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CUTANEOUS MELANOMA OF THE HEAD AND NECK: THE ROLE OF NECK DISSECTION. JAMES M. ROTH, M.D. PAUL FRIEDLANDER, M.D. CUTANEOUS MELANOMA. IN 2001, 47,700 NEW CASES WILL BE DIAGNOSED INCIDENCE IS INCREASING AT 5% PER YEAR BY THE YEAR 2000 1 IN 75 PEOPLE WILL DEVELOP MELONAMA

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cutaneous melanoma of the head and neck the role of neck dissection

CUTANEOUS MELANOMA OF THE HEAD AND NECK: THE ROLE OF NECK DISSECTION

JAMES M. ROTH, M.D.

PAUL FRIEDLANDER, M.D.

cutaneous melanoma
CUTANEOUS MELANOMA
  • IN 2001, 47,700 NEW CASES WILL BE DIAGNOSED
  • INCIDENCE IS INCREASING AT 5% PER YEAR
  • BY THE YEAR 2000 1 IN 75 PEOPLE WILL DEVELOP MELONAMA
  • THIS INCREASE IS GREATER THAN ANY OTHER CANCER IN MEN AND SECOND ONLY TO LUNG CANCER IN WOMEN
cutaneous melanoma3
CUTANEOUS MELANOMA
  • 15-30% OF MELANOMA OCCUR IN THE HEAD AND NECK
  • 10 YEAR SURVIVAL FOR STAGE 1 MELANOMA OF THE HEAD AND NECK IS 69% COMPARED TO 89% WITH MELANOMA OF THE EXTREMITY
  • 50% RECCURRENCE RATE AFTER 5 YEARS FOR HEAD AND NECK COMPARED TO 50% IN 10 YEARS FOR EXTREMITY
risk factors
RISK FACTORS
  • SUN EXPOSURE: UV B AND TO SOME EXTENT UV A/ VISIBLE
  • CONTROVERSY OVER CUMULATIVE EXPOSURE AND EARLY EXPOSURE
  • PRE-EXISTING LESION: 1/3 ARISE IN CONGENITAL NEVI; 1/3 IN NEVI > 5 YEARS; 1/3 IN NEVI < 5 YEARS
  • BLUE/GREEN EYES; BLOND/RED HAIR; FAIR CMPLEXION; INABILITY TO TAN
slide5
ABCD
  • ASSYMETRY- UNEVEN GROWTH RATE
  • BORDER- IRREGULAR (THE STRONGEST PREDICTOR OF MALIGNANCY)
  • COLOR- VARIETIONS AND SHADING
  • DIAMETER- INCREASES IN SIZE OR A DIAMETER >6MM
history
HISTORY
  • MAJORITY ARE DETECTED BY THE PATIENT WITH ONLY 25% BEING DETECTED BY PHYSICIANS
  • GROWTH OR COLOR CHANGE IN A PRE-EXISTING LESION
  • BLEEDING, ITCHING, ULCERATION, AND PAIN- ALL OF THESE ARE USUALLY LATE SIGNS
history7
HISTORY
  • XERODERMA PIGMENTOSA
    • AUTOSOMAL RECESSIVE
    • MULTIPLE SKIN CANCERS BEFORE AGE 10
    • NUCLEOTIDE EXCISION REPAIR
  • FAMILIAL MELANOMA/ DYSPLASTIC NEVUS SYNDROME
    • p16 GENE ON CHROMOSOME 9p21
pathological subtypes
PATHOLOGICAL SUBTYPES
  • LENTIGO MALIGNA MELANOMA
  • SUPERFICIAL SPREADING MELANOMA
  • NODULAR MELANOMA
  • ACRAL LENTIGINOUS MELANOMA
  • DESMOPLASTIC MELANOMA
lentigo maligna melanoma
LENTIGO MALIGNA MELANOMA
  • 5-10% OF ALL MELANOMA
  • PROLONGED RADIAL GROWTH PHASE
  • INVASION OF THE PAPILLARY DERMIS
  • ULCERATION VERY SIGNIFICANT IN PROGNOSIS
superficial spreading
SUPERFICIAL SPREADING
  • MOST COMMON SUBTYPE (75%)
