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Background: Cutaneous melanoma of the head and neck region accounts for up to 20% of all primary melanoma lesions. Metastatic spread and nodal basin drainage are important determinants of surgical management. Surgical excision of primary lesions, sentinel lymph node biopsies and lymph node dissections for metastatic spread are routinely performed at varying stages of disease progression. Data linking clinical outcomes to key management decisions have been limited, leading to variability in certain surgical approaches. Management of sentinel lymph nodes (SLN) in the region of the parotid and the approach to submandibular nodes during modified radical neck dissection present particular challenges. In a previous study at our institution, the charts of patients from the Yale Melanoma Unit who underwent resection of their head and neck melanoma from January 2000 to December 2006 were reviewed. Parotid-sparing SLN biopsies comprised 94.8% of total surgical approaches for SLN biopsies in the parotid region. The rate of melanoma recurrence in the parotid region was 0% following SLN biopsies that spared the parotid gland. Additionally, specific recurrence of melanoma in the submandibular basin was similar for lymph node dissections that spared the level I nodes as compared to those that excised the level I nodes (4% vs 6.25%, P= 0.488). Thus, we sought to understand how practices at our institution compared to national trends. This study presents the evaluation of survey responses by national experts on the management of head and neck melanoma.
Methods: A 10-question survey was created using commercial online software. The survey was designed to be short in length to maximize response rates. The survey was distributed electronically to members of the American Head and Neck Society. Respondents were matched to Internet provider addresses to ensure that each respondent completed the survey only once.
Results: A total of 88 respondents completed the survey. A majority of respondents routinely use lymphoscintigraphy to identify sentinel lymph nodes for biopsy (84%) and perform modified radical neck dissections for positive lymph nodes after melanoma excision (77%). When performing modified radical neck dissections, 71% of respondents remove submandibular lymph nodes, though only 59% believe leaving the submandibular nodes increases the risk of recurrence. For SLN in the parotid region, 68% of respondents identify and excise the sentinel lymph node only, 28% carry out a superficial parotidectomy, and 4% perform a total parotidectomy. For SLN within the parotid gland itself, 48% of respondents carry out a superficial parotidectomy, 13% perform a total parotidectomy, and 39% identify and excise the sentinel lymph node only.
Conclusions: The surgical management of cutaneous melanoma lesions of the head and neck continues to be a challenge. Techniques in sentinel lymph node dissection and radical neck dissection have become less morbid over time. In contrast to current practices at the Yale Melanoma Unit, a minority of surgeons nationwide utilize morbidity-sparing surgical approaches for these procedures. This study highlights the need for further randomized controlled trials in the surgical management of head and neck melanoma.