The current American Joint Committee on Cancer (AJCC) melanoma staging system which is the seventh

was published in 2009, on the basis of an analysis of 30 946 patients with stages I, II and III melanoma
and 7972 patients with stage IV melanoma [ 248 ] (Tables 143.1 and 143.2 ). In patients with localized
melanoma (stage I and II), tumour thickness, mitotic rate (histologically defi ned as mitoses/mm 2 ), and
ulceration are the most dominant prognostic factors with 5‐year and 10‐year survival rate estimates
ranging from 97% and 93% for patients with stage IA melanomas (Breslow 4 mm with ulceration). All
patients with nodal metastases including micrometastasis detected by immunohistochemistry (i.e.
sentinel node involvement) are classifi ed as stage III. Number of tumour‐bearing nodes, tumour burden
at the time of staging (i.e. microscopic versus macroscopic), presence or absence of primary tumour
ulceration and thickness of the primary melanoma are the most predictive factors for survival in these
patients. Five‐year survival rates are 78%, 59% and 40% for patients with stage IIIA, IIIB and IIIC
melanoma, respectively (Table 143.3 ). CT scan is mainly useful as a reference document for subsequent
follow‐up. The role of sentinel lymph node biopsy in staging is covered on p. 143.25 .
Follow‐up The main purposes of follow‐up are to detect any local recurrence around the scar of the
excised melanoma, to palpate the draining lymph nodes for any clinically detectable evidence of nodal
spread and to examine the rest of the skin for second primary melanomas. Such second primary
melanomas have beenreported to develop in 1.0–4.4% of patients diagnosed with a fi rst melanoma [
249 ]. All patients should be taught self‐examination in order to detect early recurrence, how to palpate
for lymph nodes and how to detect a second primary melanoma. Patients should have a point of contact
to enable early review in case recurrence is suspected. Guidance on follow‐up after surgery varies
between countries, since there is no clear evidence that routine follow‐up examinations, or periodic CT
scans have an impact on mortality. The majority of patients detect recurrence between medical visits, so
intervals and duration of follow‐up are usually adapted to the estimated risk of metastases based on the
prognostic markers (Breslow thickness and sentinel node procedure), but also on the actual risk at a
given period after primary melanoma resection [ 250 ]. Medical surveillance is usually proposed every 3–
6 months for the fi rst 3–5 years after diagnosis and then with a lower frequency. Comparison of follow‐
up guidelines in Table 143.4 [ 251 ] shows that, in the absence of comparative trials, there are divergent
point of views. Periodic radiological examinations in asymptomatic patients are not considered useful,
although they are performed in many countries. However, the development of recent very active
molecules (targeted therapy and immune therapies) may change this paradigm, since early diagnosis of
metastasis may confer an advantage to patients who will be treated earlier, and periodic radiological
examinations may be indicated. Follow‐up for patients with melanoma in situ (stage 0) is less stringent
and some individuals can be discharged after appropriate surgery and education on self‐examination
and sun protection. However, there are different situations with melanoma in situ which deserve
particular attention. First, many patients with melanoma in situ harbour a large number of clinically
atypical moles and should remain in surveillance for additional secondary melanomas. Second, in the
specifi c case of lentigo melanoma in situ , the risk is mainly the growth of another focus of melanocytic
dysplasia at the margins of the initial melanoma, or in the same anatomical fi eld, and dermoscopy or
even confocal microscopy can be helpful. Management of patients with advanced disease is discussed
on p. 143.28

Biopsy

Early detection of melanoma is associated with thinner tumours with better prognosis and outcomes.
Melanoma is still most commonly detected by the patient or a signifi cant other, but physician detection
is more frequently associated with thinner lesions [ 1 ]. Historical features that raise suspicion in a lesion
include a change in size, shape or colour, or lesion pruritus [ 1,2 ]. Ulceration, tenderness and bleeding
are later signs. On physical examination, criteria such as the ABCD checklist can help identify suspicious
lesions (see p. 143.7 ) [ 3 ]. An E for evolving may be added as a reminder of the importance of a history
of a changing lesion [ 4 ]. Additionally, an overall assessment of the skin in which a lesion appears unique
or different compared to the patient’s other lesions (the ugly ducking (UD) sign) raises concern for
melanoma [ 5 ]. Any lesion suspicious for melanoma on the basis of the history or clinical examination
requires a biopsy to provide a diagnosis and direct appropriate treatment. The ideal biopsy is a prompt,
narrow ∼2 mm margin excision of the entire clinically apparent lesion. This is most often performed as
a sutured ellipse or punch biopsy, but also with the option of deep saucerization approximating at least
the dermis–adipose junction. This allows determination of diagnosis, key melanoma parameters and
accurate microstaging, while preserving the accuracy of sentinel lymph node biopsy (SLNB) should this
be indicated. The biopsy should be oriented with defi nitive wide excision in mind, and for the arms and
legs, more parallel to the extremity to facilitate SLNB if indicated. A wide local excision (WLE) or fl ap
closure as the initial biopsy may prevent the option of subsequent SLNB or grossly overtreat a benign
melanoma mimic. Palpation of the regional lymph nodes on the day of biopsy is indicated.

