Balch C M, Soong S J, Murad T M, Ingalls A L, Maddox W A
Ann Surg. 1981 Mar;193(3):377-88. doi: 10.1097/00000658-198103000-00023.
Twelve prognostic features of melanoma were examined in a series of 185 patients with nodal metastases (Stage II), who underwent surgical treatment at our institution during the past 20 years. Forty-four per cent of the patients presented with synchronous nodal metastases (substage IIA), 44% of the patients had delayed nodal metastases (substage IIB), and 12% of the patients had nodal metastases from an unknown primary site (substage IIC). The patients with IIB (delayed) metastases had a better overall survival rate than patients with IIA (synchronous) metastases, when calculated from the time of diagnosis. These differences could be explained on the basis of tumor burden at the time of initial diagnosis (microscopic for IIB patients versus macroscopic for IIA patients). Once nodal metastases became evident in IIB patients, their survival rates were the same as for substage IIA patients, when calculated from the onset of nodal metastases. The survival rates for both subgroups was 28% at five years and 15% for ten years. Substage IIC patients (unknown 1 degrees site) had better five-year survival rates (39%), but the sample size was small and the differences were not statistically significant. A multifactorial analysis was used to identify the dominant prognostic variables from among 12 clinical and pathologic parameters. Only two factors were found to independently influence survival rates: 1) the number of metastatic nodes (p = 0.005), and the presence or absence of ulceration (p = 0.0019). Additional factors considered that had either indirect or no influence on survival rates (p > 0.10) were: anatomic location, age, sex, remission duration, substage of disease, tumor thickness, level of invasion, pigmentation, and lymphocyte infiltration. All combinations of nodal metastases were analyzed from survival differences. The combination that showed the greatest differences was one versus two to four versus more than four nodes. Their five-year survival rates were 58%, 27% and 10%, respectively (p < 0.001). Ulceration of the primary cutaneous melanoma was associated with a <15% five-year survival rate, while nonulcerative melanomas had a 30% five-year survival rate (p < 0.001). The combination of ulceration and multiple metastatic nodes had a profound adverse effect on survival rates. While tumor thickness was the most important factor in predicting the risk of nodal metastases in Stage I patients (p < 10(-8)), it had no predictive value on the patient's clinical course once nodal metastases had occurred (p = 0.507). The number of metastatic nodes and the presence of ulceration are important factors to account for when comparing surgical results, and when analyzing the efficacy of adjunctive systemic treatments.
在过去20年里，我们机构对185例有淋巴结转移（II期）的黑色素瘤患者进行了手术治疗，并对12项黑色素瘤预后特征进行了研究。44%的患者出现同步淋巴结转移（IIA亚期），44%的患者出现延迟淋巴结转移（IIB亚期），12%的患者淋巴结转移来自未知原发部位（IIC亚期）。从诊断时算起，IIB期（延迟）转移患者的总生存率高于IIA期（同步）转移患者。这些差异可以根据初始诊断时的肿瘤负荷来解释（IIB期患者为微观，IIA期患者为宏观）。一旦IIB期患者出现明显的淋巴结转移，从淋巴结转移开始算起，他们的生存率与IIA亚期患者相同。两个亚组的五年生存率均为28%，十年生存率为15%。IIC亚期患者（未知原发部位）的五年生存率较高（39%），但样本量较小，差异无统计学意义。采用多因素分析从12项临床和病理参数中确定主要的预后变量。仅发现两个因素独立影响生存率：1）转移淋巴结数量（p = 0.005），以及是否存在溃疡（p = 0.0019）。其他被认为对生存率有间接影响或无影响（p > 0.10）的因素包括：解剖位置、年龄、性别、缓解期、疾病亚期、肿瘤厚度、浸润深度、色素沉着和淋巴细胞浸润。分析了所有淋巴结转移组合的生存差异。差异最大的组合是1个淋巴结转移与2至4个淋巴结转移与超过4个淋巴结转移。它们的五年生存率分别为58%、27%和10%（p < 0.001）。原发性皮肤黑色素瘤溃疡患者的五年生存率<15%，而无溃疡黑色素瘤患者的五年生存率为30%（p < 0.001）。溃疡和多个转移淋巴结的组合对生存率有严重的不利影响。虽然肿瘤厚度是预测I期患者淋巴结转移风险的最重要因素（p < 10^(-8)），但一旦发生淋巴结转移，它对患者的临床病程没有预测价值（p = 0.507）。在比较手术结果以及分析辅助全身治疗的疗效时，转移淋巴结数量和溃疡的存在是需要考虑的重要因素。
