Analysis of 7104 patients with melanoma seen at Duke University identified 168 who experienced their first recurrence 10 or more years after diagnosis, for an incidence of 2.4%. This included patients with all stages of disease. There was no sex, age, or primary site predominance. The mean disease-free interval for cutaneous melanomas was 14.3 years versus 22.3 years for ocular primary melanomas. The prognosis following relapse was related to the site of recurrence. Survival after local or regional node recurrence was often prolonged; survival after distant metastases was usually limited. Patients with ocular primaries had the highest incidence of distant metastases, and the shortest subsequent survival. An additional 483 patients were identified who survived 10 or more years without evidence of recurrence; of these 651 patients with long disease-free intervals, 25% (168 of 651) developed recurrent disease. This demonstrates that a 10-year disease-free interval cannot be considered a cure, and emphasizes the importance of continued annual follow-up.

A total of 2468 patients with recurrent melanoma were subdivided on the basis of disease-free interval: group 1 had recurrences within 1 year (n = 810), group 2 at years 1 to 3 (n = 1001), group 3 at years 3 to 5 (n = 363), group 4 at years 5 to 10 (n = 329), and group 5 after 10 years (n = 145). Ten-year survivals were 21%, 23%, 25%, 28%, and 35%, respectively. Patients who had recurrences within 1 year had a decreased median survival compared with those who had later recurrences, although the differences were not clinically significant (only 6 to 8 months). Survival was improved for the few patients who had recurrences longer than 10 years from diagnosis. However, for the majority of patients, who had recurrences between 1 and 10 years, the disease-free interval did not predict subsequent survival. The data support the hypothesis that malignant cells can exist in a state of relative quiescence for extended periods. Once disease reactivation occurs, however, the subsequent survival is relatively predictable and is independent of the initial period of tumor dormancy.

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A retrospective search of patients seen at the Duke Melanoma Clinic from 1970 to 1986 identified 308 clinically Stage I patients, with 4.0 to 10.0 mm cutaneous melanomas. Five-year and ten-year survival was 56% and 43%, respectively. Elective lymph node dissection (ELND) was done in 116 patients (37.7%); there was no difference in disease-free interval (DFI) or survival between these patients versus patients treated with wide excision only (P = 0.9). Thirty-two patients (27.6%) had pathologically positive nodes on ELND. These patients had a shorter DFI (P = 0.05) and survival (P = 0.03) compared with patients with negative node dissections. When further divided by Breslow's thickness, this difference persisted in patients with 4.0 to 6.0 mm lesions (P = 0.01). However, for thicker lesions (>6.0 mm), there was no difference in survival between the node-negative and node-positive groups (P = 0.9). The mean follow-up was 7.1 years. Elective lymph node dissection was not done in 192 patients; 78 of these recurred first in the regional nodes. These 78 patients were compared with the 32 patients who had pathologically positive nodes by ELND to see if patient survival was improved by early removal of nodal disease. There was no difference in DFI (P = 0.5) or survival (P = 0.3) between these two groups. It is concluded that ELND may provide prognostic information for patients with thick cutaneous melanomas. However, there was no change in DFI or ultimate survival when patients were followed, and nodes removed when clinically positive. The authors do not recommend ELND for patients with thick melanomas because the risk of distant metastases outweighs any benefit of regional node dissection. Cancer 66:2522-2527.1990. HE ROLE of elective lymph node dissection (ELND)