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Table 1. 
Development of Lung Metastases in Patients With Localized Melanoma
Development of Lung Metastases in Patients With Localized Melanoma
Table 2. 
Clinical Characteristics of 1032 Patients With Localized Melanoma (Stages I and II)
Clinical Characteristics of 1032 Patients With Localized Melanoma (Stages I and II)
Table 3. 
Initial Staging Chest X-ray Film Results of Patients With Localized Melanoma
Initial Staging Chest X-ray Film Results of Patients With Localized Melanoma
1.
American Joint Committee on Cancer, Malignant melanoma of the skin (excluding eyelid). American Joint Committee on Cancer: Manual for Staging of Cancer Philadelphia, Pa JB Lippincott Co1992;143- 148
2.
Balch  CMCascinelli  NDrzewiecki  KT  et al. Balch  CMedHoughton  ANedMilton  GWedSober  AJedSoong  Sed A comparison of prognostic factors worldwide. Cutaneous Melanoma Philadelphia, Pa JB Lippincott Co1992;188- 199
3.
Meyer  JEStolbach  L Pretreatment radiographic evaluation of patients with malignant melanoma. Cancer. 1978;42125- 126Article
4.
Khansur  TSanders  JDas  SK Evaluation of staging workup in malignant melanoma. Arch Surg. 1989;124847- 849Article
5.
Ardizzoni  AGrimaldi  ARepetto  LBruzzone  MSertoli  MRRosso  R Stage I-II melanoma: the value of metastatic work-up. Oncology. 1987;4487- 89Article
6.
Zartman  GMThomas  MRRobinson  WA Metastatic disease in patients with newly diagnosed malignant melanoma. J Surg Oncol. 1987;35163- 164Article
7.
Gromet  MAOminsky  SHEpstein  WLBlois  MS The thorax as the initial site for systemic relapse in malignant melanoma: a prospective survey of 324 patients. Cancer. 1979;44776- 784Article
8.
Buzaid  ACSandler  ABMani  S  et al.  Role of computed tomography in the staging of primary melanoma. J Clin Oncol. 1993;11638- 643
9.
Curtis  AMRavin  CEDeering  TFPutman  CEMcLoud  TCGreenspan  RH The efficacy of full-lung tomography in the detection of early metastatic disease from melanoma. Radiology. 1982;14427- 29
10.
Roth  JAEilber  FRBennett  LRMorton  DL Radionuclide photoscanning: usefulness in preoperative evaluation of melanoma patients. Arch Surg. 1975;1101211- 1212Article
11.
Au  FCMaier  WPMalmud  LSGoldman  LIClark Jr  WH Preoperative nuclear scans in patients with melanoma. Cancer. 1984;532095- 2097Article
12.
Evans  RABland  KIMcMurtrey  MIBallantyne  M Radionuclide scans not indicated for clinical stage I melanoma. Surg Gynecol Obstet. 1980;150532- 534
13.
Patel  JKDidolkar  MSPickren  JWMoore  RH Metastatic pattern of malignant melanoma. Am J Surg. 1978;135807- 810Article
14.
Balch  CMSoong  SMurad  TMSmith  JWMaddox  WADurant  JR A multifactorial analysis of melanoma, IV: prognostic factors in 200 melanoma patients with distant metastases (stage III). J Clin Oncol. 1983;1126- 134
15.
Amer  MHAl-Sarraf  MVaitkevicius  VK Clinical presentation, natural history and prognostic factors in advanced malignant melanoma. Surg Gynecol Obstet. 1979;149687- 692
16.
Stehlin  JSHills  WJRufino  C Disseminated melanoma: biologic behavior and treatment. Arch Surg. 1967;94495- 501Article
17.
Johnson  TMSmith  JNelson  BRChang  A Current therapy of cutaneous melanoma. J Am Acad Dermatol. 1995;32689- 707Article
