Surgical management of patients with intermediate thickness melanoma: current role of elective lymph node dissection

The appropriate role of elective hymph node dissection (ELND) in patients with clinical stage I intermediate thickness melanoma lesions remains a dilemma. Despite an impressive number of carefully performed nonrandomized/retrospective studies and two criticized multi-institutional prospective randomized trials, a clear benefit from ELND is still debatable. As a result, there currently is no standard approach for selecting patients who should undergo this procedure. Further prospective trials performed by the Intergroup/National Cancer Institute and World Health Organization (WHO) Melanoma groups, addressing Intermediate thickness extremity and truncal lesions respectively, have recently been completed. No long-term survival data is yet available from either group. Potentially conflicting preliminary results recently presented noted a significant ELND survival advantage for a subgroup of men with axial lesions in the Intergroup study, and no differential in survival demonstrable for the World Health Organization study at a median follow-up of 4 years. One area of agreement among surgeons on either side of the controversy is the need to be able to identify in a minimally invasive manner stage I-II melanoma patients with clinically occult lymph node metastases from the population at risk. Technologies such as polymerase chain reaction and lymphoscintigraphy to improve our ability to detect clinically occult lymph node metastases and facilitate the identification of sentinel node(s) for selective lymphadenectomy hold some promise. Although more research needs to be performed, these approaches potentially would allow for a more directed application of ELND in a much smaller number of melanoma patients. This could provide an entirely novel and more effective approach to the manner in which we evaluate patients with intermediate thickness melanoma lesions and would decrease the significance of this controversy. It is hoped that the long-term data about the appropriate role of ELND from the current prospective trials will provide definitive information on which to base decisions, or that current research will fundamentally alter our approach to these patients. In the interim, surgeons must continue to make their best judgments about the management of regional lymph nodes in an individual patient setting based on prior experience or personal bias.