The role of surgeons in stage I–II melanoma

“Invasive treatments should improve either overall survival, local control, or the quality of life of patients,” stated Dr Dirk Grünhagen (Erasmus MC, the Netherlands). According to Dr Grünhagen, the role of the surgeon in the treatment of stage I–II melanoma has become largely redundant in recent years. However, in some instances, surgeons still play an important part in the management of these patients. He discussed the use of re-excisions, sentinel node procedures, and adjuvant therapy.

The purpose of re-excision

One purpose of re-excision is to avoid microsatellitosis. However, according to Dr Grünhagen, this occurs in less than 5% of patients. “In thin melanoma, the incidence of microsatellitosis is even lower,” he added. Re-excision is also not useful in improving overall survival. “Although local control will be slightly improved after re-excision, local relapse occurs in less than 5% of patients,” which suggests that 95% of the re-excision procedures for patients with stage I–II melanoma are redundant. “Since the usefulness of re-excision is limited, decision-making by a melanoma surgeon is crucial,” concluded Dr Grünhagen.

Sentinel node procedure and lymph node dissection

“Performing a sentinel node procedure plus complete lymph node dissection does not lead to an overall survival benefit for patients either,” continued Dr Grünhagen. However, local control is slightly improved after complete lymph node dissection for sentinel node-positive melanoma. According to Dr Grünhagen, this effect is not very relevant, since these nodes can be monitored clinically, and one can perform a delayed lymph node dissection if the patient presents with swelling at a later moment. In terms of quality of life, Dr Grünhagen mentioned that 6% of the patients who undergo a sentinel node procedure experience lymph oedema compared with 24% of patients who had a complete lymph node dissection.

Adjuvant therapy

“Since the arrival of adjuvant immunotherapies for stage III melanoma in 2017, the sentinel procedure gained renewed attention,” said Dr Grünhagen. Adjuvant immunotherapy has been shown to provide a disease-free survival benefit for patients with stage III [2,3]. “A sentinel node procedure can discriminate patients with stage I–II melanoma from those with stage III melanoma, and hence select patients eligible for adjuvant immunotherapy,” Dr Grünhagen explained. However, after 5 more years of follow-up, an overall survival benefit of these adjuvant therapies has not yet been demonstrated.

“Adjuvant therapy can be administered in a later stage of the disease as well, with a similar effect for the patient. Therefore, the sentinel node procedure may not be as important as we thought for the selection of patients,” he said. “Furthermore, 80% of the patients eligible for a sentinel node procedure test negative, making the procedure in retrospect unnecessary.”

The way forward

To avoid unnecessary sentinel node procedures in the future, clinical parameters in combination with genetic testing could estimate the risk of a negative sentinel node. With these tools, low-risk patients could be discouraged to undergo a sentinel node procedure. This could help to reduce the number of negative sentinel node procedures.

“Finally, I plead for an individual risk classification with respect to selecting patients for adjuvant therapy. If you know the absolute risk of relapse or death of the patient, there is a larger potential effect of adjuvant therapy. I think, in future, the characteristics of the melanoma that are documented during the primary excision can help to further stratify patients into risk categories. The high-risk group will receive adjuvant therapy, the low-risk group will be monitored, and the intermediate-risk group may receive a sentinel node procedure to further clarify their risk profile.”

1. 
   
   1. Grünhagen DJ. Het nut van re-excisie, sentinel node en adjuvante therapie bij melanoom. Blok 2, Dermatologendagen 2023, 9–10 March, Ermelo, the Netherlands.
   2. Weber J, et al. N Engl J Med 2017;377:1824–1835.
   3. Eggermont AMM, et al. N Engl J Med 2018;378:1789–1801.

 

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Posted on 10 May, 2023