18.
Balch  CMSoong  SJShaw  HMBalch  CMedHoughton  ANedMilton  GWedSober  AJedSoong  Sed An analysis of prognostic factors in 8,500 patients with cutaneous melanoma. Cutaneous Melanoma 2nd ed. Philadelphia, Pa JB Lippincott1992;165- 187
19.
Vollmer  RT Malignant melanoma: a multivariate analysis of prognostic factors. Pathol Annu. 1989;24383- 407
20.
Sondergaard  KSchou  G Survival with primary cutaneous malignant melanoma evaluated from 2012 cases: a multivariate regression analysis. Virchows Arch A Pathol Anat Histopathol. 1985;406179- 195Article
21.
Schmoeckel  CBockelbrink  ABockelbrink  HKoutsis  JBraun-Falco  O Low- and high-risk malignant melanoma, I: evaluation of clinical and histological prognosticators in 585 cases. Eur J Cancer Clin Oncol. 1983;19227- 235Article
22.
Blois  MSSagebiel  RWAbarband  RMCaldwell  TMTuttle  MS Malignant melanoma of the skin, I: the association of tumor depth and type, and patient sex, age, and site with survival. Cancer. 1983;521330- 1341Article
23.
Worth  MGallagher  RPElwood  JM  et al.  Pathologic prognostic factors for cutaneous malignant melanoma: the Western Canada Melanoma Study. Int J Cancer. 1989;43370- 375Article
24.
Meyskens Jr  FLBerdeaux  DHParks  BTong  TLoescher  LMoon  TE Cutaneous malignant melanoma (Arizona Cancer Center experience), I: natural history and prognostic factors influencing survival in patients with stage I disease. Cancer. 1988;621207- 1214Article
25.
Van der Esch  EPCascinelli  NPreda  FMorabito  ABufalino  R Stage I melanoma of the skin: evaluation of prognosis according to histologic characteristics. Cancer. 1981;481668- 1673Article
26.
Balch  CMMurad  TMSoong  SJIngalls  ALHalpern  NBMaddox  WA A multifactorial analysis of melanoma: prognostic histopathologic features comparing Clark's and Breslow's staging methods. Ann Surg. 1978;188732- 742Article
27.
Day Jr  CLLew  RAMihm Jr  MC  et al.  The natural break points for primary-tumor thickness in clinical Stage I melanoma. N Engl J Med. 1981;3051155
28.
Breslow  A Thickness, cross-sectional areas, and depth of invasion in the prognosis of cutaneous melanoma. Ann Surg. 1970;172902- 908Article
29.
Thomas  JHPanoussopoulous  DLiesmann  GEJewell  WRPreston  DF Scintiscans in the evaluation of patients with malignant melanomas. Surg Gynecol Obstet. 1979;149574- 576
30.
Webb  WRGamsu  G Thoracic metastasis in malignant melanoma: a radiographic survey of 65 patients. Chest. 1977;71176- 181Article
31.
Chen  JTTDahmash  NSRavin  CE  et al.  Metastatic melanoma to the thorax. AJR Am J Roentgenol. 1981;137293- 298Article
32.
Das Gupta  TBrasfield  R Metastatic melanoma. Cancer. 1964;171323- 1339Article
33.
Libshitz  HINorth  LB Pulmonary metastases. Radiol Clin North Am. 1982;20437- 451
34.
Heaston  DKPutnam  CERodan  BA  et al.  Solitary pulmonary metastases in high-risk melanoma patients: a prospective comparison of conventional and computed tomography. AJR Am J Roentgenol. 1983;141169- 174Article
35.
Simeone  JFPutnam  CEGreenspan  RH Detection of metastatic malignant melanoma by chest roentgenography. Cancer. 1977;391993- 1996Article
Study
May 1998

