Surgical Resection Now Individualized Approach in Modern Melanoma Paradigm

Richard L. Shapiro, MD

The role of radical surgical resection in advanced melanoma has become more conservative and cosmetically sensitive, according to Richard L. Shapiro, MD.

"We have so many tools to treat [patients with advanced] melanoma now," said Shapiro. "We have to think about [surgery] in a multidisciplinary way. The days of a surgeon operating on someone and then sending them to the medical oncologist [are waning]. It is not in the best service of the patient. Timing and coordination is important."

Though the need for radical resection has diminished, patients with bulky disease may derive a survival benefit from complete lymph node dissection, explained Shapiro.

In an interview during the 2020 OncLive^® State of the Science Summit™ on Advanced Melanoma, Shapiro, a professor in the Department of Surgery, and director of Surgical Oncology Operations at the NYU Langone Health’s Perlmutter Cancer Center, discussed the evolution and current role of surgery in advanced melanoma.

OncLive: How has the role of surgery in advanced melanoma changed over the years?

Shapiro: [Surgery] is the mainstay of treatment for patients with melanoma. It can be performed by a dermatologist, primary care physician, or surgical oncologist.

Over the past few years, surgery has evolved. It has become more conservative and cosmetically sensitive. Additionally, now that we have some effective treatments for melanoma, we have to [consult] with our medical colleagues in real-time so the patient can derive the optimal result.

What factors do you consider when deciding whether a patient is eligible for surgical resection?

As most surgeons say, surgical resectability is a state of mind and almost any [tumor] is resectable. The real question is, “How are you going to best serve the patient?”

Today, we are more cosmetically sensitive in terms of surgical resection. In the modern era, radical resections have a very little role in the management of melanoma.

We have effective agents that may work in the neoadjuvant setting [for patients whose surgery] may be very challenging or disfiguring. Patients today have more options than they did in the past. Surgeons have to be aware of this so that their patients can get the best result.

Eligibility has to do with the clinical extent of disease and the presence of disease downstream. In the past, we had very little to offer patients with large, bulky tumors other than radical surgery with or without radiation afterward. Radiation sometimes helped, but often did not.

In today's age, biomarkers and immunotherapy have had a good track record over many years. We are beginning to seriously consider using immunotherapy before we contemplate surgery in those patients with extensive disease.

What is the utility of complete lymph node dissection?

Complete lymph node dissection in melanoma has been studied for [decades] throughout the world. As such, [we have] clarified several things.

Patients who have microscopic disease in the sentinel lymph nodes do not benefit from complete lymph node dissection. [A few] large studies have proven that. Patients who have bulky disease in the lymph nodes do achieve a survival advantage and [decreased] local recurrence rates with complete resections. Like anything else in medicine, patient selection is important.

What role does adjuvant treatment have for patients who undergo complete lymph node dissection?

Although there are some exciting advances in advanced melanoma treatment, most patients do not need [adjuvant treatment]. The majority of patients are cured or treated effectively with surgery alone.

That being said, patients who present with bulky disease in the lymph nodes have high recurrence rates and would certainly benefit from adjuvant immunotherapy.

What challenges remain in this space?

We are trying to design trials to study the timing of immunotherapy in patients with advanced melanoma. Should they undergo a radical surgical resection following immunotherapy? Or, are they better served by being down-staged with [neoadjuvant] immunotherapy [prior to surgery] in the same way we treat late-stage breast cancer?

That is a new, exciting challenge. It is made more challenging because we do not see many patients with bulky disease [as a result] of early detection and [increased] awareness about melanoma.

It is going to be difficult to accrue a large number of patients for randomized trials to study this. Centers have to work together to pool their patients and figure out how we can best serve those patients with advanced melanoma.