  • INITIAL RADIAL GROWTH PHASE
  • VERTICAL GROWTH HERALDED BY ULCERATION AND BLEEDING
  • CELLS HAVE A UNIFORM APPEARANCE
nodular melanoma
NODULAR MELANOMA
  • 10-15%
  • NO RADIAL GROWTH PHASE
  • VERTICAL GROWTH FROM THE ONSET
acral lentiginous
ACRAL LENTIGINOUS
  • PALMS AND SOLES
  • MOST COMMON MELANOMA IN AFRICAN AMERICANS
desmoplastic melanoma
DESMOPLASTIC MELANOMA
  • SPINDLE CELLS AMONG A FIBROUS STROMA “SCHOOLS OF FISH”
  • OFTEN NOT PIGMENTED
  • PROPENSITY TO SPREAD PERINEURALLY
staging systems
STAGING SYSTEMS
  • CLARK LEVEL
  • BRESLOW THICKNESS
  • AJCC TNM CLASSIFICATION
  • MODIFICATIONS OF THE AJCC
clark level
CLARK LEVEL
  • LEVEL I
    • ONLY INVOLVES THE EPIDERMIS
  • LEVEL II
    • INVASION OF PAPILLARY DERMIS BUT DOES NOT REACH THE PAPILLARY RETICULAR INTERFACE
  • LEVEL III
    • INVASION FILLS AND EXPANDS THE PAPILLARY DERMIS
clark level16
CLARK LEVEL
  • LEVEL IV
    • INVASION INTO THE RETICULAR DERMIS
  • LEVEL V
    • INVASION THROUGH THE RETICULAR DERMIS INTO THE SUBCUTANEOUS TISSUE
breslow thickness
BRESLOW THICKNESS
  • STAGE I
    • 0.75MM OR LESS
  • STAGE II
    • 0.76MM TO 1.50MM
  • STAGE III
    • 1.51MM TO 4.0MM
  • STAGE 1V
    • 4.0MM OR GREATER
ajcc tnm classification
AJCC TNM CLASSIFICATION
  • PRIMARY TUMOR (T)
    • TX: CAN NOT BE ASSESSED
    • T0: NO EVIDENCE OF PRIMARY TUMOR
    • Tis: MELANOMA IN SITU CLARK LEVEL I
    • T1: BRESLOW STAGE I CLARK LEVEL II
    • T2: BRESLOW STAGE II CLARK LEVEL III
    • T3: BRESLOW STAGE III CLARK LEVEL IV
      • a- 1.5mm but no more than 3mm
      • b- 3mm but no more than 4mm
    • T4: BRESLOW STAGE IV CLARK LEVEL V AND/OR SATELLITE LESIONS WITHIN 2CM
      • a-> 4mm or invades the subcutaneous tissue
      • b- Satellite(s) within 2 cm of the primary
ajcc tnm classification19
AJCC TNM CLASSIFICATION
  • REGIONAL LYMPH NODES (N)
    • NX: CAN NOT BE ASSESSED
    • NO: NO REGIONAL LYMPH NODES
    • N1: >3CM DIAMETER IN ANY REGIONAL LYMPH NODE
    • N2: >3CM AND OR IN-TRANSIT METASTASIS
      • a-> 3cm in diameter
      • b- in-transit metastasis
      • c- both a and b
      • in-transit metastasis involves skin or subcutaneous tissue >2cm from primary but not beyond the regional lymph nodes
ajcc tnm classification20
AJCC TNM CLASSIFICATION
  • DISTANT METASTASIS
    • MX: CAN NOT BE ASSESSED
    • MO: NO DISTANT METASTASIS
    • M1: DISTANT METASTASIS
      • a: Metastasis in the skin or subcutaneous nodules beyond the regional lymph nodes
      • b: visceral metastasis
ajcc tnm classification21
AJCC TNM CLASSIFICATION
  • STAGE 0: Tis, NO, MO
