Journal of Surgical Oncology 2011;103:290–291

LETTER TO THE EDITOR

Ultra-Late Recurrence of Malignant Melanoma

After 40 Years of Quiescent Disease

Delayed recurrence of melanoma of greater than 10 years since

initial diagnosis is thought to be approximately 6% [1]. For this reason

current some units advocate up to 10 year follow-up for even thin

melanomas [2]. There is evidence melanoma deposits undergo periods

of dormancy as exemplified by ultra-late recurrences with upto

20 years disease free intervals reported [3]. However, the exact

mechanism that induces dormancy or triggers recurrence is poorly

understood.

A 73-year-old female had wide excision of a confirmed primary

cutaneous melanoma from the left leg aged 19 (1956) we do not have

histological sub-data for this tumour. Secondary solitary satellite and

in-transit disease was excised aged 20, 25 and 31 (1957, 1962 and

1968) and subsequent left inguinal node dissection for palpable disease

was performed aged 33 (1970). There were no surgical complications.

At presentation 40 years following her last excision of regional

metastatic nodes the patient re-presented to our melanoma service

following a period of malaise, fever, rigors, and dysuria. This illness

lasted for approximately 9 weeks and a diagnosis of pyelonephritis had

been made by physicians. Toward the end of her illness the patient

noticed new lesions on her left leg.

Excisional biopsy of five discreet pigmented lesions on the left calf

and thigh was performed. The histological appearances were those of

epidermotropic metastatic melanomas. Histology has shown all of

these lesions to be identical. In the following 12 months she had 22

further lesions excised, all from her left leg. These exhibited similar

histological patterns of metastatic growth. There was no regional nodal

relapse. Furthermore the patient did not receive any adjuvant therapies.

Staging computed tomography (CT) showed no evidence of

metastastic nodal relapse or visceral disease.

This case typifies the unpredictable course of some cutaneous

melanomas. There is clear case report evidence that late presentation of

metastatic melanoma exists, and in some retrospective series,

recurrence over 10 years later can be seen in upto 6% of primary

cutaneous melanomas [2,3].

This patient did fall into the minority of those who experience a

metastasis over 10 years following primary excision. Data from one

large series of patients followed up with primary cutaneous melanoma

was reviewed with other reports and estimated a 5-year survival of 55%

in those patients who had recurrent regional disease more than 10 years

after primary surgery [4].

Of particular interest is the disease free interval of 40 years between

groin dissection and new in-transit lesions. There are no previous

reports of such latency, however, it is postulated from retrospective

analysis of this group of patients that delayed local or regional

recurrence can signify less aggressive disease [4], yet a significant

proportion succumb to widespread disease within 5 years. It has been

observed patients with ultra-delayed presentation of distant skin or

visceral metastases have an inferior prognosis to those with local

or regional disease [5]. The natural course of disease following local or

regional recurrence unfortunately has not been discussed in previous

case reports hence it is unknown if further long periods of disease free

survival is seen as in this case (Box 1). The time between excision of

primary disease and most recent in-transit disease is approximately

54 years.

Chronology of melanoma disease

The occurrence of medical illness prior to and during the

development of recurrent lesions may be significant. It is acknowl-

edged that metastatic melanoma may be suppressed by regression of

primary tumours and that immunological therapy may play a role in

future adjuvant treatment [6]. Furthermore there is case evidence of

melanoma regression following withdrawal of immunosuppressant

therapies for medical conditions [7]. An event to aid dormant

melanoma to escape immunosurveillance may be sufficient to instigate

disease recurrence as observed in this case. We postulate that a trigger

factor to development of metastatic deposits in this case was the

intercurrent illness. The metastatic melanoma succeeds where the host

is less immunologically equipped, and the metastatic deposits are thus

unimpeded to grow.

It is vital medical and surgical practitioners faced with patients who

have a history of melanoma always consider local or distant metastases

if they present with new lesions or systemic problems. It is also

possible those who have long periods of disease free survival between

primary and first regional recurrence may go on to enjoy further

long periods of quiescence compared to those with similar primary

tumour biology and earlier recurrence and therefore warrant continued

aggressive treatment.

D. Saleh, MB, ChB, MRCS*,{

A.H.S. Peach, FRCS(Plast){

Leeds General Infirmary

Leeds, UK

{Registrar Plastic and Reconstructive Surgery{Consultant Plastic and Reconstructive Surgeon

*Correspondence to: D. Saleh, MB, ChB, MRCS, Registrar Plastic andReconstructive Surgery; Leeds General Infirmary, Great George St, LeedsLS1 3EX, UK. Fax No.: þ44-113-3927153.E-mail: dan_saleh@hotmail.com

Received 31 October 2009; Accepted 2 November 2010

DOI 10.1002/jso.21821

Published online 15 January 2011 in Wiley Online Library(wileyonlinelibrary.com).

� 2011 Wiley-Liss, Inc.

REFERENCES

1. Pearlman NW, Takach TJ, Robinson WA, et al.: A case-controlstudy of late recurrence of malignant melanoma. Am J Surgery1992;164:458–461.

2. Gimotty PA, Guerry D, Ming M, et al.: Thin primary cutaneousmalignant melanoma: A prognostic tree for 10-year metastasis ismore accurate than American Joint Committee on cancer staging.J Clin Oncol 2004;22:3668–3676.

3. Ossowski L, Aguirre-Ghiso JA: Dormancy of metastatic mela-noma. Pigment Cell Melanoma Res 2010;23:41–57.

4. Tsao H, Cosimi AB, Sober AJ: Ultra-late recurrence (15 yearsor longer) of cutaneous melanoma. Cancer 1997;79:2361–2370.

5. Tahery DP, Moy RL: Lack of predictive factors in late recurrence ofstage 1 melanoma. Int J Dermatol 1992;31:629–631.

6. Hersey P: Immunotherapy of melanoma. Asia Pac J Clin Oncol2010;6:S2–S8.

7. Dillon P, Thomas N, Sharpless N, et al.: Regression of advancedmelanoma upon withdrawal of immunosuppression case series andliterature review. Nov 2009 [Epub ahead of print].

Journal of Surgical Oncology

Letter to the Editor 291