Use of Chest Radiography in the Initial Evaluation of Patients With Localized Melanoma

Author Affiliations

From the Departments of Dermatology, Otolaryngology, and Surgery (Division of Plastic Surgery), University of Michigan Medical Center and Comprehensive Cancer Center, Ann Arbor. Dr Terhune is now with the University of Kentucky, Lexington. Dr Swanson is now with the Oregon Health Sciences Center, Portland.

Arch Dermatol. 1998;134(5):569-572. doi:10.1001/archderm.134.5.569
Abstract

Objective  To evaluate the use of an initial staging chest x-ray film in asymptomatic patients who present with localized primary cutaneous melanoma.

Design  The staging workup of 1032 consecutive asymptomatic patients with localized melanoma was retrospectively reviewed via database chart review.

Setting  Regional melanoma referral center in an academic medical center.

Patients  The melanoma database identified 1032 asymptomatic patients with localized melanoma for retrospective review. Of the patients studied, 876 (85%) of 1032 had an initial staging chest x-ray film performed. A chest x-ray film was considered initial if performed within 6 months of melanoma diagnosis.

Main Outcome Measure  The rate of positive, negative, and suspicious findings of initial chest x-ray films.

Results  One hundred thirty (15%) of 876 patients had suspicious findings necessitating additional workup. Based on follow-up radiologic findings, only 1 (0.1%) of 876 had a true-positive chest x-ray film demonstrating pulmonary metastasis.

Conclusions  The yield of detection of unsuspected pulmonary metastasis by chest x-ray film in the initial evaluation of asymptomatic patients with localized melanoma was exceedingly low (0.1%). Our results support the concept that routine chest radiograph screening in asymptomatic patients presenting with stage I and intermediate-thickness (1.5- to 4.0-mm) stage II melanoma is unlikely to yield true-positive findings of silent pulmonary metastasis. No definitive conclusions were drawn for the subset of patients with stage II thick melanoma (>4.0 mm) because of the small number of patients (n = 40) in our series. Prospective studies are necessary to ultimately define the yield of initial radiographs in asymptomatic patients with localized melanoma.

THE MAJORITY of patients with melanoma present with local disease (American Joint Committee on Cancer [AJCC] stages I and II) with a 5-year survival rate of approximately 80%.1,2 These data indicate that 20% of patients with stages I and II disease have occult distant metastases at the time of diagnosis. In an attempt to detect these occult lesions, an initial staging evaluation is often performed on patients newly diagnosed as having melanoma. While a detailed medical history taking and physical examination are essential for this purpose, there are few data to support the use of screening studies such as chest x-ray films,37 computed tomographic (CT) scans,8,9 liver-spleen scans,36,1012 bone scans,36,10,11 and brain scans36,1012 in asymptomatic patients. Despite this, the initial workup for patients with localized melanoma often includes multiple diagnostic studies, most frequently chest radiography. This may be due to the ease of ordering and performing the test and because the lung is the most common visceral site for metastases.7,13 We performed a retrospective analysis to evaluate the use of chest x-ray films in the initial screening evaluation of patients with localized melanoma.

PATIENTS AND METHODS

The University of Michigan melanoma database in Ann Arbor was retrospectively reviewed for 1982 to 1993 to evaluate the initial staging workup and follow-up of 1032 consecutive asymptomatic patients presenting with in situ and stages I and II melanoma. The AJCC stages I and II represent local disease with Breslow depth of 1.50 mm or less and more than 1.50 mm, respectively. Stage III represents regional disease and stage IV, distant disease.1

Standard workup of all patients included a medical history taking and physical examination. All pathologic specimens were reviewed at the University of Michigan by dermatopathologists and evaluated for level of invasion according to Breslow depth and Clark level when possible. Patients were classified according to the AJCC staging system based on findings of the clinicopathologic evaluation. Chest radiography was performed in the majority of patients (85%). Hematologic studies, such as complete blood cell counts and liver function tests, were not routinely performed and then only at the discretion of the attending physician.

