0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Melanoma of the Clavicular Region:  Multimodal Treatment FREE

Linh Lam, MD; Edward Krementz, MD; Clifton McGinness, MD; Richard Godfrey, MD
[+] Author Affiliations

From the Departments of Surgery, Tulane University Medical Center (Dr Krementz) and Memorial Medical Center (Dr McGinness), New Orleans, La; and Kaiser Permanente Medical Center, Oakland, Calif (Drs Lam and Godfrey).


Arch Surg. 2001;136(9):1054-1058. doi:10.1001/archsurg.136.9.1054.
Text Size: A A A
Published online

Hypothesis  Treatment for melanoma that has metastasized to the supraclavicular nodes should be intensive and use a multimodality approach.

Design  Retrospective analysis of clinical records.

Setting  Six primary care centers, 2 of which were referral centers.

Patients  Eighteen patients diagnosed as having a rare pattern of advanced melanoma metastatic to the clavicular region.

Intervention  Combined radiotherapy, chemotherapy, and thorough surgical excision of the affected nodal basins.

Main Outcome Measure  Length of survival from time of diagnosis and treatment to time of follow-up.

Results  Median survival among the 18 patients was 28 months with a 22% survival rate at 5 years after diagnosis. Among patients who received radiotherapy to the clavicular node basin, mean length of survival was 88.7 months with a 50% 5-year survival rate compared with a mean length of survival of 33.8 months and an 8.3% 5-year survival rate in patients who did not receive radiotherapy (P<.001). Mean survival among patients who had supraclavicular node dissection was 45.8 months with a 23.1% survival rate at 5 years after diagnosis, compared with a mean survival of 52 months and a 20% 5-year survival rate among patients who did not receive therapeutic lymphadenectomy. Of the 11 patients who had therapeutic lymphadenectomy, 2 also received radiotherapy to the supraclavicular nodal basin and continued to be disease-free at 82 and 130 months. All long-term survivors had been treated with intra-arterial chemotherapy.

Conclusion  In a series of patients with malignant melanoma metastatic to the clavicular lymph nodes, multimodality treatment using radiotherapy, chemotherapy, and thorough surgical excision of affected nodal basins provided an appreciable 5-year survival rate.

Figures in this Article

MALIGNANT melanoma represents 3% of all malignant neoplasms and 5% of all skin cancers. It accounts for nearly 75% of all deaths of skin cancer and is the second leading cause of death of cancer in US men aged 15 to 34 years. Moreover, its incidence is increasing at a rate of 3% to 5% annually, and an estimated 47 700 new cases were expected to be diagnosed in the year 2000.13

Malignant melanoma grows locally and metastasizes by lymphatic and hematogenous routes. Regional lymph node metastasis is the most common manifestation of recurrent melanoma.4,5 When nodal involvement has occurred, prognosis is affected primarily by the number of positive lymph nodes involved, extent of lymph node involvement, recurrence in other regional lymph nodes, and presence of extranodal disease.4,5

The medical literature contains extensive information and discussion of the clinical management of melanoma metastatic to cervical, axillary, and inguinal nodes.4,6,7 Very little, however, has been written about the clinical course of the disease or about therapy in patients who are initially seen with metastases to the clavicular nodes. A search of the medical literature in English identified no articles describing this disease entity specifically.

We describe clinical treatment and treatment outcome in a series of patients with clavicular lymph node metastases, and review management of regionally advanced disease. We hypothesize that multimodal therapy can improve survival for some patients.

A retrospective analysis of clinical records was conducted for 325 patients diagnosed as having malignant melanoma treated at 6 medical centers (Tulane University Medical Center, New Orleans, La; Southern Baptist Hospital, New Orleans; Hotel Dieu, New Orleans; Touro Infirmary, New Orleans; Veterans Administration Hospital, New Orleans; and Kaiser Permanente Medical Center, Oakland, Calif) between 1959 and 1998. Of the 325 patients, 18 (5.5%), including 11 patients seen in New Orleans and 7 patients seen in Oakland, had melanoma that had metastasized to the clavicular region; of these 18 patients, 17 had metastases to the axillary nodes and subsequently received axillary lymphadenectomy before affected nodes that were clinically palpable developed in the clavicular region. Only 1 patient was noted to have affected nodes at initial axillary node dissection. Clavicular node dissection was done in 13 patients, 6 patients received radiation therapy, and 18 patients received chemotherapy. The mean follow-up interval was 28 months (range, 3-118 months) from the date clavicular node metastasis was diagnosed to the date of last follow-up or death. Cumulative survival rates were calculated from this interval.

