Surgical Management of Distant Melanoma Metastases

Diagnostic and Therapeutic Particularities of Symptomatic Melanoma Brain Metastases from Case Report to Literature Review

“…Neoadjuvant therapy could provide reliable insights on the response of tumors to systemic medication to personalize the postoperative adjuvant treatment [14]. Thompson et al estimate that surgery is likely to maintain a crucial role in advancing the systemic treatment of melanoma metastases, since assessing tumor histology is essential to understanding the mechanisms of response and resistance to medical therapy to develop more effective molecularly targeted therapies [40].…”

“…Neurosurgery can generally be performed for up to 3-4 brain metastases (defining oligometastatic disease, illustrated by our patient's case) and represents the primary treatment in the case of a solitary, surgically accessible or symptomatic lesion associated with vasogenic edema or the mass effect. It is particularly effective for large, rapidly progressive tumors that are located in critical areas where SRS is more hazardous [10,15,41]; it is also the most reliable method of decompressing the damaged areas and alleviating the associated debilitating symptoms before they become permanent [10,15,40,41].…”

“…WBRT used to be the standard radiotherapy procedure applied before the development of SRS [14,15,44]. Nowadays, considering its extreme neurotoxicity, negative neurocognitive effects, decreased performance status and lack of clinical benefit in oligometastatic disease in comparison with alternative therapies, its indications have been reduced to multiple symptomatic brain metastases (more than four or those that are difficult to address through SRS or surgery), carcinomatosis or leptomeningeal disease [10,15,40,[44][45][46][47][48]. Chemotherapy and WBRT are almost obsolete treatment options, and are used as a last resort for patients with an adequate performance status, unresponsive tumors or prohibitive toxicity from other treatments [14].…”

“…The standard craniotomy indications for MBM enumerated by Kreidieh et al are as follows: diagnostic uncertainty based solely on imaging and observation (surgery provides tissue samples for diagnosis and molecular testing), symptoms unresponsive to steroids, bulky metastases (>3-4 cm), and solitary MBM in the absence of extracranial disease [15]. The presence of symptoms, the performance status, comorbidities, primary tumor characteristics and staging usually determine the decision to operate on certain patients [10,40,41,[45][46][47]. Craniotomy has a mortality rate of between 1 and 3%, and can be associated with significant risks, including neurocognitive decline, leptomeningeal spread, and complications (wound infection, encephalitis, hematoma, hydrocephalus, edema, or seizures) that may require the postponement of the administration of oncologic treatment [15,40,41,48].…”

Overview of Subcutaneous Metastatic Melanoma

“…Until recently, surgical resection, when radical, was the only therapeutic strategy with some realistic chance of prolonging life and improving its quality [ 4 , 5 ].…”