Combined inguinal and pelvic lymph node dissection for stage III melanoma

The incidence of melanoma is increasing in the UK and a significant number of patients are still presenting with primary lesions of poor prognosis. As a consequence there is likely to be an increasing number of patients with lymph node metastases for whom the appropriate extent of groin dissection remains controversial. This review summarizes the evidence to enable surgeons to make an informed decision about the management of patients with melanoma metastases to the groin lymph nodes.

A Medline search was performed to identify all English language articles about melanoma containing the words lymphadenectomy, lymph nodes, inguinal or lymphoedema. Eighty-seven relevant articles were selected from 3904 abstracts retrieved; 34 were related directly to the aim of this review.

There are no randomized controlled trials comparing the outcome of combined inguinal and pelvic lymph node dissection (CLND) and superficial inguinal lymph node dissection (SLND). Excision of pelvic lymph node metastases is reported to yield a 5-year survival rate of 0-35 per cent. Recurrence within the pelvis occurs in 9-18 per cent of patients after SLND and in less than 5 per cent after CLND. Morbidity following either CLND or SLND is poorly reported. Major long-term lymphoedema limiting patient activity affects 6-20 per cent of patients after groin dissection. Cloquet's node was demonstrated in one study to be a useful predictor of pelvic lymph node involvement. Patients may be selected for pelvic node dissection on the basis of clinical findings, the results of pelvic computed tomography and the status of Cloquet's node.

The controversy surrounding the appropriate management of cytologically positive inguinal nodes in melanoma can be resolved only by a prospective randomized trial comparing CLND with SLND. Morbidity and local disease control must be measured as outcomes in addition to disease-free and overall survival.