Rodrigo Arrangoiz MS, MD, FACS, FSSO

Management of the nodal basins in a patient with drainage to both an epitrochlear and axillary or a popliteal and inguinal nodal pattern:
- Warrants SLN biopsy of both basins and attention to each basin based on the SLN status of that respective basin
It is not possible, based on lymphoscintigraphy:
- To determine whether the proximal lymphatic basins drain the primary tumor site through lymphatic channels that are separate from those that drain to the distal nodal basin
If found to have a positive sentinel lymph node:
- Current management of the regional lymph node basin(s):
  - Have shifted towards observation by ultrasound as compared to completion lymph node dissection:
    - This shift in treatment paradigm was influenced by two randomized control trials:
      - MSLT II and DeCOG-SLT:
        
        Both of which demonstrated no improved in survival in sentinel lymph node positive patients who underwent immediate completion lymph node dissection as compared to observation
Additionally, referral for adjuvant immunotherapy or targeted therapy:
- Should be considered as recent evidence has demonstrated improvement in disease free survival:
  - Among resectable stage III melanoma patients that went on to receive adjuvant therapy
If unable to undergo close observation:
- The appropriate next step is completion lymphadenectomy of all involved nodal basins:
  - Complete axillary dissection including all lymph nodes in levels 1, 2, and 3 along with the nodes superior to the axillary vein and superficial to the axillary artery and brachial plexus along with all of the nodal tissue along the subscapular musculature is the standard of care for patients with melanoma
Unlike the situation with breast cancer, adjuvant radiation and chemotherapy are not uniformly used and does is not a substitute for appropriate surgical therapy
References:
- Bilimoria KY, Balch CM, Bentrem DJ, et al. Complete lymph node dissection for sentinel node-positive melanoma: assessment of practice patterns in the United States. Ann Surg Oncol. 2008;15:1566-1576.
- Gershenwald JE, Andtbacka R, Prieto V, et al. Microscopic tumor burden in sentinel lymph nodes predicts synchronous nonsentinel lymph node involvement in patients with melanoma. J ClinOncol. 2008;26:4296-4303.
- Pollock RE, Curley SA, Ross MI, et al, eds. Advanced Therapy in Surgical Oncology. Hamilton, Ontario, Canada: BC Decker; 2008.