Contemporary management of locoregionally advanced melanoma in Australia and New Zealand and the role of adjuvant systemic therapy

Abstract

Australia and New Zealand have the highest incidence and mortality rates for melanoma in the world. Local surgery is still the standard treatment of primary cutaneous melanoma, and it is therefore important that surgeons understand the optimal care pathways for patients with melanoma. Accurate staging is critical to ensure a reliable assessment of prognosis and to guide treatment selection. Sentinel node biopsy (SNB) plays an important role in staging and the provision of reliable prognostic estimates for patients with cutaneous melanoma. Patients with stage III melanoma have a substantial risk of disease recurrence following surgery, leading to poor long‐term outcomes. Systemic immunotherapies and targeted therapies, known to be effective for stage IV melanoma, have now also been shown to be effective as adjuvant post‐surgical treatments for resected stage III melanoma. These patients should be made aware of this and preferably managed in an integrated multidisciplinary model of care, involving the surgeon, medical oncologists and radiation oncologists. This review considers the impact of a recent update to the American Joint Committee on Cancer (AJCC) staging system, the role of SNB for patients with high‐risk primary melanoma and recent advances in adjuvant systemic therapies for high‐risk patients.

Sentinel lymph node biopsy rates in Victoria, 2018 and 2019

“…The calculators improve targeting of SLNB by distinguishing patients for whom positive SLNB results are more likely from those at lower risk, including people with melanomas of greater than 1 mm thickness but without high risk features 5 . By improving the accuracy of staging, the calculators enable targeted access to adjuvant therapy 9 . SLNB is typically recommended for patients with greater than 10% risk of nodal metastases, and can be considered for those with a 5–10% risk 8 …”

Melanoma management in the 21st century: a change in paradigm

“…The management of melanoma has evolved considerably in the last couple of decades, which has been comprehensively reviewed by Smithers et al 1 . The authors point out several advances which largely reflect a better understanding of tumour biology and have significantly impacted melanoma management.…”

“…The review by Smithers et al has clearly and thoroughly described the advances in our knowledge of melanoma tumour biology. 1 Gone are the days of 5 cm excision margins, prophylactic nodal dissection and ineffective systemic treatments. Instead, melanoma management has evolved into a multidisciplinary field, in which surgery still plays a role, but advances in knowledge of the tumour biology and the immune system have revolutionized treatment.…”

“…Another major advance in the approach to stage III disease has been the development of effective adjuvant systemic therapy. As summarized by Smithers et al ., 1 the two main classes of systemic therapy used in adjuvant melanoma treatment are combination BRAF/MEK inhibitors and the anti‐PD1 immunotherapy checkpoint inhibitors. Combination BRAF and MEK inhibition is indicated in patients whose tumours are BRAF mutant, which occurs in approximately 40% of melanomas.…”

“…The review by Smithers et al . has clearly and thoroughly described the advances in our knowledge of melanoma tumour biology 1 . Gone are the days of 5 cm excision margins, prophylactic nodal dissection and ineffective systemic treatments.…”