Melanoma

The management of cutaneous malignant melanoma has been transformed by the development of effective medical treatment for what was previously a chemo-resistant disease. The management of primary stage I and stage II disease remains complete excision of the primary with a wider excision being performed in most cases assuming morbidity is not excessive. A series of randomized trials have demonstrated that historical very wide margins did not improve outcome and introduced significant morbidity. Much more conservative margins are now advised. A synchronous sentinel node biopsy is performed in patients with a primary melanoma greater than 1 mm in Breslow thickness to determine whether patients should receive adjuvant systemic therapy. Complete nodal dissection is performed only in patients who present with palpable nodal disease. Genetic analysis of the melanoma for a mutation in the BRAF gene should be performed in all patients with stage III and IV disease as this will determine whether patients will respond to therapies targeting the BRAF signalling pathway. Stage IV metastatic disease is now amenable to effective treatment by either immunotherapy or BRAF-targeted therapy. Surgery still has an important role to play in the treatment symptomatic localized disease that is refractory to these medical therapies.