恶性黑素瘤的最新动态(三)
2.3 退行性变[11]:MM有时可出现退行性改变。其在组织学上的表现是：在MM的表皮和真皮的一侧或两侧，缺失MM的病理改变，在此区真皮内有轻微的纤维性变，有散在的淋巴细胞和噬黑素细胞。完全退化性MM是少见的，但在解释某些有转移性MM而未发现原发病灶时，可能认为是原发MM完全性退化了。退行性改变也可见于原位MM及转移性病灶。一些研究提示，退行性变伴随着不良的预后和较低的存活率。与退化程度较轻者比，明显退化者和全部退行性变者预后更差。退行性改变出现在薄的MM时，要特别注意。对比研究表明，在部分<1mm厚度的有转移MM中，退行性变的出现率高达42%,而对照组只有5%。复习<0.76mmMM的资料，发生转移者的原发灶，有严重退化现象者占40%,而无转移者只有17%出现退化性改变。另一资料报道，薄的(0.76mm)MM103例中有30例出现部分退行性改变，此30 例中有6例发生转移并病死。这6 例的原发灶都有超过75%的退行性改变。73例薄的MM无退行性变者无1例发生转移。有一个辐射式生长相和垂直生长相的MM研究报告，没有退行性变的垂直生长相的MM患者，可以有较长期的存活率。回顾性研究1 716例皮肤MM患者，1mm或者更薄的MM 证实转移者有67例，这67例中有13例属于第II期MM。在这13例II期有转移的病例中，有8例有另1个皮肤MM原发灶者，在转移发生前，至少已发生III层的侵犯，其余的5例有退行性改变。作者的结论是，II期的MM发生转移而没有退行性改变者是很少见的。
, 百拇医药
2.4 肿瘤浸润淋巴细胞[12]：这类细胞有活跃的、不活跃的及缺乏的三种状态。72例临床I期厚度为1.51～3.99mm者，随诊5年发现，低的有丝分裂率及有浸润淋巴细胞反应者，有良好的预后。有6个因素对I期MM预后预测有意义，包括：肿瘤浸润淋巴细胞、有丝分裂率、瘤体厚度、原发病灶的位置、性别及退行性变。关于肿瘤浸润淋巴细胞对285例原发性皮肤I、II期垂直生长相MM预后的影响分析，其5年、10年成活率：有活跃的肿瘤浸润细胞反应者分别为77%和55%；肿瘤浸润淋巴细胞不活跃者分别为53%和45%；而肿瘤浸润淋巴细胞缺乏者，分别只有37%和27%。多变量分析显示，肿瘤厚度及肿瘤浸润淋巴细胞是两个独立的、重要的预后因素。作者结论：对垂直生长相的MM，肿瘤浸润淋巴细胞反应是判断预后的重要参数。
2.5 血管淋巴侵入及血管趋向性[13]:由于MM比较薄的特性，要查明血管的长入状况比较困难。但研究表明血管淋巴的侵入对预后有影响。在102个结节性MM中查明有15例存在血管侵入现象，而且与肿瘤厚度、直径、溃疡、淋巴结受累及远处转移有关。回顾性研究215个I、II期MM，46例前哨淋巴结为阳性。淋巴结受累的危险因素有：溃疡、高有丝分裂率、肿瘤血管淋巴侵入及微型卫星病灶。瘤体厚度>1mm，没有上述危险因素者，只有14%发生转移。血管的趋向性，在皮肤MM显示有预测转移危险的意义。
, 百拇医药
2.6新近Vaisanen等(Hum Pathol,2008.1)报道，曾经认为基质金属蛋白酶MMP-2和MMP-9的表达与MM的病情、预后有关,而且MMP-2的过度表达与MM血液转移相关。作者通过对157例原发性MM患者的检测，认为MMP-2过表达(>20%恶性细胞阳性者)MM10年存活率为51%，而低于此值者为79%。特别是在男性中，这种差异更明显。MMP-2高表达的男性MM患者，10年存活率只有41%，而低表达者可为77%。不过MMP-9与此关系并未显示。
[参考文献]
[1]Markovic SN,Erickson LA,Rao RD,et al. Melanoma Study Group of the Mayo Clinic Cancer Center.M alignant melanoma in the 21st century,part 1: epidemiology, risk factors, screening, prevention,and diagnosis[J]. Mayo Clin Proc,2007,82:364-380.
