VALUE OF ELECTIVE LYMPH MODE DISSECTION IN HEAD AND NECK MELANOMA

Based on the hypothesis that melanoma spreads stepwise from the primary tumour to the regional lymph nodes and thereafter to distant sites, it is suggested that elective lymph node dissection (ELND) in head and neck melanoma can remove microscopic disease and thereby improve survival. Although from a theoretical point of view this represents an attractive theory, there is still no consensus about the beneficial role of ELND. So far, retrospective studies present conflicting evidence and it is hypothesized that only a subgroup of patients may have survival benefit from this procedure. The primary melanoma harbours the most significant prognostic indicators, among which the tumour thickness is of utmost importance. Since patients with an intermediate thickness melanoma(Breslow 1.51-4 mm) probably have a higher risk of developing lymphatic metastases than distant metastases. this subgroup of patients may have survival benefit from additional regional surgery. ELND is not indicated in thin melanomas as they have a favourable outcome, and thick melanomas are excluded because of the high risk of distant disease at the time of presentation. Elective procedures for primary lesions of the face, anterior scalp and ear may be limited to dissection of levels I through IV, including a parotidectomy. For posterior lesions sparing of level I may be justified. Advanced radiological diagnostic techniques may reduce the number of patients who will be potential candidates for ELND. Further refinements in the diagnosis of occult neck node metastases may emerge from intraoperative biopsy of the sentinel node for primary melanomas of the neck and posterior scalp. New multicentric randomized surgical trials involving ELND are still warranted, however, for a reduced number of patients because of the more exact inclusion criteria on staging of the neck and on the main prognostic indicators.