Role of radiation therapy in the management of cutaneous malignant melanoma

The Diagnosis and Management of Cutaneous Metastases from Melanoma

Melanoma is one of the deadliest skin tumors, accounting for almost 90% of skin cancer mortality. Although immune therapy and targeted therapy have dramatically changed the prognosis of metastatic melanoma, many patients experience disease progression despite the currently available new treatments. Skin metastases from melanoma represent a relatively common event as first sign of advanced disease or a sign of recurrence. Skin metastases are usually asymptomatic, although in advanced stages, they can present with ulceration, bleeding, and superinfection; furthermore, they can cause symptoms related to compression on nearby tissues. Treatments vary from simple surgery resections to topical or intralesional local injections, or a combination of these techniques with the most recent systemic immune or target therapies. New research and studies should focus on the pathogenesis and molecular mechanisms of the cutaneous metastases of melanoma in order to shed light on the mechanisms underlying the different behavior and prognoses of different patients.

ROS Pleiotropy in Melanoma and Local Therapy with Physical Modalities

Metabolic energy production naturally generates unwanted products such as reactive oxygen species (ROS), causing oxidative damage. Oxidative damage has been linked to several pathologies, including diabetes, premature aging, neurodegenerative diseases, and cancer. ROS were therefore originally anticipated as an imperative evil, a product of an imperfect system. More recently, however, the role of ROS in signaling and tumor treatment is increasingly acknowledged. This review addresses the main types, sources, and pathways of ROS in melanoma by linking their pleiotropic roles in antioxidant and oxidant regulation, hypoxia, metabolism, and cell death. In addition, the implications of ROS in various physical therapy modalities targeting melanoma, such as radiotherapy, electrochemotherapy, hyperthermia, photodynamic therapy, and medical gas plasma, are also discussed. By including ROS in the main picture of melanoma skin cancer and as an integral part of cancer therapies, a greater understanding of melanoma cell biology is presented, which ultimately may elucidate additional clues on targeting therapy resistance of this most deadly form of skin cancer.

LINC01224 facilitates the proliferation and inhibits the radiosensitivity of melanoma cells through the miR-193a-5p/NR1D2 axis

Melanoma is a skin cancer characterized by early metastasis and high mortality. Radiotherapy is a common treatment for melanoma in patients. Long noncoding RNAs play pivotal roles in regulating the radiosensitivity of many tumors, including melanomas. In this study, the role of LINC01224 in the radiosensitivity of melanoma cells was explored. The expression of LINC01224 in melanoma was examined by reverse transcription-quantitative polymerase chain reaction, and the results showed that LINC01224 was upregulated in melanoma tissues and cells. The effects of LINC01224 on cell proliferation and apoptosis in melanoma were assessed by 3-(4,5-Dimethylthiazol-2-yl)-2,5-Diphenyltetrazolium Bromide (MTT), colony formation, and flow cytometry assays. The effects of LINC01224 on the radiosensitivity of melanoma were analyzed by colony formation assay. The results implied that LINC01224 knockdown inhibited cell viability and proliferation but enhanced cell apoptosis and radiosensitivity. Luciferase reporter and RNA pull-down assays were performed to evaluate the relationships between LINC01224 and miR-193a-5p or miR-193a-5p and nuclear receptor subfamily 1 group D member 2 (NR1D2). We found that LINC01224 binds to miR-193a-5p, which directly targets NR1D2. In addition, we discovered that LINC01224 upregulated NR1D2 expression by sponging miR-193a-5p in melanoma cells. Overall, the data collected in this study suggest that LINC01224 exerts oncogenic effects in melanoma via the miR-193a-5p/NR1D2 axis.

Immunostimulatory Effects of Radiotherapy for Local and Systemic Control of Melanoma: A Review

Recently, modern therapies involving immune checkpoint inhibitors, cytokines, and oncolytic virus have been developed. Because of the limited treatment effect of modern therapy alone, the immunostimulatory effect of radiotherapy attracted increasing attention. The combined use of radiotherapy and modern therapy has been examined clinically and non-clinically, and its effectiveness has been confirmed recently. Because melanomas have high immunogenicity, better therapeutic outcomes are desired when using immunotherapy. However, sufficient therapeutic effects have not yet been achieved. Thus far, radiotherapy has been used only for local control of tumors. Although extremely rare, radiotherapy has also been reported for systemic control, i.e., abscopal effect. This is thought to be due to an antitumor immune response. Therefore, we herein summarize past information on not only the mechanism of immune effects on radiotherapy but also biomarkers reported in case reports on abscopal effects. We also reviewed the animal model suitable for evaluating abscopal effects. These results pave the way for further basic research or clinical studies on new treatment methods for melanoma. Currently, palliative radiation is administered to patients with metastatic melanoma for local control. If it is feasible to provide both systemic and local control, the treatment benefit for the patients is very large.

