What is the false statement regarding management of a 5mm thick melanoma on the skin with palpable inguinal nodes?

Management of a 5mm Thick Melanoma with Palpable Inguinal Nodes

The statement that "If further work-up reveals multiple lung metastases of melanoma, they should be excised as soon as possible" is false. Surgical excision of multiple lung metastases is not the standard of care for metastatic melanoma.

Primary Melanoma Management

• For a 5mm thick melanoma on the right calf, a wide excision with 3cm margins is the appropriate surgical approach in the absence of systemic disease 1
• Melanomas with Breslow thickness >4mm should have excision margins of 2-3cm, with 3cm being preferred based on evidence showing increased locoregional recurrence with narrower margins 1
• The excision should include the primary tumor and surrounding normal-appearing skin to ensure complete removal of all malignant cells 1

Management of Regional Lymph Nodes

• Complete right inguinal node dissection is indeed indicated if there is no evidence of systemic metastasis 1
• Surgical dissection of involved nodes is the standard treatment for patients presenting with regional node involvement 1
• The number of involved nodes is the most important prognostic factor for patients with locoregional node involvement 1
• Sentinel lymph node biopsy is not indicated when nodes are clinically palpable, as these patients should proceed directly to complete lymph node dissection 1

Management of Metastatic Disease

• Multiple lung metastases should NOT be surgically excised as soon as possible, making this statement false 1
• For patients with multiple metastatic sites (such as multiple lung metastases), systemic therapy rather than surgical excision is the appropriate approach 1, 2
• Surgical metastasectomy may be considered for isolated metastases in selected patients, but not for multiple lung metastases 3, 2
• The prognosis for patients with multiple metastatic sites is significantly worse than those with isolated metastases 2

Role of Chemotherapy

• Chemotherapy for melanoma is indeed primarily palliative, and surgical therapy is preferred if there is no evidence of metastatic disease beyond the inguinal region 1
• Dacarbazine has been the standard chemotherapy but offers only palliative benefit 1
• Immunotherapy has shown better outcomes than traditional chemotherapy for advanced melanoma 4, 5
• For metastatic disease, systemic immunotherapy with checkpoint inhibitors is now the first-line treatment 4

Prognosis

• If the nodes do not contain metastatic disease but are simply reactive, the 5-year survival rate would still be 50% or less for a 5mm thick melanoma, making this statement true 1
• Melanomas with Breslow thickness >4mm have approximately 50% 5-year survival rate even with negative nodes 1
• The prognosis worsens significantly with increasing tumor thickness and the presence of nodal metastases 1, 4
• Breslow thickness is the most powerful prognostic factor for primary melanoma, and 5mm represents a very thick, high-risk tumor 1, 4

Common Pitfalls in Management

• Inadequate surgical margins for thick melanomas can lead to increased local recurrence 1
• Failure to perform complete lymph node dissection when nodes are clinically positive can result in inadequate staging and treatment 1
• Overaggressive surgical approach to multiple distant metastases (such as multiple lung metastases) does not improve survival and may delay appropriate systemic therapy 3, 2
• Relying solely on chemotherapy without appropriate surgical management of the primary tumor and regional nodes when no distant metastases are present 1