The paradigm of care for patients with melanoma has been revolutionized over the past decade. Pivotal discoveries have transformed the therapeutic landscape and, while these have separately affected systemic options and surgical decision making, they cannot be considered in isolation. Adjuvant therapy has undergone a sea change and, in the context of results from surgical trials, shapes an evolving viewpoint on completion lymphadenectomy (CLND).
First, there are no new data on the surgical management of clinically detected lymph nodes that should compel clinicians to change the approach to the nodal basin for these patients, although many recent successes in adjuvant therapy do apply. At present, it remains standard practice to perform therapeutic lymph node dissection for clinically apparent and biopsy-proved nodal disease that is detected either radiographically or on physical examination. More important, recent practice-changing clinical trials1,2 have demonstrated a benefit to adjuvant therapy for this patient population. Although the support for neoadjuvant therapy is not as conclusive, a recent study3 has demonstrated utility for this approach and many favor neoadjuvant therapy for reasons that are beyond the scope of this article.