Опухоли головы и шеи. 2020; 10: 55-64
Влияют ли морфологические признаки на частоту местных рецидивов и отдаленных метастазов при меланоме кожи головы и шеи?
https://doi.org/10.17650/2222-1468-2020-10-3-55-64Аннотация
Введение. Под термином «местный рецидив» обычно понимают повторный рост опухоли после хирургического вмешательства, который возникает в пределах 3–5 см от послеоперационного рубца. Причины продолженного роста опухоли или рецидива у пациентов с меланомой кожи – нерадикальное хирургическое лечение, а также сателлитные или транзитные метастазы, которые не были удалены единым блоком вместе с первичной опухолью. Многочисленные исследования особенностей биологии меланомы, морфологических критериев ее диагностики и особенностей ее клинического течения позволили выделить в отдельную группу сателлитные и транзитные метастазы, которые реализуются внутри- или подкожно на расстоянии <2 см или >2 см от первичной опухоли, но не достигая места расположения первого регионарного барьера.
Цель исследования – определить влияние основных прогностических факторов, таких как толщина опухоли по Breslow, уровень инвазии по Clark и наличие изъязвлений, на частоту местных рецидивов при меланоме кожи головы и шеи.
Материалы и методы. В исследовании приняли участие 174 пациента с меланомой кожи головы и шеи, проходившие лечение в 1995–2014 гг. С помощью полученного нами индекса сокращения кожного лоскута (медиана 30 %) истинные границы резекции были точно определены у всех пациентов. В зависимости от этого были сформированы 3 группы с отступом <0,5; 0,6–1,0 и >1,0 см, в которых проанализированы отдаленные результаты лечения.
Результаты. Безрецидивная выживаемость не коррелировала с величиной хирургического отступа. Она была лучшей при минимальном хирургическом отступе (77,3 %) и худшей при максимальном отступе (38,7 %), т. е. отдаленные результаты лечения не зависят от ширины хирургического отступа.
Заключение. С использованием ROC-кривых определены безопасные границы хирургического отступа для меланомы кожи головы и шеи: при толщине меланомы кожи головы и шеи <2мм отступ 0,46мм (p = 0,13), при толщине меланомы 0,58мм – 2,01–4,00мм (р = 0,002), при толщине меланомы >4 мм – 0,72 мм (р = 0,016). В нашей работе такие факторы, как толщина опухоли по Breslow, уровень инвазии по Clark и наличие изъязвлений, не влияли на частоту местных рецидивов меланомы кожи головы и шеи, что дает основание утверждать, что уменьшение хирургического отступа действительно не приводит к ухудшению отдаленных результатов лечения.
Список литературы
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29. Ann Surg 1993;218(3):262–7. DOI: 10.1097/00000658-199309000-00005.
30. Balch C.M., Soong S.J., Smith T. et al. Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1–4 mm melanomas. Ann Surg Oncol 2001;8(2):101–8. DOI: 10.1007/s10434-001-0101-x.
31. Karakousis C.P., Balch C.M., Urist M.M. et al. Local recurrence in malignant melanoma: long-term results of the multiinstitutional randomized surgical trial. Ann Surg Oncol 1996;3(5):446–52. DOI: 10.1007/BF02305762.
32. Thomas J.M., Newton-Bishop J., A’Hern R. et al. Excision margins in highrisk malignant melanoma. N Engl J Med 2004;350(8):757–66. DOI: 10.1056/NEJMoa030681.
33. Ringborg U., Brahme E.M., Drewiecki K. Randomized trial of a resection margin of 2 cm versus 4 cm for cutaneous malignant melanoma with a tumor thickness of more than 2 mm. In: World Congress on Melanoma. Vancouver, 2005.
34. Wheatley K., Wilson J.S., Gaunt P., Marsden J.R. Surgical excision margins in primary cutaneous melanoma: a metaanalysis and Bayesian probability evaluation. Cancer Treat Rev 2016;42:73–81. DOI: 10.1016/j.ctrv.2015.10.013.
