Journal of the American Academy of Dermatology
Zhu et al.
10.
11. 12.
13.
epidermal protein recognized by pemphigoid autoantibodies [Abstract]. J Invest Dermatol 1989;92:420A. Soh H, Miyauchi H, Izumi H, et aL Subclass distribution of IgG autoantibodies in bullous pemphigoid analyzed by indirect immunofluorescence and immunoblotting [Abstract}. J Invest Dermatol 1989;92:521A. Roledo M, Labib RS, Korman N, et al. The 230 kD and 180 kD bullous pemphigoid antigens are immunologically related [Abstract}. ] Invest Dermatol 1989;92:508A. Meyer LJ, Tayor TB, Kadunce DP, et al. Two classes of bullous pemphigoid antigens are identified by affinity purified antibodies [Abstract]. J Invest Dermatol 1989; 92:480A. Labib RS, Anahalt GJ, Patel HP, et al. Molecular heterogeneity of the bullous pemphigoid antigens as detected by immunoblotting. J Immunol 1986;136:1231-5.
14. Diaz LA, Calvanico NJ, Tomasi TB Jr, et aI. Bullous pemphigoid antigen: isolation from normal human skin. J Immunol 1977;118:455-60. IS. Diaz LA, Patel H, Calvanico NJ. Bullous pemphigoid antigen II. Isolation from the urine of a patient. J Immunol 1979;122:605-8. 16. Woodley DT, Briggaman RA, O'Keefe EJ, et al. Identification of the skin basement-membrane autoantigen in epidermolysis bullosa acquisita. N EnglJ Med 1984;310:100713. 17. Zhu X-J, Niimi Y, Bystryn J-C. Identification of a 160 kD molecule as a component of the basement membrane zone and as a minor bullous pemphigoid antigen. J Invest Dermatol (In press.)
Polypoid melanoma: A virulent variant of nodular melanoma Report of three cases and literature review Harold Plotnick, MD,a Nikolai Rachmaninoff, MD,b and Henry J. VandenBerg, Jr., MDc Detroit, Michigan We report the cases of three patients with polypoid melanoma. In no case was there microscopic evidence of melanoma cell invasion below the papillary dermis. In the polypoid variant of nodular melanoma, melanoma cells accumulate in large volume above the skin's surface. This increase in tumor volume encourages dislodgment of melanoma cells that are carried to superficial lymphatic vessels without invading the reticular dermis; this feature differentiates polypoid melanoma from the nonpolypoid nodular variant. Although polypoid melanoma is considered the most malignant form of melanoma, our findings, albeit limited to three cases, suggest that early diagnosis and prompt surgical excision may provide a favorable 5-year survival rate. (J AM ACAD DERMATOL 1990;23:880-4.)
Polypoid (pedunculated) melanoma originates as a pigmented macule with a slow-growing radial pattern that is transfonned within months into a rapidly growing vertical phase. 1 The melanoma cells
From the Departments of Dermatology,' Pathology,b and Surgery,C Harper-Grace Hospitals, Wayne State University School of Medicine. Presented in part before the Joint Conference of the Noah Worcester Dermatological Society and the Department of Dermatology, School ofMedicine, University of Lausanne, Lausanne, Switzerland, April 26, 1988. Accepted for publication March 14, 1990. Reprint requests: Harold Plotnick, MD, Department of Dermatology, Wayne State University School of Medicine, 540 E. Canfield Ave., Detroit, MI 48201. 16/1/21011
880
ofthe vertical phase grow in an expansile fashion and neoplastic cells invade both the epidermis and the superficial papillary dermis. 2 As the expansive growth continues, the lateral margins of the neoplasm become everted and the bulk of the tumor assumes a mushroomlike appearance that projects above the surface of the skin. The marked increase in tumor volume within the polypoid mass encourages the dislodgment of malignant cells from the tumor's periphery, which become free to permeate the surrounding rich bed of superficial capillaries and lymphatic vessels. 1,3,4 In transient melanoma cells often bypass the reticular dermis and can be present in regionallymph nodes by the time the patient seeks medical attention. This I'bypass behavior" pattern of polypoid melanoma is contrary to the nonpolypoid
Volume 23 Number 5, Part 1 November 1990
Polypoid melanoma 881
Fig. 1. Case 1. Polypoid lesion with overhanging border and surface ulceration. Tumor infiltrate is thick, non-pigment-producing, and confined to papillary dermis. (Hematoxylineosin stain; X7.)