Of the patients studied, 876 (85%) of 1032 had initial staging chest radiography performed. In the other 156 patients, patient refusal, pregnancy, or lack of a radiography order at the discretion of the attending physician accounted for the lack of test results. A chest x-ray film was considered initial if performed within 6 months of melanoma diagnosis.

A suspicious chest x-ray film was defined by abnormalities or findings that were suggestive of, or could not be distinguished from, metastatic melanoma by the radiologist. The most common findings considered suspicious included multiple or solitary nodules, an opacity, pleural thickening, a prominent hilum, or an interstitial pattern of disease. Follow-up of suspicious findings involved obtaining a previous chest x-ray film for comparison or ordering a second chest x-ray film or a chest CT scan. Repeated x-ray films or CT scans were obtained on an average within 4 months of the initial study (range, 1-33 months).

Long-term follow-up data were available in 685 (66%) of all patients (Table 1). Lack of all available data was attributable to return of patients to referring physicians and loss of patients to follow-up, in general.

RESULTS

The study population consisted of 53% male and 47% female patients with an average age of 50 years (range, 1.5-98 years). Nearly all patients were white (99%) (Table 2). The majority of tumors (57%) were of the superficial spreading type and occurred most commonly on the trunk. Six hundred nine patients (59%) were classified as having stage I disease and 303 (29%) as having stage II. Seventy-three (7%) represented cases of melanoma in situ and 47 (5%) could not be staged because the depth of invasion could not be determined accurately because of tumor extending to the deep margins following a shave biopsy or misorientation of the biopsy specimen (Table 3). Forty-six (5%) of the 876 patients suitable for study analysis had melanoma in situ, 543 (62%) had stage I disease, 218 (25%) had stage II disease (Breslow depth, 1.5-4.0 mm), 40 (5%) had stage II disease (Breslow depth, >4.0 mm), and 29 (3%) had unknown thickness invasive melanoma.

One hundred thirty (15%) of the 876 patients had suspicious findings on the chest x-ray film, necessitating further evaluation. Additional evaluation included a comparison with previous chest x-ray films, a second chest x-ray film, or a chest CT scan. In 35 patients, a combination of these follow-up studies or multiple repeated tests were necessary to definitively confirm the nature of the abnormal findings. In 128 of these 130 patients, the follow-up evaluation found the pulmonary abnormalities to have resolved, remained stable, or clearly represented benign disease, thus confirming the absence of lung metastases. In 1 patient no radiographic follow-up evaluation was documented, but clinically the patient remained free of disease several years after the suspicious findings on the chest x-ray film. In only 1 patient did repeated studies suggest the presence of lung metastasis. This individual was a 45-year-old white man with a melanoma, Breslow depth of 2.94 mm and Clark level IV, on his back. The initial chest x-ray film revealed a solitary nodule. Repeated chest x-ray film and CT scan indicated enlargement of the nodule and hilar adenopathy. Analysis of a lung biopsy specimen confirmed the nodule to be metastatic melanoma.

Silent pulmonary metastasis was found in only 1 (0.1%) of 876 patients. No metastatic lung disease was detected in cases of melanoma in situ and stage I disease, while lung metastasis was found in 1 (0.4%) of 258 patients with stage II disease. Overall, the frequency of false-positive results was 15%.

Of the group with long-term follow-up data available, 30 developed lung metastases and 2 developed a primary lung cancer. Metastases were detected between 4 months and 9 years after initial diagnosis (average, 2.8 years). Seventeen cases of lung metastases were found in patients with initial negative findings on chest x-ray films and 5 were found in patients with initial suspicious findings on chest x-ray films.

COMMENT

Melanoma may disseminate to any organ system. The most common sites of dissemination in decreasing frequency are the skin, lymph nodes, lungs, liver, brain, bone, and gastrointestinal tract.1416 Clearly, a certain number of patients initially diagnosed as having localized melanoma will develop distant metastases. Tumor thickness measured in millimeters remains the strongest predictor of the risk of metastasis. 1728 In a collaborative study, Balch et al2 reported the average 5-year survival rate for patients with stages I and II melanoma to be 79%. This suggested that at least 20% of patients with localized melanoma have occult distant metastases at the time of initial diagnosis. Based on these results, patients diagnosed as having primary localized melanoma often undergo exhaustive evaluations in search of metastatic disease.

