Therapeutic considerations in the management of melanoma

The utilization of Breslow-Clark microstaging has proved helpful in deciding whether or not to perform elective regional node dissection for patients with melanoma. The marked biologic diversity of the disease, however, mandates a strict therapeutic policy of individualization with respect to prognostic variables and special clinical presentation. Specifically, melanomas associated with ulcerations, truncal location, and regional node involvement appear to be more aggressive. Lesions with cutaneous penetration more than 1.5 mm in depth, and showing blood and lymphatic vessel invasion are more often associated with regional node involvement and worse prognosis. The association of any of these adverse prognostic signs with an intermediate thickness lesion (0.76-1.5 mm) may justify elective node dissecton. Head and neck, mucosal, and subungual melanomas are all associated with poor prognosis due to rapid growth and early dissemination. The role of elective node dissection in these patients in unclear.