35. Breslow A. Thickness, cross-sectional areas and depth of invasion in prognosis of cutaneous melanoma. Ann Surg 1970;172:902–8.
36. Balch C.M., Houghton A.N., Sober A.J. et al. Thompson complex closures of melanoma excisions. In: Cutaneous melanoma. 5th edn. St. Louis: Quality Medical Publishing, 2009. P. 275–319.
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38. Bagley F.H., Cady B., Lee A. et al. Changes in clinical preservation and management of malignant melanoma. Cancer 1981;47:2126–34.
39. Gershenwald J.E., Scolyer R.A., Hess K.R. et al. Melanoma staging: Evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin 2017;67(6):472–92. DOI: 10.3322/caac.21409.
Head and Neck Tumors (HNT). 2020; 10: 55-64
Does morphology have real impact on local and distant recurrences in head and neck cutaneous melanoma?
https://doi.org/10.17650/2222-1468-2020-10-3-55-64Abstract
Introduction. The term “local recurrence” is usually understood as regrowth of a tumor after surgical treatment. The regrowth appears within 3–5 cm from postoperative cicatrix. The causes for such prolonged tumor growth or recurrence of patients with cutaneous melanoma are nonradical surgical treatment as well as satellite or transit metastases that were not removed in-block with primary tumor. A great number of clinical researches, aimed at examination of melanoma, its patterns, anatomical criteria and features of clinical course, gave an opportunity to separate satellite or transit metastases into an independent group. Such metastases are realized inside or subdermally, up to 2 cm or more than 2 cm from the primary tumor, yet, not reaching the location of the first regional barrier.
The aim of the study is to define influence of the main prognostic factors such as tumor thickness according to Breslow, the level of invasion according to Clark and the presence of ulceration on the frequency of local recurrence with cutaneous melanoma of head and neck.
Materials and methods. The research involved 174 patients with cutaneous melanoma of head and neck (1995–2014). According to our index of contraction of a skin flap (median 30 %) the true borders of resection were clearly defined within all the patients. Thereby, 3 groups were identified with the following resection margin: 1.0 cm, where followed-up treatment results were analyzed.
Results. Progression-free survival didn’t correlate with the size of surgical resection margins. The survival rates were the best with the lowest resection margin under 0.5 cm (77.3 %) and the worst with the highest resection margin more then 1.0 cm (38.7 %). That means that the treatment results don’t depend on the width increase of tumor resection margin.
Conclusions. We consider that clear surgical margins for any thickness of cutaneous melanoma of head and neck should be as follows: 4 mm – 0.72 mm (p = 0.016). In our work, the influence of the main prognostic factors, such as tumor thickness according to Breslow, level of invasion according to Clark and ulceration on the frequency of head and neck cutaneous melanoma local recurrences had no impact.
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13. Urist M.M., Balch C.M., Soong S.J. et al. Head and neck melanoma in 534 clinical stage I patients. A prognostic factors analysis and results of surgical treatment. Ann Surg 1984;200(6):769–75. DOI: 10.1097/00000658-198412000-00017.
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19. Stage I melanoma of the skin: the problem of resection margins. W.H.O. Collaborating Centres for Evaluation of Methods of Diagnosis and Treatment of Melanoma. Eur J Cancer 1980;16(8):1079–85.
20. Day C.L., Harrist T.J., Gorstein F. et al. Prognostic significance of “microscopic satellites” in the reticular dermis and subcutaneous fat. Ann Surg 1981;194(1):108–12. DOI: 10.1097/00000658-198107000-00019.
21. Levine A. On the histological diagnosis and prognosis of malignant melanoma. J Clin Pathol 1980;33(2):101–24. DOI: 10.1136/jcp.33.2.101.
22. Banzet P., Thomas A., Vuillemin E. Wide versus narrow surgical excision in thin (<2 mm) stage I primary cutaneous melanoma: long term results of a French multicentric prospective randomized trial on 319 patients. Proc Am Assoc Clin Oncol 1993;12:387.