Of the 18 patients with clavicular node metastases, 6 (33%) were women and 12 (67%) were men. Ages ranged from 27 to 69 years (median, 43.5 years) (Table 1). Three patients (17%) survived after clavicular node metastases, 1 (5%) was unavailable at follow-up, and 14 (78%) died of cancer. Median length of survival for the entire 18 patients was 28 months with a 22% 5-year survival rate calculated from the date clavicular node metastases was diagnosed (Figure 1).

Table Graphic Jump LocationAge and Disease Stage at Diagnosis for 12 Male and 6 Female Adult Patients With Supraclavicular Malignant Melanoma*
Place holder to copy figure label and caption
Figure 1.

Length of survival among 11 patients at Tulane University Medical Center and Charity Hospital (New Orleans, La) and among 7 patients at Kaiser Permanente Medical Center (Oakland, Calif) diagnosed as having metastatic supraclavicular melanoma.

Graphic Jump Location
CLINICAL MANAGEMENT

Radiotherapy to the clavicular node basin was administered to 6 patients, 3 of whom were still alive at the time of analysis, 1 of whom survived for 9 years and 10 months, and another who was alive at the 11-year follow-up despite being seen initially with stage IV disease (classification according to the American Joint Committee on Cancer manual). Median length of survival in this subset of patients was 88.7 months with a 50% 5-year survival rate, whereas patients without radiation treatment survived for a median of 33.8 months and had an 8.3% 5-year survival rate (P = .009).

Thirteen of the 18 patients had supraclavicular node dissection. Their mean length of survival was 45.8 months with a 23.1% 5-year survival rate, whereas patients who did not receive therapeutic lymphadenectomy survived for a mean of 52 months and had a 20% 5-year survival rate. Two of the 11 patients with supraclavicular node dissection also received radiotherapy to the supraclavicular nodal basin, and both were disease-free at follow-up.

All 18 patients were treated with chemotherapy: 12 patients were treated with systemic chemotherapy, 7 patients received perfusion chemotherapy, and 8 patients received intra-arterial chemotherapy. Combinations of chemotherapy were administered at different times in most patients' courses of treatment. All long-term survivors had been treated with intra-arterial chemotherapy.

SITE OF PRIMARY LESION

Eleven patients (61%) were seen initially with clinical stage I disease. Of these patients, 4 (36%) had a primary lesion in an extremity and 7 had a primary lesion in the head, neck, or trunk (Figure 2 and Figure 3). Median length of survival for patients with melanoma of the head, neck, or trunk was 58.7 months with a 0% 5-year survival rate. Median length of survival for patients with a primary lesion in an extremity was 10.5 months with a 25% 5-year survival rate.

Place holder to copy figure label and caption
Figure 2.

Preoperative photograph shows a patient with periclavicular metastasis.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Postoperative photograph of same patient shows myocutaneous flap created after radiation necrosis was seen in clavicular region.

Graphic Jump Location

Adverse clinical outcomes among patients with stage III disease can differ markedly: 5-year survival rates range from 10% for patients with more than 4 positive nodes to 58% for patients with a single positive node.6 Patients with clinically negative but histologically positive nodes have better prognoses, while risk of mortality is greater in patients with a greater number of positive nodes, a higher percentage of positive lymph nodes, greater extent of lymph node replacement, extranodal extension into soft tissue, presence of disease in the highest node of a lymphatic chain, and increasing number of lymphatic basins affected.4 Nodal involvement is often more extensive in patients with melanoma of the head, neck, and trunk than in patients with melanoma of the extremities, although one study of a series of patients at the M. D. Anderson Cancer Center of the University of Texas7 showed no statistically significant difference in survival rates for patients with cervical nodal metastases compared with patients who had inguinal or axillary lymph node metastases.

In 1983, the American Joint Committee on Cancer placed patients with more than 1 affected regional lymph node basin into the stage IV category.8 This classification remains unchanged in the currently proposed classification revisions.9 Stage IV disease has a poor prognosis: 5-year survival rates range from 6% to 10% in undifferentiated patient groups10 to 26% in patients who received metastatectomy and vaccine treatment.11 Coit4 reported only a 9% 5-year survival rate for patients with 2 nodal basins affected with melanoma, whereas Barth and associates12 noted a 27% 5-year survival rate in a series of 21 patients. The 22% 5-year survival rate noted in our group is favorable, but the groups may not be comparable. Some of our patients were initially seen with metachronous disease, and the 5-year survival rate in our study was calculated from time of onset of supraclavicular disease.