, 百拇医药
[2]Markovik SN,Erickson LA,Roa RD,et al.M alignant Melanoma in the 21st century,part 2: Staging ,prognosis,and treatment[J].Mayo clin Pro,2007,82:490.
[3]Balch CM,Soong SJ,Gershenwald JE,et al.Prognostic factors analysis of 17 600 melanoma patients:validation of the American Joint Committee on Cancer melanoma staging system[J].J Clin Oncol,2001,19:3622-3634.
[4]Retsas S,Henry K,Mohammed MQ,et al. Prognostic factors of cutaneous melanoma and a new staging system proposed by the American Joint Committee on Cancer (AJCC): validation in a cohort of 1284 patients[J].Eur J Cancer,2002,38:511-516.
, 百拇医药
[5]Marghoob AA,Koenig K,Bittencourt FV,et al. Breslow thickness and Clark level in melanoma: support for including level in pathology reports and in American Joint Committee on Cancer Staging[J].Cancer,2000,88:589-595.
[6]Balch CM,Buzaid AC,Atkins MB,et al.A new American Joint Committee on Cancer staging system for cutaneous melanoma[J].Cancer,2000,88:1484-1491.
[7]Rao UN,Ibrahim J,Flaherty LE,et al.Implications of microscopic satellites of the primary and extracaspular lymph node spread in patients with high-risk melanoma: pathologic corollary of Eastern Cooperative Oncology Group Trial E1690[J].J Clin Oncol,2002,20:2053-2057.
, 百拇医药
[8]Yan S,Brennick JB.False-positive rate of the immunoperoxidase stains for MART1/MelanA in lymph nodes[J].Am J Surg Pathol,2004,28:596-600.
[9]Lefevre M,Vergier B,Balme B,et al.Relevance of vertical growth pattern in thin level II cutaneous superficial spreading melanomas[J].Am J Surg Pathol,2003,27:717-724.
[10]Azzola MF,Shaw HM,Thompson JF,et al.Tumor mitotic rate is a more powerful prognostic indicator than ulceration in patients with primary cutaneous melanoma: an analysis of 3661 patients from a single center[J].Cancer,2003,97:1488-1498.
, 百拇医药
[11]Guitart J,Lowe L,Piepkorn M,et al.Histological characteristics of metastasizing thin melanomas: a case-control study of 43 cases[J]. Arch Dermatol,2002,138:603-608.
[12]Masback A,Olsson H,Westerdahl J,et al.Prognostic factors in invasive cutaneous m alignant melanoma: a population-based study and review[J]. Melanoma Res,2001,11:435-445.
[13]Lugassy C,Haroun RI,Brem H,et al.Pericytic-like angiotropism of glioma and melanoma cells[J].Am J Dermatopathol,2002,24:466,473-478.
[收稿日期]2008-02-20
编辑/李阳利, http://www.100md.com(李荟元)
, 百拇医药
2.4 肿瘤浸润淋巴细胞[12]：这类细胞有活跃的、不活跃的及缺乏的三种状态。72例临床I期厚度为1.51～3.99mm者，随诊5年发现，低的有丝分裂率及有浸润淋巴细胞反应者，有良好的预后。有6个因素对I期MM预后预测有意义，包括：肿瘤浸润淋巴细胞、有丝分裂率、瘤体厚度、原发病灶的位置、性别及退行性变。关于肿瘤浸润淋巴细胞对285例原发性皮肤I、II期垂直生长相MM预后的影响分析，其5年、10年成活率：有活跃的肿瘤浸润细胞反应者分别为77%和55%；肿瘤浸润淋巴细胞不活跃者分别为53%和45%；而肿瘤浸润淋巴细胞缺乏者，分别只有37%和27%。多变量分析显示，肿瘤厚度及肿瘤浸润淋巴细胞是两个独立的、重要的预后因素。作者结论：对垂直生长相的MM，肿瘤浸润淋巴细胞反应是判断预后的重要参数。
2.5 血管淋巴侵入及血管趋向性[13]:由于MM比较薄的特性，要查明血管的长入状况比较困难。但研究表明血管淋巴的侵入对预后有影响。在102个结节性MM中查明有15例存在血管侵入现象，而且与肿瘤厚度、直径、溃疡、淋巴结受累及远处转移有关。回顾性研究215个I、II期MM，46例前哨淋巴结为阳性。淋巴结受累的危险因素有：溃疡、高有丝分裂率、肿瘤血管淋巴侵入及微型卫星病灶。瘤体厚度>1mm，没有上述危险因素者，只有14%发生转移。血管的趋向性，在皮肤MM显示有预测转移危险的意义。
