Biomedical subjects
Publications and source records attributed to H K Koh.
The primary care physician has a critical role in the early detection and cure of malignant melanoma. We present an overview of melanoma epidemiology, offer guidelines for recognition of melanoma and its precursors, review prognosis and staging, and describe the latest developments in surgical and medical treatment.
While the association of discoid lupus erythematosus (DLE) and subsequent squamous cell carcinoma is well known, there are no reports in the English-language literature concerning the association of DLE and soft-tissue sarcoma. We describe a patient with DLE and malignant fibrous histiocytoma.
We have described the epidemiology and clinical characteristics of malignant melanoma and its precursors in the hope that this discussion will help physicians to recognize suspicious pigmented lesions earlier, thus helping to decrease avoidable cancer deaths from melanoma.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Several varieties of ocular pathology are associated with acquired cutaneous hypomelanosis (leukoderma; vitiligo). Our current study was undertaken to investigate the relationship between ophthalmologic disorders and a specific depigmentary phenomenon, the vitiligolike leukoderma of cutaneous melanoma. Over the past 14 years, eight patients with cutaneous melanoma and widespread areas of hypopigmentation were identified at the Pigmented Lesion Clinic of the Massachusetts General Hospital. The seven patients who underwent ophthalmologic examination had pigment-related ocular abnormalities. Among these were inflammations of the uveal tract in three patients, heterochromia in two, halo nevi of the choroid in one, and hypopigmentation and/or atrophy of the retinal pigment epithelium or choroid in four. Our findings demonstrate that ocular disease may be a component in a syndrome consisting also of cutaneous melanoma and vitiligolike leukoderma and suggest the need for complete ophthalmologic examinations in patients with melanoma and leukoderma.
We tested 12 clinical and histologic variables to see which ones best predicted death from melanoma in 66 patients with positive elective regional node dissections (clinical stage I, pathologic stage II [CSI, PSII]). Despite the presence of lymph node metastases, not all patients had poor prognoses. Patients with tumors less than or equal to 3.5 mm and a percentage of positive nodes less than or equal to 20% had a 7-year survival rate of 66%. Within this low-risk group the subset with primary lesions on the trunk or extremities (except hands and feet) had a 7-year survival rate of 76%. This compares with poor 7-year survivals of 29% and 30% observed in other defined high-risk groups. Our results confirm and extend earlier observations concerning the prognoses of CSI, PSII melanoma patients and are relevant to any ongoing and future studies concerning elective regional node dissection (ERND) or adjuvant therapy trials in melanoma.
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The emergence of revised definitions for the high-risk patient with cutaneous malignant melanoma prompts us to re-examine the current status of adjuvant therapy in this disease. We wish to address the question, "once a cutaneous melanoma is surgically removed and the patient is currently free of disease but at high risk for metastases, what can be done to prevent recurrence"?
Although intermittent intense solar exposure and genetic traits such as fair skin continue to be associated with the risk of developing cutaneous melanoma, these factors fail to account for much of the incidence. Suggestive evidence has increased speculation that viral agents, radiation, hormones, chemicals in the workplace, and dietary factors play some etiologic role.
A prospective study on 289 women with clinical stage I cutaneous melanoma was done to determine the relationship between estrogen administration, tumor characteristics, and survival. Eighty-two women took oral contraceptives (OC) and 44 took menopausal estrogens (MPE) prior to the diagnosis of melanoma. Users of OC presented with thinner primary tumors than nonusers of OC (P less than .01). A similar trend was observed in users of MPE. Women who used OC in the year prior to the diagnosis of melanoma had statistically thinner tumors than those who had discontinued use of OC more than 1 year prior to diagnosis (P less than .025). A statistically significant preponderance of truncal lesions was observed among users of OC (P less than .01). Other tumor characteristics were unaltered by estrogen administration. Duration of use and time in relation to diagnosis of melanoma did not affect survival. Women who took hormones had slightly better 5- and 9-year survival rates than nonusers. These results suggest that prior estrogen use and, particularly, use of OC in women developing melanoma have no deleterious effect.
Heavy cigarette smoking (current smoking with greater than 15-pack-year smoking history), along with 13 other variables, were tested for their ability to predict death in 196 patients with clinical Stage I melanoma. A stepwise proportional hazards general linear model (Cox multivariate analysis) showed that although heavy cigarette smoking as a single variable is an adverse prognostic marker (P = 0.0065), it has only suggestive prognostic significance once thickness factors are taken into account (P = 0.0747). People who stopped smoking had the same survival as nonsmokers. Clinical Stage I patients with melanoma who were heavy smokers presented with thicker lesions than their nonsmoking counterparts (P = 0.037). Although cigarette smoking may play a role in the biologic behavior of melanoma by mediating an effect on thickness, it need not be considered as an independent stratification criterion when analyzing results of melanoma prognosis or treatment.
Two patients experienced a recurrence of cutaneous malignant melanoma more than ten years after initial diagnosis, treatment, and presumed cure. A review of the literature shows that delayed metastases (more than ten years) have been clearly documented in only seven previous patients with cutaneous malignant melanoma. With the rising incidence of cutaneous malignant melanoma, physicians may begin to see more cases of late recurrence in patients with a history of presumably cured disease. Although uncommon, late recurrence has important implications in the long-term management of all patients with malignant melanoma.
We studied 48 patients with lentigo maligna melanoma (LMM) and compared the clinical stage I patients with non-LMM melanoma patients (matched by site and thickness) to see if prognosis differed. There was no significant difference in mortality from melanoma between the two groups (P = .68) after a mean follow-up time of five years (67.5 months for LMM, 60.5 months for non-LMM). In addition, a Cox multivariate analysis of the entire matched group showed that only thickness was significantly associated with death from melanoma (P = .0007) while histology (LMM v non-LMM) did not make a significant contribution (P = .61). Our data suggest that after accounting for primary tumor thickness and site, LMM and non-LMM have the same prognosis and biologic behavior, in contrast to the widely held belief that LMM has a better prognosis than other forms of melanoma.
In an earlier study we found that patients with clinical Stage 1 and 2 cutaneous malignant melanoma and increased splenic radiocolloid uptake had more frequent recurrence at 24 mo, compared with melanoma patients having normal liver-spleen scintigrams. This report, an 80-mo follow-up study, gives further information on 119 clinical Stage 1 patients. Fifteen of 35 patients with increased splenic uptake (42.9%) died from melanoma as opposed to only 16 of 84 (19.1%) with normal liver-spleen images (p less than 0.01). Multivariate analysis showed that augmented splenic uptake of technetium-99m sulfur colloid is a marker for adverse prognosis in patients with malignant melanoma but does not appear to be an independent variable in predicting death. In clinical Stage 1 patients, increased splenic uptake correlated significantly with pathologic stage (positive elective node biopsy) as well as thickness and mitotic rate in patients with thicker lesions. It may be that patients with thicker, pathologically aggressive tumors have an increased splenic blood flow and/or enhanced immune and reticuloendothelial response (as manifested by abnormal liver-spleen scintigram). If so, the enhanced immune response does not appear to contribute to overall survival.