THE YALE JOURNAL OF BIOLOGY AND MEDICINE
48, 399-401 (1975)
The Current Status of the Melanoma Problem A Symposium Presented at Surgical Grand Rounds at the Yale University School of Medicine, January 1975
NEAL KOSS Department ofSurgery, Section of Plastic and Reconstructive Surgery, Yale University School ofMedicine, 333 Cedar Street, New Haven, Connecticut 06510 Received August 8, 1975
Because of many recent diagnostic and therapeutic advances, malignant melanoma has been receiving new notoriety. Nevertheless, it is far from a new disease. Hippocrates (1) is credited with the first description of the lesion, which has always been regarded with some fear and superstition. There was little contribution of any significance until the seventeenth century, when Highmore, Bartholin, and Bonet at various times described the "fatal black tumor" (2). In 1806, Laennec and Dupuytren independently published treatises on melanosis (1). Thirty years later, Carswell coined the term melanoma (1). Pemberton (3), in 1858, was the first to note the significance of the regional lymph nodes and suggested lymphadenectomy. In 1868, Langerhans (4) noted melanocytes in histologic specimens of skin as the "branched cells," but it was not until 1951 that the term melanocyte was adopted. Wide excision with regional node dissection was introduced by Handley (5) in 1907. This concept was expanded by Pringle (6) the following year to include depth with the primary excision. More recent advances are seen with the work of Creech (7), who introduced regional perfusion in 1958 by the use of an extracorporeal circuit, and the introduction of immunotherapy by Morton et al. (8) in 1970. These historical milestones are summarized in Table 1 and may also be found, along with a statistical review of the subject, in Knutson's monograph (9). Current concepts of melanoma fall naturally into four broad areas: (i) diagnosis, (ii) staging, (iii) surgery, and (iv) immunology. A symposium on melanoma was prepared for Surgical Grand Rounds at Yale University in January of 1975, based on such an outline. The first paper deals with the clinical appearance of melanoma and some important points in the differential diagnosis of these lesions. Since there are an average of 15 pigmented nevi per Caucasian, if 10,000 surgeons worked 8 hr/day excising one nevus every 15 min, then the current population would be free of nevi in 25 yr (Table 2). In order to avoid having to excise or biopsy every nevus, Dr. Nordlund presents the important features of nevi that should make one suspicious of the diagnosis of melanoma. In so doing, he discusses the first classification system that differentiates melanomas by appearance: lentigo maligna (Hutchinson freckle), superficial spreading, and nodular. One of the most important advances in the study of melanoma has been the recognition of the importance of pathologic classification by depth, as first reported by Clark (10). Dr. Smith, in the next paper in the series, describes this system and discusses its relation to prognosis. 399 Copyright© 1975 by Academic Press, Inc. All rights of reproduction in any form reserved.
400
NEAL KOSS
TABLE 1 Summary of Historic Milestones in Melanoma Hippocrates First recorded description 1651 1677 1679 1806 1806
1836 1858 1868 1907 1908 1958 1970
Highmore Bartholin Bonet Laennec Dupuytren Carswell Pemberton Langerhans Handley Pringle Creech Morton
Described "fatal black tumor" Independently published treatises on melanosis Coined the term melanoma Suggested lymphadenectomy Noted melanocytes ("branched cells") Wide excision + RLND Added depth + incontinuity RLND Regional perfusion Immunotherapy
TABLE 2 The Statistics of Excising All Pigmented Nevi
15, average per Caucasian If 10,000 surgeons worked 8 hr per day excising 1 nevus every 15 min Then the current population would be free of nevi in 25 yr
TABLE 3 How Melanoma Statistics May Be Biased
Statistics on melanoma are biased by Who is reporting Where he is reporting from Cancer center Primary care physician University hospital Dermatologist General surgeon City hospital Plastic surgeon Community hospital HMO Chemotherapist Industrial clinic Immunotherapist Pathologist As well as country of origin, racial and sex predominance of the population, etc.