23. Khayat D., Rixe O., Martin G. et al. Surgical margins in cutaneous melanoma (2 cm versus 5 cm for lesions measuring less than 2.1-mm thick). Cancer 2003; 97(8):1941–6. DOI: 10.1002/cncr.11272.
24. Cohn-Cedermark G., Rutqvist L.E., Andersson R. et al. Long term results of a randomized study by the Swedish Melanoma Study Group on 2-cm versus 5-cm resection margins for patients with cutaneous melanoma with a tumor thickness of 0.8– 2.0 mm. Cancer 2000;89(7):1495–501.
25. Ringborg U., Andersson R., Eldh J. et al. Resection margins of 2 versus 5 cm for cutaneous malignant melanoma with a tumor thickness of 0.8 to 2.0 mm: randomized study by the Swedish Melanoma Study Group. Cancer 1996;77(9):1809–14.
26. Cascinelli N., Belli F., Santinami M. et al. Sentinel lymph node biopsy in cutaneous melanoma: the WHO Melanoma Program experience. Ann Surg Oncol 2000;7(6):469–74. DOI: 10.1007/s10434-000-0469-z.
27. Veronesi U., Cascinelli N. Narrow excision (1-cm margin). A safe procedure for thin cutaneous melanoma. Arch Surg 1991;126(4):438–41. DOI: 10.1001/archsurg.1991.01410280036004.
28. Balch C.M., Urist M.M., Karakousis C.P. et al. Efficacy of 2-cm surgical margins for intermediate-thickness melanomas (1 to 4 mm). Results of a multiinstitutional randomized surgical trial.
29. Ann Surg 1993;218(3):262–7. DOI: 10.1097/00000658-199309000-00005.
30. Balch C.M., Soong S.J., Smith T. et al. Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1–4 mm melanomas. Ann Surg Oncol 2001;8(2):101–8. DOI: 10.1007/s10434-001-0101-x.
31. Karakousis C.P., Balch C.M., Urist M.M. et al. Local recurrence in malignant melanoma: long-term results of the multiinstitutional randomized surgical trial. Ann Surg Oncol 1996;3(5):446–52. DOI: 10.1007/BF02305762.
32. Thomas J.M., Newton-Bishop J., A’Hern R. et al. Excision margins in highrisk malignant melanoma. N Engl J Med 2004;350(8):757–66. DOI: 10.1056/NEJMoa030681.
33. Ringborg U., Brahme E.M., Drewiecki K. Randomized trial of a resection margin of 2 cm versus 4 cm for cutaneous malignant melanoma with a tumor thickness of more than 2 mm. In: World Congress on Melanoma. Vancouver, 2005.
34. Wheatley K., Wilson J.S., Gaunt P., Marsden J.R. Surgical excision margins in primary cutaneous melanoma: a metaanalysis and Bayesian probability evaluation. Cancer Treat Rev 2016;42:73–81. DOI: 10.1016/j.ctrv.2015.10.013.
35. Breslow A. Thickness, cross-sectional areas and depth of invasion in prognosis of cutaneous melanoma. Ann Surg 1970;172:902–8.
36. Balch C.M., Houghton A.N., Sober A.J. et al. Thompson complex closures of melanoma excisions. In: Cutaneous melanoma. 5th edn. St. Louis: Quality Medical Publishing, 2009. P. 275–319.
37. Barchuk L.S. Khirurgicheskoe lechenie melanom. Prakticheskaya onkologiya 2001;(34):30–6.
38. Bagley F.H., Cady B., Lee A. et al. Changes in clinical preservation and management of malignant melanoma. Cancer 1981;47:2126–34.
39. Gershenwald J.E., Scolyer R.A., Hess K.R. et al. Melanoma staging: Evidence-based changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin 2017;67(6):472–92. DOI: 10.3322/caac.21409.