  • STAGE I: T1/2, NO, MO
  • STAGE II: T3/4, NO, MO
  • STAGE III: ANY T, N1/2, MO
  • STAGE IV: ANY T, ANY N, M1
m d anderson modifications
M.D. ANDERSON MODIFICATIONS
  • NOT USING OPTIMAL CUTOFFS OF TUMOR THICKNESS
  • NO USE OF ULCERATION IN THE SYSTEM DESPITE IT BEING A POWERFUL PROGNOSTIC INDICATOR
  • NUMBER OF NODES MORE IMPORTANT THAN SIZE
  • SATELLITES, IN-TRANSIT METASTASIS HAVE SIMILAR OUTCOMES
m d anderson modifications23
M.D. ANDERSON MODIFICATIONS
  • CUTOFFS FOR TUMOR THICKNESS SHOULD BE 1, 2, 4 MM- SIMPLER AND STILL SIGNIFICANT
  • INCORPORATE ULCERATION SINCE THIS HAS BEEN SEEN IN MORE AGGRESSIVE LESIONS AND HAS BEEN STRONG IN PREDICTING OUTCOME
m d anderson modifications24
M.D. ANDERSON MODIFICATIONS
  • NODAL STATUS STRONG INFLUENCE ON SURVIVAL 5YEARS SURVIVAL DATA N+ 32% AND N- 71% IN THICK TUMORS
  • REGIONAL SKIN AND SUBCUTANEOUS METASTASIS A SEPARATE CATEGORY
  • NUMBER OF NODES POSITIVE SHOULD REPLACE NODAL SIZE
primary lesions
PRIMARY LESIONS
  • WIDE LOCAL EXCISION
  • TUMOR THICKNESS MOST SIGNIFICANT FACTOR FOR LOCAL RECURRENCE
  • MARGINS RECOMMENDED FOR EXTREMITY NOT ALWAYS POSSIBLE IN THE HEAD AND NECK
    • <1MM 1CM MARGIN
    • 1-4MM 2CM MARGIN
    • >4 MM 2-3CM MARGIN
regional lymphatics
REGIONAL LYMPHATICS
  • SHAH 1991 MSK- ANALYZED 111 PATIENTS WITH MELANOMA AND METASTAIC DISEASE
  • LESIONS INVOLVING THE EAR, FACE, AND ANTERIOR SCALP WERE AT HIGH RISK FOR PAROTID INVOLVEMENT
  • LEVELS II THROUGH IV WERE MOST COMMONLY INVOLVED WITH LEVEL I INVOLVED 23% OF THE TIME AND LEVEL V INVOLVED 19% OF THE TIME
regional lymphatics27
REGIONAL LYMPHATICS
  • POSTERIOR NECK/ SCALP HAD NO INVOLVEMENT OF THE PAROTID GLAND, LOW INVOLVEMENT OF LEVEL 1 , AND INCREASED INVOLVEMENT OF LEVEL 5
regional lymphatics28
REGIONAL LYMPHATICS
  • LESIONS LESS THAN .76MM RARELY METASTASIZE
  • LESIONS .76MM TO 4.0MM METASTASIZE 14-44% OF PATIENTS
  • LESIONS >4.00 METASTASIZE 50-60% OF PATIENTS
  • LESIONS <1.5MM HAD ONLY 8% METASTASIS
node positive neck
NODE POSITIVE NECK
  • RADICAL VERSUS MODIFIED/ SELECTIVE NECK DISSECTION
  • RADICAL NECK DISSECTION IS NOT ALWAYS NECESSARY AND MAY NOT PROVIDE ADDITIONAL BENEFIT
  • O’BRIEN 1995 SYDNEY MELANOMA UNIT
sydney melanoma unit
SYDNEY MELANOMA UNIT
  • 175 PATIENTS WITH 183 NECK DISSECTIONS
  • 58% HAD A MODIFIED/SELECTIVE NECK DISSECTION IN THE PRESENCE OF CLINICAL NECK DISEASE
  • NECK RECURRENCE OCCURRED IN 14% OF RADICAL, 0% OF MODIFIED, AND 23% OF SELECTIVE NECK DISSECTIONS
sydney melanoma unit31
SYDNEY MELANOMA UNIT
  • RADICAL NECK DISSECTIONS WERE MORE LIKELY TO HAVE MULTIPLE POSITIVE NODES AND NO ADJUVANT RADIATION THERAPY