Reversal of Resistance in Targeted Therapy of Metastatic Melanoma: Lessons Learned from Vemurafenib (BRAFV600E-Specific Inhibitor)

Malignant melanoma is the most aggressive form of skin cancer and has a very low survival rate. Over 50% of melanomas harbor various BRAF mutations with the most common being the V600E. BRAF^V600E mutation that causes constitutive activation of the MAPK pathway leading to drug-, immune-resistance, apoptosis evasion, proliferation, survival, and metastasis of melanomas. The ATP competitive BRAF^V600E selective inhibitor, vemurafenib, has shown dramatic success in clinical trials; promoting tumor regression and an increase in overall survival of patients with metastatic melanoma. Regrettably, vemurafenib-resistance develops over an average of six months, which renders melanomas resistant to other therapeutic strategies. Elucidation of the underlying mechanism(s) of acquisition of vemurafenib-resistance and design of novel approaches to override resistance is the subject of intense clinical and basic research. In this review, we summarize recent developments in therapeutic approaches and clinical investigations on melanomas with BRAF^V600E mutation to establish a new platform for the treatment of melanoma.

Role for radiation therapy in melanoma

Although melanoma is generally considered a relative radioresistant tumor, radiation therapy (RT) remains a valid and effective treatment option in definitive, adjuvant, and palliative settings. Definitive RT is generally only used in inoperable patients. Despite a high-quality clinical trial showing adjuvant RT following lymphadenectomy in node-positive melanoma patients prevents local and regional recurrence, the role of adjuvant RT in the treatment of melanoma remains controversial and is underused. RT is highly effective in providing symptom palliation for metastatic melanoma. RT combined with new systemic options, such as immunotherapy, holds promise and is being actively evaluated.

Role of radiotherapy in melanoma management

BACKGROUND

In melanoma, radiotherapy has generally been considered as a palliative treatment option indicated only for advanced cases or disseminated disease. In the 70s of the previous century, the technological advances in radiotherapy, linked to rapid development of computer sciences, resulted in restored interest for radiotherapy in melanoma management. Although a fundamental lack of well designed prospective and/or randomized clinical trials critically influenced the integration of radiotherapy into treatment strategies in melanoma, radiotherapy was recently recognized as an indispensable part in the multidisciplinary management of patients with melanoma. Altogether, approximately 23% of melanoma patients should receive at least one course of radiotherapy during the course of the disease. In this review, radiobiological properties of melanoma that govern the decisions for the fractionation patterns used in the treatment of this disease are described. Moreover, the indications for irradiation and the results of pertinent clinical studies from the literature, creating a rationale for the use of radiotherapy in the management of this disease, are reviewed and a brief description of radiotherapy techniques is given.

CONCLUSIONS

Basic treatment modality in melanoma is surgery. However, whenever surgery is not radical or there are adverse prognostic factors identified on histopathological examination of resected tissue specimen, it needs to be supplemented. Also, in patients with unresectable disease or in those not being suitable for major surgery or who refuse proposed surgical intervention, other effective mode(s) of therapy need to be implemented. From this perspective, supported by clinical experiences and literature results, radiotherapy is a valuable option: it is effective and safe, in curative and palliative setting.

[Treatment of metastatic malignant melanoma localized to an extremity]

BACKGROUND

At the Norwegian Radium Hospital, most patients who were treated for metastases (localized to an extremity) from malignant melanoma in the period 1977-99 underwent intra-arterial chemotherapy combined with radiotherapy. We have evaluated the effects of this treatment, which has now been replaced by isolated limb perfusion (with melphalan and tumor necrosis factor).

MATERIAL AND METHODS

Medical records were reviewed for patients with metastatic malignant melanoma (localized to an extremity) who had been treated at the Norwegian Radium Hospital with intra-arterial chemotherapy (5-[3,3 dimethyl-1-triazeno]-imidazole-4-carboxamide [DTIC]) in the period 1977-99.

