Extent of Groin Dissection in Melanoma: A Mixed-Methods, Population-Based Study of Practice Patterns and Outcomes

Melanoma metastases to the groin are frequently managed by therapeutic lymph node dissection. Evidence is lacking regarding the extent of dissection required. Thus, we sought to describe practice patterns for the use of inguinal vs. ilioinguinal dissection, as well as the perioperative/oncologic outcomes of each procedure. A mixed-methods approach was employed to evaluate surgical practice patterns. A retrospective review of three multi-site databases was carried out, together with semi-structured interviews of melanoma surgeons. A total of 347 patients who underwent dissection were reviewed. The main indications stated for adding a “deep” ilioinguinal dissection were palpable or radiologically positive disease. There was no significant difference in complications, length of stay or lymphedema between patients having inguinal vs. ilioinguinal dissection, irrespective of method of diagnosis. There was also no significant difference in recurrence, cancer-specific survival or overall survival between groups. In conclusion, ilioinguinal dissection is a safe and well-tolerated procedure, with no significant added morbidity relative to an inguinal dissection. The indications for ilioinguinal dissection currently in use produce an appropriate deep node positivity rate and ilioinguinal dissection should continue to be used selectively. Randomized data are needed to clarify the impact of ilioinguinal dissection on regional control and survival.

Vulva and lower limb cancer: Results of inguinal lymph node staging on 81 cases

Background: The objective of this work completed at the Cancer Institute in Dakar is to report the results of inguinal lymph node dissection in cancers of the lower limb and of the lower genital tract. Methods: This is a retrospective study over a 10-year period. The parameters being studied are histological type, lymph node involvement, postoperative morbidity, recurrence, and survival. Results: 81 patients received surgery over a period of 7 years. The average age of our patients was 61. The sex ratio is 0.74 with 34 men and 47 women. There were 70 cases of cancer of the lower limbs (86%) and 11 cases of cancer of the vulva (14%). The most common histological type was squamous cell carcinoma (SCC) with 41 cases (51%). Clinical inguinal involvement was noted in 58 patients (72.5%) with palpable lymph nodes. All vulvar cancer patients developed histologically positive nodes. Melanoma patients were more susceptible to developing positive nodes. In sarcoma there were more matches between clinical and histological positive nodes. No vascular and nerve damage was reported. The average length of hospitalization was 5 days, with 3 days being the shortest stay, and 40 days the longest stay. Local complications consisted of suture releases in 9 cases, and 6 surgical necrosis of the wound. A seroma was found with an average duration of 35 days in 69 patients (85%). Postoperative deaths occurred in 5 cases (6%), 1 after a renal failure, 1 due to thromboembolic disease, 1 due to sepsis, and 2 deaths occurred after patients experienced respiratory distress. Conclusion: After five years of follow-up care, no patient presented chronic sequelae after inguinal dissection, 7 patients (8.75%) had local recurrence, and 4 patients (7.7%) had lymph node metastases. We recorded 33 cancer-related deaths (41%). Chronic complications, including lymphedema are underestimated and require better assessment methods for prevention and treatment.

Diagnosis and Treatment ofKIT-Mutant Metastatic Melanoma

A 52-year-old man has unresectable locally recurrent melanoma of the left foot ( Fig 1 ) and pulmonary metastases. Nine months before this presentation, he underwent a wide local excision and sentinel node biopsy for an acral melanoma on his left heel. Pathology disclosed Breslow thickness of 4.8 mm, Clark level IV, and tumor ulceration with a mitotic rate of 37 mitoses/mm2. Both sentinel nodes in the left groin were positive for melanoma cells, which expressed S100, HMB45, and melan A. At subsequent left inguinal dissection, seven more nodes showed no additional nodal metastases. Within 3 months of his original surgery, the patient developed a local recurrence in the foot, and over the subsequent 6 months, he underwent serial local excisions and topical diphencyprone treatment. A recent staging scan showed at least 20 foci of in-transit disease in the left lower leg and foot, as well as a solitary lung metastasis (12 mm). His Eastern Cooperative Oncology Group performance status is 1, with no significant comorbidities. High-resolution melt followed by sequencing of an in-transit metastasis showed there is no BRAF exon 15 mutation. However, Sanger sequencing of KIT exons 9, 11, 13, and 17, performed as screening for a clinical trial enrolling patients with metastatic acral and mucosal melanomas, showed an exon 13 K642E mutation.

Postoperative Complications following Nodal Dissection and Their Association with Melanoma Recurrence

Background. Although postoperative complications are common after lymph node dissection, its association with disease recurrence has not yet been fully investigated. Methods. A retrospective review of a prospectively maintained database was conducted, looking at all malignant melanoma patients with sentinel nodes positive disease requiring axillary or inguinal dissection between 2002 and 2011. Results. A total of 124 patients required nodal clearance from 317 patients with stage I/II malignant melanoma who had undergone sentinel lymph node biopsy. Of these, 104 patients met the inclusion criteria and were divided into inguinal lymph node dissections (ILND; ) or axillary lymph node dissections (ALND; ). Immunohistochemical deposits had higher detection rate in ALND (). The ILND patients had a higher recurrence rate (84.1% versus 63.4%; ) and mortality (68.3% versus 48.8%; ) without a significant difference in complications. In patients whom complications developed, 75% of the ILND group and 71.4% of the ALND group had disease recurrence, but without reaching a statistical value as an independent predictor of melanoma recurrence. Conclusion. Complications are common following ILND and ALND; however there is no significant difference in complications rates between the groups with some associations with recurrence without reaching a significant difference.