  • MODIFIED NECK DISSECTION HAD ONLY ONE NODE INVOLVEMENT
  • CLINICAL METASTATIC MELANOMA (N+) CAN BE WELL CONTROLLED BY MRND
sydney melanoma unit32
SYDNEY MELANOMA UNIT
  • SELECTIVE NECK DISSECTION, WHERE ONLY SPECIFIC LEVELS WERE DISSECTED, SEEMED LESS EFFECTIVE
  • BYERS 1998 M.D. ANDERSON AGREED THAT LESS THAN RADICAL SURGERY IS AN OPTION SECONDARY TO “PUSHING” CHARACTERISTIC OF THE NODES
node positive neck33
NODE POSITIVE NECK
  • STAGE III AND IV MELANOMA OF THE HEAD AND NECK SHOULD UNDERGO NECK DISSECTION AND MODIFIED RADICAL NECK DISSECTION APPEARS APPROPRIATE
  • LEVELS I-IV IN ANTERIOR LESIONS
  • LEVELS II-V IN POSTERIOR LESIONS
node negative necks
NODE NEGATIVE NECKS
  • THE ROLE OF ELECTIVE NECK DISSECTION IS EVEN MORE CONTROVERSIAL
  • LACK OF DATA TO SHOW ANY SIGNIFICANT SURVIVAL BENEFIT
  • TUMOR < 0.75 MM, NONULCERATED ARE VERY RARE TO METASTIASIZE
node negative necks35
NODE NEGATIVE NECKS
  • TUMORS > 4.0MM HAVE A HIGH RATE OF DISTANT METASTASIS (70%) AND POTENTIAL BENEFIT FROM NECK DISSECTION IS LOW
  • >4MM ELND MAY BENEFIT TO HELP STAGE THERE DISEASE AND POSSIBLY QUALIFY FOR ADJUVANT IMMUNOTHERAPY
  • WHAT ABOUT TUMORS .76-3.9MM?
node negative necks36
NODE NEGATIVE NECKS
  • ELECTIVE LYMPH NODE DISSECTION (ELND)
  • MAY BE OF THERAPUETIC BENEFIT
  • MAY BE USEFUL IN PREDICTING PROGNOSIS AND BENEFIT OF ADJUVANT THERAPY
  • STEPWISE PROGRESSION- LOCAL TO REGIONAL TO DISTANT
  • HEAD AND NECK MAY NOT FOLLOW THE RULES
node negative necks37
NODE NEGATIVE NECKS
  • PROPONENTS
  • PERALTA 1998 U. OF WASHINGTON
  • DREPPER 1993 MULTICENTER STUDY IN GERMANY
  • URIST 1984 AND BALCH 1996 INTERGROUP MELANOMA SURGICAL PROGRAM
  • IMMUNOTHERAPY
peralta 1998 u of washington
PERALTA 1998 U. OF WASHINGTON
  • 1.5-3.9MM LESIONS TREATED WITH AND WITHOUT ELND
  • 174 TOTAL MELANOMA TREATED OF THESE 38 HAD CLINICALLY NODE NEGATIVE AND INTERMEDIATE THICKNESS AND 10 UNDERWENT ELND
  • THE RATE OF DISTANT METASTASIS AND MORTALITY WERE 44% AND 35% LOWER THAN THOSE WHO DID NOT UNDERGO ELND AFTER 3 YEARS OF FOLLOW UP
  • NUMBERS TO SMALL TO BE SIGNIFICANT
drepper 1993
DREPPER 1993
  • 9 MEDICAL CENTERS
  • 3616 WITH T2 TO T4 LESIONS (>0.76MM)
  • <70 YEARS OLD
  • NOT SPECIFIC FOR HEAD AND NECK MELANOMA
  • ELND BENEFITTED MALE PATIENTS, NON ULCERATED LESIONS, AXIAL OR ACRAL MELANOMA, TUMORS >1.5MM TO 4.5MM
  • 20% INCREASE IN 5 YEAR SURVIVAL
balch 1996
BALCH 1996
  • 740 STAGE I AND II , 1-4MM LESIONS
  • NOT CONFINED TO THE HEAD AND NECK ONLY 8 WITH HEAD AND NECK