Fig. 2. Case 1. Compact infiltrate of epithelioid-type melanoma cells with occasional tumor cells in junctional position connected to nonulcerated portion of the epidermis. (Hematoxylin-eosin stain; X75.)
nodular melanoma that usually invades the reticular dermis before regional and/or distant lymphatic metastases appear. We report the cases of three patients with the characteristic features and clinical course of polypoid melanoma.
CASE REPORTS
Case 1 A 46-year-old white woman had a bleeding polypoid nodule on the upper part of the back of 2 months' dura-
tion. A large nontender mass was palpable in the right axilla. The biopsy specimen showed that the major portion of a severely eroded polypoid structure contained. a dense population of melanoma cells that arose from a thin basal cell layer (Fig. 1). The findings were compatible with a diagnosis of epithelioid cell-type melanoma (Fig. 2). The original tumor site and the underlying adipose tissue were widely and deeply excised. A mass offibrous adipose tissue was dissected from the right side of the upper chest wall and contiguous axillary vault. Gross examina-
882 Plotnick et at.
Journal of the American Academy of Dermatology
Fig. 3. Case 1. Metastatic malignant melanoma cells replacing normal lymphoid tissue.
Melanoma cells are large, spindly, and loosely arranged with occasional short fascicles. (Hematoxylin-eosin stain; X75.)
Fig. 4. Case 1. Fused lymph nodes almost completely replaced by metastatic melanoma. Tumor cells are large, predominantly epithelioid-type with abundant cytoplasm and have eccentric large nuclei and prominent nucleoli. (Hematoxylin-eosin stain; X75.)
tion identified nine lymph nodes; five were matted and four were separable. Step sections taken through the original tumor site showed inflammation and repair but no evidence of residual melanoma. Microscopic examination of a group of matted lymph nodes indicated that the lymphoid tissue was completely replaced by spindletype malignant melanoma cells (Fig. 3), The other four lymph nodes showed no microscopic evidence of melanoma.
Six months later a large nodule was detected along the lower left lateral edge of the trapezius muscle. During operation a circumscribed nodule, 1.8 em in diameter, was found in the fat. Microscopic examination revealed metastatic epithelioid-type malignant melanoma cells invading a lymph node (Fig. 4). The patient continued to work effectively for approximately 19 months. A bowel obstruction developed; exploratory laparotomy revealed extensive metastases.
Volume 23 Number 5, Part I November 1990
Polypoid melanoma 883
Fig. 5. Case 2. Polypoid tumor with everted base of nodule densely packed with melanoma cells. (Hematoxylin-eosin stain; X5.) The patient died 2 months later. She survived for 26 months after excision of the primary melanoma.
Case 2 A 49-year-old white man had a rapidly growing pigmented lesion on the mid back for several months. Examination revealed a medium brown, semisoft nodule, 1.2 X 1.0 X 0.6 em in diameter attached to the underlying skin by a narrow base. Regional lymph nodes were not palpable. The tumor, with a 10 mm free border, was widely and deeply excised. The microscopic findings showed a polypoid nodule composed predominantly of nonpigmented epithelioid-type melanoma cells that contained abundant pink cytoplasm with large nuclei and prominent nucleoli. Portions of the specimen showed hemorrhage and necrosis (Fig. 5). The patient's primary care physician reported that the man showed no signs of recurrence or metastases 5 years after surgical resection.
Case 3 A 45-year-old white woman claimed that a mole located on the left side of her neck at the lower edge of the occipital hairline had been traumatized recently. Within weeks, the lesion became tender, darker, and enlarged. The patient consulted a surgeon who made the following notation: "a deeply pigmented round tumor with a partially eroded surface and measuring 10 mm in diameter is attached to the skin by a narrow pedicle 4 mm in width. The area surrounding the pedicle does not appear remarkable. Shotty nodes are palpable in the left posterior cervical lymphatic chain."