STATUS OF MELANOMA
401
In addition to describing the current thinking with regard to surgery in melanoma, Dr. Arons points out that (i) melanoma is not a surgical emergency and (ii) incisional biopsy is often the correct initial step in establishing a diagnosis. In his conclusions, he states the general consensus for the surgical approach to this disease. In the final paper, Dr. Ariyan discusses the logic and the technique of the immunotherapy of melanoma. A final word must be said about the statistics of melanoma. There has been confusion and disagreement about many past conclusions concerning prognosis and management, and each proponent has always proven his results by some series of patients. Melanoma statistics, perhaps more than other malignancies, are biased by who is reporting the study and where the report is originating. Table 3 lists these and other features. Notwithstanding all the other difficulties of treating this disease, the discrepancies in the reports in the literature have often added to the confusion. By examining the melanoma problem as it is currently understood from both the diagnostic and therapeutic approaches, this symposium was intended to present a logical understanding of the disease from the viewpoint of a dermatologist, pathologist, surgeon, and immunotherapist. REFERENCES 1. Stewart, D. F., Hay, L. J., and Varco, R. L., Malignant melanoma: 92 cases treated at the University of Minnesota Hospitals since January 1, 1932. Int. Abstr. Surg. 97, 209, 1953. 2. Wilkinson, J. S., and Paletta, G. X., Malignant melanoma: Current concepts. Amer. Surg. 35, 301, 1969. 3. Lehman, J. A., Jr., Cross, F. S., and Richez, D. G., Clinical study of 40 patients with malignant melanoma. Cancer 19,611, 1966. 4. McGovern, V. J., and Brown, M. M. L., "The Nature of Melanoma." Thomas, Springfield, Ill., 1969. 5. Handley, W. S., The Hunterian Lecture on the pathology of melanotic growths in relation to their operative treatment. Lancet 1, 927, 1907. 6. Pringle, J. H., Operation in melanotic tumors of the skin. Edinburgh Med. J. 23,496, 1908. 7. Creech, O., Krementz, E. T., Ryan, R. F., and Winblad, J. N., Chemotherapy of cancer: Regional perfusion utilizing an extracorporeal circuit. Ann. Surg. 148,616, 1958. 8. Morton, D. L., et al., Immunologic factors which influence response to immunotherapy in malignant melanoma. Surgery 68, 158, 1970. 9. Knutson, D. O., Hori, J. M., and Spratt, J. S., Jr., Melanoma. Curr. Probi. Surg., December, 1971. 10. Clark, W. H., From, L., Bernardino, E. A., and Mihm, M. C., The histogenesis and biologic behavior of primary human malignant melanomas of the skin. Cancer Res. 29,705, 1969.
48, 399-401 (1975)
The Current Status of the Melanoma Problem A Symposium Presented at Surgical Grand Rounds at the Yale University School of Medicine, January 1975
NEAL KOSS Department ofSurgery, Section of Plastic and Reconstructive Surgery, Yale University School ofMedicine, 333 Cedar Street, New Haven, Connecticut 06510 Received August 8, 1975
Because of many recent diagnostic and therapeutic advances, malignant melanoma has been receiving new notoriety. Nevertheless, it is far from a new disease. Hippocrates (1) is credited with the first description of the lesion, which has always been regarded with some fear and superstition. There was little contribution of any significance until the seventeenth century, when Highmore, Bartholin, and Bonet at various times described the "fatal black tumor" (2). In 1806, Laennec and Dupuytren independently published treatises on melanosis (1). Thirty years later, Carswell coined the term melanoma (1). Pemberton (3), in 1858, was the first to note the significance of the regional lymph nodes and suggested lymphadenectomy. In 1868, Langerhans (4) noted melanocytes in histologic specimens of skin as the "branched cells," but it was not until 1951 that the term melanocyte was adopted. Wide excision with regional node dissection was introduced by Handley (5) in 1907. This concept was expanded by Pringle (6) the following year to include depth with the primary excision. More recent advances are seen with the work of Creech (7), who introduced regional perfusion in 1958 by the use of an extracorporeal circuit, and the introduction of immunotherapy by Morton et al. (8) in 1970. These historical milestones are summarized in Table 1 and may also be found, along with a statistical review of the subject, in Knutson's monograph (9). Current concepts of melanoma fall naturally into four broad areas: (i) diagnosis, (ii) staging, (iii) surgery, and (iv) immunology. A symposium on melanoma was prepared for Surgical Grand Rounds at Yale University in January of 1975, based on such an outline. The first paper deals with the clinical appearance of melanoma and some important points in the differential diagnosis of these lesions. Since there are an average of 15 pigmented nevi per Caucasian, if 10,000 surgeons worked 8 hr/day excising one nevus every 15 min, then the current population would be free of nevi in 25 yr (Table 2). In order to avoid having to excise or biopsy every nevus, Dr. Nordlund presents the important features of nevi that should make one suspicious of the diagnosis of melanoma. In so doing, he discusses the first classification system that differentiates melanomas by appearance: lentigo maligna (Hutchinson freckle), superficial spreading, and nodular. One of the most important advances in the study of melanoma has been the recognition of the importance of pathologic classification by depth, as first reported by Clark (10). Dr. Smith, in the next paper in the series, describes this system and discusses its relation to prognosis. 399 Copyright© 1975 by Academic Press, Inc. All rights of reproduction in any form reserved.