  • BENEFIT CONFINED TO PATIENT’S <60YEARS OLD, ESPECIALLY WITHOUT ULCERATION AND WITH THICKNESS OF 1-2MM (88% TO 81%)
  • >60 YEARS OLD HAD WORSE SURVIVAL WITH ELND
urist 1984
URIST 1984
  • 534 PATIENTS WITH STAGE I HEAD AND NECK MELANOMA PROSPECTIVE NON-RANDOMIZED
  • SSM AND NM ELND DID NOT PROVIDE ANY BENEFIT FOR MELANOMA <0.76MM OR >4.0MM
  • 1.5-3.99MM SHOWED A STATISTICALLY SIGNIFICANT INCREASE IN SURVIVAL RATE
  • .76-1.49MM SHOWED IMPROVEMENT THAT WAS NOT STATISTICALLY SIGNIFICANT
immunotherapy
IMMUNOTHERAPY
  • KIRKWOOD 1996 U. OF PITTSBURGH
  • MELANOMA AS A IMMUNOLOGIC DISEASE
    • SPONTANEOUSLY REGRESS
    • INFILTRATES OF B CELLS, T CELLS, AND MACROPHAGES
    • VITILIGO AS A RESULT OF ANTIMELANOCYTE ACTIVITY
    • SERA CONTAINS MELANOMA BINDING ANTIBODIES
kirkwood 1996 u of pittsburgh
KIRKWOOD 1996 U. OF PITTSBURGH
  • INTERFERON alpha- 2b
  • PROLONGATION OF RELAPSE FREE SURVIVAL AND PROLONGATION OF OVERALL SURVIVAL
  • BENEFIT GREATEST AMONG NODE POSITIVE PATIENTS
  • NOT LIMITED TO THE HEAD AND NECK
node negative necks44
NODE NEGATIVE NECKS
  • ARGUMENTS AGAINST ELND
  • KNUTSON 1972 U. OF MISSOURI
  • O’BRIEN 1991 SMU
  • KANE 1997 MAYO CLINIC
  • SURGICAL MORBIDITY
  • SENTINEL LYMPH NODE MAPPING
  • RADIATION THERAPY
knutson 1972 u of missouri
KNUTSON 1972 U. OF MISSOURI
  • 87 PATIENTS MELANOMA OF THE HEAD AND NECK 42 UNDERWENT NECK DISSECTION
  • 23 UNDERWENT ELECTIVE RADICAL NECK DISSSECTION
  • 21.7% ELND HAD POSITIVE NODES
  • 78.2% UNDERWENT A PROCEDURE WITH NO DEFINITIVE BENEFIT
  • SMALL NUMBER OF PATIENT’S
o brien 1991 smu
O’BRIEN 1991 SMU
  • THIS DATA WAS APART OF THE DATA USED BY URIST
  • WHEN THE SMU DATA WAS PULLED FROM THIS A SURVIVAL BENEFIT WAS ORIGINALLY SEEN ON UNIVARIATE ANALYSIS
  • MULTIVARIATE ANALYSIS ELIMINATED THIS BENEFIT
kane 1997 mayo clinic
KANE 1997 MAYO CLINIC
  • GREATER PROGNOSTIC UTILITY THAN SURVIVAL BENEFIT
  • 180 STAGE 1 UNDERWENT ELND
  • 8.3% HAD DISEASE ON PATHOLOGY
  • T3 AND T4 LESIONS HAD 14% AND 30% POSITVE PATHOLOGIC SPECIMENS
  • NO BENEFIT SEEN IN THESE THICKER LESIONS OR STAGE 1 LESIONS
  • STILL RECOMMEND ELND FOR TUMORS >1.5MM
surgical morbidity
SURGICAL MORBIDITY
  • SUPERFICIAL PAROTIDECTOMIES RISK INJURY TO THE FACIAL NERVE AND GUSTATORY SWEATING
  • POSTOPERATIVE HEMATOMA
  • CHYLOUS FISTULA
  • SKIN FLAP NECROSIS
  • COSMETIC AND FUNCTIONAL DEFECT
sentinel node biopsy
SENTINEL NODE BIOPSY
  • RECENT ADVANCEMENT IN MELANOMA THERAPY
  • BASED ON THE STEPWISE PROGRESSION OF CANCER
  • MOSTLY USED IN TRUNK AND EXTREMITY MELANOMA
  • IS THE HEAD AND NECK PREDICTABLE?