In general, imaging studies are used in the initial evaluation of patients with melanoma for the purpose of detecting and diagnosing metastatic disease. The demonstration of distant metastases will not only affect prognosis but also significantly alter treatment. Evaluation of the lung by chest radiography remains one of the most frequently ordered studies for staging patients with melanoma. This may be because the lung is one of the most common visceral sites of spread and a chest radiograph is relatively inexpensive, low risk, widely available, and easy to perform.

Several studies have evaluated the use of various diagnostic tests in the initial evaluation of patients with primary cutaneous melanoma. Khansur et al4 evaluated 72 patients with localized melanoma using various combinations of chest x-ray film, radionuclide scans of the brain, bone, and liver, head CT scan, and upper gastrointestinal tract series. No metastatic disease was detected in the 72 patients with clinically localized disease; however, 9 false-positive test results, including 2 false-positive chest x-ray films, were found. Ardizzoni et al5 performed initial staging chest radiography on 116 asymptomatic patients diagnosed as having melanoma; 93 had only local disease. Results of all studies in patients with localized disease were normal. Ninety patients with primary localized melanoma were studied by Zartman et al6 using chest radiography in addition to other blood and imaging studies. All patients were asymptomatic and had unremarkable findings on physical examination. Findings from all chest x-ray films were within normal limits. In addition, 209 patients are reported in the literature with localized melanoma initially evaluated with a myriad of brain, bone, and liver or spleen scans. 10,12,29 None detected unsuspected metastasis. The false-positive rate was 16% in 1 study.29 Collectively, these studies do not support the use of chest radiography, radionuclide scans, or CT scans in the initial evaluation of patients with localized melanoma.

When melanoma metastasizes to the lungs, it usually appears as multiple small foci.3032 Since the resolution of plain films is usually limited to lesions of 1 cm or greater,33 these tests have limited capacity to detect metastases smaller than this. Computed tomography of the chest has been shown to be superior to chest radiography in the detection of metastatic disease in high-risk patients.33,34 However, in low-risk patients its use is minimal. Buzaid et al8 studied the role of CT scans in the staging evaluation of 151 patients with melanoma AJCC stages I through III. Of 124 patients with localized disease, only 1 had unsuspected metastasis. This patient had a scalp melanoma of 6.6 mm in Breslow depth with a clinically undetected cervical node found on a CT scan of the head. No chest CT scans demonstrated silent pulmonary metastasis. However, false-positive results were found in 17% of cases.

The retrospective nature of this study precludes us from commenting with certainty on the available long-term data. Patients evaluated in a multidisciplinary clinic in a tertiary care hospital are often seen once and returned to referring physicians without follow-up readily available. Patients may also fail to follow-up once the melanoma has been removed. According to our data, the majority of cases in which lung metastases were eventually detected occurred in patients with initial negative chest x-ray films. However, of those with initial negative chest x-ray films 2.3% developed lung metastases and of those with initial suspicious false-positive chest x-ray films 3.8% developed lung metastases. This suggests that lung metastases occur more frequently in patients with suspicious false-positive radiographs. It is possible that these metastases were present at initial diagnosis and were not detected because of limitations of the nature, performance, and reading of chest x-ray films. Lack of availability of initial chest x-ray films for review in these cases prevents definitive conclusions. Given the limited nature of our follow-up data in terms of patient numbers and length, the ultimate use of these data is unclear. A lengthy prospective study would eliminate this difficulty.