For many lesions, size, location or other practical considerations such as time, surgical experience or low
suspicion may preclude complete excisional biopsy. In these cases, an incisional biopsy usually via
punch, ellipse or deep saucerization through the thickest darkest portion is performed. Identifi cation of
the most suspicious area to biopsy may also be facilitated by dermoscopy or confocal microscopy.
Incisional biopsies are not associated with increased risk of metastasis [ 6 ]. However, partial incisional
biopsy is subject to sampling error in diagnosis, Breslow depth and other microstaging factors. The
ability to accurately predict the deepest portion by clinical inspection or incisional biopsy is not always
reliable. In one study involving 1783 consecutive patients, 250 of whom presented with ≥50% residual
clinical lesion after incisional biopsy, removal of the remainder of the lesion altered staging and
prognosis in 21%, and 10% became candidates for SLNB only after excision of the residual lesion [ 7 ].
Therefore, if treatment recommendations might change upon further information gained on complete
sampling, a narrow‐margin excision to remove theremainder of the lesion for accurate microstaging is
recommended prior to proceeding with defi nitive treatment. Review of biopsy material by a
dermatopathologist experienced in melanoma and pigmented lesions is crucial for optimal patient
management [ 8–10 ]. Once melanoma is diagnosed, a number of histopathological features are
necessary for staging and treatment recommendations [ 11 ]. These include Breslow depth, ulceration
status, mitotic rate, status of peripheral and deep margins, Clark level (for lesions ≤1 mm where mitotic
rate is not determined) and the presence of microscopic satellites. Additional characteristics that should
be considered for inclusion are anatomical body site location, regression, tumour‐infi ltrating
lymphocytes, vertical or radial growth phase, angiolymphatic invasion, neurotropism, histological
subtype classifi cation and coexisting naevus status [ 11 ]. Wide local excision Melanoma Any patient
with a new diagnosis of melanoma requires a history and physical examination prior to WLE. The history
should include preoperative co‐morbidity factors which impact surgical approach and a melanoma‐
focused review of systems for metastatic disease. A total body skin inspection is indicated since the
patient is at risk for additional primary melanoma, which may occur anywhere on the skin surface. The
regional draining lymph node basins require palpation to detect metastatic disease, with biopsy most
commonly via fi ne‐needle aspirate prior to WLE if enlarged nodes are noted. Most newly diagnosed
melanomas are clinically localized to the primary site. Surgical resection of the primary tumour or the
diagnostic biopsy site with a clinical margin of normal skin is indicated for biopsy‐proven melanoma. The
intention of resection is to prevent local recurrence from persistent microscopic disease. Excessively
wide margins result in signifi cant morbidity and costs. In contrast, excessively narrow margins may be
associated with unacceptable rates of local recurrence with potential for lethal consequence. The
appropriate margin of resection has been investigated in fi ve prospective randomized trials (Table 143.5
).