Table I. Clinical comparison between polypoid and nonpolypoid nodular melanoma Variable
I
Polypoid
Thickness Ulceration Age at onset (yr) Sex predilection Location
Exophytic Usual 20-39 M>F Back (>M)
Survival (5-yr)
32%-42%
Nodular melanoma
Endophytic Variable 40-60 M>F Back (>M); leg (> F) 57%
The lesion was widely excised with a 10 mm margin. The microscopic findings revealed a pedunculated malignant melanoma. The bulk of the lesion was formed by several lobulated clusters of solidly packed epithelioidtype malignant melanoma cells. The invading melanoma extended into the papillary dermis. The maximal thickness of the tumor was 4 mm. The original surgical site was widely and deeply excised and a modified radical neck dissection was performed. Microscopic examination of the original operative site and lymph nodes failed to identify any evidence of residual tumor or metastatic melanoma, The woman remains in good health and displays no evidence of recurence 6 years after surgery.
DISCUSSION In a review of 236 patients with malignant melanoma, Vogler et al. 5 recorded one case of "pedunculated" melanoma. Later, Shapiro and Bodian6 described two cases of pigmented pedunculated pap-
Journal of the American Academy of Dermatology
884 Plotnick et al. ulesthat appeared clinicallybenign buthistologically were examples of melanoma. Additional reports defined this rare pedunculated tumor as a virulent variant of nodular melanoma. 3-? The early diagnosis of polypoid melanoma can influence the prognosis ofthis tumor that character~ istically metastasizes to regional lymph nodes before invading the reticular dermis. Because the initial growth phase of polypoid melanoma is radial~hori zontal, early recognition of surface changes (i.e. variations in color, shape, and size) are of major diagnostic significance. 2 Although the markings are preserved or somewhat exaggerated in the early phase of radial growth, 8 they can be abolished in areas of early vertical growth. 9 Delay by the patient in the seeking medical care in the early stages of poly~ poid melanoma is understandable because most le~ sions originate on the back. I As a result, the tumor is usually overlooked unless some adverse sign, such as bleeding, alerts the patient. lo Tumor cell type, cellular atypia, tumor thickness or volume, mitotic index, and surface ulceration are interrelated prognostic features of polypoid melanoma. ll In contrast to the nonpolypoid type of nodular melanoma, the polypoid variant has an earlier age of onset, frequent surface ulceration, increased thickness, and a lower 5~year survival rate l (Table I). Of the recognized variants of nodular malignant melanoma, patients with polypoid melanoma have the poorest 5~year survival rate because of the high rate of early metastasis to regional lymphatics and/ or occult distant sites. 2 Because the major growth pattern of polypoid melanoma is exophytic and rarely invades the reticular dermis before metasta~ sizing, Beardmore3 views the tumor as "nonstageable" and considers patients with this neoplasm to have as bad a prognosis as a patient with a high-risk level V or stage IV nodular melanoma. 12 Balch13 believes that the number of involved regional lymph nodes detected at the time of surgery in stage II polypoid melanoma may be a more decisive criterion for estimating prognosis than reliance on the measurement methods of Breslow l4 or Clark. ls The specific lymph node count in malignant melanoma appears similar to the guidelines used in determining the prognosis of carcinoma of the breast, 16 wherein the presence of three or more metastatic lymph nodes dramatically reduces the duration of survival.
