Malignancies of the skin and soft tissue are among the most common cancers diagnosed in the United States.1 While the majority of these neoplasms are basal and squamous cell cancers with very low mortality, the incidence of malignant melanoma is increasing, and this potentially fatal malignancy was the fifth and seventh most common cancer in men and women, respectively, in 2015.2 Across the country, nearly 10,000 deaths will occur annually from this disease.
Treatment of melanoma has changed dramatically over the last several decades. Emphasis on early detection and diagnosis has led to more prompt identification of melanoma, with approximately half of new diagnoses being in situ disease.2 A series of studies initiated in the 1970s have documented the safety of smaller resection margins (1–2 cm vs. the historical 5 cm), sparing patients the accompanying morbidity and healthcare costs.3,4,5,6 A series of seminal articles have extended our understanding of nodal management, including the role of sentinel node biopsy, for early identification of nodal metastases without the morbidity of anatomic nodal dissection.7,8
Accompanying the changes in surgical management have been innovations in the systemic treatment of melanoma. Adjuvant interferon has been shown to reduce recurrences and improve survival, albeit modestly.9 The biggest changes in systemic treatment for metastatic melanoma have come with the introduction of targeted therapy (BRAF and MEK inhibition) and immunotherapy targeted at the CTLA-4 and PD-1 pathways. New research seeks to better understand how to incorporate these therapies with surgery, either as adjuvant therapy for high-risk stage II and III patients, or in combination with metastectomy in stage IV disease.
Soft tissue sarcoma represents a more rare, but important set of malignancies that the general surgeon will encounter. Almost 12,000 cases of sarcoma are identified in the United States every year with approximately 4870 deaths.2 Because of the relative rarity and heterogeneity of these malignancies, rigorous clinical trials have been more difficult to produce. However, beginning with the work at the National Cancer Institute in the 1970s and 1980s, the previous practice of amputation for soft tissue sarcoma of the extremities has been replaced with a limb-sparing approach, often in conjunction with radiotherapy. Knowledge gained from the management of extremity soft tissue sarcoma has been extrapolated to tumors arising in the retroperitoneum, which constitute about 12% of all sarcomas. Management of these tumors remains controversial, including the roles of aggressive resection of adjacent organs and the application of neoadjuvant radiation. Trials attempting to answer the latter have failed to accrue in the past, but a study is currently in progress under the guidance of the European Organization for Research and Treatment of Cancer that will hopefully add to our knowledge on this topic.
a. Limb-Sparing Surgery for Soft-Tissue Sarcoma
The treatment of soft-tissue sarcomas of the extremities: ...