The World Health Organization conducted a prospective randomized study to assess the effi cacy of
narrow (1 cm) excision for thin melanoma [ 12,13 , 14 ]. In this trial, 612 patients with melanoma ≤2 mm
in thickness on the trunk, arms or legs were randomized to receive narrow (1 cm) or wide (at least 3 cm)
excision. Of note, in this trial, excision margins in the subcutaneous fat and muscular fascia were 1–2 cm
greater than at the skin surface. The patients were followed for a median of 12 years. Local recurrence,
defi ned as within 1 cm of the scar, was analysed. Eleven patients recurred locally. Eight were in the
narrow excision group; fi ve of these had melanoma 1.1–2 mm in depth. The difference in local
recurrence between the narrow and wide excision groups was not statistically signifi cant. The Swedish
Melanoma Study Group performed a prospective randomized study of 989 patients with melanoma of
the trunk and extremities, tumour thickness >0.8 mm and ≤2 mm, to evaluate the effi cacy of a 2 cm
versus 5 cm margin excision [ 15 ]. With a medianfollow‐up of 8 years for recurrence, patients who
received excision with 2 cm margins fared as well as those with wide 5 cm margins. Local recurrence in
this trial was defi ned as recurrence within the scar or graft. Of fi ve patients who experienced local
recurrence as a fi rst event, four were in the wide excision group, and one in the narrow excision group.
Of the total of eight patients who experienced local recurrence at any time, fi ve were in the wide
excision group and three in the narrow excision group. The Intergroup Melanoma Surgical Trial
conducted a prospective randomized trial to examine differences in outcomes in patients with
intermediate‐thickness melanoma treated with 2 cm versus 4 cm excision margins [ 16 ]. In this trial, 468
patients with melanoma located on the trunk or proximal extremities with tumour depth of 1–4 mm
were randomized to receive excision with 2 cm or 4 cm margins. Local recurrence in this trial was defi
ned as any melanoma recurrence within 2 cm of the surgical scar. After a median of 10 years of follow‐
up, 11 patients experienced local recurrence, which did not correlate with excision margin (local
recurrence 2.1% with 2 cm margin and 2.6% with 4 cm margin). The French Group of Research on
Malignant Melanoma prospectively randomized 337 patients with melanoma ≤2 mm in depth to receive
excision with 2 cm or 5 cm margins [ 17 ]. Patients with LMM, ALM, aged >70 and with melanoma on the
toe, nail or fi nger were excluded. Sixteen‐year follow‐up data were published. Local recurrence was defi
ned as tumour occurring within 2 cm of the excision, which affected fi ve patients (one in the narrow
excision arm, four in the wide excision arm). Finally, in a fi fth multicentre trial performed by the UK
Melanoma Study Group, 900 prospectively randomized patients with melanoma ≥2 mm on the trunk
and extremities, excluding the palms and soles, were treated with excision with 1 cm or 3 cm margins [
18 ]. Local recurrence was defi ned as recurrence within 2 cm of the primary excision site, and in‐transit
recurrence defi ned as beyond 2 cm. ‘Locoregional’ recurrence was defi ned by combining the rates of
local, in‐transit and regional nodal recurrence into a single category. When these three different types of
recurrence were pooled into a single end‐point, a signifi cant increase in ‘locoregional’ recurrence was
noted for the 1 cm margin group compared with the 3 cm margin group ( P = 0.05), possibly infl uenced
by a larger number of nodal recurrences in the 1 cm margin group. No statistically signifi cant difference
was found for the rates of local, in‐transit or nodal recurrence when each was considered alone (15 local
recurrences for 1 cm margin versus 13 for 3 cm margin). A meta‐analysis of these randomized
prospective trial data performed by the Cochrane Collaboration found no signifi cant difference in local
recurrence, overall survival or recurrence‐free survival [ 19 ]. Although none of these trials individually
had enough statistical power to detect a small benefi t, these fi ve trials represent the best available
evidence regarding WLE margins for melanoma. Based on this data, current surgical recommendation
for melanoma less than 1.0 mm thick is a 1 cm margin of clinically normal‐appearing skin and soft
tissues; for melanoma 1.01–2.0 mm thick, 1–2 cm margin; and for melanoma >2 mm, 2 cm margin
(Table 143.6 ) [ 11 , 20 , 21 ].

