MELANOMA: A Multidisciplinary Approach for the General Surgeon

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The incidence of melanoma is increasing at a rate exceeding that of all other solid tumors.41 In the United States alone, an estimated 44,200 new cases and 7300 deaths from melanoma occurred in 1999.63 Fortunately, most melanomas are diagnosed at an early stage and can be cured by surgical excision, but because of the significant risk for morbidity and mortality associated with later-stage tumors, an increasing need for a multidisciplinary approach to their treatment exists.

Over the past 2 decades, significant advances in the understanding of the biology and treatment of this disease have been made. These advances have come from well-designed prospective, randomized clinical trials and basic science and translational research. For instance, data from prospective, randomized trials now provide clear guidelines for excision margins of primary melanomas (Table 1),11, 26, 85, 105 show that no role for elective lymph node dissection exists for most patients (Table 2),8, 28, 51, 96, 103, 104 and have led to the approval by the US Food and Drug Administration (FDA) of the first systemic adjuvant therapy for melanoma.59 Basic and translational research have led to a proliferation of promising experimental therapies, many of which are now being tested in phase 2 and 3 clinical trials.

Because of these advances, surgeons will be called on to direct the care of patients with melanoma in an increasingly multidisciplinary environment, so surgeons must understand the rationale, benefits, and side effects of the various treatment options. This article reviews some of the advances in techniques, treatment, and staging of melanoma with which surgeons should be familiar.

Section snippets

SENTINEL LYMPHADENECTOMY

wThe management of the draining nodal basin in patients with clinically node-negative melanoma traditionally has been a source of controversy. Before the 1990s, two management options were available: (1) observation and (2) elective lymph-node dissection (ELND). A third option, sentinel lymph node biopsy (SLNB), is now available.

The likelihood of having occult nodal disease is directly related to the thickness of the primary melanoma (Table 3).46 Clearly, nodal observation is the best

ADJUVANT THERAPY

The risk for systemic recurrence after complete resection of nodal disease is 50% to 70% and is higher after resection of systemic disease.6, 10, 21, 23, 29, 71 This information has stimulated an ongoing intensive search for effective adjuvant therapies. In large, prospective, randomized trials, numerous agents have been shown to have no efficacy in an adjuvant setting after resection of high-risk melanoma. This list includes bacillus Calmette-GuƩrin (BCG), Corynebacterium parvum,

MOLECULAR STAGING

The American Joint Committee on Cancer staging system accurately predicts survival for patients with melanoma.71 This system stages patients according to the thickness of the primary tumor, lymph node or in-transit metastases, and distant metastases (Table 4), but significant heterogeneity exists within staging groups, especially stages II and III.71 Which patients in each of these staging groups are at higher risk for recurrence and death from systemic disease would be useful to know so that

SUMMARY

Advances in the understanding of the biology and treatment of melanoma have moved the care of melanoma patients into an increasingly multidisciplinary environment. Surgeons must understand these advances because they will often be responsible for directing the overall care of these patients.

Most patients with melanomas more than 1 mm in diameter and no evidence of metastatic disease should be offered SLNB to more accurately stage them and direct decisions about participation in postoperative

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    Address reprint requests to Daniel G. Coit, MD, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, e-mail: [email protected]

    *

    Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York

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