Correspondence 571

Author Reply

e appreciate the discussion shared by these W writers. The experience and review of Lopez-Andreu et

al. underscores the concept that pulmonary blas- toma in children is distinct from adult blastoma by its histology and prognosis. The identification of possible gene markers is intriguing, and their loca- tions at or near the Wilms’ tumor gene is not com- pletely surprising considering 1 he histologic simi- larity.

Larsen and Sorensen’s review of the literature further augments the current knowledge regarding pulmonary blastoma. We agree that the extent of resection logically depends on the extent of disease, and tumors amenable to more limited surgery are likely to have a more favorable prognosis. We also concur that it is quite difficult to compare a diverse group of patients with varying adjuvant regimens to historic controls.

Our own patient carried several unfavorable prognostic indicators (large size, biphasic histol- ogy); she remains disease free at 31 months after surgery and adjuvant chemotherapy.

The comments from these groups of authors lend additional support to the idea that cooperative efforts are necessary to add to the understanding about this rare entity.

Christopher M. Huiras, M.D., F.A.C.S. James E. Novotny, M.D.

Department of Surgery and Medical Oncology Franciscan Skemp Healthcare Medical Center

La Crosse, Wisconsin

Complete Remission Seven Years after Treatment for Metastatic Malignant Melanoma

ur article entitled “Complete Remission Seven 0 Years after Treatment for Metastatic Malignant Melanoma” has pointed out the interest in the use of surgery in residual metastatic melanoma after chemotherapy and has reviewed articles describing long term survival after chemotherapy or chemoim- munotherapy foir metastatic maliignant melanoma.’ Exclusive local treatment can also offer a reason- able expectation of prolonged survival with the proper selection of patients.

We report the case of a woman who developed a malignant melanoma on her right leg. She was treated by wide excision and inguinal lymph node dissection. The pTNM stage was pT2NOMO (Clark Level 111). This patient presented 3 years later with a right breast tumor of 6 cm in diameter. A drill biopsy confirmed an origin of malignant melanoma metastasis with intense S-100 and HMB-45 anti- body staining. There was no other secondary local- ization. The treatment was comprised of a right mastectomy and irradiation of 60 Grays (Gy) to the right pectoral wall and 55 Gy to the axillary and subclavicular lymph nodes. This patient is now in complete remission with a 23 year-follow-up.

This long survival in complete remission is note- worthy whereas a disease free interval of less than 4 years (3 years for our case report) is a pejorative prognostic factor with a 7-month median survival.* Arora and Robinson reviewed 15 patients with ma- lignant melanomas metastatic to the b r e a ~ t . ~ The median survival after diagnosis of breast metastases was 10 months. Results of surgical treatment of dis- tant metastases were analyzed by retrospective study in 143 patients by Overett and S h i ~ . ~ Success- ful complete resection of the metastases yielded a 33% 5-year survival rate. Complete resection of all clinical disease was the most important factor for survival. Due to their limited accessibility for sur- gery, multiple metastatic sites and visceral metasta- ses were pejorative prognostic factor^.^ As shown in our case report, surgical excision of all melanoma metastases can therefore provide long term survival with complete remission for carefully selected pa- tients.

REFERENCES Petit T, Bore1 C, Rixe 0, Avril MF, Monnier A, Giroux B, et al. Complete remission seven years after treatment for metastatic malignant melanoma. Cancer 1996; 77:900-2. Sirott MN, Bajorin DF, Wong GYC, Tao Y, Chapman PB, Templeton MA, et al. Prognostic factors in patients with metastatic malignant melanoma: a multivariate analysis. Cancer 1993;72:3091-8. Arora R, Robinson WA. Breast metastases from malignant melanoma. J Surg Oncol 1992;50:27-9. Overett TK, Shiu MH. Surgical treatment of distant metasta- ses: indications and results. Cancer 1985; 56:1222-30.

Thierry Petit, M.D. Jean-Claude Janser, M.D.

Jean-Christophe Petit, M.D. Paul Strauss Cancer Center

Strasbourg, France