The surgical management of metastatic melanoma

Melanoma

The surgical management of melanoma continues to evolve. A large body of information serves as a foundation for the oncologic principles, surgical excisions, and reconstructive methodologies that are currently in use. This article serves as a guide for the physician considering surgical management of the melanoma patient.

Surgical treatment of stage IV melanoma

Surgical therapy plays an important role in the management of selected patients with metastatic melanoma. Patients are frequently symptomatic from metastatic lesions, have few effective therapeutic options, and are faced with dismal outcomes. Surgical resection may provide successful palliation of symptomatic lesions with low morbidity and operative mortality. In carefully selected patients, resections performed with curative intent may result in improved survival if a pattern of disease recurrence suggestive of favorable tumor biology is present, and if complete resection of tumor is achieved. Because the majority of post-surgical metastatic patients eventually relapse and succumb to distant disease, adjuvant immunotherapeutic strategies are currently being evaluated.

Role of surgery in patients with stage IV melanoma

PURPOSE OF REVIEW

The purpose of this brief review is to highlight recent advances in the surgical treatment of metastatic melanoma; to review factors important in the decision-making process of selecting the most appropriate patients for resection; and to discuss the current literature in the context of site of recurrence.

RECENT FINDINGS

While there are relatively few new findings on the surgical treatment of metastatic melanoma, recent reports do support prior observations in the field. The recently revised staging system for melanoma groups metastatic disease according to prognostic features. There is currently a great deal of interest in the use of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) to more accurately evaluate metastatic disease. The use stereotactic radiosurgery for brain metastases has expanded recently and adds to local treatment options. When procedures are performed with palliative intent, treatment goals must be clearly defined and communicated among the patient, family and surgeon. Improved understanding of the goals of palliative surgery may be facilitated by the concept of a palliative triangle, which helps define the decision making process among the patient, family members, and surgeon.

SUMMARY

Metastatic melanoma is usually associated with a dismal prognosis. When a procedure is performed with palliative intent, appropriately selected patients usually experience reliable relief of symptoms and improved quality of life. Improved survival after a complete resection with curative intent is often predicted by good performance status, longer disease-free interval, limited extent of metastatic disease, and less aggressive tumor biology.

Laparoscopic adrenalectomy for malignancy

Laparoscopic adrenalectomy for primary malignancies and tumors metastatic to the adrenal is controversial. Most studies demonstrate that results of laparoscopic adrenalectomy for malignant lesions are similar to those of open adrenalectomy, without its morbidity. The results of laparoscopic adrenalectomy for tumor metastases suggest that it may benefit patients who have a metachronous metastasis from any of a variety of primary tumors. Selective laparoscopic adrenalectomy for potentially malignant tumors requires seeking signs of local invasion, lymphadenopathy, or distant metastasis; there are no other reliable preoperative criteria of malignancy. Diagnostic laparoscopy may be useful, and in some cases, may establish a diagnosis. Laparoscopic adrenalectomy should be cautiously performed, with the goals of achieving complete tumor resection without disruption of the adrenal capsule.

The natural course of cutaneous melanoma

The natural course of cutaneous melanoma (CM) is determined by its metastatic spread and depends on tumor thickness, ulceration, gender, localization, and the histologic subtype of the primary tumor. CM metastasis develops via three main metastatic pathways and occurs as satellite or in-transit metastasis, as regional lymph node metastasis or as distant metastasis at the time of primary recurrence. About 50% of all CM patients with tumor progression firstly develop regional lymph node metastases. In the other 50% the first metastases are satellite or in-transit metastases (about 20%), or immediately distant metastases (about 30%). Development of distant metastasis appears to be an early event in metastatic spread and may in the majority of cases originate from the primary tumor, only few cases may develop secondarily to locoregional metastasis. Reporting of organ involvement in distant metastasis greatly differs between the results of imaging techniques and autopsy results in respect to the metastatic patterns detected, pointing out that there is a need of improved imaging systems. Proliferation, neovascularization, lymphangiogenesis, invasion, circulation, and embolism are important steps in the pathogenesis of CM metastasis, with tumor vascularity as an important independent significant prognostic factor. The expression of chemokine receptors in cancer cells associated with the expression of the respective chemokine receptor ligands in the target sites of the metastasis is an interesting observation which may stimulate the development of new therapeutic strategies.

Update on the systemic treatment of malignant melanoma

The purpose of this article is to review some of the recent advances and disappointments in the systemic treatment of melanoma and to highlight some of the ongoing trials in this area. Two major advances in the staging of melanoma are the new American Joint Committee on Cancer staging system and the use of the sentinel node biopsy. Interferon remains the standard adjuvant therapy for high-risk patients. Ongoing trials are evaluating 1 month of high-dose interferon versus observation in intermediate-risk patients and comparing standard interferon with biochemotherapy. Allogeneic and peptide vaccines and granulocyte-macrophage colony-stimulating factor are also being evaluated. Dacarbazine and high-dose IL-2 are the only US Food and Drug Administration approved systemic treatments for stage IV disease. Several new agents are being evaluated. Melanoma remains a prototype disease in which patients should be encouraged to participate in clinical trials.