From the Guidelines
Inguinal lymph node resection for melanoma is indicated in patients with biopsy-proven metastatic melanoma to inguinal lymph nodes, clinically palpable inguinal lymphadenopathy suspicious for melanoma metastasis, or a positive sentinel lymph node biopsy in the inguinal region, and should involve radical node dissection as recommended by the ESMO consensus conference 1.
Indications for Inguinal Lymph Node Resection
The primary indications for inguinal lymph node resection include:
- Biopsy-proven metastatic melanoma to inguinal lymph nodes
- Clinically palpable inguinal lymphadenopathy suspicious for melanoma metastasis
- A positive sentinel lymph node biopsy in the inguinal region
- Microsatellitosis or in-transit metastases in the lower extremity or lower trunk draining to the inguinal basin
Surgical Approach
The procedure typically involves removal of superficial inguinal nodes (those below the inguinal ligament) and may include deep inguinal nodes (those around the femoral vessels) depending on the extent of disease, with radical node dissection being the recommended approach 1.
Preoperative and Postoperative Management
Preoperative imaging with CT, MRI, or PET-CT is essential to assess the extent of nodal involvement and rule out distant metastases 1. Patients should understand the potential complications including lymphedema (occurring in 20-30% of cases), wound infection, seroma formation, and nerve injury. Postoperative management includes drain placement until output is minimal, compression garments to reduce lymphedema risk, and close follow-up.
Justification for Surgical Approach
This surgical approach is justified as regional lymph node metastases significantly impact melanoma staging, prognosis, and treatment planning, with complete surgical resection offering the best chance for regional control and potentially improved survival in appropriately selected patients, as supported by the American Society of Clinical Oncology and Society of Surgical Oncology joint clinical practice guideline 1.
From the Research
Indications for Inguinal Lymph Node Resection for Melanoma
The indications for inguinal lymph node resection for melanoma include:
- Metastatic melanoma to the inguinal lymph node basin, as the standard treatment of care is lymphadenectomy 2
- Microscopic disease detected by sentinel lymph node biopsy, as inguinal lymph node dissections are more commonly performed for this indication 3
- Palpable inguinal melanoma nodal metastasis, where ilioinguinal lymph node dissection is considered due to the high incidence of metastatic pelvic nodes 4
- Adjuvant radiotherapy for inguinal lymph node metastases from melanoma, which may be indicated for patients with extracapsular extension, large lymph nodes, or multiple involved lymph nodes 5
- Therapeutic groin dissection for clinically detectable melanoma lymph node metastases, where the prognosis is variable and related to the biological characteristics of each case 6
Surgical Management
The surgical management of patients with palpable inguinal lymph node metastases from melanoma includes:
- Inguinal lymph node dissection, which may be performed as a superficial inguinal lymph node dissection (SLND) or a combined superficial inguinal and pelvic lymph node dissection (CLND) 6
- Ilioinguinal lymph node dissection, which is considered for patients with palpable inguinal nodal metastasis due to the high incidence of metastatic pelvic nodes 4
- Videoscopic inguinal lymphadenectomy (VIL), which is a minimally invasive technique designed to minimize wound complications while achieving comparable oncological control 2
Prognostic Factors
The prognosis of patients with clinically detectable melanoma metastases to the groin is variable and related to the biological characteristics of each case, including:
- Age, which is a significant prognostic factor for survival 6
- The number of involved superficial lymph nodes, which is a significant prognostic factor for survival 6
- The presence of extracapsular spread, which is a significant prognostic factor for survival 6
- The presence or absence of pelvic lymph node metastases, which is a significant prognostic factor for survival in patients who undergo CLND 6