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The prognosis of metastatic melanoma, despite many important and recent progresses, remains poor. The detection of microscopic disease must be a key point in fundamental and clinical research. Current recommendations, with clinical and radiological monitoring, only permit to detect macroscopic relapses. No seric tumor marker is presently sufficiently reproducible and determinant to be used in clinical practice to precociously diagnose a relapse. The sentinel lymph node procedure is currently the only technique largely used to determine microscopic metastasis. This technique allows defining a group of patients with poor prognosis but its therapeutic impact remains discussed. Completion lymph node dissection of the area after positive sentinel lymph node is currently performed but its real benefit to improve overall survival must be proved. Interferon is now the only treatment approved in adjuvant setting, but its interest remains discussed. Therapeutic trials are ongoing to really identify patients who could benefit from adjuvant treatment with interferon. Other trials probably more attractive (anti-CTLA4, BRAF and MEK inhibitors), with molecules recently approved in metastatic phase are also ongoing.

A therapeutic surgical de-escalation has been observed since many years with an actual prolongation for axillary lymph node area treatment. Axillary lymph node dissection (ALND) omission has been studied before and after validation of sentinel node (SN) biopsy procedure. A non-inferiority of ALND omission has been reported in case of non-involved SN. ALND omission has been studied in case of SN involvement without consensus in relation with scientific level of proof and with selective indications. The purpose of this work is to make a synthesis of the experiences on this subject then to envisage the current and future perspectives.