 patients seen over 20 years. is He wrote that although it was generally accepted that melanoma was “the most malignant of all tumours,” there were “certain remarkable exceptions.” He supported the use of wide excision and elective regional node dissection in all cases.
William Sampson Handley At London Hospital Frederick Eve and William Sampson
Handley (1872- 1962) worked in association. Sampson Handley based two Hunterian Lectures*9 on the findings made at autopsy in one of Eve’s patients. He recommended, and included a figure as demonstration, that the melanoma be excised about an inch from the edge of the tumor, down to subcutaneous fat, and that the excision of subcutaneous fat then be extended by undermining the skin for about 2 in. in all directions, including the deep fascia and some of the muscle. This was based on the patient in whom deposits of metastatic melanoma were situated on the deep fascia below the primary tumor. This case of melanoma was at least stage II, with in-transit and regional node involvement. These lectures laid a strong foundation for the radical excisions and routine elective dissections that were the basis of treatment of melanoma over the next 60 years. As a large proportion of patients presented in that time with locally advanced disease, this approach to management was probably appropriate. Renewed interest in the study of melanoma since 1960, with emphasis on early diagnosis, has led to questioning of the radical management recommended through the 19th and early 20th century.
Conclusions Through their careful observations, physicians have added greatly to our understanding of malignant melanoma since those early descriptions nearly 200 years ago. Much of modern-day care is based on their work. Although much progress has been made since 1960, we still
MCLEOD AND DAVIS
7
OVERVIEW OF MELANOMA
owe much to the pioneer students of malignant noma.
mela-
References 1. Bodenham DC. A study of 650 observed malignant melanomas in the southwest region. Ann R Co11 Surg Engl 1968;43:218. 2. Laennec RTH. Sur les melanoses. 1812;1:2.
Bull Fat Med Paris
3. Norris W. Case of fungoid disease. Edinburgh Med Surg J 1820;16:562. 4. Norris W. Eight cases of melanosis with pathological and therapeutical remarks on that disease. London: Longman, Brown, Green, Longman, and Roberts, 1857. 5: Halliday A. Case of melanosis. 1823;19:442.
Lond Med Repository
6. Silvers DN. On the subject of primary cutaneous melanoma: An historical perspective. In: Fenoglio CM, Wolff M, editors. Progress in surgical pathology. New York: Masson, 1982;Iv:277. 7. Parrish I. Case of melanosis. Am J Med Sci 1837;20:266. 8. Carswell R. Illustrations of the elementary forms of ‘disease. London: Longman, Orme, Brown, Green and Longman, 1838. 9. Cooper S. First lines of the theory and practice of surgery. 7th ed. London: Longman, Orme and Co, 1840. 10. Paget J. Lectures on surgical pathology. London: Longman, Brown, Green and Longman, 1853;2:639. 11. Pemberton 0. Observations on the history, pathology and treatment of cancerous diseases. London: J Churchill, 1858;8. 12. Hutchinson J. Melanotic disease of the great toe, following a whitlow of the nail. Trans Path01 Sot Lond 1857;8:404. 13. Under the care of Mr. Fergusson. Lancet 1857;1:289. 14. Hutchinson J. Lentigo melanosis. Arch Surg 1894;5:253256. 15. Tennent
GP. On a case of multiple melanotic sarcoma.
Glasgow Med J 1885;24:81. 16. Coats J. On a case of multiple melanotic sarcoma. Glasgow Med J 1885;24:92. 17. Snow H. Melanotic cancerous disease. Lancet 1892;2:872. 18. Eve F. A lecture on melanoma. Practitioner 1903;70:165. 19. Handley WS. The pathology of melanotic growths in relation to their operative treatment. I. Lancet 1907;1:927. 20. Handley WS. The pathology of melanotic growths in relation to their operative treatment. Lancet 1907;1:996.
