ABSTRACT
Unlike squamous-cell carcinoma of the upper aerodigestive tract, which generally spreads to the cervical lymph nodes in an orderly pattern, malignant melanoma of the skin of the head and neck region metastasizes in an unpredictable fashion.1 Clinical evaluation and prediction of the need for parotidectomy is perhaps equally difficult,2 and routine subtotal parotidectomy carries higher morbidity and risk compared with elective neck dissection alone. The incidence of nodal metastasis in thin melanomas (generally those less than 1 mm in thickness) of the skin of the head and neck is sufficiently low that elective lymph-node dissection is not recommended. In lesions more than 4 mm thick, dissection of the clinically negative neck may not have an impact on outcome because of the high incidence of distant metastases in this patient population. It is in the intermediate group of lesions, between 1.0 mm and 3.9 mm thick, that elective lymph-node dissection has generally been advocated. However, the yield of metastatic nodes in this
population is approximately 15%, and the remaining 85% are subjected to an unnecessary procedure that carries a small but significant morbidity even in the most experienced hands. A retrospective analysis by Maddox et al combining the experience of the Sydney Melanoma Unit and the University of Alabama, Birmingham, of 534 patients with localized melanoma has demonstrated a survival benefit for elective neck dissection on univariate but not on multivariate analysis for patients with intermediate-thickness melanoma.3