Most patients with locoregional metastases of melanoma have been treated with surgery, chemotherapy, radiation, or immunotherapy, and determining the statistically most effective of these methods is beyond the scope of this retrospective review. However, our study shows some important trends that are in accord with the established medical literature. In particular, all 18 patients were treated with some form of chemotherapy: 12 patients were treated with systemic chemotherapy, 7 patients received perfusion, and 8 patients received intra-arterial chemotherapy. Nine perfusions and 1 intra-arterial infusion were done at Tulane University Medical Center and Memorial Medical Center using techniques described by Krementz et al during the period of 1959 to 1998.13 Six arterial infusions were administered at Kaiser Permanente Medical Center infusing carboplatin and actinomycin D through catheters placed by interventional radiology.14,15 The technique included the use of a balloon catheter to interrupt arterial flow for 5 minutes so that regional drug concentration could be increased. This technique, different from the tourniquet method described by other institutions,16,17 resulted in no complications. Intra-arterial treatment was given on an outpatient basis in 5 patients and on an inpatient basis in 1 patient. Combinations of chemotherapy were administered at different times during the treatment phase: 4 patients had intra-arterial and systemic chemotherapy and 5 patients had perfusion and systemic chemotherapy. Each of the long-term survivors was treated with intra-arterial chemotherapy. One of the 3 long-term survivors later required systemic chemotherapy for pulmonary metastases. He did not have recurrence when seen at 11-year follow-up. Two patients underwent biochemotherapy, receiving a combination of interleukin, interferon, and chemotherapy. Both patients had a minimal response.

The role of radiotherapy in treating melanoma has been disputed. Some authors have advocated its use in the treatment of primary disease such as lentigo maligna melanoma18 and for adjuvant control after lymphadenectomy,19 when the tumor is no longer considered "radioresistant." Prospective randomized protocols have confirmed the usefulness of radiation therapy for improving the rates of disease-free survival in patients with melanoma of the head or neck as well as in patients with upper-extremity melanoma.1921 The positive effect of radiation therapy has been shown in the palliative management of inoperable and bulky metastatic melanoma.1,22 Our data support the positive role of radiation therapy when used after surgical excision of involved supraclavicular nodes. Adverse effects of radiation, however, can also be significant. One patient who received 6000 rads to the clavicular region (Figure 2) had paresis of the right arm and radiation necrosis, which required a myocutaneous flap to cover the damaged area (Figure 3).

The importance of therapeutic lymph node dissection in local or regional control of metastatic melanoma has been clearly established. Warso et al23 reported a recurrence rate as low as 0.8% in patients with previously dissected nodal basins and also stated that long-term survival is seen in about 15% of patients with such local relapses. In another series, mean 5-year survival dropped to 12%6 from a rate of 26% in patients who had recurrent nodal metastases after initial regional lymphadenectomy.5 Our 18.7% mean 5-year survival rate in the patients undergoing surgery is similar to these other studies.5,7,23 Two of our patients who had early mortality had synchronous distal metastases at the onset of clavicular nodal recurrences. With the advent of positron emission tomography scan for identifying stage IV disease, selection of surgical candidates should become more accurate.24,25

Nodal basin melanoma deeper than 1 mm is initially assessed by sentinel lymph node biopsy.2628 Currently, complete node dissection is recommended for almost all patients with immunohistochemically positive sentinel nodes. Until researchers in the Sunbelt Melanoma Trial complete their investigation of clinical outcomes in patients with only immunohistochemically positive nodes, the essential role of surgery for stage III disease is unlikely to change. Given the likelihood of earlier diagnosis by sentinel lymph node biopsy and given the improved management of intermediate- and deep-level melanoma affecting the lymph node basin, fewer patients will have metastases to the clavicular region. Since 1994, when sentinel lymph node biopsy was introduced at Kaiser Permanente Medical Center, no patients who underwent the sentinel node procedure at that facility have had clavicular metastases. Patients at risk are those who have undergone wide excision only, who have had recurrences after inaccurate lymph node dissection, or who are initially seen with unidentified primary lesions. Melanoma centers to which such patients are referred for consultation may continue to be challenged by the problem of clavicular disease.

