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Persistence, Recurrence, and Metastasis: Similar or Fundamentally Different?


Mark A. Hurt MD

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I'm certain that you read about persistence and recurrence all of the time. Here are the dictionary definitions of these words:

[b]Persistence[/b]: continued existence -- or the fact that the lesion of an attempted excision was not removed completely.

[b]Recurrence[/b]: to occur again. In such a case, the lesion is apparently removed both clinically and histopathologically. In such a case, there is no histopathological evidence of any remaining lesion.



Practically, the difference in meaning between these two words is that the lesion was never removed (persistence) [i]versus[/i] that it was thought to be removed (local or distant metastasis) but has already spread beyond the primary site.

A "recurrence" from persistence means that primary lesion was merely biopsied or thought to be removed but was not. This is also known as "true local recurrence," yet it less confusing simply to use the term "persistence."

A "recurrence" from metastasis means that the primary lesion was indeed removed both clinically and histopathologically, to the best of anyone's ability to tell; but, by whatever mechanism, it has spread beyond the primary site -- most commonly through blood vascular or lymphatic vessels (or both).



My position is that there is no need for the term "recurrence" in medical discussions, because it is ambiguous. It is sufficient to state that a lesion persists or metastasizes. The implications for prognosis are profound, as follows:

1. A persistent primary melanoma, to the best of anyone's ability to tell, retains the prognosis of the primary melanoma. Some work on this has been done by Zitelli et al in Pittsburgh (below) in relation to melanomas in situ.

2. Metastatic melanoma tends to have a poor prognosis, depending on a number of factors, especially tumor burden, etc.


The bottom line is that a persistent primary melanoma is, within certain parameters, a curable disease; whereas, metastatic melanoma, as a rule, is not.

Using the terms [i]persistent [/i]or [i]metastatic [/i]makes the distinction crystal clear.


I am curious about your experience with this issue, so please let me know.



[center][b]References[/b]:[/center]


[font=arial,helvetica,sans-serif]1: Brown CD, Zitelli JA. The prognosis and treatment of true local cutaneous recurrent malignant melanoma. Dermatol Surg. 1995 Apr;21(4):285-90. PubMed PMID: 7728476.[/font]

[font=arial,helvetica,sans-serif]2: Zitelli JA, Brown CD, Hanusa BH. Surgical margins for excision of primary cutaneous melanoma. J Am Acad Dermatol. 1997 Sep;37(3 Pt 1):422-9. PubMed PMID: 9308558.[/font]
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Completely agree. I am not sure who introduced the word 'recurrence' in the first place, but it has been abused to no end! I would go to the extent of saying that 'Recurrence' is a term that should be banned from the dermato-oncology literature. It is either persistence to to incomplete removal or local metastasis, if a lesion that has apparently been treated comes back. If it is neither, then it is a new tumour in the same area, but not recurrence....
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