Surgery and other local-regional modalities for all stages of melanoma

The recommendations for the surgical management of clinically localized melanoma are now more clearly defined. Based on the results of two large randomized trials, optimal excision margins for primary tumors of varying thickness up to 4 mm have been determined: 1 cm for lesions smaller than 1 mm and 2 cm for lesions that are between 1 and 4 mm. In 90% of patients, the soft-tissue defect created by 2-cm excisions can be closed primarily, allowing surgery for early-stage melanoma to be performed predominantly on an outpatient basis. The role for an elective lymph node dissection in those patients with higher risk primary tumors is still under debate. 'Selective lymphadenectomy' using lymphatic mapping and sentinel node biopsy offers a rational approach to clinically negative regional lymph node basins. The promising early results with lymphatic mapping are exciting, but need to be confirmed in a multi-institutional trial. Renewed interest has developed in hyperthermic limb perfusion for the treatment of intransit and locally advanced recurrent disease because of the availability of melphalan and the recent reports of higher response rates with the addition of tumor necrosis factor and interferon gamma to melphalan. In the management of metastatic disease, recent large series have demonstrated that surgery can offer excellent palliation and, in some selected clinical settings, prolong survival. In those patients with surgically inaccessible lesions, radiation therapy can provide valuable palliation. The value of hyperthermia in addition to radiation therapy in the treatment of metastatic melanoma is still under investigation.