Sentinel lymph node biopsies may signi­cantly inform patient conversation and potential immunotherapy decisions. In a recent paper using SEER data to model estimated 5-year melanoma­specic risk, the inclusion of sentinel lymph node biopsy in Stage IIB/C melanoma patients improved adjuvant therapy decision-making [12]. When considering adjuvant therapy, certain agents, specically BRAF/MEK inhibitors, remain approved only for Stage III disease, and thus completion of lymph node staging in this patient population remains crucial [7].

gional control is an additional consideration, par­ticularly in patients who may not be candidates for further systemic therapy.

A diagnosis of cancer in an elderly patient pres­ents a unique challenge to the surgeon. Not only do patients in this population have a higher likeli­hood of presenting with multiple other comorbid medical conditions that render them more fragile and complex, but they are also more likely to have lower health literacy and higher rates of depression [13]. Discussions regarding quality of life and not just quantity of life should be a prior­ity for all patients who are faced with undergoing cancer treatment but are particularly important for elderly patients for whom life expectancy at baseline is shorter than their younger counter­parts. Goals of care including cure, minimizing toxicities, and feeling well enough to participate in activities of daily living (ADLs) should be dened early [14, 15]. In some cases, this discus­sion may lead to a decision for nonoperative management, or less aggressive surgical manage­ment. For patients who are poor operative candi­dates or wish to avoid surgery for other reasons and have early-stage melanoma (melanoma in situ or T1aN0 invasive), data supports the use of Mohs micrographic surgery as an alternative to standard wide local excision with a slight sur­vival advantage for Mohs micrographic surgery in a retrospective study using the National Database [16]. Older patients often have less physiologic reserve and can be expected to respond to surgery differently than younger patients and require longer recovery time. Thus, while standard of care stipulates the performance of sentinel node biopsy for invasive melanomas >1.01mm in depth, the surgeon should carefully consider the risks and benets of sentinel node biopsy in elderly patients with melanoma. It has been observed that sentinel node involvement by melanoma is less common in elderly patients, even those with thick melanomas, which may be due to atrophy of dermal lymphatic channels in