Highlights
- •The role of surgery for asymptomatic oligometastatic stage IV melanoma has changed.
- •Patient/tumour factors impact on decision-making (upfront surgery vs immunotherapy).
- •Discussion at specialist melanoma multidisciplinary meetings is recommended.
- •Prospective randomised trial evidence is required to resolve uncertainties.
Abstract
Although previously the mainstay of treatment, the role of surgery in the management
of patients with oligometastatic stage IV melanoma has changed with the advent of
effective systemic therapies (most notably immunotherapy). Contemporary treatment
options for patients with asymptomatic solitary or oligo-metastases include upfront
surgery followed by adjuvant immunotherapy or upfront immunotherapy with salvage surgery
as required. For suspected solitary or oligo-metastases, surgery serves both diagnostic
and therapeutic purposes. Advances in radiological technology allow metastases to
be detected earlier and surgery to be less morbid. Surgical morbidities are generally
more tolerable than serious immune-related adverse effects, but surgery may be less
effective. Upfront immunotherapy ensures that futile surgery is not offered for rapidly
progressive disease. It also provides an opportunity to assess response to treatment,
which predicts outcome, and may obviate the need for surgery. However, it is important
not to miss a window of opportunity for surgical intervention, whereby if disease
progresses on immunotherapy it becomes unresectable. In situations where local therapy
is recommended but surgery is not desired, stereotactic radiosurgery may be an effective
alternative. The decision-making process regarding upfront surgery versus immunotherapy
needs to take place within a specialist melanoma multidisciplinary setting and be
customised to individual patient and tumour factors. Ultimately, high-level clinical
trial evidence is required to resolve uncertainties in the management of patients
with oligometastatic stage IV melanoma but the complexity of the varying presentations
may make trial design challenging.
Keywords
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References
- Surgical management of distant melanoma metastases.in: Balch C.M. Atkins M.B. Cutaneous melanoma. Springer, Cham2020: 1359-1402
- Adrenalectomy for metastatic melanoma: current role in the age of nonsurgical treatments.Am Surg. 2015; 81: 1005-1009
- Metastasectomy for abdominal visceral oligometastatic melanoma.JAMA Surg. 2017; 152: 678
- Association of surgical treatment, systemic therapy, and survival in patients with abdominal visceral melanoma metastases, 1965-2014: relevance of surgical cure in the era of modern systemic therapy.JAMA Surg. 2017; 152: 672-678
- Improved overall survival in melanoma with combined dabrafenib and trametinib.N Engl J Med. 2015; 372: 30-39
- Five-year survival with combined nivolumab and ipilimumab in advanced melanoma.N Engl J Med. 2019; 381: 1535-1546
- Adjuvant nivolumab plus ipilimumab or nivolumab monotherapy versus placebo in patients with resected stage IV melanoma with no evidence of disease (IMMUNED): a randomised, double-blind, placebo-controlled, phase 2 trial.Lancet. 2020; 395: 1558-1568
- The role of fluorine-18 deoxyglucose positron emission tomography in the management of patients with metastatic melanoma: impact on surgical decision making.Clin Nucl Med. 2003; 28: 961-965
- Surgery for distant melanoma metastasis.Canc J. 2012; 18: 176-184
- A Phase 2 trial of complete resection for stage IV melanoma: results of Southwest Oncology Group Clinical Trial S9430.Cancer. 2011; 117 (4740–4706)
- Long-term survival after complete surgical resection and adjuvant immunotherapy for distant melanoma metastases.Ann Surg Oncol. 2017; 24: 3991-4000
- Survival after surgical resection of isolated pulmonary metastases from malignant melanoma.Canc Contr. 2006; 13: 218-223
- Surgical resection for melanoma metastatic to the gastrointestinal tract.Arch Surg. 1996; 131: 975-979
- T-cell invigoration to tumour burden ratio associated with anti-PD-1 response.Nature. 2017; 545: 60-65
- Exosomal PD-L1 contributes to immunosuppression and is associated with anti-PD-1 response.Nature. 2018; 560: 382-386
- Adjuvant nivolumab versus ipilimumab in resected stage IIIB-C and stage IV melanoma (CheckMate 238): 4-year results from a multicentre, double-blind, randomised, controlled, phase 3 trial.Lancet Oncol. 2020; S1470–2045: 30494-30500
- Improved efficacy of neoadjuvant compared to adjuvant immunotherapy to eradicate metastatic disease.Canc Discov. 2016; 6: 1382-1399
- Pathological response and survival with neoadjuvant therapy in melanoma: a pooled analysis from the International Neoadjuvant Melanoma Consortium (INMC).Nat Med. 2021; 27: 301-309
- Outcome predictors of gamma knife surgery for melanoma brain metastases.J Neurosurg. 2011; 114: 769-779
- Stereotactic ablative radiotherapy for the comprehensive treatment of oligometastatic cancers: long-term results of the SABR-COMET phase II randomized trial.J Clin Oncol. 2020; 38: 2830-2838
- Skin surgery: prevention and treatment of complications.in: UpToDate Miller SJ. UpToDate, Waltham, MA2020
- Completion dissection or observation for sentinel-node metastasis in melanoma.N Engl J Med. 2017; 376: 2211-2222
- Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database.J Thorac Cardiovasc Surg. 2010; 139: 366-378
- Complications of laparoscopic and retroperitoneoscopic adrenalectomies in 370 cases in Japan: a multi-institutional study.Biomed Pharmacother. 2000; 54: 211s-214s
- Immunotherapy comes of age in octagenarian and nonagenarian metastatic melanoma patients.Eur J Canc. 2019; 108: 61-68
- Checkpoint Inhibition and melanoma: considerations in treating the older adul.J Geriatr Oncol. 2017; 8: 237-241
- Anti-PD-1 therapy in patients with advanced melanoma and preexisting autoimmune disorders or major toxicity with ipilimumab.Ann Oncol. 2017; 28: 368-376
- Immune checkpoint inhibitor therapy in solid organ transplant recipients: a patient-centered systematic review.J Am Acad Dermatol. 2020; 82: 1490-1500
- Baseline tumor size is an independent prognostic factor for overall survival in patients with melanoma treated with pembrolizumab.Clin Canc Res. 2018; 24: 4960-4967
- Site-specific response patterns, pseudoprogression, and acquired resistance in patients with melanoma treated with ipilimumab combined with anti–PD-1 therapy.Cancer. 2020; 126: 86-97
- Surgery for unresectable stage IIIC and IV melanoma in the era of new systemic therapy.Cancers. 2020; 12: 1176
- Survival outcomes after metastasectomy in melanoma patients categorized by response to checkpoint blockade.Ann Surg Oncol. 2020; 27: 1180-1188
- The impact of effective systemic therapies on surgery for stage IV melanoma.Eur J Canc. 2018; 103 (Epub 2018 Sep 7): 24-31https://doi.org/10.1016/j.ejca.2018.08.008
- Surgical resection for metastatic melanoma to the liver: the John Wayne Cancer Institute and Sydney melanoma unit experience.Arch Surg. 2001; 136: 950-955
- Adrenal metastasectomy in the presence and absence of extraadrenal metastatic disease.Ann Surg. 2019; 270: 373-377
- Combination nivolumab and ipilimumab or nivolumab alone in melanoma brain metastases: a multicentre randomised phase 2 study.Lancet Oncol. 2018; 19: 672-681
Article info
Publication history
Published online: June 12, 2021
Accepted:
April 22,
2021
Received in revised form:
April 17,
2021
Received:
March 21,
2021
Identification
Copyright
Crown Copyright © 2021 Published by Elsevier Ltd. All rights reserved.
