What level of lymph node (LN) dissection is recommended for an old aged male with right arm melanoma and a positive sentinel lymph node (SLN) biopsy?

Level of Lymph Node Dissection for Melanoma with Positive SLN

For an elderly male with right arm melanoma and positive sentinel lymph node (SLN) that has been excised with lymphadenectomy, the appropriate level of lymph node dissection is Level I axillary lymph nodes. 1, 2

Rationale for Level I Axillary Lymph Node Dissection

Evidence-Based Approach

• For melanoma patients with a positive SLN in the axilla, the evidence supports a more conservative approach to lymph node dissection:

  • Studies show that level III nodal involvement is extremely rare (1.5%) in patients with positive sentinel lymph nodes 2
  • Level II metastasis is also infrequent (4.4%) in patients with positive SLN 2
  • A retrospective study found 0% level III involvement in patients with positive SLN (compared to 16.9% in those with clinically palpable disease) 3

Anatomical Considerations

• Level I axillary nodes are located lateral to the pectoralis minor muscle
• Level II nodes are posterior to the pectoralis minor
• Level III nodes are medial to the pectoralis minor

Clinical Decision Algorithm

1. For patients with positive SLN (microscopic disease):

   • Level I axillary dissection is appropriate 2, 4
   • Studies show that level I/II dissection for positive SLN has regional recurrence rates comparable to more extensive dissections 4

2. For patients with clinically palpable disease (macroscopic):

   • Consider more extensive dissection including levels I, II, and potentially III 3, 5
   • Level III involvement is seen in approximately 16.9% of patients with palpable disease 3

3. Special considerations for inguinal lymphadenectomy (not applicable to this case):

   • For axillary disease, the principles differ from inguinal lymphadenectomy where pelvic dissection may be indicated with multiple positive nodes 1

Important Caveats

• The extent of axillary lymph node dissection for melanoma remains somewhat controversial, with practice patterns varying across institutions 6
• Complications increase with more extensive dissection, including lymphedema risk
• The patient's age is an important consideration - elderly patients may benefit from more conservative approaches that minimize morbidity while maintaining oncologic outcomes
• Quality of life considerations are particularly important in the elderly population

Conclusion Based on Evidence

The most appropriate answer for this elderly male patient with right arm melanoma and positive SLN is Level I axillary lymph nodes (option A). This approach balances oncologic control with minimizing morbidity, as evidence shows that level III involvement is extremely rare in SLN-positive cases, and even level II involvement is infrequent.