Lymph node metastasis is the most common manifestation of recurrent melanoma. Although management of melanoma affecting the cervical, axillary, and inguinal nodal regions has been widely documented, no published reports have described the clinical course and management of metastases to the supraclavicular nodes. This pattern of metastasis represents a more advanced stage of melanoma, and given its poor prognosis, we advocate an intensive, multimodal approach for treating metastases to the clavicular area. Our retrospective analysis showed that combined use of radiotherapy, chemotherapy, and thorough surgical excision of affected nodal basins can provide an appreciable 5-year survival rate. Additional reports of this rare pattern of metastatic melanoma may provide a better understanding of the clinical entity.

The Medical Editing Department at the Kaiser Foundation Research Institute provided editorial assistance.

Corresponding author and reprints: Richard Godfrey, MD, Department of Surgery, Kaiser Permanente Medical Center, 280 W MacArthur Blvd, Oakland, CA 94611-5693.

Greenlee  RTMurray  TBolden  SWingo  PA Cancer statistics, 2000. CA Cancer J Clin. 2000;507- 33
Link to Article
Parker  SLTong  TBolden  SWingo  PA Cancer statistics, 1996. CA Cancer J Clin. 1996;465- 27
Link to Article
Lenhard  RE  Jr Cancer statistics: a measure of progress. CA Cancer J Clin. 1996;463- 4
Link to Article
Coit  DG Prognostic factors in patients with melanoma metastatic to regional nodes. Surg Oncol Clin N Am. 1992;1281- 295
Karakousis  CP Therapeutic node dissections in malignant melanoma. Ann Surg Oncol. 1998;5473- 482
Link to Article
Balch  CMSoong  SJMurad  TMIngalls  ALMaddox  WA A multifactorial analysis of melanoma, III: prognostic factors in melanoma patients with lymph node metastases (stage II). Ann Surg. 1981;193377- 388
Link to Article
Singletary  SEShallenberger  RGuinee  VFMcBride  CM Melanoma with metastasis to regional axillary or inguinal lymph nodes: prognostic factors and results of surgical treatment in 714 patients. South Med J. 1988;815- 9
Link to Article
Beahrs  OHedMyers  MHed Manual for Staging of Cancer. 2nd ed. Philadelphia, Pa Lippincott1983;117
Balch  CMBuzaid  ACAtkins  MB  et al.  A new American Joint Committee on Cancer staging system for cutaneous melanoma. Cancer. 2000;881484- 1491
Link to Article
Meyers  MLBalch  CM Diagnosis and treatment of metastatic melanoma. Balch  CMHoughton  ANSober  AJSoong  S-Jeds.Cutaneous Melanoma 3rd ed. St Louis, Mo Quality Medical Publishing1998;325- 372
Morton  DLFoshag  LJHoon  DS  et al.  Prolongation of survival in metastatic melanoma after active specific immunotherapy with a new polyvalent melanoma vaccine. Ann Surg. 1992;216463- 482[published erratum appears in Ann Surg. 1993;217:309].
Link to Article
Barth  RJ  JrVenzon  DJBaker  AR The prognosis of melanoma patients with metastases to two or more lymph node areas. Ann Surg. 1991;214125- 130
Link to Article
