Changes in the surgical management of melanoma and measures to implement change.

Abstract

Background: Cutaneous malignant melanoma has traditionally been a surgically managed disease. Recent clinical trials highlight major shifts in surgical management of this disease, emphasizing a multidisciplinary approach.

Methods: Clinical trials evaluating the role of completion lymph node dissection (CLND) in the management of sentinel lymph node positive patients and more recent trials evaluating the impact of neoadjuvant immunotherapy on patients presenting with clinically advanced but surgically resectable melanoma are reviewed, as well as ongoing trial evaluating surgical margins.

Results: Both DeCOG and MSLT-II trials confirmed that CLND is no longer standard management of the sentinel node positive patient. CLND offers no melanoma-specific survival benefit. Associated surgical morbidity justifies a surveillance and observation approach, combined with adjuvant therapy. Patients presenting with clinically advanced surgically resectable disease are best served by neoadjuvant therapy. This approach demonstrates significantly improved melanoma-specific survival compared to upfront surgery, underscoring the need for rapid adoption by surgeons.

Conclusions: Changes in surgical management of melanoma have been dramatic and offer patients improved outcomes though both reduction in the magnitude of surgery, as well as improved disease specific survival for patients with advanced surgically resectable disease.