Our results, based on large patient numbers, support the notion that initial screening chest radiography screening in asymptomatic patients presenting with stage I and intermediate thickness (1.5- to 4.0-mm) stage II melanoma is highly unlikely to detect silent pulmonary metastasis, thus suggesting that it may be neither useful nor cost-effective.46,35 Additionally, the high false-positive rate of 15% led to costly investigations and contributed to an increase in the patient anxiety's level. Of greatest importance is a thorough medical history taking and physical examination. Conclusions based on retrospective analysis are useful to define prospective studies for definitive conclusions.

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Article Information

Accepted for publication November 24, 1997.

Reprints: Timothy M. Johnson, MD, Department of Dermatology, University of Michigan, 1910 Taubman Center, Box 0314, Ann Arbor, MI 48109-0314 (e-mail: timjohn@umich.edu).

References
1.
American Joint Committee on Cancer, Malignant melanoma of the skin (excluding eyelid). American Joint Committee on Cancer: Manual for Staging of Cancer Philadelphia, Pa JB Lippincott Co1992;143- 148
2.
Balch  CMCascinelli  NDrzewiecki  KT  et al. Balch  CMedHoughton  ANedMilton  GWedSober  AJedSoong  Sed A comparison of prognostic factors worldwide. Cutaneous Melanoma Philadelphia, Pa JB Lippincott Co1992;188- 199
3.
Meyer  JEStolbach  L Pretreatment radiographic evaluation of patients with malignant melanoma. Cancer. 1978;42125- 126Article
4.
Khansur  TSanders  JDas  SK Evaluation of staging workup in malignant melanoma. Arch Surg. 1989;124847- 849Article
5.
Ardizzoni  AGrimaldi  ARepetto  LBruzzone  MSertoli  MRRosso  R Stage I-II melanoma: the value of metastatic work-up. Oncology. 1987;4487- 89Article
6.
Zartman  GMThomas  MRRobinson  WA Metastatic disease in patients with newly diagnosed malignant melanoma. J Surg Oncol. 1987;35163- 164Article
7.
Gromet  MAOminsky  SHEpstein  WLBlois  MS The thorax as the initial site for systemic relapse in malignant melanoma: a prospective survey of 324 patients. Cancer. 1979;44776- 784Article
8.
Buzaid  ACSandler  ABMani  S  et al.  Role of computed tomography in the staging of primary melanoma. J Clin Oncol. 1993;11638- 643
9.
Curtis  AMRavin  CEDeering  TFPutman  CEMcLoud  TCGreenspan  RH The efficacy of full-lung tomography in the detection of early metastatic disease from melanoma. Radiology. 1982;14427- 29
10.
Roth  JAEilber  FRBennett  LRMorton  DL Radionuclide photoscanning: usefulness in preoperative evaluation of melanoma patients. Arch Surg. 1975;1101211- 1212Article
11.
Au  FCMaier  WPMalmud  LSGoldman  LIClark Jr  WH Preoperative nuclear scans in patients with melanoma. Cancer. 1984;532095- 2097Article
12.
Evans  RABland  KIMcMurtrey  MIBallantyne  M Radionuclide scans not indicated for clinical stage I melanoma. Surg Gynecol Obstet. 1980;150532- 534
13.
Patel  JKDidolkar  MSPickren  JWMoore  RH Metastatic pattern of malignant melanoma. Am J Surg. 1978;135807- 810Article
14.
Balch  CMSoong  SMurad  TMSmith  JWMaddox  WADurant  JR A multifactorial analysis of melanoma, IV: prognostic factors in 200 melanoma patients with distant metastases (stage III). J Clin Oncol. 1983;1126- 134
15.
Amer  MHAl-Sarraf  MVaitkevicius  VK Clinical presentation, natural history and prognostic factors in advanced malignant melanoma. Surg Gynecol Obstet. 1979;149687- 692