  • NEED FOR LYMPHOSCINTIGRAPHY?
  • WELLS 1997 U. OF SOUTH FLORIDA
wells 1997 u of south florida
WELLS 1997 U. OF SOUTH FLORIDA
  • IF PREOPERATIVE LYMPHOSCINTIGRAPHY IS NOT PERFORMED ELND AND NODE BIOPSIES MAY BE MISDIRECTED IN 50% OF CASES
  • ALL NODAL BASINS AT RISK
  • IN-TRANSIT NODAL AREAS
  • NUMBER OF SENTINEL NODES
  • LOCATION OF THE SENTINEL NODE IN RELATION TO OTHER NODES
sentinel node biopsy51
SENTINEL NODE BIOPSY
  • USE OF TWO MAPPING TECHNIQUES MAY INCREASE SENSITIVITY TO 95%
  • IF PAROTID INVOLVED NEED TO PERFORM SUPERFICIAL PAROTIDECTOMY
  • LESSER SURGERY GOES AGAINST SAFE PAROTID SURGERY
  • NO PROSPECTIVE RANDOMIZED STUDIES
sentinel node biopsy52
SENTINEL NODE BIOPSY
  • TECHNICHALLY A DEMANDING PROCEDURE THAT REQUIRES MORE DATA TO SUPPORT ITS USE IN THE HEAD AND NECK
radiation therapy
RADIATION THERAPY
  • ORIGINALLY THOUGHT TO BE OF NO BENEFIT IN MELANOMA
  • HYPERFRACTIONATION MAY PROVIDE BENEFIT
  • GEARA 1996 M.D. ANDERSON 174 PATIENTS
  • >1.5MM + WLE, WLE + TLND, TLND FOR RELAPSE
  • 6GY FIVE TIMES OVER 2.5 WEEKS
radiation therapy54
RADIATION THERAPY
  • 9 OUT 174 HAD A RECURRENCE ABOVE THE CLAVICLES
  • 58 OUT OF 174 HAD DISTANT FAILURE
  • 88% 5 YEAR LOCO-REGIONAL CONTROL
  • 47% 5 YEAR SURVIVAL
  • O’BRIEN DECREASE IN LOCAL RECURRENCE OF 12.2% IN PATIENTS WITH NODE (+) NECKS
conclusions
CONCLUSIONS
  • MELANOMA IS A COMPLEX AND PERPLEXING DISEASE PROCESS ESPECIALLY IN THE HEAD AND NECK
  • CUTANEOUS MELANOMA OF THE HEAD AND NECK MAY BEHAVE DIFFERENTLY THAN MELANOMA OF THE EXTREMITY
conclusions56
CONCLUSIONS
  • FOR NODE (+) NECKS- NECK DISSECTION IS APPROPRIATE AND A MODIFIED NECK DISSECTION IS OFTEN POSSIBLE
  • IMMUNOTHERAPY WITH INTERFERON alpha- 2b APPEARS PROMISING FOR INDIVIDUALS WITH PATHOLOGICALLY POSITIVE NECK DISEASE
conclusions57
CONCLUSIONS
  • NODE (-) NECKS
    • LACK OF RANDOMIZED PROSPECTIVE DATA
    • ROLE OF SENTINEL NODE BIOPSY AND RADIATION THERAPY HOLD PROMISE BUT NEED FURTHER INVESTIGATION
    • PET SCAN?
