Background Numerous predictive factors for cutaneous melanoma metastases to sentinel lymph nodes have been identified; however, few have been found to be reproducibly significant. This study investigated the significance of factors for predicting regional nodal disease in cutaneous melanoma using a large multicenter database. Methods Seventeen institutions submitted retrospective and prospective data on 3463 patients undergoing sentinel lymph node (SLN) biopsy for primary melanoma. Multiple demographic and tumor factors were analyzed for correlation with a positive SLN. Univariate and multivariate statistical analyses were performed. Results Of 3445 analyzable patients, 561 (16.3%) had a positive SLN biopsy. In multivariate analysis of 1526 patients with complete records for 10 variables, increasing Breslow thickness, lymphovascular invasion, ulceration, younger age, the absence of regression, and tumor location on the trunk were statistically significant predictors of a positive SLN. Conclusions These results confirm the predictive significance of the well-established variables of Breslow thickness, ulceration, age, and location, as well as consistently reported but less well-established variables such as lymphovascular invasion. In addition, the presence of regression was associated with a lower likelihood of a positive SLN. Consideration of multiple tumor parameters should influence the decision for SLN biopsy and the estimation of nodal metastatic disease risk.

Carcinoembryonic antigen has been demonstrated to be a valuable clinical aid in the management of patients with colorectal carcinoma. Its elevation in the serum prior to evidence of clinical recurrence in up to 80% of patients highlights its utility. CEA has also been found to be elevated in the serum of patients with other epithelial malignancies, but these have not been as well studied as has colorectal carcinoma. In patients with breast cancer CEA elevations may be found in 40-73% of patients presenting with disease in stages I-IV. In addition, 80% of patients will have a CEA elevation 3-10 months prior to clinical symptoms of recurrence. Seventy-seven percent of patients with bronchogenic lung cancer will have an elevated preoperative value. However, cigarette smoking also causes an increase in the CEA assay level and, thus, differentiation between benign and malignant conditions is more difficult. In small cell carcinoma of the lung, CEA assay levels above 10 ng/ml correlate highly with metastatic disease, while values less than 2.5 ng/ml correlate with localized disease. Pancreatic and gastric malignancies demonstrate CEA level elevations in just over 50% of cases. But these, however, have not been clinically useful. Epithelial neoplasms of the female reproductive tract (cervix, uterus, and ovary) also produce CEA in 47-75% of cases and may correlate with stage of disease at diagnosis and level of cellular differentiation. CEA assay levels are elevated in a variety of tumors and correlate with tumor stage, degree of differentiation, and effectiveness of therapy; they may also be the earliest marker of recurrence.

We concluded that gamma probe-directed sentinel lymph node biopsy is a straightforward procedure which can be done in the outpatient setting and facilitates management of patients with cutaneous malignant melanoma. It allows the surgeon to identify all basins at risk for metastatic disease and the location of the sentinel node(s) in relation to the basin.

A rare adenosquamous carcinoma of the colon occurred in a 41-year-old patient. Its presentation with hypercalcemia, in the absence of osseous metastases, has not been described previously. The hypercal-cemia in this case was due to the elaboration of a parathyroid hormone-like substance by the tumor. The general characteristics of primary adenosquamous and squamous cell carcinomas of the colon are presented. These tumors present with advanced disease, in younger patients, and follow a highly aggressive course, as compared with adenocarcinomas of the colon. The cause of the malignancies, in the light of current theories regarding their genesis, is discussed. Cancer60:1111-1116, 1987. RIMARY ADENOSQUAMOUS and squamous carci-P noma of the colon are extremely rare entities. Approximately 60 cases have been reported. The incidence in a number of series has been estimated to be 0.25 to 0.5 cases per 1000 colon malignancies.'-* The coincident finding of hypercalcemia in a colon malignancy has been reported in only three previous ~ases~,~-only one was a case of adenosquamous c a r ~ i n o m a. ~ In the case of adenosquamous carcinoma, the patient had diffuse bony metastases, and a normal parathyroid hormone level. In the other two cases a parathyroid hormone-like substance was identified in the tumor cells of one patient , thus explaining the cause of the hypercalcemia, whereas the cause of the hypercalcemia in the other patient was not a~certained.~ To these we add another rare case, one in which a parathyroid hormone-like substance was identified in an adenosquamous carcinoma of the colon. Case Report A 4 1-year-old woman was admitted to the surgical oncology service at SUNY-Stony Brook's University Hospital in Jan-uary 1986. She complained of weakness, cachexia, nausea, and vomiting. Her complaints began in November 1985, when she was seen by her private physician for abdominal pain. A uri-nary tract infection was diagnosed and treated with antibiotics. She continued to feel poorly, however, and was subsequently admitted to another hospital, where she received intravenous antibiotics. She was then readmitted in December 1985, at which time hepatomegaly and multiple liver nodules were noted. The biopsy specimen of her liver disclosed metastatic adenocarcinoma, and she was referred to University Hospital. Her history was significant for total abdominal hysterectomy and bilateral salpingo-oophorectomy for leiomyomata, and peptic ulcer disease. On physical examination she was noted to be extremely cachectic and in moderate distress. Her abdomen was soft with mild diffuse tenderness. The liver was nodular and hard, and palpated 4 inches below the costal margin. Findings of rectal and pelvic examinations were negative. The stool guaiac was negative. Admission laboratory studies showed the following values: hemoglobin, I0 g/dl; he-matocrit, 33.2%; calcium, 18.4 mg/dl; phosphate, 4.9 U/dl; albumin, 3.9 g/dl; lactate dehydrogenase (LDH), 2267 U/l; aspartate aminotransferase (AST), 66 U/I; alanine aminotrans-ferase (ALT), 41 U...