16.
Stehlin  JSHills  WJRufino  C Disseminated melanoma: biologic behavior and treatment. Arch Surg. 1967;94495- 501Article
17.
Johnson  TMSmith  JNelson  BRChang  A Current therapy of cutaneous melanoma. J Am Acad Dermatol. 1995;32689- 707Article
18.
Balch  CMSoong  SJShaw  HMBalch  CMedHoughton  ANedMilton  GWedSober  AJedSoong  Sed An analysis of prognostic factors in 8,500 patients with cutaneous melanoma. Cutaneous Melanoma 2nd ed. Philadelphia, Pa JB Lippincott1992;165- 187
19.
Vollmer  RT Malignant melanoma: a multivariate analysis of prognostic factors. Pathol Annu. 1989;24383- 407
20.
Sondergaard  KSchou  G Survival with primary cutaneous malignant melanoma evaluated from 2012 cases: a multivariate regression analysis. Virchows Arch A Pathol Anat Histopathol. 1985;406179- 195Article
21.
Schmoeckel  CBockelbrink  ABockelbrink  HKoutsis  JBraun-Falco  O Low- and high-risk malignant melanoma, I: evaluation of clinical and histological prognosticators in 585 cases. Eur J Cancer Clin Oncol. 1983;19227- 235Article
22.
Blois  MSSagebiel  RWAbarband  RMCaldwell  TMTuttle  MS Malignant melanoma of the skin, I: the association of tumor depth and type, and patient sex, age, and site with survival. Cancer. 1983;521330- 1341Article
23.
Worth  MGallagher  RPElwood  JM  et al.  Pathologic prognostic factors for cutaneous malignant melanoma: the Western Canada Melanoma Study. Int J Cancer. 1989;43370- 375Article
24.
Meyskens Jr  FLBerdeaux  DHParks  BTong  TLoescher  LMoon  TE Cutaneous malignant melanoma (Arizona Cancer Center experience), I: natural history and prognostic factors influencing survival in patients with stage I disease. Cancer. 1988;621207- 1214Article
25.
Van der Esch  EPCascinelli  NPreda  FMorabito  ABufalino  R Stage I melanoma of the skin: evaluation of prognosis according to histologic characteristics. Cancer. 1981;481668- 1673Article
26.
Balch  CMMurad  TMSoong  SJIngalls  ALHalpern  NBMaddox  WA A multifactorial analysis of melanoma: prognostic histopathologic features comparing Clark's and Breslow's staging methods. Ann Surg. 1978;188732- 742Article
27.
Day Jr  CLLew  RAMihm Jr  MC  et al.  The natural break points for primary-tumor thickness in clinical Stage I melanoma. N Engl J Med. 1981;3051155
28.
Breslow  A Thickness, cross-sectional areas, and depth of invasion in the prognosis of cutaneous melanoma. Ann Surg. 1970;172902- 908Article
29.
Thomas  JHPanoussopoulous  DLiesmann  GEJewell  WRPreston  DF Scintiscans in the evaluation of patients with malignant melanomas. Surg Gynecol Obstet. 1979;149574- 576
30.
Webb  WRGamsu  G Thoracic metastasis in malignant melanoma: a radiographic survey of 65 patients. Chest. 1977;71176- 181Article
31.
Chen  JTTDahmash  NSRavin  CE  et al.  Metastatic melanoma to the thorax. AJR Am J Roentgenol. 1981;137293- 298Article
32.
Das Gupta  TBrasfield  R Metastatic melanoma. Cancer. 1964;171323- 1339Article
33.
Libshitz  HINorth  LB Pulmonary metastases. Radiol Clin North Am. 1982;20437- 451
34.
Heaston  DKPutnam  CERodan  BA  et al.  Solitary pulmonary metastases in high-risk melanoma patients: a prospective comparison of conventional and computed tomography. AJR Am J Roentgenol. 1983;141169- 174Article
35.
Simeone  JFPutnam  CEGreenspan  RH Detection of metastatic malignant melanoma by chest roentgenography. Cancer. 1977;391993- 1996Article
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