James Jakub, MD discusses highlights from his lecture on Managing Melanoma, Trends in Melanoma, When to Refer Melanoma, and In-Transit Melanoma at the 2021 Elevate-Derm Conference.

In this video

In this conversation with Douglas DeGiro, Mayo Clinic surgical oncologist James Jakub, MD lays out the "clean line in the sand" for referral: Breslow thickness is the first thing to focus on. Melanomas greater than one millimeter typically need to see a surgeon, those under 0.76 mm almost never require sentinel lymph node biopsy, and the 0.76-to-1 mm range remains "a lot of controversy" and is still evolving. He acknowledges the real-world challenge of knowing whether a local surgeon does enough melanoma cases, noting it's "probably not something you want to be doing one or two a year of," while recognizing that many excellent general surgeons in small communities manage it well.

Dr. Jakub points to needle biopsy of palpable nodes as "a marker of someone who's keeping up to date" — an ultrasound plus needle biopsy of the basin gives the same information as an excisional biopsy while sparing the patient repeat trips to surgery. On in-transit melanoma, he embraces DeGiro's "trail of breadcrumbs" analogy: it's rare, but a tiny biopsied spot between the primary and the nodal basin means advanced stage III disease and near-certain recurrence. Those patients should make the 100-mile trip to a multidisciplinary team, because it's "the tip of the iceberg." He closes on hope, highlighting the newer therapies since 2011 that now offer a real chance of curing advanced melanoma.

  • Start with Breslow thickness: >1 mm typically needs a surgeon, <0.76 mm almost never needs sentinel lymph node biopsy, and 0.76–1 mm is the evolving, controversial gray zone.
  • Melanoma surgery volume matters to outcomes — it's not something a surgeon should be doing just once or twice a year, though skilled general surgeons exist in small communities.
  • For palpable nodes, ultrasound plus needle biopsy gives the same information as excisional biopsy and avoids unnecessary surgery — a sign your surgeon is keeping up to date.
  • In-transit melanoma is rare but is the "tip of the iceberg": even a tiny spot means stage III disease, likely recurrence, and warrants referral to a multidisciplinary team.
  • Newer therapies since 2011 mean there is real hope of curing patients with advanced melanoma — a treatment landscape clinicians should keep up with.