Surgical excision is the appropriate treatment for melanoma. Although resection usually controls the primary lesion, melanoma often metastasizes through lymphatic channels to regional lymph nodes. Accurate staging at diagnosis is important to assess the prognosis and determine whether the patient is eligible for clinical trials of adjuvant therapies (table 1A-B). (See "Tumor node metastasis (TNM) staging system and other prognostic factors in cutaneous melanoma".)
The physical examination of regional lymph nodes is often inaccurate, since approximately 20 percent of clinically node-negative patients have metastatic involvement, and 20 percent of those with clinically positive nodes are pathologically negative. More definitive information about the status of the regional nodes can be obtained from sentinel lymph node biopsy (SLNB), elective lymph node dissection, or fine needle aspiration [1,2].
Both the staging of subclinical disease using lymphatic mapping followed by SLNB and the management of clinically apparent regional lymph nodes will be reviewed here. The surgical management of the primary lesion and adjuvant therapy are discussed separately. (See "Initial surgical management of melanoma of the skin and unusual sites" and "Adjuvant immunotherapy for melanoma".)
CLINICALLY NEGATIVE REGIONAL LYMPH NODES
Sentinel lymph node biopsy — Lymphatic mapping and sentinel lymph node biopsy (SLNB) is the standard approach for the management of patients with melanoma in whom there is a substantial risk of regional node metastasis. This approach permits the identification of patients with positive nodes and avoids elective lymph node dissection in those without nodal involvement. Proper application of this technique requires sufficient experience to identify the sentinel lymph nodes and ensure a low false negative rate.
The impact of lymphatic mapping with SLNB (with completion lymphadenectomy when positive nodes are identified) on survival remains uncertain [3-8].