What is the role of adrenalectomy in managing isolated recurrence of stage IIIc melanoma, occurring 2 years after the original diagnosis, in a patient who declined adjuvant therapy?

Is the adrenal gland the only site of recurrence? Also, is the recurrence unilateral or bilateral? Unilateral adrenalectomy will not lead to permanent adrenal insufficiency, but bilateral adrenalectomy will (the patient will end up needing maintenance steroids permanently and need to have an endocrinologist on board before the surgery). Afterwards, I would suggest having a serious discussion with the patient about the recurrence risk, as stage IV oligometastatic disease (the patient's current situation) can progress to widely metastatic disease without adjuvant systemic therapy. Based on the published Society for Immunotherapy of Cancer consensus definition for resistance to immune checkpoint inhibitors (Kluger et al., PMID 36918224, the patient's disease is still immunotherapy-sensitive and has a good chance of survival with the appropriate adjuvant treatment (whether immunotherapy or targeted therapy if BRAF V600E/K mutations present).     

The other consideration if the patient really wants to avoid adrenalectomy is to consider a neoadjuvant immunotherapy approach (either 2 cycles of ipi/nivo based on the NADINA trial (Blank et al., PMID 38828984 or 1 year of neoadjuvant-adjuvant pembrolizumab based on the SWOG 1801 study (Patel et al., PMID 36856617. If the patient is able to achieve a CR or very good PR, it may be able to avoid the risk of permanent adrenal insufficiency from adrenalectomy.