Management of patients with intermediate-thickness melanoma

It is important to understand the management of patients with melanoma because of a rising incidence of this cancer in the United States. The most important prognostic factor is tumor thickness. Patients with early melanoma (thickness <1.0 mm) have an excellent prognosis and are effectively treated with narrow local excision (1-cm radius). Those with advanced melanomas (tumor thickness >4.0 mm) have a high risk of metastases and are treated with a wider local excision (2-3 cm). Controversies surrounding the management of patients with intermediate-thickness melanoma (thickness 1-4 mm) center on the issues of local excision and management of regional lymph nodes. Randomized trials have shown that a 2-cm radius of excision will minimize the risk for local recurrence. Although retrospective analyses have indicated a survival advantage for elective regional lymph node dissection, two randomized trials have not shown a benefit for the early removal of lymph nodes. Two more randomized trials are in progress. Techniques are now available to identify the sentinel lymph node, which will help to limit lymph node dissections to those patients with nodal metastases. Postoperative surveillance for recurrence is most effectively performed with a combination of patient self-examination and regular physician examinations rather than frequent X-rays and laboratory tests. Adjuvant therapy has not been proven effective for melanoma patients; however, many investigational trials are available.