The appropriate depth for any melanoma resection is also debated but typically recommended to
extend to the deep adipose tissue for thin melanoma and melanoma in situ , and through the
subcutaneous fat to the plane of the muscular fascia for intermediate and thick depth melanoma.
Surgical resection of melanoma on special sites such as the face, hands and feet may require
amendment of the recommended margin due to anatomical considerations. However, tumour clearance
is the highest priority, followed by cosmesis. When considering the morbidity of treatment, one should
not ignore the morbidity of recurrence. Coordination with multiple specialties may be optimal. It is
important to note that, to date, all studies of margins for melanoma that inform current practice
guidelines used clinically measured margins, not histologically measured margins. Therefore, margin size
recommendations are based on clinical margin. Histopathological evaluation of the excision specimen is
required to demonstrate negative margins. If the margin is deemed positive, re‐excision is warranted.
Melanoma in situ For melanoma in situ , current practice guidelines recommend a clinical margin of 0.5–
1 cm [ 11 , 20 , 21 ]. The pathological fi nding of regression in melanoma in situ may represent invasive
melanoma that has been obscured or obliterated by the host immuneresponse, suggesting the
potential, albeit small, for locoregional or metastatic disease. Therefore, consideration may be given to a
margin of 1 cm when regression is noted in melanoma in situ [ 22 ]. Lentigo maligna melanoma and
lentigo maligna melanoma in situ Lentigo maligna pattern invasive (LMM) and in situ melanoma (LM)
warrant special consideration, especially on the head and neck. This pattern is seen most commonly in
chronically sun‐damaged skin on the head and neck. Subclinical extension and local recurrence are
characteristic features of LM/LMM lesions. Standard margins of 0.5 cm for in situ LM are inadequate in
many cases. A study of 68 patients using Mohs margin control demonstrated the average margin
required to clear in situ LM was 0.8 cm, with 1.5 cm margins required to clear 96%. The average margin
required to clear invasive LMM was 1.1 cm, with 2.6 cm required to clear 95% [ 23 ]. Another study of 40
patients with melanoma on periorbital skin, using a staged excision (0.5 cm margin per stage) with
permanent section total peripheral margin control, required a mean margin of 1.3 cm (median, 1.2 cm;
range, 0.5–2.5 cm) to clear in situ LM, and 1.6 cm (median, 1.5 cm; range, 0.5–3.0 cm) for invasive LMM
[ 24 ]. Several techniques for treatment of LM/LMM have been reported to mitigate between the
subclinical extension on the one hand, and the cosmetic sensitivity on the other. Options include
standard excision with delayed reconstruction to allow for permanent section margin analysis; Mohs
surgery with immunostaining; and permanent sectioning mapped (i.e. ‘slow Mohs’) or staged mapped
(i.e. ‘square’) techniques. Distinguishing between the trailing edge of the melanoma versus background
sun damage requires high dermatopathology expertise and clinical pathological correlation. To date,
permanent section analysis with dermatopathologist expertise represents the gold standard for margin
analysis for melanoma [25 ]. Sentinel lymph node biopsy Optimal treatment of melanoma involves WLE
with appropriate margins and also consideration and completion of SLNB in appropriate patients.
Melanoma can spread beyond the skin with the most frequent site of fi rst metastasis being the regional
nodal basin [ 26 ]. Historically, patients with melanoma were treated with a combination of WLE and
elective lymph node dissection (ELND). The overall rate of nodal metastasis in melanoma ranges from
15% to 20%, and ultimately several randomized controlled trials did not demonstrate an overall survival
benefi t within the ELND group. While these trials were likely underpowered, given that the majority of
patients subjected to ELND would not benefi t from the surgery and no overall survival advantage was
noted, ELND, with its associated signifi cant morbidity, is not routinely recommended for melanoma [
27–31 ]. Interestingly, subset analysis comparing outcomes from only node‐positive patients from the
World Health Organization Melanoma trial showed that ELND improved 5‐year survival compared to
delayed LND [ 30 ], suggesting further study may be warranted [27 ]. SLNB was fi rst introduced in 1992
by Morton et al . as a minimally invasive procedure for melanoma to identify patients with occult nodal
disease who may benefi t from completion lymph node dissection (CLND), while sparing those without
nodal disease the morbidity of the dissection [ 32 ]. When metastatic cells enter the lymphatic system,
they typically fi rst involve only one node (or possibly a small number of nodes) within the regional nodal
basin. Clinicians are able to identify the fi rst node of potential involvement, the sentinel node, by
utilizing tracers injected intradermally at the site of the primary lesion (Figure 143.23 ). These tracers,
typically radiocolloid and vital blue dye, collect in the sentinel node allowing for identifi cation of the
most likely site of microscopic metastasis. This node (or nodes) isremoved and evaluated thoroughly
with serial sectioning and both haematoxylin and eosin and immunohistochemical stains [ 27 ]. Since the
introduction of the technique, multiple studies worldwide have confi rmed the high accuracy of the
procedure. Even within the head and neck region, where complex lymphatic drainage may make SLNB
more diffi cult, SLNB has been shown to have high accuracy when performed by an experienced surgeon
and centre [ 33–36 ]. Particularly within the head and neck, use of single photon emission computed
tomography/computed tomography (SPECT/CT), a three‐dimensional, precise imaging modality,
improves sentinel node identifi cation rates as compared to standard SLNB without SPECT/CT [ 37 ]. It
should be noted that accuracy may be decreased if SLNB is performed after WLE or a fl ap closure at any
site but particularly in ambiguous drainage areas like the head, neck, or central trunk. Thus, SLNB is
ideally performed at the time of WLE to allow tracers to be injected near the true site of the initial lesion
[ 38 ]. SLNB has been endorsed globally by almost every practice guideline and staging committee and
has been routinely used for over two decades. However, its use is not without controversy regarding
interpretation of the value and limitations [ 38 ]. In general, consideration for SLNB in relatively healthy
patients without known metastasis with primary melanoma ≥1.0 mm is accepted practice in the US,
Europe, Australia, New Zealand and most parts of the world [ 20 , 21 , 39–41 , 42 ]. While numerous
publications detail known and potential benefi ts of SLNB, there is currently only one prospective
randomized controlled trial comparing WLE plus SLNB with immediate CLND for a positive sentinel node;
versus WLE plus observation, with CLND upon the development of regional disease. This trial, the
Multicenter Selective Lymphadenectomy Trial‐I (MSLT‐I), began in 1994 across 18 centres worldwide,
funded by the National Cancer Institute, National Institutes of Health, and the Australia and New
Zealand Melanoma Trials Group ( ClinicalTrials.gov number, NCT00275496; last accessed June 2015) [ 43
]. The main aims were to determine if SLNB could be used to identify patients with subclinical regional
nodal disease and whether immediate CLND in those with occult disease could result in improved
outcomes compared to observation and subsequent CLND upon the development of clinically apparent
regional disease. Interim outcomes data was published in 2006 [ 44 ]. In 2014, the fi nal analysis of
outcomes data from MSLT‐I was published [ 43 ]. The overall rate of nodal disease within the study was
20.8%, meaning that the majority of randomized participants could not benefi t from SLNB. Therefore, it
was neither surprising nor unexpected that the 10‐year melanoma‐specifi c survival rate was not
different between the two arms overall. The improved disease‐free survival noted in the interim analysis
was maintained with an improved 10‐year disease‐free survival noted in the SLNB arm: 71% versus 65%
for patients with intermediate thickness melanoma (1.2–3.5 mm Breslow depth) ( P = 0.01); and 51%
versus 41% for patients with thick melanoma (≥3.5 mm Breslow depth) ( P = 0.03).
In the fi nal analysis, the 10‐year melanoma‐specifi c survival rate

for intermediate‐thickness melanoma was 85% for patients with

a negative sentinel node versus 62% for patients with a positive

sentinel node (hazard ratio, 3.09; P <0.001), confi rming the prognostic

value of sentinel node status. Among patients with thick

melanoma, this rate was 65% for patients with a negative sentinel

node versus 48% for patients with a positive sentinel node (hazard

ratio, 1.75; P = 0.03). Sentinel node status was the most powerful

prognostic factor in multivariate analysis.

A comparison of the estimated cumulative incidence of nodal

metastasis for intermediate‐thickness melanoma was similar

between the two arms at 10 years: 19.5% in the observation arm

compared to 21.9% in the SLNB arm. For those patients with nodal

disease in the interim analysis, use of SLNB was associated with

a reduction in the total number of tumour‐positive nodes identifi

ed following completion lymphadenectomy (1.4 versus 3.3,

P <0.001) [ 44 ]. These fi ndings support disease progression and

greater tumour burden with observation. Additionally, evidence

indicates the rate of regional node basin recurrence and complications

including lympho‐oedema are greater following CLND for

palpable disease compared to CLND for occult disease found by

SLNB [38 , 42 , 45,46 ].

Within MSLT‐I, a secondary latent subgroup analysis was used

to determine if there was a survival benefi t associated with early

CLND for patients with nodal metastasis. This analysis compared

outcomes between patients treated with CLND following identifi

cation of occult nodal disease with SLNB to patients treated

with CLND upon development of clinically apparent disease

found during close observation. Despite controversy regarding

subgroup analysis validity, within the subset of patients with

intermediate‐thickness melanoma and nodal disease, early identifi

cation and intervention with CLND for a positive sentinel

node was associated with improved 10‐year melanoma‐specifi c

survival. Among patients with intermediate‐thickness melanoma,

the survival rate was 56% for patients with CLND in the

SLNB arm (including those patients with a false negative SLNB)

versus 42% for patients in the observation arm (hazard ratio for

death from melanoma, 0.56; P = 0.04). Among patients with thick

melanoma, a treatment‐related difference was not demonstrated:

10‐year melanoma‐specifi c survival rates were 48% for patients

in the SLNB arm versus 46% for patients in the observation arm

( P = 0.78).

For patients with primary lesions <1.0 mm, the risk of occult

nodal metastasis is quite low, in general felt to be ≤5% [ 47 ]. Many

studies, mostly small and retrospective, have been performed to

evaluate risk factors in thin lesions that predict nodal involvement

[ 38 , 48 ]. Characteristics of the patient and primary lesion that

support the use of SLNB for thin lesions are under investigation.

Currently, many clinicians will consider performing SLNB for

lesions between 0.75 and 0.99 mm Breslow depth if other adverse

parameters are present, such as: young age as a continuous variable

centred around 40–45; the presence of angiolymphatic invasion,

ulceration or increased mitotic rate as a continuous variable

starting at 1/mm 2 ; a positive deep margin usually on shave biopsy

such that the true Breslow depth is unknown; and dermal regression

to 1 mm thickness [ 21 , 38 , 42 , 49–51 ].

Thankfully, the majority of melanomas worldwide are diagnosed

early and do not require treatment beyond WLE. However,

given the available evidence, healthcare providers managing

patients with melanoma should identify patients who may benefi

t from SLNB and discuss with them the benefi ts, risks and limitations

of the procedure. In general, relatively healthy patientswith primary localized lesions ≥1.0 mm Breslow
depth and those with thinner lesions between 0.75 and 0.99 mm with other adverse features should be
considered for SLNB. In summary, the utility of SLNB as a staging test to identify occult melanoma in the
lymph nodes in appropriate candidates is valid. Patients who undergo SLNB staging benefi t from
prognostic information gained, which is usually clinically signifi cant. For those with positive SLNB who
undergo immediate CLND, versus those who undergo observation to palpable disease, the SLNB group
benefi ts from improved regional control and less morbidity following CLND. Although still debated by
some, improved survival in a subgroup with intermediate thickness lesions is published. In addition,
accurate identifi cation of patients with stage III disease allows for better adjuvant treatment,
counselling or entrance into a clinical trial. Recent advances in melanoma led to FDA approval in 2011 of
two new therapies for patients with stage IV disease, ipilimumab (Yervoy ® ; Bristol‐Myers Squibb, New
York) and vemurafenib (Zelboraf ® ; Genentech, California). These medications as well as other novel
agents are being studied eagerly in clinical trials to evaluate their effi cacy for patients with stage III
disease. The results of these trials are optimized by the most accurate staging prior to entrance, best
accomplished by SLNB [ 52 ].

Lymph node dissection Therapeutic total lymph node dissection (TLND) of metastases to regional lymph
nodes, despite the associated morbidity, is potentially curative. The current standard of care is to
perform TLND following the identifi cation of nodal disease by SLNB. The results of the randomized
prospective MSLT‐II comparing nodal basin observation with ultrasound surveillance versus completion
node dissection in the setting of a positive SLNB may further characterize the ability to alter the course
of disease with TLND [53,54 ]. Patients presenting with palpable nodal disease without evidence of
distant disease on further staging work‐up should undergo TLND. After TLND, options include
observation versus adjuvant high‐dose interferon‐α2b (IFN‐α) versus clinical trial involving several new
investigational drugs. TLND may also be considered in patients with proven metastatic disease in certain
cases, as TLND may decrease the morbidity of uncontrolled regional disease. Adjuvant radiation to the
nodal basin following surgery can be considered for select patients. This may improve nodal disease
control in the presence of nodal metastasis with extracapsular extension or high nodal disease burden [
20 ].

Future work The fi eld of melanoma care, including surgical management, is continuously evolving. This
chapter presents the most relevant current treatment guidelines; however, guidelines are fl uid and will
continue to change. Future research will expand our understanding of the biology of melanoma and
allow us to determine additional characteristics of the patient and primary lesion that can guide optimal
patient selection for biopsy, local excision and SLNB. In the future, SLNB may be able to identify patients
with occult nodal disease who can be treated with a less invasive, targeted, personalized adjuvant
therapy approach; or who do not require further treatment. In the coming era of personalized medicine
and the global research pipeline, sweeping changes in treatment options and guidelines will
undoubtedly occur. Practice guidelines are dynamic, and rigorous discovery efforts will allow guidelines
to continue to evolve to improve clinical practice.