Although examination of the primary tumor site in case 1gave no microscopic evidence of melanoma
cells below the superificial papillary dermis, metastases were already established in five axillary lymph nodes. The patients reported as cases 2 and 3 illustrated that although the thickness of the melanomas measured 2.85 mm (level III) and 4 rom (level IV), respectively, there was no evidence of regional or distant metastases. REFERENCES 1. Manci EA, Balch CM, Murad TM, et aI. Polypoid melanoma, a virulent variant of nodular growth pattern. Am J Clin PathoI1981;75:810-5. 2. Balch CM, Wilkerson JA, Murad TM, et al. The prognostic significance of ulceration of cutaneous melanoma. Cancer 1980;45:3012-7. 3. Beardmore GL. Primary cutaneous polypoid non-stageable melanomas in Queensland. Australas J Dermatol 1977;18:73-6. 4. Niven J, Lubin J. Pedunculated malignant melanoma. Arch DermatoI1975;11l:755-6. 5. Vogler WR, Perdue GD, Wilkins SA Jr. A clinical evaluation of malignant melanoma. Surg Gynecol Obstet 1958;106:586-94. 6. Shapiro L, Bodian EL. Malignant melanoma in the form of pedunculated papules. Arch DermatoI1969;99:49-50. 7. Rosenberg L, Goldstein J, Ben-Yakar Y. The pedunculated malignant melanoma. J Dermatol Surg Oncol 1981;7: 123-6. 8. Bondi EE, Elder DE, Dupont G IV. Skin markings in malignant melanoma. JAMA 1983;250:503-5. 9. Mihm MC, Fitzpatrick TB. Early detection of malignant melanoma. Cancer 1976;37:597-603. 10. Temoshok L, Di Clemente RJ, Sweet DM, et al. Factors related to patient delay in seeking medical attention for cutaneous malignant melanoma. Cancer 1984;545:3048-53. 11. Larsen TE, Grude TH. Retrospective histological study of 669 cases of primary cutaneous malignant melanoma in clinical stage I. 3. The relation between tumour-associated lymphocyte infiltration and age and sex, tumour cell type, pigmentation, cellular atypia, mitotic count, depth of invasion, ulceration, tumour type and prognosis. Acta Path Microbiol Scand A 1978;86:523-30. 12. McGovern VJ. The classification of melanoma and its relationship with prognosis. Pathology 1970;2:85-98. 13. Balch CM. A world-wide comparison of prognostic factors in melanoma. Synopses of addresses and papers presented at the Second World Congress on Cancer of the Skin. J Dermatol Surg OncoI1985;1l:773-4. 14. Breslow A. Thickness, cross-section and depth of invasion in the prognosis of cutaneous melanoma. Ann Surg 1970; 172:902-8. 15. Clark WH Jr, From L, Bernadino EA, et aL The histogenesis and biologic behavior of primary malignant melanoma of the skin. Cancer Res 1969;29:705-27. 16. Slamon D, Clark GM, Wong SG, et al. Oncogene amplification may indicate breast cancer prognosis. Science 1987;235:177-82.
Zhu et al.
10.
11. 12.
13.
epidermal protein recognized by pemphigoid autoantibodies [Abstract]. J Invest Dermatol 1989;92:420A. Soh H, Miyauchi H, Izumi H, et aL Subclass distribution of IgG autoantibodies in bullous pemphigoid analyzed by indirect immunofluorescence and immunoblotting [Abstract}. J Invest Dermatol 1989;92:521A. Roledo M, Labib RS, Korman N, et al. The 230 kD and 180 kD bullous pemphigoid antigens are immunologically related [Abstract}. ] Invest Dermatol 1989;92:508A. Meyer LJ, Tayor TB, Kadunce DP, et al. Two classes of bullous pemphigoid antigens are identified by affinity purified antibodies [Abstract]. J Invest Dermatol 1989; 92:480A. Labib RS, Anahalt GJ, Patel HP, et al. Molecular heterogeneity of the bullous pemphigoid antigens as detected by immunoblotting. J Immunol 1986;136:1231-5.
14. Diaz LA, Calvanico NJ, Tomasi TB Jr, et aI. Bullous pemphigoid antigen: isolation from normal human skin. J Immunol 1977;118:455-60. IS. Diaz LA, Patel H, Calvanico NJ. Bullous pemphigoid antigen II. Isolation from the urine of a patient. J Immunol 1979;122:605-8. 16. Woodley DT, Briggaman RA, O'Keefe EJ, et al. Identification of the skin basement-membrane autoantigen in epidermolysis bullosa acquisita. N EnglJ Med 1984;310:100713. 17. Zhu X-J, Niimi Y, Bystryn J-C. Identification of a 160 kD molecule as a component of the basement membrane zone and as a minor bullous pemphigoid antigen. J Invest Dermatol (In press.)
