Current Surgical Management for Acral Melanoma

Melanoma is one of the most aggressive and lethal forms of skin cancer, with acral melanoma (AM) associated with the poorer prognosis among melanoma subtypes. Historically, it was considered that more extensive surgery could prolong survival; however, multiple randomized trials have demonstrated that greater surgical intervention does not improve survival. Over the past few years, novel therapeutic agents including immune checkpoint inhibitors and molecular-targeted drugs have remarkably improved prognosis of melanoma and potentially reduced the role of surgery. Furthermore, predictive models that integrate clinicopathologic features and gene expression profiling may further optimize patient selection and guidance for surgical de-escalation. In parallel, the use of these agents in adjuvant and neoadjuvant settings highlights the need for multimodal approaches combined with surgery. However, the landmark clinical trials have included few cases of AM, which is rare melanoma subtype in Western populations. Because of its unique molecular alterations, the applicability of findings from Western-based clinical trials to AM remains uncertain, leading to a lack of high-level evidence for this subtype. In this article, we review the available, albeit limited, evidence on surgical management for AM and discuss future perspectives and challenges for optimizing treatment strategies for this distinct melanoma subtype.