conclusions58
CONCLUSIONS
  • WEAR YOUR SUNSCREEN!!!
bibliography
BIBLIOGRAPHY
  • Balch, C. et al. Efficacy of an Elective Regional Lymph Node Dissection of 1-4mm Thick Melanoma for Patients 60 Years of Age and Younger. Annals of Surgery. 1996; 224 (3): 255-266
  • Buzaid, A. et al. Critical Analysis of the Current AJCC Staging System for Cutaneous Melanoma and Proposal of a New Staging System. Journal of Clinical Oncology. 1997; 15(3): 1039-51
  • Breslow, A. Thickness, Cross-Sectional Area and Depth of invasion in Prognosis of Cutaneous Melanoma. Annals of Surgery. 1970; 172 (5): 902-8
  • Byers, R. Treatment of the Neck in Melanoma. Otolaryngologic Clinics of North America. 1998; 31 (5): 833-39
  • Drepper, H. et al.Benefit of Elective Lymph Node Dissection in Subgroups of Melanoma Patients. Cancer. 1993; 72(3): 741-49
  • Jansen, L. et al.Sentinel Node Biopsy for Melanoma in the Head and Neck Region. Head and Neck. 2000:27-33
  • Kane, W. et al.Treatment Outcome for 424 Primary Cases of Clinical Stage 1 Cutaneous Malignant Melanoma of the Head and Neck. Head and Neck. 1997:457-65
bibliography60
BIBLIOGRAPHY
  • Kirkwood, J. et al. Interferon Alfa-2b Adjuvant Therapy of High-Risk Resected Cutaneous Melanoma: the ECOG Trial EST 1684. Journal of Clinical Oncology. 1996; 14(1):7-17
  • Knutson, C. et al.Melanoma of the Head and Neck. American Journal of Surgery. 1972; 124:543-550
  • Lentsch, E. et al.Melanoma of the Head and Neck: Current Concepts in Diagnosis and Management. The Laryngoscope. 2001; 11:1209-22
  • Myers, J. Value of Neck Dissection in the Treatment of Patients with Intermediate- Thickness Cutaneous Malignant Melanoma of the Head and Neck. AOHN. 1999; 125:110-115
  • O’Brien, C. et al.Experience with 998 Cutaneous Melanomas of the Head and Neck over 30 Years. American Journal of Surgery. 1991; 162:310-314
  • O’Brien, C. et al. Radical, Modified, and Selective Neck Dissection for Cutaneous Malignant Melanoma. Head and Neck. 1995:232-41
  • O’Brien, C. et al.Adjuvant Radiotherapy Following Neck Dissection and Parotidectomy for Metastatic Malignant Melanoma. Head and Neck. 1997:589-94.
bibliography61
BIBLIOGRAPHY
  • Peralta, E. et al. Malignant Melanoma of the Head and neck: Effect of Treatment on Survival. The Laryngoscope. 1998; 108:220-223
  • Shah, J. et al. Patterns of Lymph Node Metastases from Cutaneous Melanomas of the Head and Neck. American Journal of Surgery. 1991; 162: 320-23
  • Shah, P. et al. Adjuvnt Immunotherapy for Patients with Melanoma: Are Patients with Melanoma of the Head and Neck Candidates for This Therapy. Head and Neck. 1997:595-603
  • Stadlemann, W. et al. Cutaneous Melanoma of the Head and neck: Advances in Evolution and Treatment. Plastic and Reconstructive Surgery. 2000; 105(6): 2105-26
  • Urist, M. et al.The Influence of Surgical Margins and Prognostic Factors Predicting the Risk of Local Recurrence in 3445 Patients with Primary Cutaneous Melanoma. Cancer. 1985; 55:1398-1402
  • Urist, M. et al. Head and Neck Melanoma in 534 Clinical Stage 1 Patients. Annals of Surgery. 1984:769-75
  • Wells, K. et al. Sentinel Lymph Node Biopsy in Melanoma of the Head and Neck. Plastic and Reconstructive Surgery. 1997; 100(3):591-94
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