RESULTS

36 patients had received such treatment; in 30 of these the induction treatment was combined with radiation of the tumour area.. 24 patients were in complete remission after treatment (12 of these had all the metastases surgically removed before treatment). Nine patients had a partial remission while three patients had progressive disease. Median observation time was 49 months. 15 of 31 patients had an observation time of more than five years, and seven of these patients were alive after ten years. Three patients with metastasis localized to the lower extremity died of other causes. In one case the intra-arterial catheterisation caused serious aortic damage.

INTERPRETATION

It is possible to achieve long-term remission in patients with metastatic malignant melanoma localized to an extremity after intra-arterial chemotherapy combined with radiotherapy.

Dose escalation of whole-brain radiotherapy for brain metastases from melanoma

PURPOSE

The majority of patients with brain metastases from melanoma receive whole-brain radiotherapy (WBRT). However, the results are poor. Hypofractionation regimens failed to improve the outcome of these patients. This study investigates a potential benefit from escalation of the WBRT dose beyond the "standard" regimen 30 Gy in 10 fractions (10x3 Gy).

METHODS AND MATERIALS

Data from 51 melanoma patients receiving WBRT alone were retrospectively analyzed. A dosage of 10x3 Gy (n = 33) was compared with higher doses including 40 Gy/20 fractions (n = 11) and 45 Gy/15 fractions (n = 7) for survival (OS) and local (intracerebral) control (LC). Additional potential prognostic factors were evaluated: age, gender, performance status, number of metastases, extracerebral metastases, and recursive partitioning analysis (RPA) class.

RESULTS

At 6 months, OS rates were 27% after 10x3 Gy and 50% after higher doses (p = 0.009). The OS rates at 12 months were 4% and 20%. On multivariate analysis, higher WBRT doses (p = 0.010), fewer than four brain metastases (p = 0.012), no extracerebral metastases (p = 0.006), and RPA class 1 (p = 0.005) were associated with improved OS. The LC rates at 6 months were 23% after 10x3 Gy and 50% after higher doses (p = 0.021). The LC rates at 12 months were 0% and 13%. On multivariate analysis, higher WBRT doses (p = 0.020) and fewer than brain metastases (p = 0.002) were associated with better LC.

CONCLUSIONS

Given the limitations of a retrospective study, the findings suggest that patients with brain metastases from melanoma receiving WBRT alone may benefit from dose escalation beyond 10x3 Gy. The hypothesis generated by this study must be confirmed in a randomized trial stratifying for significant prognostic factors.

Inhibition of melanogenesis as a radiation sensitizer for melanoma therapy

Melanin pigment displays strong photo- and radioprotective properties, suggesting that inhibition melanogenesis could increase sensitivity of melanoma to ionizing radiation. We tested this concept in human melanoma cells cultured in either Ham's F10 medium to maintain amelanotic phenotype or DMEM to induce/stimulate melanin production, respectively; N-phenylthiourea (PTU) and D-penicillamine were used as an inhibitor of melanogenesis. Melanogenic activity was evaluated by visual inspection (color of cell pellets) or by measurement of tyrosinase (dopa oxidase) activity assay. Amelanotic cells or cells with various melanin content were exposed to gamma radiation and tested for viability and colony forming capability. Gamma radiation at doses of 2-15 Gy inhibited cell viability and colony forming efficiency in dose- and time-dependent manner, but pigmented melanoma cells were significantly more resistant to gamma radiation than nonpigmented cells (p < 0.05-0.001). Both PTU and D-penicillamine inhibited strongly tyrosinase activity and melanin production in melanoma cells (p < 0.05-0.001). Furthermore, inhibition of melanogenesis by PTU or D-penicillamine resulted in enhancement of melanoma cells sensitivity to killing by gamma rays. In conclusion, the results of these cell culture experiments give support to a clinical trial of pharmacologically induced decrease in melanin synthesis to enhance the efficacy of radiotherapy in advanced melanomas.

