The case for minimal margins and delayed regional node dissection for high-risk cutaneous melanoma

Some aspects of the surgical treatment of cutaneous melanoma are still currently debated. There is presently a general agreement in favor of a less wide excision of primary lesions. Specifically, data coming from a randomized study of the World Health Organization (WHO) Melanoma Programme indicates that the width of resection has no impact on either disease-free and overall survival of 612 stage I entered patients. Opportunity of an elective (ELND) or delayed (DLND) lymph node dissection remains much more controversial. Complications, including lymphedema, associated with this type of surgery, and no evidence of regional lymph node disease in at least 70% of clinical stage I patients submitted to node dissection, argue for avoiding ELND. Some studies show a positive value for ELND, but they are flawed by biased entry of patients into the ELND group, and conclusions are not derived from randomized studies. Two prospective trials show that ELND does not improve the prognosis of patients with stage I cutaneous melanoma. The results of the WHO study of 553 cases will be evaluable at 20 years. So far, on the basis of many biologic, clinical, and statistical findings, there is no evidence, in our opinion, of a substantial benefit related to ELND.