Polypoid melanoma: A virulent variant of nodular melanoma Report of three cases and literature review Harold Plotnick, MD,a Nikolai Rachmaninoff, MD,b and Henry J. VandenBerg, Jr., MDc Detroit, Michigan We report the cases of three patients with polypoid melanoma. In no case was there microscopic evidence of melanoma cell invasion below the papillary dermis. In the polypoid variant of nodular melanoma, melanoma cells accumulate in large volume above the skin's surface. This increase in tumor volume encourages dislodgment of melanoma cells that are carried to superficial lymphatic vessels without invading the reticular dermis; this feature differentiates polypoid melanoma from the nonpolypoid nodular variant. Although polypoid melanoma is considered the most malignant form of melanoma, our findings, albeit limited to three cases, suggest that early diagnosis and prompt surgical excision may provide a favorable 5-year survival rate. (J AM ACAD DERMATOL 1990;23:880-4.)
Polypoid (pedunculated) melanoma originates as a pigmented macule with a slow-growing radial pattern that is transfonned within months into a rapidly growing vertical phase. 1 The melanoma cells
From the Departments of Dermatology,' Pathology,b and Surgery,C Harper-Grace Hospitals, Wayne State University School of Medicine. Presented in part before the Joint Conference of the Noah Worcester Dermatological Society and the Department of Dermatology, School ofMedicine, University of Lausanne, Lausanne, Switzerland, April 26, 1988. Accepted for publication March 14, 1990. Reprint requests: Harold Plotnick, MD, Department of Dermatology, Wayne State University School of Medicine, 540 E. Canfield Ave., Detroit, MI 48201. 16/1/21011
880
ofthe vertical phase grow in an expansile fashion and neoplastic cells invade both the epidermis and the superficial papillary dermis. 2 As the expansive growth continues, the lateral margins of the neoplasm become everted and the bulk of the tumor assumes a mushroomlike appearance that projects above the surface of the skin. The marked increase in tumor volume within the polypoid mass encourages the dislodgment of malignant cells from the tumor's periphery, which become free to permeate the surrounding rich bed of superficial capillaries and lymphatic vessels. 1,3,4 In transient melanoma cells often bypass the reticular dermis and can be present in regionallymph nodes by the time the patient seeks medical attention. This I'bypass behavior" pattern of polypoid melanoma is contrary to the nonpolypoid
Volume 23 Number 5, Part 1 November 1990
Polypoid melanoma 881
Fig. 1. Case 1. Polypoid lesion with overhanging border and surface ulceration. Tumor infiltrate is thick, non-pigment-producing, and confined to papillary dermis. (Hematoxylineosin stain; X7.)
Fig. 2. Case 1. Compact infiltrate of epithelioid-type melanoma cells with occasional tumor cells in junctional position connected to nonulcerated portion of the epidermis. (Hematoxylin-eosin stain; X75.)
nodular melanoma that usually invades the reticular dermis before regional and/or distant lymphatic metastases appear. We report the cases of three patients with the characteristic features and clinical course of polypoid melanoma.
CASE REPORTS
Case 1 A 46-year-old white woman had a bleeding polypoid nodule on the upper part of the back of 2 months' dura-
tion. A large nontender mass was palpable in the right axilla. The biopsy specimen showed that the major portion of a severely eroded polypoid structure contained. a dense population of melanoma cells that arose from a thin basal cell layer (Fig. 1). The findings were compatible with a diagnosis of epithelioid cell-type melanoma (Fig. 2). The original tumor site and the underlying adipose tissue were widely and deeply excised. A mass offibrous adipose tissue was dissected from the right side of the upper chest wall and contiguous axillary vault. Gross examina-
882 Plotnick et at.
Journal of the American Academy of Dermatology
Fig. 3. Case 1. Metastatic malignant melanoma cells replacing normal lymphoid tissue.
Melanoma cells are large, spindly, and loosely arranged with occasional short fascicles. (Hematoxylin-eosin stain; X75.)
Fig. 4. Case 1. Fused lymph nodes almost completely replaced by metastatic melanoma. Tumor cells are large, predominantly epithelioid-type with abundant cytoplasm and have eccentric large nuclei and prominent nucleoli. (Hematoxylin-eosin stain; X75.)
tion identified nine lymph nodes; five were matted and four were separable. Step sections taken through the original tumor site showed inflammation and repair but no evidence of residual melanoma. Microscopic examination of a group of matted lymph nodes indicated that the lymphoid tissue was completely replaced by spindletype malignant melanoma cells (Fig. 3), The other four lymph nodes showed no microscopic evidence of melanoma.
