Surgical management of metastatic melanoma
- Michael Stone, MD
Michael Stone, MD
- Chairman of Surgery
- Stamford Hospital
- Section Editors
- Michael B Atkins, MD
Michael B Atkins, MD
- Section Editor — Malignant Melanoma and Other Cutaneous Neoplasms; Cancer of the Kidney
- Deputy Director
- Georgetown Lombardi Comprehensive Cancer Center
- Russell S Berman, MD
Russell S Berman, MD
- Section Editor — Skin and Soft Tissue Surgery
- Chief of Surgical Oncology
- New York University Langone Medical Center
Although the incidence of malignant melanoma is increasing, most cases are diagnosed at an early stage. Surgical excision is curative in most cases of early stage disease, and patients at high risk of developing metastatic disease may benefit from adjuvant therapy with interferon alpha or ipilimumab. (See "Initial surgical management of melanoma of the skin and unusual sites" and "Adjuvant immunotherapy for melanoma".)
The management of patients with disseminated disease is a difficult problem. Systemic approaches that have been shown to provide clinically important benefit for appropriately selected patients with disseminated melanoma include immunotherapy with high-dose interleukin-2 (IL-2), immunotherapy with checkpoint inhibitors directed against CTLA-4 and programmed death 1 protein (PD1), and inhibition of the MAP kinase pathway with a BRAF and MEK inhibitors in patients whose tumors contain a V600 mutation in the BRAF gene.
The role of surgery in the treatment of metastatic disease is discussed in this topic. An overview of the management of advanced melanoma is presented separately. (See "Overview of the management of advanced cutaneous melanoma".)
Patients who have limited sites of metastatic disease may be amenable to surgical resection (algorithm 1). Complete surgical excision of limited metastatic disease can result in prolonged overall and occasionally relapse-free survival in carefully selected patients. Surgery for distant metastatic melanoma, however, is rarely curative since the majority of patients with distant metastases have widespread micrometastatic disease even if clinical and imaging criteria suggest limited spread. Resection should be reserved for the relief or prevention of morbidity due to local tumor growth and for patients in whom a longer survival might be expected with surgical rather than medical treatment.
When surgery is considered, careful patient selection is important and treatment must be individualized. Factors to be considered include the severity of symptoms, pace of disease progression, previous treatment and treatment response, patient age and medical condition, and the desires of the patient. Quality of life should be the principal goal of treatment for many patients.
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- CRITERIA FOR SURGERY
- DIAGNOSTIC EVALUATION
- SURGERY FOLLOWING SYSTEMIC THERAPY
- SURGICAL MANAGEMENT OF SPECIFIC METASTATIC SITES
- Skin, subcutaneous tissue, and lymph nodes
- Gastrointestinal tract
- Other sites
- Second recurrence
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS