Insights in Melanoma Surgery

Dr Bart Appeltans, an oncologic surgeon at the Jessa Hospital in Hasselt, Belgium, discussed some interesting novelties in melanoma surgery. 

This session featured several notable studies from leading Italian research groups, including the Italian Melanoma Group and the Instituto dei Tumori di Milano. These studies provided updates on surgical decision-making in the era of adjuvant therapy, resection margins, staging, and emerging technologies.

One key study from Torino revisited nodal dissection in sentinel node-positive patients. Using older statistical methods, they compared outcomes before and after the introduction of adjuvant therapy. As already known from the MSLT-II and DeCOG trials, nodal dissection doesn’t improve recurrence-free or overall survival. However, in the current adjuvant era, adjuvant therapy alone—regardless of lymph node dissection—improves recurrence-free survival, though not overall survival.

A second study addressed resection margins in cosmetically and technically sensitive areas like the head and neck. It showed that narrower excision margins in carefully selected patients did not compromise local control, offering reassurance to surgeons when wider resections are not feasible or desired by patients. These techniques may apply to other body regions.

A particularly intriguing study from the Milan team focused on the mitotic rate across melanoma stages. Surprisingly, a high mitotic rate in T1 and T2 melanomas was more predictive of a positive sentinel lymph node than in T3–T4 tumours. This counterintuitive finding could influence future updates to AJCC staging criteria.

Another technical advancement presented was the use of indocyanine green (ICG) fluorescence for sentinel lymph node detection. Compared to traditional blue dye and lymphoscintigraphy, ICG showed similar effectiveness. It offers advantages where nuclear medicine is limited or in cases of dye allergy. However, the technology requires expensive cameras and poses technical challenges in practice.

Finally, a Brazilian study explored AI tools, including ChatGPT, to predict sentinel lymph node positivity. ChatGPT slightly outperformed traditional nomograms (like the one from Memorial Sloan Kettering), though concerns remain regarding data transparency and reliability. The study emphasised that AI should complement, not replace, clinical judgment and statistical evidence for optimal decision-making.