The surgical treatment of a melanoma patient with macroscopic metastasis in peri and retrocaval lymph nodes and with a positive sentinel lymph node in the groin

Abstract

BACKGROUND: The extension of iliac-obturator dissection in melanoma patient with metastatic sentinel node of the groin is very debated. More recent studies - in accord with guidelines for urogenital cancers - suggest the extension to pelvic lymph nodes. At present, however, anatomical limits and indications to pelvic dissection are not defined in melanoma patients with metastatic lymph nodes of groin.

CASE REPORT: A 46-year-old man affected by nodular cutaneous melanoma (Breslow-thickness 10 mm, Clark-level V) on the anterior-medial surface of the right leg underwent sentinel node biopsy of groin. Three macro-metastatic sentinel lymph nodes were removed in right inguinal field and, after 2 weeks, an ipsi-lateral inguinal lymphadenectomy with an extended pelvic dissection was performed. During the surgery, we reported the presence of macrometastases also in retro/peri caval lymph nodes. As a result of these findings, we decided to perform the super-extended pelvic lymphadenectomy. Overall we removed 56 lymph nodes with 9 peri-caval and 2 retro-caval macro metastatic lymph nodes. After a period of 49 months, the patients came to our attention with multiple scrotal metastases. The imagining restaging of the patient was already negative for other melanoma localizations.

DISCUSSION: Currently there are no guidelines about indications and anatomical limits of iliac-obturator extension in melanoma patients. The extended pelvic dissection is the gold-standard procedure used in urogenital carcinomas. In case of finding of macro-metastases during the surgical procedure, the approach to follow is even more uncertain. We perform a super-extended pelvic dissection with a good prognosis for the patient.