Therapie von Hautmetastasen beim malignen Melanom

Malignant melanoma represents a particular challenge for dermatologists and oncologists because of its high and increasing incidence and the poor prognosis of patients with thick primary tumors (T3, T4). In advanced stages of melanoma, cutaneous and subcutaneous metastases have a special significance, as they markedly affect the patient and may lead to a limitation in quality of life. While topical therapy is possible, there are only limited clinical studies. The location, number, size and distribution of skin metastases, involvement of internal organs, age and general condition should be considered in assessing therapeutic options. Especially with solitary, easily accessible metastases, surgical excision represents the therapy of choice. Ablation using CO(2) laser is an alternative. With extensive metastases in just one extremity, isolated limb perfusion (ILP) with melphalan is an option, while multiple, smaller metastases can be irradiated. Further, several chemotherapeutic agents and immune modulators can be used topically, peri- and intralesionally.

Isolated limb perfusion for melanoma patients—a review of its indications and the role of tumour necrosis factor-α

AIMS

The treatment of melanoma in-transit metastases (IT-mets) can vary widely and is dependant on the size and the number of the lesions. When multiple, large lesions exist, isolated limb perfusion (ILP) has established itself as an attractive treatment option with high response rates.

METHODS

Review on the various methods of treatment of melanoma in-transit metastases, with a focus on isolated limb perfusion. A Medline based literature search was performed for articles relating to this topic. Additional original papers were obtained from citations in those identified by the initial search. Indications and results are discussed and the extra value of tumour necrosis factor (TNF) is evaluated.

RESULTS

ILP with Melphalan results in complete response rates of 40-82% and showed to be 54% in a large retrospective meta-analysis. The addition of TNF can improve these completes response rates (59-85%) and although no data from randomized controlled trials are available, it seems of particular value in large, bulky lesions or in patients with recurrent disease after previous ILP.

CONCLUSIONS

TNF-based ILP has earned a permanent place in the treatment of patients with melanoma IT-mets. In patients with a high tumour burden, TNF-based ILP is the most efficacious procedure to obtain local control and achieve limb salvage.

Combined-modality therapy for patients with regional nodal metastases from melanoma

PURPOSE

To evaluate the outcome and patterns of failure for patients with nodal metastases from melanoma treated with combined-modality therapy.

METHODS AND MATERIALS

Between 1983 and 2003, 466 patients with nodal metastases from melanoma were managed with lymphadenectomy and radiation, with or without systemic therapy. Surgery was a therapeutic procedure for clinically apparent nodal disease in 434 patients (regionally advanced nodal disease). Adjuvant radiation was generally delivered with a hypofractionated regimen. Adjuvant systemic therapy was delivered to 154 patients.

RESULTS

With a median follow-up of 4.2 years, 252 patients relapsed and 203 patients died of progressive disease. The actuarial 5-year disease-specific, disease-free, and distant metastasis-free survival rates were 49%, 42%, and 44%, respectively. By multivariate analysis, increasing number of involved lymph nodes and primary ulceration were associated with an inferior 5-year actuarial disease-specific and distant metastasis-free survival. Also, the number of involved lymph nodes was associated with the development of brain metastases, whereas thickness was associated with lung metastases, and primary ulceration was associated with liver metastases. The actuarial 5-year regional (in-basin) control rate for all patients was 89%, and on multivariate analysis there were no patient or disease characteristics associated with inferior regional control. The risk of lymphedema was highest for those patients with groin lymph node metastases.

CONCLUSIONS

Although regional nodal disease can be satisfactorily controlled with lymphadenectomy and radiation, the risk of distant metastases and melanoma death remains high. A management approach to these patients that accounts for the competing risks of distant metastases, regional failure, and long-term toxicity is needed.

Neurotropic Melanoma of the Head and Neck With Clinical Perineural Invasion

OBJECTIVE

The purpose of this article is to report our experience with neurotropic melanoma, a rare malignancy that sometimes produces neurologic symptoms because of a direct extension of the primary tumor.

METHODS

We report 3 consecutive patients with neurotropic melanoma of the head and neck who presented with clinical perineural invasion.

RESULTS

Two patients had incompletely resectable tumors and were treated with definitive radiotherapy (RT), and 1 patient received surgery and postoperative RT. One patient experienced recurrence in a regional lymph node 30 months after RT and underwent salvage surgery; he is disease-free at 45 months after initial treatment. The remaining 2 patients are disease-free 34 months and 14 months after treatment.

CONCLUSIONS

Radiotherapy alone or combined with surgery may provide relatively long-term local control in patients who have neurotropic melanoma with clinical perineural invasion.

