Excellent question, my old friend!  My immediate gut instinct is to say no to iSR- should do a wide APER.  I have no ready evidence to support this, but melanoma is is not nice.  My initial thought was to ask you for the depth of invasion of the melanoma and whether it had been completely excised etc. but given that you've mentioned LN +++, I think that would be irrelevant.  There is a short window of opportunity now given that there are no mets (at least none that can be identified) to achieve potential cure.... the more radical the surgery, in my opinion, the better the chances...  Will await with interest an update on this case in due course.

Best Wishes

Haray

Dear prof haray

these were exactly the kind of thoughts I had whem I saw this patient 2 years back. Infact he had a polyps tony done in jan 2013 and saw us in jun 2013 with no local disease but mesorectal nodes on ct and pet.

after much discussion at patient request,  we performed a lap intersphincteric resection. His histology showed no residual disease in rectum or anal canal. 2/7 nodes showed metastases. He followed up last week ( 2 years post surgery) with no local recurrence and reasonably good function.

would I do it again, I am not sure?

Hi.... me a radiologist ...what do I tell a surgeon ? :)

But thought I could share this with you---from pubmed...

Med Oncol. 2015 Jan;32(1):445. doi: 10.1007/s12032-014-0445-2. Epub 2014 Dec 13.

Anorectal malignant melanoma: retrospective analysis of management and outcome in a single Portuguese Institution.

Miguel I1, Freire J, Passos MJ, Moreira A.

Abstract

Anorectal melanoma is an uncommon cancer with a poor prognosis. We aim to describe the clinical presentation, treatment and outcome of patients with anorectal melanoma in our center. Retrospective study of patients with anorectal melanoma treated between 2000 and 2011 at a cancer center in Lisbon. Ten patients were identified, eight females and two males, with median age 70.5 years (32-79). Symptoms at presentation were rectal bleeding (8), anal pain (4) and discomfort (3). Tumor location was anal (6), rectal (3) and anorectal transition (2). Seven patients had surgery: abdomino-pelvic resection (5) and local resection (2). Among the two patients who underwent local resection, one was an incidental finding in a hemorrhoidectomy specimen. This patient had further adjuvant chemotherapy (dacarbazine). Three patients had distant metastasis at diagnosis, one had chemotherapy and two had best supportive care. Six of the seven operated patients relapsed in a median time of 5.4 months: distant metastasis (4), local recurrence (1), both (1). The two local relapse patients had surgical widening of resection margins (1) and radiotherapy (2). One-year survival was 30 %; 3-year survival was 20 %. Anorectal melanoma has a poor prognosis due to advanced disease at presentation and aggressive course, with relapse in almost all operated patients. Treatment guidelines have not been established due to the lack of randomized studies. However, recent studies show that sphincter-sparing surgical procedures along with low dose intensity radiotherapy seem to achieve a local control similar to abdomino-pelvic resection. No systemic therapy is considered standard of care for advanced disease, and regimens are extrapolated from cutaneous melanoma experience.

Hope this helps!

Thanks Dr Arya, very useful paper.  As the paper mentions, there is very little Grade A evidence in this field due to the rarity of the problem (not only ano-rectal melanoma but  diagnosed at an early stage with the potential for cure).  I'm gratified to hear Prof Saklani's success story... hope the patient continues to be free of local recurrence.  However, I can't help but ask - why only 7 nodes in a TME specimen - some MDTs would consider that inadequate sampling and request the pathologists to check again...

Dear prof haray

i am in agreement with you on lymph node harvest count. While surgery remains same, lymph node harvest also depends on diligence of pathologists. Our median lymph node count on rectal cancer is 13 including patients with CTRT. However we do end up in some patients with low lymph nodes despite requesting pathogist to regross( I doubt if it was done for this case) In fact at TMH just recently pathologist have selected one area as their speciality eg Gi only , gu only. This has improved the dedication of our pathiologist even more.

this patient had a pet Scan on follow up ( we do pet only for melanomas at presentation and yearly follow up as study protocol) , which was normal

regards

i shall probably make my decision according to the depth of invasion of the tumor, if its

Even the most adequate methods wont give you every detail of tumour invasion depth (which is a three dimensional picture). If the tumour is a Melanoma with its´ known invasive growth, even to err on the safe side  (APR) is not a proof of local control. Intersphincteric manipulation  may further promote dislocation and cell spread, although we know that this mechanism may give less mets than the regular one (with niche preconditioning). Was is already biopsied, as you know the diagnosis?