Is radical inguinal lymph node dissection (ILND) still required for melanoma?

From the Guidelines

Radical inguinal lymph node dissection is still required for melanoma when lymph node surgery is indicated, as recommended by the ESMO consensus conference. This approach is based on the standard practice of complete removal of node-bearing tissue within the anatomic boundaries of the nodal basin, as stated in the ESMO guidelines committee recommendations 1. The committee recommends radical node dissection over 'node picking' when lymph node surgery is indicated, with a level of evidence III and a strength of recommendation B.

When considering the extent of nodal dissection, the committee notes that drainage patterns from primary melanomas are highly variable, making it challenging to develop reliable algorithms for inclusion or exclusion of areas within the basin. However, it was felt that the addition of more levels within a given nodal basin is not broadly associated with substantially increased procedural morbidity, as the number of excised nodes has not been associated with morbidity in melanoma 1.

Some considerations are given to tailoring the extent of dissection based on the location of the primary tumor, such as preserving certain cervical nodal levels or considering the inclusion of iliac/pelvic lymph nodes when macroscopic inguinal metastases are present. However, these decisions should be made on a case-by-case basis, taking into account the individual patient's circumstances and the potential risks and benefits of each approach. The ESMO guidelines committee recommendations emphasize the importance of preserving important functional components of the neck, such as motor nerves, whenever possible 1.

Key points to consider when deciding on the extent of lymph node dissection include:

• The presence of clinically detectable nodal metastases confirmed by fine needle aspiration or sentinel lymph node biopsy results
• The location and extent of the primary tumor
• The potential risks and benefits of each approach, including the risk of lymphedema and other complications
• The importance of preserving important functional components of the neck, such as motor nerves.

Overall, the current recommendation is to perform radical inguinal lymph node dissection when lymph node surgery is indicated, while considering individual patient factors and the potential risks and benefits of each approach 1.

From the Research

Radical Inguinal Lymph Node Dissection for Melanoma

• The requirement for radical inguinal lymph node dissection in melanoma patients is still a topic of discussion, with various studies presenting different outcomes and recommendations 2, 3, 4, 5, 6.
• A study from 2007 found that patients undergoing inguinal lymph node dissection (ILND) for a positive sentinel lymph node (SLN) had a significantly lower risk of postoperative complications or lymphedema compared to those undergoing ILND for clinically palpable disease 2.
• Another study from 2009 reported a high wound complication rate of 34% after radical inguinal/iliacal lymph node dissection, with lymphatic fistula and seroma being common complications 3.
• The role of adjuvant radiotherapy in preventing regional recurrence after inguinal lymph node dissection is still controversial, with some studies suggesting a benefit in regional control but not in overall survival 4.
• Radical lymphadenectomy for melanoma has been associated with significant morbidity, including wound complications and lymphedema, with inguinal node dissection having a higher rate of complications than axillary dissection 5.
• A study from 2001 found that the extent of surgery, including superficial inguinal and radical ilioinguinal lymph node dissection, did not significantly influence survival or local control rates in patients with palpable melanoma metastases to the groin 6.

Morbidity and Complications

• Wound complications, such as infection and delayed healing, are common after radical inguinal lymph node dissection, with rates ranging from 19% to 34% 2, 3, 5.
• Lymphedema is also a significant complication, occurring in up to 30% of patients after inguinal lymph node dissection 2, 5.
• Other complications, such as seroma and lymphatic fistula, can also occur, with rates ranging from 22% to 34% 3, 5.

Survival and Local Recurrence

• The presence of pelvic metastases indicates systemic disease and is associated with a poor prognosis 6.
• The number of positive nodes and the presence of intransit metastases are significant predictors of local recurrence and survival 6.
• Radical lymphadenectomy can achieve low local recurrence rates, but overall survival is often limited by distant metastases 5.