VALUE OF ELECTIVE LYMPH MODE DISSECTION IN HEAD AND NECK MELANOMA

Based on the hypothesis that melanoma spreads stepwise from the primar y 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 surv ival. Although from a theoretical point of view this represents an att ractive theory, there is still no consensus about the beneficial role of ELND. So far, retrospective studies present conflicting evidence an d it is hypothesized that only a subgroup of patients may have surviva l 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 m elanoma(Breslow 1.51-4 mm) probably have a higher risk of developing l ymphatic metastases than distant metastases. this subgroup of patients may have survival benefit from additional regional surgery. ELND is n ot indicated in thin melanomas as they have a favourable outcome, and thick melanomas are excluded because of the high risk of distant disea se at the time of presentation. Elective procedures for primary lesion s 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 can didates 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 multic entric randomized surgical trials involving ELND are still warranted, however, for a reduced number of patients because of the more exact in clusion criteria on staging of the neck and on the main prognostic ind icators.