Combined inguinal and pelvic lymph node dissection for stage III melanoma

Background: The incidence of melanoma is increasing in the UK and a signifi cant number of patients are still presenting with primary lesions of poor p rognosis. As a consequence there is likely to be an increasing number of pa tients with lymph node metastases for whom the appropriate extent of groin dissection remains controversial. This review summarizes the evidence to en able surgeons to make an informed decision about the management of patients with melanoma metastases to the groin lymph nodes. Methods: A Medline search was performed to identify all English language ar ticles about melanoma containing the words lymphadenectomy, lymph nodes, in guinal or lymphoedema. Eighty-seven relevant articles were selected from 39 04 abstracts retrieved; 34 were related directly to the aim of this review. Results: There are no randomized controlled trials comparing the outcome of combined inguinal and pelvic lymph node dissection (CLND) and superficial inguinal lymph node dissection (SLND). Excision of pelvic lymph node metast ases is reported to yield a 5-year survival rate of 0-35 per cent. Recurren ce within the pelvis occurs in 9-18 per cent of patients after SLND and in less than 5 per cent after CLND. Morbidity following either CLND or SLND is poorly reported. Major long-term lymphoedema limiting patient activity aff ects 6-20 per cent of patients after groin dissection. Cloquet's node was d emonstrated in one study to be a useful predictor of pelvic lymph node invo lvement. Patients may be selected for pelvic node dissection on the basis o f clinical findings, the results of pelvic computed tomography and the stat us of Cloquet's node. Conclusion: The controversy surrounding the appropriate management of cytol ogically positive inguinal nodes in melanoma can be resolved only by a pros pective randomized trial comparing CLND with SLND. Morbidity and local dise ase control must be measured as outcomes in addition to disease-free and ov erall survival.