, 百拇医药
2.6新近Vaisanen等(Hum Pathol,2008.1)报道，曾经认为基质金属蛋白酶MMP-2和MMP-9的表达与MM的病情、预后有关,而且MMP-2的过度表达与MM血液转移相关。作者通过对157例原发性MM患者的检测，认为MMP-2过表达(>20%恶性细胞阳性者)MM10年存活率为51%，而低于此值者为79%。特别是在男性中，这种差异更明显。MMP-2高表达的男性MM患者，10年存活率只有41%，而低表达者可为77%。不过MMP-9与此关系并未显示。
[参考文献]
[1]Markovic SN,Erickson LA,Rao RD,et al. Melanoma Study Group of the Mayo Clinic Cancer Center.M alignant melanoma in the 21st century,part 1: epidemiology, risk factors, screening, prevention,and diagnosis[J]. Mayo Clin Proc,2007,82:364-380.
, 百拇医药
[2]Markovik SN,Erickson LA,Roa RD,et al.M alignant Melanoma in the 21st century,part 2: Staging ,prognosis,and treatment[J].Mayo clin Pro,2007,82:490.
[3]Balch CM,Soong SJ,Gershenwald JE,et al.Prognostic factors analysis of 17 600 melanoma patients:validation of the American Joint Committee on Cancer melanoma staging system[J].J Clin Oncol,2001,19:3622-3634.
[4]Retsas S,Henry K,Mohammed MQ,et al. Prognostic factors of cutaneous melanoma and a new staging system proposed by the American Joint Committee on Cancer (AJCC): validation in a cohort of 1284 patients[J].Eur J Cancer,2002,38:511-516.
, 百拇医药
[5]Marghoob AA,Koenig K,Bittencourt FV,et al. Breslow thickness and Clark level in melanoma: support for including level in pathology reports and in American Joint Committee on Cancer Staging[J].Cancer,2000,88:589-595.
[6]Balch CM,Buzaid AC,Atkins MB,et al.A new American Joint Committee on Cancer staging system for cutaneous melanoma[J].Cancer,2000,88:1484-1491.
[7]Rao UN,Ibrahim J,Flaherty LE,et al.Implications of microscopic satellites of the primary and extracaspular lymph node spread in patients with high-risk melanoma: pathologic corollary of Eastern Cooperative Oncology Group Trial E1690[J].J Clin Oncol,2002,20:2053-2057.
, 百拇医药
[8]Yan S,Brennick JB.False-positive rate of the immunoperoxidase stains for MART1/MelanA in lymph nodes[J].Am J Surg Pathol,2004,28:596-600.
[9]Lefevre M,Vergier B,Balme B,et al.Relevance of vertical growth pattern in thin level II cutaneous superficial spreading melanomas[J].Am J Surg Pathol,2003,27:717-724.
[10]Azzola MF,Shaw HM,Thompson JF,et al.Tumor mitotic rate is a more powerful prognostic indicator than ulceration in patients with primary cutaneous melanoma: an analysis of 3661 patients from a single center[J].Cancer,2003,97:1488-1498.
, 百拇医药
[11]Guitart J,Lowe L,Piepkorn M,et al.Histological characteristics of metastasizing thin melanomas: a case-control study of 43 cases[J]. Arch Dermatol,2002,138:603-608.
[12]Masback A,Olsson H,Westerdahl J,et al.Prognostic factors in invasive cutaneous m alignant melanoma: a population-based study and review[J]. Melanoma Res,2001,11:435-445.
[13]Lugassy C,Haroun RI,Brem H,et al.Pericytic-like angiotropism of glioma and melanoma cells[J].Am J Dermatopathol,2002,24:466,473-478.
[收稿日期]2008-02-20
编辑/李阳利, http://www.100md.com(李荟元)