Melanoma is now the sixth most common cancer, and more than 8000 patients die from the disease each year. Stage I and II melanoma remains a highly curable disease, but stage III melanoma is a significant threat to life. The basics of surgical treatment for advanced disease have not changed significantly in the last century. In 1892 Snow proposed lymph node dissection as a method to control regional nodal metastasis for early stage melanoma. Surgical resection remains the only proven treatment for local and advanced melanoma.

Sentinel node biopsy (SNB) has been the most significant advance in the treatment of melanoma. This procedure can help identify patients with early stage III disease who may benefit from complete node dissection. Before the advent of sentinel lymph node biopsy, elective lymph node dissection (ELND) was advocated for many patients with intermediate-depth melanoma of the extremity, yet the benefit of ELND remained unproven. Several nonrandomized studies suggested a survival benefit to ELND, yet all randomized studies of ELND showed no proven survival benefit. ELND also carries a significant risk of morbidity. This is problematic, most notably in patients who were node negative. Since occult disease was identified in only 20% to 33% of ELNDs, many patients were subjected to this morbidity unnecessarily. The era of ELND ended with the advent of SNB. In 1999 the World Health Organization declared SNB as the standard of care in melanoma in patients with no clinical evidence of metastasis.

The Multicenter Selective Lymphadenectomy Trial (MSLT) was initiated in 1993 to determine whether intraoperative lymphatic mapping followed by selective lymphadenectomy would effectively prolong overall survival. Subset analysis of the data suggested that for patients with tumors of intermediate thickness and occult metastasis, disease-free survival is better among those patients who undergo immediate lymphadenectomy compared with those who delay lymphadenectomy until after the clinical appearance of nodal metastasis.

The terminology used for node dissections is confusing, with references to complete lymph node dissections (CLNDs), ELNDs, therapeutic lymph node dissections (TLNDs), and radical lymph node dissection (RLNDs). The term TLND is used if clinically positive lymphadenopathy is identified on physical examination. ELND is referred to only if the nodal status is unknown and the dissection is performed prophylactically. Since the advent of SNB, this procedure has virtually been abandoned. CLND and RLND are often used interchangeably. The terms complete and radical are used to differentiate these dissections from node-sampling procedures performed for other diseases, such as breast cancer. Unlike nodal sampling for breast cancer, which is a staging procedure, CLND for melanoma is performed as a curative resection with a goal of removing all of the lymph nodes and metastatic disease in a lymphatic basin. Young surgeons, with training in heavy breast oncology, often fail to realize the difference between these surgical procedures and to understand the much more extensive dissection required for the CLND.