Krementz  ETRyan  RFMuchmore  JHCarter  RDSutherland  CMReed  RJ Hyperthermic regional perfusion for melanoma of the limbs. Balch  CMHoughton  ANMilton  GWSoong  S-JSober  AJeds.Cutaneous Melanoma 2nd ed. Philadelphia, Pa Lippincott1992;403- 426
Godfrey  RSaha  SKrementz  E Chemotherapy by tourniquet infusion and with water bath hyperthermia for treatment of limb melanomas. American Society of Clinical Oncology. Twenty-fourth Annual Meeting of the American Society of Clinical Oncology May 22-24, 1988 New Orleans, LouisianaProceedings.Vol. 7. Alexandria, Va ASCO1988;253
Godfrey  RSSaha  SKrementz  ET Clinical experience with intra-arterial chemotherapy and hyperthermia [abstract].  Proceedings of the 37th Annual Meeting of the Radiation Research Society and the 9th Annual Meeting of the North American Hyperthermia Group March 18-23, 1989 Seattle, Wash Oakbrook, Ill Radiation Research Society1989;
Thompson  JFKam  PCWaugh  RCHarmon  CR Isolated limb perfusion with cytotoxic agents: a simple alternative to isolated limb perfusion. Semin Surg Oncol. 1998;14238- 247
Link to Article
Karakousis  CPKanter  PMPark  HCSharma  SDMoore  REwing  JH Tourniquet infusion versus hyperthermic perfusion. Cancer. 1982;49850- 858
Link to Article
Geara  FBAng  KK Radiation therapy for malignant melanoma. Surg Clin N Am. 1996;761383- 1398
Link to Article
Strom  EARoss  MI Adjuvant radiation therapy after axillary lymphadenectomy for metastatic melanoma: toxicity and local control. Ann Surg Oncol. 1995;2445- 449
Link to Article
Ang  KKByers  RMPeters  LJ  et al.  Regional radiotherapy as adjuvant treatment for head and neck malignant melanoma: preliminary results. Arch Otolaryngol Head Neck Surg. 1990;116169- 172
Link to Article
Creagan  ETCupps  REIvins  JC  et al.  Adjuvant radiation therapy for regional nodal metastases from malignant melanoma: a randomized, prospective study. Cancer. 1978;422206- 2210
Link to Article
Burmeister  BHSmithers  BMPoulsen  M  et al.  Radiation therapy for nodal disease in malignant melanoma. World J Surg. 1995;19369- 371
Link to Article
Warso  MADas Gupta  TK Melanoma recurrence in a previously dissected lymph node basin. Arch Surg 1994;129252- 255
Link to Article
Holder  WD  JrWhite  RL  JrZuger  JHEaston  EJ  JrGreene  FL Effectiveness of positron emission tomography for the detection of melanoma metastases. Ann Surg. 1998;227764- 769Discussion pp 769-771.
Link to Article
Rinne  DBaum  RPHor  GKaufmann  R Primary staging and follow-up of high risk melanoma patients with whole-body 18F-fluorodeoxyglucose positron emission tomography: results of a prospective study of 100 patients. Cancer. 1998;821664- 1671
Link to Article
Morton  DLWen  DRWong  JH  et al.  Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 1992;127392- 399
Link to Article
Reintgen  DBalch  CMKirkwood  JRoss  M Recent advances in the care of the patient with malignant melanoma. Ann Surg. 1997;2251- 14
Link to Article
Ross  MIGershenwald  JE Melanoma lymphatic mapping: scientific support for the sentinel lymph node concept and biological significance of the sentinel node. Whitman  EDReintgen  Deds.Radioguided Surgery Austin, Tex Landes Bioscience1999;47- 62

