Clinician-to-Clinician Update Clinician-to-Clinician Update

Endoscopic Lymph Node Dissection Arrests Melanoma with Minimal Scarring

February 2017

Contributed by Todd Tuttle, MD

Lymphadenectomy is indicated when a patient’s melanoma has metastasized to the lymph nodes. With traditional open approaches, surgical dissection of lymph nodes, particularly of inguinal lymph nodes, can pose a risk of complications, including wound rupture, scarring, and infection. A minimally invasive surgical approach developed in Minnesota is proving to be a safe alternative to traditional surgical lymph node dissection. In this case study, that technique— minimally invasive inguinal lymph node dissection (MILND)—yielded excellent results.

Patient

A 35-year-old female patient with no family history of melanoma presented at a University of Minnesota Health facility requesting examination of a mole on her left anterior thigh. She reported that she had been aware of the mole for a couple of years. She indicated that she thought the mole had not changed perceptively, but agreed to undergo a shave biopsy, the results of which suggested that the mole was melanoma. An excisional biopsy revealed an invasive melanoma measuring .85 mm in thickness. Her physicians found no evidence of ulceration and no mitotic figures. They proceeded with a wide local excision and a sentinel lymph node biopsy. The sentinel lymph node—located in the left femoral region—was found to contain isolated tumor cells. A PET-CT scan came back clear, and there were no signs of lymphadenopathy.

Management

The patient was presented with two treatment options: close observation with ultrasound or lymph node dissection. She was told that the isolated tumor cells may not be clinically relevant, but if she opted for a surgical procedure, the femoral lymph dissection could be done with a minimally invasive or open procedure. The minimally invasive option, she was informed, would likely require more surgery time, but the risk of scarring, infection, and a longer hospital stay would be lower. The patient elected to have MILND.

On the date of the procedure, the patient successfully underwent the MILND procedure. Instead of a large incision, 3 flaps were created: one about 4 cm above the inguinal ligament, another lateral to the anterior border of the sartorius muscle, and another medial to the anterior border of the adductor muscle. Following the procedure, she was brought to the recovery room in stable condition. She was discharged the same day and experienced no wound complications.

Feb-2017-Melanoma-Case-Study-Main-247495 M Health CONSULT Table1
— A comparison of open vs. minimally invasive inguinal lymph node dissection. Data from Abbott, AM, Grotz, TE, Rueth, NM, et al.

Discussion

Postprocedure, the patient received care from lymphedema specialists to support her recovery. She is now followed by a medical oncologist, and more than 2 years later, continues to do well. Her periodic PET scans show no sign of melanoma recurrence. For this patient, MILND allowed for a swift recovery with negligible scarring. MILND, when compared to open approaches to inguinal lymph node dissection, has been reported to result in shorter hospital stays and fewer complications.1 (See Table 1.)

While this patient required limited treatment after MILND, M Health cancer patients have access to the full spectrum of supportive care during and following cancer treatment, including, but not limited to, lymphedema care, physical and occupational therapy, and integrative therapies.

References

  1. Abbott, AM, Grotz, TE, Rueth, NM, Hernandez Irizarry, RC, Tuttle, TM, and Jakub, JW. Minimally invasive inguinal lymph node dissection (MILND) for melanoma: experience from two academic centers. Ann Surg Oncol. 2013;20:340–345. DOI 10.1245/s10434-012-2545-6
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