Six months later a large nodule was detected along the lower left lateral edge of the trapezius muscle. During operation a circumscribed nodule, 1.8 em in diameter, was found in the fat. Microscopic examination revealed metastatic epithelioid-type malignant melanoma cells invading a lymph node (Fig. 4). The patient continued to work effectively for approximately 19 months. A bowel obstruction developed; exploratory laparotomy revealed extensive metastases.
Volume 23 Number 5, Part I November 1990
Polypoid melanoma 883
Fig. 5. Case 2. Polypoid tumor with everted base of nodule densely packed with melanoma cells. (Hematoxylin-eosin stain; X5.) The patient died 2 months later. She survived for 26 months after excision of the primary melanoma.
Case 2 A 49-year-old white man had a rapidly growing pigmented lesion on the mid back for several months. Examination revealed a medium brown, semisoft nodule, 1.2 X 1.0 X 0.6 em in diameter attached to the underlying skin by a narrow base. Regional lymph nodes were not palpable. The tumor, with a 10 mm free border, was widely and deeply excised. The microscopic findings showed a polypoid nodule composed predominantly of nonpigmented epithelioid-type melanoma cells that contained abundant pink cytoplasm with large nuclei and prominent nucleoli. Portions of the specimen showed hemorrhage and necrosis (Fig. 5). The patient's primary care physician reported that the man showed no signs of recurrence or metastases 5 years after surgical resection.
Case 3 A 45-year-old white woman claimed that a mole located on the left side of her neck at the lower edge of the occipital hairline had been traumatized recently. Within weeks, the lesion became tender, darker, and enlarged. The patient consulted a surgeon who made the following notation: "a deeply pigmented round tumor with a partially eroded surface and measuring 10 mm in diameter is attached to the skin by a narrow pedicle 4 mm in width. The area surrounding the pedicle does not appear remarkable. Shotty nodes are palpable in the left posterior cervical lymphatic chain."
Table I. Clinical comparison between polypoid and nonpolypoid nodular melanoma Variable
I
Polypoid
Thickness Ulceration Age at onset (yr) Sex predilection Location
Exophytic Usual 20-39 M>F Back (>M)
Survival (5-yr)
32%-42%
Nodular melanoma
Endophytic Variable 40-60 M>F Back (>M); leg (> F) 57%
The lesion was widely excised with a 10 mm margin. The microscopic findings revealed a pedunculated malignant melanoma. The bulk of the lesion was formed by several lobulated clusters of solidly packed epithelioidtype malignant melanoma cells. The invading melanoma extended into the papillary dermis. The maximal thickness of the tumor was 4 mm. The original surgical site was widely and deeply excised and a modified radical neck dissection was performed. Microscopic examination of the original operative site and lymph nodes failed to identify any evidence of residual tumor or metastatic melanoma, The woman remains in good health and displays no evidence of recurence 6 years after surgery.
DISCUSSION In a review of 236 patients with malignant melanoma, Vogler et al. 5 recorded one case of "pedunculated" melanoma. Later, Shapiro and Bodian6 described two cases of pigmented pedunculated pap-
Journal of the American Academy of Dermatology
884 Plotnick et al. ulesthat appeared clinicallybenign buthistologically were examples of melanoma. Additional reports defined this rare pedunculated tumor as a virulent variant of nodular melanoma. 3-? The early diagnosis of polypoid melanoma can influence the prognosis ofthis tumor that character~ istically metastasizes to regional lymph nodes before invading the reticular dermis. Because the initial growth phase of polypoid melanoma is radial~hori zontal, early recognition of surface changes (i.e. variations in color, shape, and size) are of major diagnostic significance. 2 Although the markings are preserved or somewhat exaggerated in the early phase of radial growth, 8 they can be abolished in areas of early vertical growth. 9 Delay by the patient in the seeking medical care in the early stages of poly~ poid melanoma is understandable because most le~ sions originate on the back. I As a result, the tumor is usually overlooked unless some adverse sign, such as bleeding, alerts the patient. lo Tumor cell type, cellular atypia, tumor thickness or volume, mitotic index, and surface ulceration are interrelated prognostic features of polypoid melanoma. ll In contrast to the nonpolypoid type of nodular melanoma, the polypoid variant has an earlier age of onset, frequent surface ulceration, increased thickness, and a lower 5~year survival rate l (Table I). Of the recognized variants of nodular malignant melanoma, patients with polypoid melanoma have the poorest 5~year survival rate because of the high rate of early metastasis to regional lymphatics and/ or occult distant sites. 2 Because the major growth pattern of polypoid melanoma is exophytic and rarely invades the reticular dermis before metasta~ sizing, Beardmore3 views the tumor as "nonstageable" and considers patients with this neoplasm to have as bad a prognosis as a patient with a high-risk level V or stage IV nodular melanoma. 12 Balch13 believes that the number of involved regional lymph nodes detected at the time of surgery in stage II polypoid melanoma may be a more decisive criterion for estimating prognosis than reliance on the measurement methods of Breslow l4 or Clark. ls The specific lymph node count in malignant melanoma appears similar to the guidelines used in determining the prognosis of carcinoma of the breast, 16 wherein the presence of three or more metastatic lymph nodes dramatically reduces the duration of survival.
