- Definition and Clinical Presentation:
- Clinically detectable lymph node disease in cutaneous melanoma refers to:
- The presence of palpable or radiologically evident nodal metastases:
- Distinguishing it from microscopic (sentinel lymph node-positive) disease:
- Which is only identified histologically after sentinel lymph node biopsy
- Distinguishing it from microscopic (sentinel lymph node-positive) disease:
- Clinically detectable (macroscopic) nodal disease typically presents as:
- Enlarged, firm, or fixed lymph nodes on physical examination or as nodal masses on imaging:
- It is classified as stage III melanoma in the absence of distant metastases
- Enlarged, firm, or fixed lymph nodes on physical examination or as nodal masses on imaging:
- The presence of palpable or radiologically evident nodal metastases:
- Clinically detectable lymph node disease in cutaneous melanoma refers to:
- For patients who present with clinically apparent or detectable disease in the regional lymph node basin:
- A staging work up is recommended
- A thorough clinical examination is essential:
- Physical examination:
- Should be performed to identify lesions suspicious for additional primary melanoma:
- As well as to identify satellite disease and / or in-transit metastases
- A thorough nodal examination should also be performed to exclude clinically suspicious nodal disease in other regional basins
- Should be performed to identify lesions suspicious for additional primary melanoma:
- Staging evaluation typically includes baseline imaging with:
- CT chest / abdomen / pelvis or PET/CT, and MRI of the brain:
- This approach allows the surgeon to identify disease beyond the regional basin:
- That may preclude a recommendation for lymphadenectomy
- This is recommended by the American Academy of Dermatology and the National Comprehensive Cancer Network
- This approach allows the surgeon to identify disease beyond the regional basin:
- If not already excised at the time of referral:
- Image-guided biopsy (generally fine-needle aspiration biopsy or core) is preferred over excision to confirm regional disease
- A similar approach may be used to document other patterns of metastasis, such as distant disease, that would alter treatment planning
- CT chest / abdomen / pelvis or PET/CT, and MRI of the brain:
- Mutation testing for BRAF should also be performed
- In the absence of distant metastasis:
- Regional nodal disease has generally been approached with a recommendation for formal therapeutic lymphadenectomy followed by consideration of adjuvant therapy
- Therapeutic lymph node dissection (TLND):
- Is the standard of care for patients with clinically detectable lymph node metastases from cutaneous melanoma:
- Provided there is no evidence of distant metastatic disease
- The goal is complete resection of all involved nodal tissue in the affected basin:
- The extent of surgery may be individualized based on the burden and distribution of nodal disease, patient comorbidities, and evolving evidence regarding the prognostic and therapeutic impact of nodal clearance
- In select cases, less extensive surgery may be considered if the index node can accurately predict response, but this approach remains investigational
- Is the standard of care for patients with clinically detectable lymph node metastases from cutaneous melanoma:
- Role of Systemic Therapy:
- Following complete surgical resection:
- Adjuvant systemic therapy is recommended to reduce the risk of recurrence
- Immune checkpoint inhibitors (such as nivolumab or pembrolizumab):
- Are standard options, and for patients with BRAF V600-mutant melanoma:
- Adjuvant targeted therapy with dabrafenib plus trametinib is also an established approach:
- These therapies have demonstrated improvements in recurrence-free survival
- Adjuvant targeted therapy with dabrafenib plus trametinib is also an established approach:
- Are standard options, and for patients with BRAF V600-mutant melanoma:
- Neoadjuvant systemic therapy:
- Is under active investigation and may be considered in select cases:
- Particularly in the context of clinical trials or multidisciplinary discussion:
- But is not yet standard of care
- Particularly in the context of clinical trials or multidisciplinary discussion:
- Is under active investigation and may be considered in select cases:
- Following complete surgical resection:
- Multidisciplinary Approach and Patient Counseling:
- Management should be coordinated in a multidisciplinary setting:
- Involving surgical oncology, medical oncology, and radiology:
- To ensure optimal staging, treatment planning, and integration of systemic therapies
- Shared decision-making is critical, with discussion of the risks and benefits of surgery, the role of adjuvant therapy, and the importance of surveillance for recurrence
- Involving surgical oncology, medical oncology, and radiology:
- Management should be coordinated in a multidisciplinary setting:
- Areas Needing Further Evidence:
- The optimal sequencing and selection of neoadjuvant versus adjuvant systemic therapy, as well as the potential for de-escalation of surgery in select patients, are areas of ongoing research and require further evidence before routine adoption into clinical practice
- References:
- Current Management of Melanoma Patients With Nodal Metastases. Han D, van Akkooi ACJ, Straker RJ, et al. Clinical & Experimental Metastasis. 2022;39(1):181-199. doi:10.1007/s10585-021-10099-7.
- NCCN Guidelines® Insights: Melanoma: Cutaneous, Version 2.2021. Swetter SM, Thompson JA, Albertini MR, et al. Journal of the National Comprehensive Cancer Network : JNCCN. 2021;19(4):364-376. doi:10.6004/jnccn.2021.0018.
- The Extent of Surgery for Stage III Melanoma: How Much Is Appropriate?. Franke V, van Akkooi ACJ. The Lancet. Oncology. 2019;20(3):e167-e174. doi:10.1016/S1470-2045(19)30099-3.
- Guidelines of Care for the Management of Primary Cutaneous Melanoma. Swetter SM, Tsao H, Bichakjian CK, et al. Journal of the American Academy of Dermatology. 2019;80(1):208-250. doi:10.1016/j.jaad.2018.08.055.
Rodrigo Arrangoiz MS, MD, FACS, FSSO 