Figures

Place holder to copy figure label and caption
Figure 1.

Length of survival among 11 patients at Tulane University Medical Center and Charity Hospital (New Orleans, La) and among 7 patients at Kaiser Permanente Medical Center (Oakland, Calif) diagnosed as having metastatic supraclavicular melanoma.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Preoperative photograph shows a patient with periclavicular metastasis.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Postoperative photograph of same patient shows myocutaneous flap created after radiation necrosis was seen in clavicular region.

Graphic Jump Location

Tables

Table Graphic Jump LocationAge and Disease Stage at Diagnosis for 12 Male and 6 Female Adult Patients With Supraclavicular Malignant Melanoma*

References

Greenlee  RTMurray  TBolden  SWingo  PA Cancer statistics, 2000. CA Cancer J Clin. 2000;507- 33
Link to Article
Parker  SLTong  TBolden  SWingo  PA Cancer statistics, 1996. CA Cancer J Clin. 1996;465- 27
Link to Article
Lenhard  RE  Jr Cancer statistics: a measure of progress. CA Cancer J Clin. 1996;463- 4
Link to Article
Coit  DG Prognostic factors in patients with melanoma metastatic to regional nodes. Surg Oncol Clin N Am. 1992;1281- 295
Karakousis  CP Therapeutic node dissections in malignant melanoma. Ann Surg Oncol. 1998;5473- 482
Link to Article
Balch  CMSoong  SJMurad  TMIngalls  ALMaddox  WA A multifactorial analysis of melanoma, III: prognostic factors in melanoma patients with lymph node metastases (stage II). Ann Surg. 1981;193377- 388
Link to Article
Singletary  SEShallenberger  RGuinee  VFMcBride  CM Melanoma with metastasis to regional axillary or inguinal lymph nodes: prognostic factors and results of surgical treatment in 714 patients. South Med J. 1988;815- 9
Link to Article
Beahrs  OHedMyers  MHed Manual for Staging of Cancer. 2nd ed. Philadelphia, Pa Lippincott1983;117
Balch  CMBuzaid  ACAtkins  MB  et al.  A new American Joint Committee on Cancer staging system for cutaneous melanoma. Cancer. 2000;881484- 1491
Link to Article
Meyers  MLBalch  CM Diagnosis and treatment of metastatic melanoma. Balch  CMHoughton  ANSober  AJSoong  S-Jeds.Cutaneous Melanoma 3rd ed. St Louis, Mo Quality Medical Publishing1998;325- 372
Morton  DLFoshag  LJHoon  DS  et al.  Prolongation of survival in metastatic melanoma after active specific immunotherapy with a new polyvalent melanoma vaccine. Ann Surg. 1992;216463- 482[published erratum appears in Ann Surg. 1993;217:309].
Link to Article
Barth  RJ  JrVenzon  DJBaker  AR The prognosis of melanoma patients with metastases to two or more lymph node areas. Ann Surg. 1991;214125- 130
Link to Article
Krementz  ETRyan  RFMuchmore  JHCarter  RDSutherland  CMReed  RJ Hyperthermic regional perfusion for melanoma of the limbs. Balch  CMHoughton  ANMilton  GWSoong  S-JSober  AJeds.Cutaneous Melanoma 2nd ed. Philadelphia, Pa Lippincott1992;403- 426
Godfrey  RSaha  SKrementz  E Chemotherapy by tourniquet infusion and with water bath hyperthermia for treatment of limb melanomas. American Society of Clinical Oncology. Twenty-fourth Annual Meeting of the American Society of Clinical Oncology May 22-24, 1988 New Orleans, LouisianaProceedings.Vol. 7. Alexandria, Va ASCO1988;253
Godfrey  RSSaha  SKrementz  ET Clinical experience with intra-arterial chemotherapy and hyperthermia [abstract].  Proceedings of the 37th Annual Meeting of the Radiation Research Society and the 9th Annual Meeting of the North American Hyperthermia Group March 18-23, 1989 Seattle, Wash Oakbrook, Ill Radiation Research Society1989;
Thompson  JFKam  PCWaugh  RCHarmon  CR Isolated limb perfusion with cytotoxic agents: a simple alternative to isolated limb perfusion. Semin Surg Oncol. 1998;14238- 247
Link to Article
Karakousis  CPKanter  PMPark  HCSharma  SDMoore  REwing  JH Tourniquet infusion versus hyperthermic perfusion. Cancer. 1982;49850- 858
Link to Article
Geara  FBAng  KK Radiation therapy for malignant melanoma. Surg Clin N Am. 1996;761383- 1398
Link to Article
Strom  EARoss  MI Adjuvant radiation therapy after axillary lymphadenectomy for metastatic melanoma: toxicity and local control. Ann Surg Oncol. 1995;2445- 449
Link to Article
Ang  KKByers  RMPeters  LJ  et al.  Regional radiotherapy as adjuvant treatment for head and neck malignant melanoma: preliminary results. Arch Otolaryngol Head Neck Surg. 1990;116169- 172
Link to Article
Creagan  ETCupps  REIvins  JC  et al.  Adjuvant radiation therapy for regional nodal metastases from malignant melanoma: a randomized, prospective study. Cancer. 1978;422206- 2210
Link to Article
Burmeister  BHSmithers  BMPoulsen  M  et al.  Radiation therapy for nodal disease in malignant melanoma. World J Surg. 1995;19369- 371
Link to Article
Warso  MADas Gupta  TK Melanoma recurrence in a previously dissected lymph node basin. Arch Surg 1994;129252- 255
Link to Article
Holder  WD  JrWhite  RL  JrZuger  JHEaston  EJ  JrGreene  FL Effectiveness of positron emission tomography for the detection of melanoma metastases. Ann Surg. 1998;227764- 769Discussion pp 769-771.
Link to Article
Rinne  DBaum  RPHor  GKaufmann  R Primary staging and follow-up of high risk melanoma patients with whole-body 18F-fluorodeoxyglucose positron emission tomography: results of a prospective study of 100 patients. Cancer. 1998;821664- 1671
Link to Article
Morton  DLWen  DRWong  JH  et al.  Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 1992;127392- 399
Link to Article
Reintgen  DBalch  CMKirkwood  JRoss  M Recent advances in the care of the patient with malignant melanoma. Ann Surg. 1997;2251- 14
Link to Article
Ross  MIGershenwald  JE Melanoma lymphatic mapping: scientific support for the sentinel lymph node concept and biological significance of the sentinel node. Whitman  EDReintgen  Deds.Radioguided Surgery Austin, Tex Landes Bioscience1999;47- 62

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 2

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles