I favor the approach proposed by MD Anderson Cancer Center team – sphincter-saving surgery and hypofractionated radiation therapy plus liver resection in this case. As the patient is presented with advanced, metastatic disease the balance between harm and benefit is more difficult.

Anal melanoma carries extremely dismal prognosis. Surgical treatment is palliative in this setting. However, if attempt at liver resection is taken, then APR should be a choice for primary tumour.

Vote for chemorxt for primary and met liver ressecation if , in an individualized manner, if benefit-harm ratio potentially favourable. Regards

I am not sure about role of CTRT in melanoma primary. Morbidity of lap aper low. With regards to liver mets interesting article shows good survival liver resection

Systematic review and meta-analysis of liver resection for metastatic melanoma

J.-M. Aubin1, J. Rekman1, F. Vandenbroucke-Menu2, R. Lapointe2, R. J. Fairfull-Smith1, R. Mimeault1, F. K. Balaa1 and G. Martel1,2

1Liver and Pancreas Unit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, and 2HPB Surgery and Liver Transplantation Unit, Hoˆ pital Saint-Luc, Centre Hospitalier de l’Universite ́ de Montre ́ al, Montreal, Quebec, Canada

Correspondence to: Dr G. Martel, The Ottawa Hospital, General Campus, CCW Room 1667, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada (e-mail: [email protected])

Background: The multidisciplinary management of metastatic melanoma now occasionally includes major hepatic resection. The objective of this work was to conduct a systematic review of the literature on liver resection for metastatic melanoma.

Methods: MEDLINE, Embase, the Cochrane Library and Scopus were searched (1990 to December 2012). Studies with at least ten patients undergoing liver resection for metastatic melanoma were included. Data on the outcomes of overall survival (OS) and/or disease-free survival (DFS) were abstracted and synthesized. Hazard ratios (HRs) were derived from survival curves and subjected to meta-analysis using random-effects models.

Results: Twenty-twostudiesinvolving579patients(13percentweightedresectionrate)whounderwent liver resection were included. Study quality was poor to moderate. Median follow-up ranged from 9 to 59 months. Median DFS ranged from 8 to 23 months, and median OS ranged from 14 to 41 months (R0, 22–66months, R2, 10–16months; R0 versus R1/R2: HR 0.52, 95 per cent confidence interval (c.i.) 0.37 to 0.73). The OS rate was 56–100 per cent at 1year, 34–53 per cent at 3years and 11–36 per cent at 5 years. Median OS with non-operative management ranged from 4 to 12 months. Comparison of OS with resection and non-operative management favoured resection (HR 0.32, 95 per cent c.i. 0.22 to 0.46).

Conclusion: Radical resection of liver metastases from melanoma appears to improve overall survival compared with non-operative management or incomplete resection, but this observation requires future confirmation as selection bias may have confounded the results.

BJS 2009

Since it is a only one-metastasis case, I vote for primary control (eithet surgery, or rxt+-chemo) and liver local treatment, with surgery for ex. Any other approach carries a no chance of long term control without disease.

Regards.

Chemoradiation may be done with paclitaxel+carboplatin, similar to lung cancer protocols (p ex Belani's in Jco 2005 I think).

Thanks, otherwise it seems I am a lone crusader in favor of surgery for liver metastasis from melanoma

Actually probably all liver surgeons will prefer resection. It is fastest method to achieve local control. And there is still no serious competitors in terms of effectiveness of the treatment.

I would go for anatomical (stereotactic) ablation using multiple probe positions. You can achieve the same local control rate as compared to resection with minimal morbidity.

This is an example of an anatomical srfa.

 The choice of local excision of the anal canal melanoma will depend on the results of your own personnal endo-anal ultrasound together with an MRI. This is metastaic disease with usually a poor prognosis. so i would be wary of liver resection unless you can exclude further disease (PET-CT) and the patient benefit outways morbidity and operative recovery. a period of observation after chemotherapy and then consider hepatic surgery may be the way to go.