Although examination of the primary tumor site in case 1gave no microscopic evidence of melanoma
cells below the superificial papillary dermis, metastases were already established in five axillary lymph nodes. The patients reported as cases 2 and 3 illustrated that although the thickness of the melanomas measured 2.85 mm (level III) and 4 rom (level IV), respectively, there was no evidence of regional or distant metastases. REFERENCES 1. Manci EA, Balch CM, Murad TM, et aI. Polypoid melanoma, a virulent variant of nodular growth pattern. Am J Clin PathoI1981;75:810-5. 2. Balch CM, Wilkerson JA, Murad TM, et al. The prognostic significance of ulceration of cutaneous melanoma. Cancer 1980;45:3012-7. 3. Beardmore GL. Primary cutaneous polypoid non-stageable melanomas in Queensland. Australas J Dermatol 1977;18:73-6. 4. Niven J, Lubin J. Pedunculated malignant melanoma. Arch DermatoI1975;11l:755-6. 5. Vogler WR, Perdue GD, Wilkins SA Jr. A clinical evaluation of malignant melanoma. Surg Gynecol Obstet 1958;106:586-94. 6. Shapiro L, Bodian EL. Malignant melanoma in the form of pedunculated papules. Arch DermatoI1969;99:49-50. 7. Rosenberg L, Goldstein J, Ben-Yakar Y. The pedunculated malignant melanoma. J Dermatol Surg Oncol 1981;7: 123-6. 8. Bondi EE, Elder DE, Dupont G IV. Skin markings in malignant melanoma. JAMA 1983;250:503-5. 9. Mihm MC, Fitzpatrick TB. Early detection of malignant melanoma. Cancer 1976;37:597-603. 10. Temoshok L, Di Clemente RJ, Sweet DM, et al. Factors related to patient delay in seeking medical attention for cutaneous malignant melanoma. Cancer 1984;545:3048-53. 11. Larsen TE, Grude TH. Retrospective histological study of 669 cases of primary cutaneous malignant melanoma in clinical stage I. 3. The relation between tumour-associated lymphocyte infiltration and age and sex, tumour cell type, pigmentation, cellular atypia, mitotic count, depth of invasion, ulceration, tumour type and prognosis. Acta Path Microbiol Scand A 1978;86:523-30. 12. McGovern VJ. The classification of melanoma and its relationship with prognosis. Pathology 1970;2:85-98. 13. Balch CM. A world-wide comparison of prognostic factors in melanoma. Synopses of addresses and papers presented at the Second World Congress on Cancer of the Skin. J Dermatol Surg OncoI1985;1l:773-4. 14. Breslow A. Thickness, cross-section and depth of invasion in the prognosis of cutaneous melanoma. Ann Surg 1970; 172:902-8. 15. Clark WH Jr, From L, Bernadino EA, et aL The histogenesis and biologic behavior of primary malignant melanoma of the skin. Cancer Res 1969;29:705-27. 16. Slamon D, Clark GM, Wong SG, et al. Oncogene amplification may indicate breast cancer prognosis. Science 1987;235:177-82.
