Abstract

Historically, melanoma patients were subject to wide local excisions and elective lymph node dissections (ELND). Both approaches have been the focus of intense scrutiny over the past three decades, and many surgical dogmas were abolished. The role of surgery in providing local control over the primary tumor is largely undisputed. However, surgical management strategies of the regional lymph nodes (RLN) have undergone considerable change in the past, with lymphatic mapping and sentinel lymph node (SLN) identification being the most relevant contribution, allowing for selection of patients for adjuvant treatment (completion lymph node dissection, Interferon therapy). Surgery has also a place in palliative treatment of isolated systemic metastases for select cases of stage IV melanoma in which the patient displays a good performance status.
In the past decades, the incidence of cutaneous malignant melanoma has risen steadily, faster than all cancers except lung cancer, accompanied by an increase in mortality in male patients [1]. It accounts for the sixth highest number of newly diagnosed cancer cases and is the sixth most common cancer among men and seventh most common among women [2]. Due to major prevention efforts, the numbers seem to have stabilized in younger age groups [1]. Early diagnosis has increased the proportion of thin melanomas with a higher cure rate [3]. However, overall melanoma-specific survival remains unaffected, despite all efforts towards improving medical care. Historically, melanoma patients were subject to wide local excisions and ELND. Both approaches have been the focus of intense scrutiny over the past three decades, and many surgical dogmas were abolished. The role of surgery in providing local control over the primary tumor is largely undisputed. However, the surgical management strategies of the regional lymph nodes (RLN) have undergone considerable change in the past, with lymphatic mapping and SLN identification being the most relevant contribution [4]. Today, SNB is the most important staging tool, because the status of the SLN represents the most important prognostic factor for recurrence and survival in melanoma patients and identifies patients who might benefit from further therapy, such as completion lymph node dissection (CLND) and adjuvant interferon therapy [5, 6]. Nevertheless, the impact of sentinel lymph node biopsy (SLNB) and CLND on survival remains unclear. Surgery also has a place in palliative treatment of systemic metastases in stage IV melanoma. Surgery of visceral metastases may be appropriate for select cases of good patient performance status and isolated tumor manifestation.