From the Guidelines
The management of the neck in sinonasal mucosal melanoma typically involves observation rather than elective neck dissection for clinically negative necks (cN0), with postoperative radiation therapy (RT) recommended for high-risk features such as extracapsular disease, involvement of 2 or more neck or intraparotid nodes, any node 3 cm or greater, neck excision (alone) with no further basin dissection, or recurrence in the neck or soft tissue after initial surgical resection 1.
Key Considerations
- Patients should undergo careful clinical examination and imaging (CT, MRI, or PET-CT) to evaluate for nodal metastases at diagnosis and during follow-up.
- For patients with clinically positive neck nodes (cN+), therapeutic neck dissection is recommended, targeting the involved nodal levels.
- The overall risk of regional metastasis in sinonasal mucosal melanoma is approximately 10-20%, which is lower than cutaneous melanoma but still significant.
- Sentinel lymph node biopsy has limited utility in sinonasal melanoma due to complex lymphatic drainage patterns and technical challenges.
- Conventional fractionation is recommended for postoperative RT, at 2 Gy per fraction to a total postoperative dose of 60–66 Gy, or to 70 Gy for gross disease 1.
Treatment Approach
- The management approach should be individualized based on the primary tumor extent, patient factors, and multidisciplinary team input, as sinonasal mucosal melanoma generally has a poor prognosis with high rates of distant metastasis being the predominant pattern of failure.
- For patients with advanced disease, adjuvant therapy may include immunotherapy (such as pembrolizumab or nivolumab) or targeted therapy if BRAF mutations are present.
- Intensity modulated RT may be very helpful for achieving homogenous dose distributions and sparing of critical organs, especially in paranasal sinus sites 1.
From the Research
Management of the Neck in Sinonasal Mucosal Melanoma
- The management of the neck in sinonasal mucosal melanoma (SNMM) is a crucial aspect of treatment, as the disease has a high metastatic potential and poor outcomes 2.
- Surgical resection with adjuvant radiotherapy and/or systemic therapy may offer the best outcome, and lymphadenectomy, including possible parotidectomy and neck dissection, should be considered in patients with regional lymph node metastasis 2.
- The role of elective lymph node dissection is controversial, but elective neck irradiation (ENI) has been shown to significantly reduce the regional recurrence rate in clinical node-negative (cN0) SNMM patients 3.
- Ipsilateral levels Ib and II are the most common locations of regional relapse, and ENI may be considered to improve regional control 3.
- A multidisciplinary team approach is essential in the management of SNMM, and recent studies suggest that immunotherapy may confer survival benefit to patients with advanced disease 4.
- The primary management for SNMM is surgery, when feasible, followed by adjuvant radiotherapy, and the identification of genetic mutations common to mucosal melanoma has allowed for early trials of targeted therapies 5, 6.