Current Controversies in Melanoma Treatment

Abstract

Learning Objectives: After reading this article and viewing the videos, the participant should be able to: 1. Discuss margins for in situ and invasive disease and describe reconstructive options for wide excision defects, including the keystone flap. 2. Describe a digit-sparing alternative for subungual melanoma. 3. Calculate personalized risk estimates for sentinel node biopsy using predictive nomograms. 4. Describe the indications for lymphadenectomy and describe a technique intended to reduce the risk of lymphedema following lymphadenectomy. 5. Offer options for in-transit melanoma management. Summary: Melanoma management continues to evolve, and plastic surgeons need to stay at the forefront of advances and controversies. Appropriate margins for in situ and invasive disease require consideration of the trials on which they are based. A workhorse reconstruction option for wide excision defects, particularly in extremities, is the keystone flap. There are alternative surgical approaches to subungual tumors besides amputation. It is now possible to personalize a risk estimate for sentinel node positivity beyond what is available for groups of patients with a given stage of disease. Sentinel node biopsy can be made more accurate and less morbid with novel adjuncts. Positive sentinel node biopsies are now rarely managed with completion lymphadenectomy. Should a patient require lymphadenectomy, immediate lymphatic reconstruction may mitigate the lymphedema risk. Finally, there are minimally invasive modalities for effective control of in-transit recurrences.

Malignant melanoma in the hand: current evidence and recommendations

“…Digit-sparing surgery involves a WLE of the nail apparatus, with the deep margin either at the periosteum, subperiosteal or including a thin section of dorsal distal phalanx with an osteotomy in the coronal plane (Temple-Oberle et al., 2023)). This may leave a graftable bed that can then be reconstructed with a full-thickness skin graft (Anda-Juárez et al., 2016).…”

Sentinel lymph node biopsy for melanoma in the older population: A prospective analysis of outcomes

“…Various controversies remain when considering SLNB in melanoma—including its use in thin melanomas, use of nomograms and techniques to improve its accuracy and limit its risks through the adoption of new mapping techniques 6 …”

“…5 Various controversies remain when considering SLNB in melanoma-including its use in thin melanomas, use of nomograms and techniques to improve its accuracy and limit its risks through the adoption of new mapping techniques. 6 The use of SLNB in the older population, defined as those over 70 years old, has also been debated since the adoption of SLNB into routine practice. Opponents of its use in the older population debate its role based on the age-related changes in lymphatic drainage patterns, decreased immune response with adjuvant therapy and potential complications and risks associated with surgery.…”