Current surgical management for melanoma

Abstract

Melanoma is a major malignant cutaneous neoplasm with a high mortality rate. In recent years, the treatment of melanoma has developed dramatically with the invention of new therapeutic agents, including immune checkpoint inhibitors and molecular-targeted agents. These agents are available as adjuvant therapies for postoperative patients with stage IIB, IIC, and III melanomas. Furthermore, neoadjuvant therapy has been studied in several global clinical trials and has demonstrated promising and favorable clinical efficacy, mainly in patients with palpable regional lymph nodes. A recent large phase III clinical trial investigating early lymph node dissection for sentinel lymph node metastases demonstrated no survival benefits. Based on these data, surgery should be reconsidered as an appropriate treatment modality for melanoma. The need for invasive surgical procedures will be reduced with the invention of effective adjuvant and neoadjuvant therapies and novel clinical trial data on regional lymph node dissection. However, surgery still plays an important role in treating early-stage melanoma, accurately determining the disease stage, and effective palliative treatment for advanced melanoma. In this article, we focus on surgery for primary tumors, regional lymph nodes, and metastatic sites in an era of remarkably revolutionary drug treatments for melanoma.

Keywords: malignant melanoma; neoadjuvant therapy; regional lymph node dissection; sentinel lymph node biopsy; surgery.

FIGURE 1

A male patient with invasive nail apparatus melanoma who was enrolled in JCOG 1602 and received non‐amputative digit preservation surgery. (a) Black‐colored nail plate with ulcerative nodular lesion and Hutchinson's phenomenon on the left big toenail. Black line indicates incision line of non‐amputative digit preservation surgery. (b) After removal of the nail apparatus at the level of the distal phalanx. (c) Histopathology of resected nail apparatus. The black dotted line indicates the proliferative area of melanoma cells. The yellow double‐ended arrow indicates tumor thickness (2.2 mm). The blue double‐ended arrow indicates the shortest tumor‐to‐deep margin distance (0.9 mm). (d) Clinical appearance 3 years after coverage of defect by skin grafting.

FIGURE 2

Different extents of selective neck dissection according to the location of primary tumor and clinical nodal disease. (a) Scheme of the dissection levels and areas in the left head and neck region. (b) A patient with melanoma on the left cheek receiving selective neck dissection (level IB, II, III, and superficial parotidectomy). (c) A patient with melanoma on the upper chest receiving narrow area selective neck dissection (level IV and VB). (d) A patient with melanoma on the left occipital region receiving selective neck dissection (level II–V and occipital nodes).