Neurotropic melanoma invading the inferior alveolar nerve

BACKGROUND

Desmoplastic neurotropic melanoma (DNM) and neurotropic melanoma (NM), rare lesions of the head and neck, often present as a benign-appearing nodule which later progresses to cranial nerve involvement.

OBJECTIVE

To discuss treatment and outcome of 3 cases of DNM/NM of the lower lip.

METHODS

Three case reports with 12- to 54-month follow-up and literature review.

RESULTS

The first case had an initial excision of melanoma of his lower lip and presented 16 years later with severe bilateral atrophy of his muscles of mastication with NM and underwent intensity modulated radiation therapy but no further resection. We also report two other cases of DNM of the lip, one of which received gamma knife radiosurgery for intracranial extension.

LIMITATIONS

Small retrospective case series.

CONCLUSIONS

Locoregional recurrences from DNM are more common than distant metastasis warranting vigilant surveillance following resection of the initial lesion. Radiation therapy and gamma knife radiosurgery may be used for cases of unresectable recurrences.

A Critical Assessment of Adjuvant Radiotherapy for Inguinal Lymph Node Metastases from Melanoma

BACKGROUND

Although patients with inguinal or pelvic lymph node (LN) metastases from melanoma may develop regional recurrence after dissection, the role of adjuvant radiotherapy remains controversial.

METHODS

The medical records of 40 patients with inguinal and/or pelvic lymph node metastases from melanoma were reviewed retrospectively. Indications for adjuvant radiotherapy included the following nodal characteristics: extracapsular extension, LNs > or =3 cm in diameter, > or =4 involved LNs, and LN recurrence after prior nodal surgery. Thirty-seven of 40 patients underwent formal LN dissection. Three patients had only local excision of gross disease for recurrence after prior dissection. All patients received radiation to a median dose of 30 Gy at six Gy/fraction delivered twice weekly.

RESULTS

With a median follow-up time of 22.5 months, the 3-year actuarial distant metastasis-free and overall survival rates were 35% and 38%, respectively. The 3-year regional control rate was 74%. Univariate analyses of patient, tumor, and treatment characteristics failed to reveal any association with distant metastasis-free survival, overall survival, or regional control. Regional failures occurred in nine patients; seven of these were isolated dermal failures within the field of irradiation. Only two patients (5%) had LN basin recurrences; one of these patients also developed dermal recurrence. Fifteen of 40 patients developed lymphedema; in seven of these, lymphedema was present before initiation of radiation therapy.

CONCLUSIONS

Radiation may prevent recurrence of nodal disease in patients at high risk for regional failure, but in-field dermal recurrences may sometimes occur (8 of 40, 20%). Treatment-related lymphedema and death from metastatic melanoma were common.

Management of in-transit metastases from cutaneous malignant melanoma

Background

In-transit metastases from cutaneous malignant melanoma (cutaneous or subcutaneous deposits between the primary melanoma and regional lymph nodes) represent late-stage disease, and their treatment should be tailored accordingly. This article reviews the pathology, clinical significance and treatment options for in-transit disease from melanoma.

Methods

An initial Medline search was undertaken using the keywords ‘melanoma and in-transit’ and ‘melanoma and non-nodal regional recurrence’. Additional original articles were obtained from citations in articles identified by the initial search.

Results and conclusion

In-transit metastases carry a poor prognosis. The method of treatment should be tailored to the extent of cutaneous disease. The first line of treatment remains complete excision with negative histopathological margins. There is no need for wide excision. Carbon dioxide laser therapy is valuable for multiple small cutaneous deposits. Isolated limb perfusion has a role for numerous or bulky advanced in-transit metastases in the limbs that are beyond the scope of simpler techniques. Systemic chemotherapy has response rates of about 25 per cent and is reserved for patients for whom surgery is no longer feasible.

Controversies in the management of metastatic melanoma to regional lymphatic basins

The primary management of lymph nodes involved with metastatic melanoma is regional lymphadenectomy. Many controversies of regional lymph node dissection exist including extent and nature of the lymphadenectomy, treatment of lymphatic metastases in unusual locations and the role of adjuvant radiotherapy. Although radical neck dissection has been the gold standard for cervical disease, modified dissections do not seem to compromise regional control in appropriately selected patients. In the axilla, a Level I, II, and III dissection is most commonly performed. Combined superficial and deep groin dissection is justified for clinically palpable disease although management of patients with histologically positive yet clinically non-palpable disease is more controversial. Burden of disease, imaging, patient co-morbidity, and Cloquet nodal status must be considered. Many technical variations exist in an attempt to improve morbidity rates secondary to lymphadenectomy. Unfortunately, complication rates are difficult to compare secondary to variable study designs, definitions, and patient populations. Adjuvant radiation therapy appears warranted in patients with high risk of regional recurrence including bulky disease, extracapsular extension or cervical location.

