Kim S H, Garcia C, Rodriguez J, Coit D G
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
J Am Coll Surg. 1999 Mar;188(3):241-7. doi: 10.1016/s1072-7515(98)00296-8.
Ten percent of all patients with melanoma present with thick primary tumors (> or = 4 mm or Clark level V). To determine factors associated with outcomes, we performed a retrospective analysis of 120 patients who had definitive primary treatment of their thick cutaneous melanomas at Memorial Sloan-Kettering Cancer Center between January 1986 and April 1995.
Data were collected via chart review and patient interview. Association between factors was determined by chi-square analysis. Survival analysis was performed by the method of Kaplan and Meier. Univariate analysis by log-rank testing and multivariate analysis using the Cox regression model were used to identify factors associated with disease-free and overall survival.
Median age was 61 years (range 19 to 87 years). There were 80 males and 40 females. Median Breslow thickness was 6 mm (range 1.8 to 25.0 mm). Ninety-three patients (78%) underwent lymphadenectomy (52 elective and 41 therapeutic). Twenty-one percent (11 of 52) of the elective dissections were positive. Median followup was 3.8 years (5.2 years for patients no evident disease and 2.0 years for those dead of disease). Overall survival for the entire group was 62% at 5 years and 43% at 10 years. Age, gender, and anatomic site (axial versus extremity) were not factors predictive of overall survival. Increasing thickness, nodal status at presentation (American Joint Commission on Cancer stage II versus III), and the presence of ulceration were significant predictors of both disease relapse and disease-specific mortality in both univariate and multivariate analyses. There was no difference in postrelapse survival between patients suffering local, nodal, or distant relapse (p = 0.63).
Patients presenting with thick cutaneous melanomas are expected to have more than 50% 5-year survival, and they should not be denied the opportunity for aggressive locoregional management. Thickness, positive nodal status, and ulceration are associated with a higher mortality rate. The fact that patients with local or nodal recurrences fare as poorly as those with overt distant metastases implies that the former events are predictors of subclinical systemic disease.
所有黑色素瘤患者中有10%表现为原发性厚肿瘤（厚度≥4mm或Clark分级为V级）。为了确定与预后相关的因素，我们对1986年1月至1995年4月期间在纪念斯隆凯特琳癌症中心接受原发性厚皮黑色素瘤确定性治疗的120例患者进行了回顾性分析。
通过查阅病历和患者访谈收集数据。通过卡方分析确定因素之间的关联。采用Kaplan-Meier方法进行生存分析。使用对数秩检验进行单因素分析，并使用Cox回归模型进行多因素分析，以确定与无病生存和总生存相关的因素。
中位年龄为61岁（范围19至87岁）。男性80例，女性40例。中位Breslow厚度为6mm（范围1.8至25.0mm）。93例患者（78%）接受了淋巴结切除术（52例为选择性切除，41例为治疗性切除）。选择性切除的患者中有21%（52例中的11例）为阳性。中位随访时间为3.8年（无明显疾病的患者为5.2年，死于疾病的患者为2.0年）。整个组的5年总生存率为62%，10年为43%。年龄、性别和解剖部位（躯干与四肢）不是总生存的预测因素。在单因素和多因素分析中，肿瘤厚度增加、初诊时的淋巴结状态（美国癌症联合委员会II期与III期）以及溃疡的存在是疾病复发和疾病特异性死亡的重要预测因素。局部、淋巴结或远处复发的患者复发后的生存率无差异（p = 0.63）。
原发性厚皮黑色素瘤患者预计5年生存率超过50%，不应剥夺他们积极进行局部区域治疗的机会。肿瘤厚度、阳性淋巴结状态和溃疡与较高的死亡率相关。局部或淋巴结复发的患者与明显远处转移的患者预后同样差，这一事实表明前者是亚临床系统性疾病的预测因素。
