van Akkooi Alexander C J, Eggermont Alexander M M
Melanoma Institute Australia, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Melanoma and Surgical Oncology, Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
University Medical Center Utrecht & Princess Maxima Center, Utrecht, the Netherlands; Comprehensive Cancer Center Munchen of the Technical University Munich & Ludwig Maximilians University, Munich, Germany.
Eur J Cancer. 2025 May 2;220:115376. doi: 10.1016/j.ejca.2025.115376. Epub 2025 Mar 20.
Melanoma surgery has evolved from elective lymph node dissection (ELND) to sentinel lymph node biopsy (SLNB) and wide local excision (WLE) margins have come down from 5 cm to nowadays 1 - 2 cm. Recent studies have illustrated the low frequency of residual tumour cells in WLE specimen, particularly for pT2 or lower tumours, where 97 % of patients cannot benefit from WLE. Moreover, a cohort of completely excised primary melanomas did not seem to have inferior clinical outcomes to those who did undergo WLE. Biomarkers, such as clinicopathological gene expression profilers (CP-GEP), can stratify high- and low-risk disease and make therapy decisions, in particular in clinical stage I/II melanoma and make sentinel lymph node biopsy (SLNB) largely redundant. Also SLNB needs to be reconsidered due to the lack of a clear overall survival benefit for adjuvant therapy in stage III. Moreover SLNB is redundant in stage IIB/C for decision making on adjuvant anti-PD1 therapy. Moreover the superiority of neo-adjuvant to salvage patients with macroscopic stage III over adjuvant therapy leads to sharp reduction of therapeutic lymph node dissections (TLND). Overall, the major impact of current developments is that SLNB might soon become obsolete and may be replaced by standard CP-GEP testing of the primary for clinical management, reduction of surgical interventions and simplification of follow up schedules in low risk patients. Thus, we are on the eve of a significant reduction in surgical interventions for melanoma that will come in the upcoming years.
黑色素瘤手术已从选择性淋巴结清扫术（ELND）发展到前哨淋巴结活检（SLNB），广泛局部切除（WLE）的切缘已从5厘米降至如今的1 - 2厘米。最近的研究表明，WLE标本中残留肿瘤细胞的频率较低，特别是对于pT2或更低分期的肿瘤，97%的患者无法从WLE中获益。此外，一组完全切除的原发性黑色素瘤患者的临床结局似乎并不比接受WLE的患者差。生物标志物，如临床病理基因表达谱（CP-GEP），可以对高风险和低风险疾病进行分层并做出治疗决策，特别是在临床I/II期黑色素瘤中，这使得前哨淋巴结活检（SLNB）在很大程度上变得多余。由于III期辅助治疗缺乏明确的总生存获益，SLNB也需要重新考虑。此外，在IIB/C期，SLNB对于辅助抗PD1治疗的决策是多余的。此外，新辅助治疗对于宏观III期患者优于挽救性治疗，这导致治疗性淋巴结清扫术（TLND）急剧减少。总体而言，当前发展的主要影响是SLNB可能很快过时，可能会被对原发性肿瘤进行标准CP-GEP检测所取代，用于临床管理、减少手术干预并简化低风险患者的随访计划。因此，我们正处于未来几年黑色素瘤手术干预显著减少的前夕。
