[Therapy of malignant melanoma].
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Biomedical subjects
Publications and source records attributed to J Civatte.
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According to Clark there are three different types of melanoma: malignant melanoma which develops from the floor of a precancerous melanosis, the extensive superficial melanoma and nodular malignant melanoma. Therapeutically, surgery occupies the first place. Chemotherapeutically the combination of 3 or 4 different substances has given favorable results. Immunotherapeutically, immunization with BCG and mycobacteria, especially Cornyebacterium parvum, is considered the most reliable and least dangerous procedure. Altogether, a better prognosis for malignant melanoma can be expected in the future if diagnosis is made early and if treated with an optimum combination therapy.
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In a prospective randomized study, the effect of chemotherapy (either systemic or combined intraarterial and systemic) was studied in 117 patients undergoing a curative resection of Clark's level III, IV or V malignant melanoma. Systemic chemotherapy was started one month after surgery one week courses with an I.V. injection of Vinblastin 6 mg/m2, Thiotepa 6 mg/m2, Rufocromomycine 60 microgram/m2, Methotrexate 15 mg/m2 on day one with procarbazine 30 mg/m2 orally daily were given every other week for three months and later every four weeks. Intraarterial chemotherapy of DTIC 80 mg/kg day for ten days was given 28 days prior to surgery. 65 patients with limb malignant melanoma were treated either by surgery only (27 patients), or by systemic chemotherapy (23 patients) or by preoperative intraarterial chemotherapy and systemic chemotherapy (15 patients): 52 patients with non limb malignant melanoma were treated either by surgery only (28 patients) or by systemic chemotherapy (24 patients). We drew curves of disease free survival following surgery and studied the levelling off of the curves, 24 months after surgery 65% of the patients treated by surgery alone were alive and free of disease whereas 81% of the patients treated by surgery and chemotherapy were alive and free of disease (p less than 0.05) suggesting a possible benefit of adjuvant chemotherapy. Intraarterial preoperative chemotherapy has not proved of additional benefit to date.
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This histologic classification is based upon the arrangement and cytologic composition of the infiltrate. We separate diseases with intraepidermal exocytosis from diseases without intraepidermal exocytosis. In the first group, mycosis fungoides is the most important: the infiltrate is often polymorphous, but sometimes it consists of histiocytes and lymphocytes. Varying number of Sézary cells are present. The Woringer-Kolopp syndrome and histiocytosis X are included in this group as well. The second group comprises many neoplastic diseases: mycosis fungoides without Pautrier microabscesses, so-called 'reticulosis', 'Crosti's reticulosis', leukemia and lymph node lymphoma. Difficulties may arise in the differential diagnosis between these various diseases with well-differentiated lymphocytes and without intraepidermal exocytosis. These diseases must also be differentiated from the non-malignant lymphocytic infiltrates found in lupus erythematosus, lymphocytoma cutis and Jessner's lymphocytic infiltration of the skin.
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The feeling of the authors is that their seven reported cases of a pigmented dermatosis are different from the ashy dermatosis and from the erythema dyschromicum perstans. This disease, which affects children and teenagers, males as well as females, is characterized by pigmented macules 5-25 mm in diameter, affecting the neck, the trunk and the limbs. The first symptom is whether a pigmented spot, or an erythematous, papular or achromic lesion; in the latter instance the pigmentation occurs only secundarily. In most of the cases this dermatose is slowly and spontaneously regressive. The histological picture is not really specific. In one case there was a marked intraepidermal dyskeratosis of the sweat duct openings. The etiology remains unknown.
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