The Role of Surgery for Melanoma in an Era of Effective Systemic Therapy
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Purpose of Review
The recent discovery of effective systemic treatments for melanoma has dramatically improved the prognosis for patients with advanced disease. As a result, the multidisciplinary management of melanoma has evolved significantly. In the past decades surgery was reserved for symptomatic palliation in patients with metastatic melanoma. Today surgical treatment of patients responding to systemic therapies has become an integral part of disease control.
Current efforts are focused on minimizing the morbidity of surgery (laparoscopic inguinal lymph node dissection, selective completion lymphadenectomy) as well as combining surgery with systemic therapy in novel ways (neoadjuvant targeted and/or immunotherapy, isolated limb infusion/perfusion with systemic immunotherapy).
This review examines the use of surgery for advanced melanoma in the era predating modern systemic therapy as well as potential applications moving forward.
KeywordsSurgery Metastasectomy Melanoma Targeted therapy Immunotherapy
Compliance with Ethical Standards
Conflict of Interest
Siavash Raigani, Sonia Cohen, and Genevieve M. Boland declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: •Of importance ••Of major importance
- 4.•• Morton DL, Thompson JF, Cochran AJ, et al. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med. 2014;370:599–609. The Multicenter Selective Lymphadenectomy Trial (MSLT-I) is a phase 3 trial designed to determine whether identifying patients with clinically occult nodal melanoma metastases via sentinel node biopsy and then performing an immediate completion lymphadenectomy in those patients improves outcomes. Results of the study suggest that sentinel node biopsy and early completion lymphadenectomy do provide survival benefit to patients with intermediate thickness melanoma, most likely because those individuals in the biopsy group with clinically occult metastases at the time of the study were identified and treated, preventing regional recurrence. However, whether completion lymphadenectomy is necessary or whether removal of the sentinel nodes themselves provides adequate therapeutic benefit will be further addressed by MSLT-II (ongoing) CrossRefPubMedPubMedCentralGoogle Scholar
- 8.Jakub JW, Terando AM, et al. Safety and feasibility of minimally invasive inguinal lymph node dissection in patients with melanoma (SAFE-MILND): report of a prospective multi-institutional trial. Ann Surg. 2016; In pressGoogle Scholar
- 10.National Comprehensive Cancer Network. Melanoma. Version 3.2016. Available at: www.nccn.org. Accessed Oct 1, 2016.
- 12.• Robert C, Schachter J, Long GV, et al. Pembrolizumab versus ipilimumab in advanced melanoma. N Engl J Med. 2015;372:2521–32. These randomized, phase 3 trials demonstrate the efficacy of anti-programmed cell death inhibition (PD-1) in advanced melanoma by significantly improving progression-free and overall survival with less toxicity than inhibition of cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4). Combination therapy with anti PD-1 and CTLA4 agents was shown to be most effective with median patient survival approaching one year. The advent of systemic therapies able to control the progression of advanced disease has introduced new roles for surgical approaches to minimize disease burden in metastatic melanoma CrossRefPubMedGoogle Scholar
- 15.Memoral Sloan Kettering Cancer Center. Availble at https://www.mskcc.org/cancer-care/clinical-trials/10-101. Accesses September 30, 2016.
- 32.MD Anderson Cancer Center. Available at https://www.mdanderson.org/research/departments-labs-institutes/departments-divisions/melanoma-medical-oncology/clinical-trials.html. Accessed October 3, 2016.
- 33.ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT02858921. Accessed November 3, 2016.