Background
The incidence of metastatic melanoma is increasing, with Australia and New Zealand having the highest worldwide mortality rates. Primary melanoma of the head and neck accounts for 20% of melanoma cases and is associated with worse survival. Treatment of metastatic melanoma largely depends on staging and BRAF genotyping, with more than half of melanomas carrying an activating mutation in V600E. The current treatment for non-metastatic melanoma is curative surgery. Staging of the disease determines the use of adjuvant therapies and is becoming common practice with the advent of immunotherapy. However, a persistent problem with melanoma treatment is the locoregional progression in the absence of metastatic disease, and the appropriateness of aggressive salvage surgery.
We present a small case series to highlight not just the problem of locoregional recurrence in primary head and neck melanoma but also the potentially durable results in seemingly hopeless cases.
Case description
A case series was conducted at Wollongong hospital of three patients that had locoregional recurrence of melanoma without distant metastatic spread who underwent salvage surgery, including free tissue transfer. BRAF mutations were present on all pathology and each patient had at least two or more positive lymph nodes. All cases were stage 3 in accordance to AJCC 8th edition. There was a mix of adjuvant therapy used either pre or post operatively including anti-PD1 immunotherapy, a BRAF and MEK inhibition combination and radiotherapy.
Outcome
Two patients, both previously denied further therapy at other centres, were alive with no evidence of recurrence at 36 months. Both of these patients were male. One female patient died of early distant disease emergence, despite no evidence on immediate pre-operative PET scan.
Conclusion
Aggressive salvage surgery for recurrent locally advanced melanoma is appropriate in the absence of distant metastatic disease, even after adjuvant radiotherapy and targeted systemic therapy.