Redefining the Role of Surgical Management in the Evolving Therapeutic Landscape of Melanoma: Towards a more holistic approach

The introduction of adjuvant therapy for selected patients with early melanoma and the finding that a completion lymph node dissection after a positive sentinel node is not associated with a survival benefit, have recently drastically changed the treatment of melanoma. This thesis focusses on the evolving therapeutic landscape of melanoma, with special focus on the role of surgery. For example, we developed and validated models that amongst others predict disease recurrence in both patients with a negative- and positive sentinel node. The model for patients with a negative sentinel node could be used to select those who might also benefit from adjuvant therapy, while the model for patients with a positive sentinel node may be used to select those who might not need adjuvant treatment. Interestingly, this latter model only uses information from the patient, melanoma and sentinel node and not from the completion lymph node dissection. We demonstrated that this procedure leads to a shift in staging in just a minority of patients and only marginally adds to the prediction accuracy. Furthermore, this thesis concentrates on the criteria for thin melanoma, a more minimal invasive alternative for the sentinel lymph node procedure, ulcerated melanomas, melanomas of unknown primary and the use of surgery in more advanced melanoma. Altogether, the treatment of melanoma changed significantly and reflects a complicated interplay between several disciplines, including the surgeon.

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