Desmoplastic neurotropic melanoma of the head and neck: the role of radiation therapy

BACKGROUND

Desmoplastic neurotropic melanoma (DNM) is an uncommon cutaneous melanoma variant with pronounced neurotropism. In contrast to ordinary melanomas, locoregional recurrences are common and distant metastasis are uncommon in patients with DNM. Local control with surgery and radiation therapy may assume a more important role in this variant of melanoma. We present a case of an unresectable skull base recurrence of DNM that was controlled using radiation therapy alone and review the literature.

METHODS

Case report with 36-month follow-up.

RESULTS

The patient is a 68-year-old with multiple recurrences of a DNM that originated on the forehead. After extensive surgery, including total parotidectomy and temporal bone resection, the patient had an unresectable recurrence of the skull base develop. This was treated with definitive radiation therapy, resulting in a complete response. The patient has had no evidence of recurrence at 3 years.

CONCLUSIONS

DNM is a locally aggressive type of melanoma with a high risk of local recurrence that can be radioresponsive. The incidence of distant metastasis is low, so aggressive treatment to control local disease is warranted. This may include surgery plus adjuvant radiation therapy or definitive radiotherapy for unresectable recurrences.

Adjuvant therapy of malignant melanoma

High risk surgically resected melanoma is associated with a less than 50% 5-year survival. Adjuvant therapy is an appropriate treatment modality in this setting, and is more likely to be effective as the tumour burden here is small. Clinical observations of spontaneous tumour regressions and a highly variable rate of disease progression suggest a role of the immune system in the natural history of melanoma. Biological agents have therefore been the subjects of numerous adjuvant studies. Early, randomised controlled trials (RCTs) of Bacillus Calmette-Guerin (BCG), levamisole, Corynebacterium parvum, chemotherapy, isolated limb perfusion (ILP), radiotherapy, transfer factor (TF), megestrol acetate and vitamin A yielded largely negative results. Current trials focus on vaccines and the interferons. To date the latter is the only therapy to have shown a significant benefit in the prospective randomised controlled phase III setting. This report represents a systematic review of studies in adjuvant therapy in melanoma. Data from ongoing studies is awaited before a role for adjuvant agents in high risk melanoma is confirmed.

Lymph node dissection for clinically evident lymph node metastases of malignant melanoma

AIMS

A considerable number of melanoma patients present with clinically evident regional lymph node metastases. Factors influencing prognosis following therapeutic lymph node dissection (TLND) were evaluated.

METHODS

In total 140 patients (68 women, 72 men, median age 53 years) with established regional lymph node metastases, but without clinically detectable distant metastases, received cervical, axillary or ilioinguinal TLND between 1978 and 1997 and were retrospectively reviewed. Uni- and multivariate survival analysis was performed.

RESULTS

Median survival for all 140 patients was 25 months; the observed overall 5 year survival rate was 30%. Age greater than 50 years, primary tumour site on the trunk, more than three lymph node metastases and extracapsular spread were associated with a poor prognosis. In multivariate analysis age (< or =50 years vs >50 years, P=0.02), location of the primary tumour (non-truncal vs truncal, P=0.005), number of lymph nodes involved ( n< or =3 vsn >3, P=0.01) and extracapsular spread (none vs present, P=0.04) proved to be independent prognostic factors.

CONCLUSIONS

TLND is worthwhile and offers a potential chance of cure in about one-third of melanoma patients with established regional lymph node metastases. There are subgroups with a particularly poor prognosis in whom the benefit of radical surgery alone is limited.

Management of node-positive melanoma in the era of sentinel node biopsy

Regional lymph node metastasis is a powerful predictor of decreased overall survival from malignant melanoma. However, the therapeutic value of elective node dissections and the role of adjuvant therapy for node-positive disease have been highly controversial. Sentinel lymph node biopsy has reshaped the debate by allowing for staging of the regional lymph nodes with less morbidity and greater accuracy. This review summarizes the current consensus on the management of node-positive melanoma in the era of sentinel lymph node biopsy.