400
NEAL KOSS
TABLE 1 Summary of Historic Milestones in Melanoma Hippocrates First recorded description 1651 1677 1679 1806 1806
1836 1858 1868 1907 1908 1958 1970
Highmore Bartholin Bonet Laennec Dupuytren Carswell Pemberton Langerhans Handley Pringle Creech Morton
Described "fatal black tumor" Independently published treatises on melanosis Coined the term melanoma Suggested lymphadenectomy Noted melanocytes ("branched cells") Wide excision + RLND Added depth + incontinuity RLND Regional perfusion Immunotherapy
TABLE 2 The Statistics of Excising All Pigmented Nevi
15, average per Caucasian If 10,000 surgeons worked 8 hr per day excising 1 nevus every 15 min Then the current population would be free of nevi in 25 yr
TABLE 3 How Melanoma Statistics May Be Biased
Statistics on melanoma are biased by Who is reporting Where he is reporting from Cancer center Primary care physician University hospital Dermatologist General surgeon City hospital Plastic surgeon Community hospital HMO Chemotherapist Industrial clinic Immunotherapist Pathologist As well as country of origin, racial and sex predominance of the population, etc.
STATUS OF MELANOMA
401
In addition to describing the current thinking with regard to surgery in melanoma, Dr. Arons points out that (i) melanoma is not a surgical emergency and (ii) incisional biopsy is often the correct initial step in establishing a diagnosis. In his conclusions, he states the general consensus for the surgical approach to this disease. In the final paper, Dr. Ariyan discusses the logic and the technique of the immunotherapy of melanoma. A final word must be said about the statistics of melanoma. There has been confusion and disagreement about many past conclusions concerning prognosis and management, and each proponent has always proven his results by some series of patients. Melanoma statistics, perhaps more than other malignancies, are biased by who is reporting the study and where the report is originating. Table 3 lists these and other features. Notwithstanding all the other difficulties of treating this disease, the discrepancies in the reports in the literature have often added to the confusion. By examining the melanoma problem as it is currently understood from both the diagnostic and therapeutic approaches, this symposium was intended to present a logical understanding of the disease from the viewpoint of a dermatologist, pathologist, surgeon, and immunotherapist. REFERENCES 1. Stewart, D. F., Hay, L. J., and Varco, R. L., Malignant melanoma: 92 cases treated at the University of Minnesota Hospitals since January 1, 1932. Int. Abstr. Surg. 97, 209, 1953. 2. Wilkinson, J. S., and Paletta, G. X., Malignant melanoma: Current concepts. Amer. Surg. 35, 301, 1969. 3. Lehman, J. A., Jr., Cross, F. S., and Richez, D. G., Clinical study of 40 patients with malignant melanoma. Cancer 19,611, 1966. 4. McGovern, V. J., and Brown, M. M. L., "The Nature of Melanoma." Thomas, Springfield, Ill., 1969. 5. Handley, W. S., The Hunterian Lecture on the pathology of melanotic growths in relation to their operative treatment. Lancet 1, 927, 1907. 6. Pringle, J. H., Operation in melanotic tumors of the skin. Edinburgh Med. J. 23,496, 1908. 7. Creech, O., Krementz, E. T., Ryan, R. F., and Winblad, J. N., Chemotherapy of cancer: Regional perfusion utilizing an extracorporeal circuit. Ann. Surg. 148,616, 1958. 8. Morton, D. L., et al., Immunologic factors which influence response to immunotherapy in malignant melanoma. Surgery 68, 158, 1970. 9. Knutson, D. O., Hori, J. M., and Spratt, J. S., Jr., Melanoma. Curr. Probi. Surg., December, 1971. 10. Clark, W. H., From, L., Bernardino, E. A., and Mihm, M. C., The histogenesis and biologic behavior of primary human malignant melanomas of the skin. Cancer Res. 29,705, 1969.
