5 Axillary and Epitrochlear Lymph Node Dissection For Melanoma
5 Axillary and Epitrochlear Lymph Node Dissection For Melanoma
5 Axillary and Epitrochlear Lymph Node Dissection For Melanoma
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Axillary Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Operative Considerations for Recurrent or Bulky Axillary Metastases in the Upper
Axilla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Postoperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Epitrochlear Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Anatomy and Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Abstract
S. L. Wong (*) Indications for regional lymph node dissection
Geisel School of Medicine at Dartmouth, Dartmouth-
Hitchcock Medical Center, Lebanon, NH, USA in melanoma have evolved over time. Once the
e-mail: Sandra.L.Wong@dartmouth.edu decision to proceed with axillary lymph node
D. S. Tyler dissection (ALND) has been made, the goal of
Department of Surgery, University of Texas Medical the procedure in patients with melanoma is
Branch, Galveston, TX, USA complete resection of all lymph nodes (levels
e-mail: dstyler@utmb.edu I, II, and III) in the axillary basin, respecting
C. M. Balch the anatomic relations of the axillary vein,
Department of Surgical Oncology, University of Texas MD thoracodorsal neurovascular bundle, and long
Anderson Cancer Center, Houston, TX, USA
e-mail: cmbalch@mdanderson.org thoracic nerve. Performed properly, ALND
offers excellent locoregional disease control
J. F. Thompson
Melanoma Institute of Australia, The University of with acceptably low morbidity rates. While
Sydney, Sydney, NSW, Australia metastasis to epitrochlear nodes is a rare
e-mail: John.Thompson@melanoma.org.au event, epitrochlear lymph node dissection
K. M. McMasters may similarly be an important component of
University of Louisville School of Medicine, Louisville, treatment for melanoma patients.
KY, USA
e-mail: kelly.mcmasters@louisville.edu
Axillary Dissection
Anatomy
progressively thicker as its base is approached. course of the thoracodorsal nerve, artery, and
The anterior flap is raised first to expose the fascia vein and, in almost all patients, allows this
overlying the superior border of the pectoralis neurovascular bundle to be identified and pro-
major muscle. It is then easy to proceed inferiorly tected. The clavipectoral fascia just anterior to
along the pectoralis major muscle. A retrac- the thoracodorsal neurovascular bundle is then
tor along the lateral aspect of the pectoralis muscle divided and can be followed up to the level of
to guide the course of dissection can expedite this the axillary vein. At its cephalad portion near the
portion of the exposure. axillary vein, the thoracodorsal nerve usually
At this point, it is appropriate to divide the curves medially, away from the artery and vein.
clavipectoral fascia along the lateral edge of the Recognition of this fact will prevent inadvertent
pectoralis major and minor muscles. Posteriorly, nerve injury.
flaps are raised until the latissimus dorsi muscle is With more firm medial retraction of the axillary
exposed, marking the lateral edge of the dissec- contents, an inferior tributary of the thoracodorsal
tion. The inferior border of dissection is the level vein is usually apparent and can be followed to the
of the fifth intercostal space or sixth rib. The chest wall. Just posterior to this vessel, along the
inferior border of the dissection is also more prac- chest wall, lies the long thoracic nerve. In most
tically marked by the inferior extent of the patients, this nerve can then be traced cephalad, as
latissimus dorsi muscle where it meets the serratus the fascial layer just anterior the nerve is divided
anterior muscle. up to and just beneath the axillary vein. Alterna-
tively, the long thoracic nerve may be exposed by
Dissection of Nodal Tissue distracting the nodal contents laterally as the
Many surgeons prefer to begin the dissection by clavipectoral fascia along the lateral border of
identifying the axillary vein, at the level of the the pectoralis major and minor muscles is
subclavius tendon, and then proceed with the dis- exposed, and dissection is carried out more deeply
section inferiorly from this structure. While this is along the edge of the serratus anterior muscle. In
a useful technique that should be familiar to all other cases, exposure of the long thoracic nerve
surgeons, an alternative is to approach the dissec- can wait until the axillary vein is fully exposed.
tion from the lateral side. The clavipectoral fascia Dissection is then carried out to expose the
along the medial edge of the latissimus dorsi is axillary vein. Using sharp dissection, the fascia
incised. Proceeding cephalad, the main overlying the mid-portion of the axillary vein is
intercostobrachial nerve will be encountered in divided from lateral to medial, and small vessels
the fibrofatty tissue of the axilla first and is from the inferior surface of the axillary vein
divided. Preservation of this sensory nerve is not should be carefully dissected, ligated or clipped,
considered a priority in axillary dissection for and divided. The thoraco-epigastric vein is the
melanoma. Next, the tendinous portion of the most sizable tributary to be divided; it enters the
latissimus will be encountered, and careful dissec- axillary vein anteriorly in the mid-portion of the
tion will reveal the lateral portion of the axillary dissection and should not be mistakenly identified
vein anterior to the tendinous portion of latissimus as the thoracodorsal vein, which enters the axil-
dorsi. lary vein more posteriorly. If the axillary vein is
Dissection of the axillary nodal basin is facili- invaded or encased by tumor, the vein can and
tated throughout by traction and countertraction to should be ligated and resected along with the
convert the relatively amorphous axillary contents nodal metastases, often with surprisingly little
into a series of planes that can be dissected in a consequence in terms of lymphedema
linear fashion. Using a laparotomy sponge, the (Karakousis et al. 1990). Alternatively, an autolo-
axillary contents may be retracted medially gous or synthetic interposition graft can be placed
while also exerting similar traction inferiorly and between the divided ends of the vein though this is
posteriorly along the inferior portion of the not commonly done.
latissimus dorsi muscle. This straightens the
6 S. L. Wong et al.
At this point, the medial extent of the dissec- insertion point on the coracoid process by bluntly
tion is approached. The arm is abducted, bent at hooking an index finger around the insertion point
the elbow, and brought anteriorly so as to bring the of the muscle and using electrocautery to com-
hand in the approximate position of a military plete the dissection. This results in excellent expo-
salute. This maneuver takes tension off the sure of the apex of the axilla and may be done
pectoralis muscles and greatly facilitates exposure when necessary for the clearance of bulky nodal
of levels II and III of the axilla. A handheld metastasis from levels II and III because of the risk
medium-sized Richardson or Fritsch retractor is of damage to the pectoral nerves.
used to retract the pectoralis major to better Attention is now focused on dissection of the
expose the interpectoral groove. Alternatively, a level II axillary lymph nodes. As mentioned pre-
self-retaining retractor system may be used to viously, several of the level II nodes are usually
provide excellent exposure of the field. The dis- contained in a fat pad that extends cephalad to the
section continues along the undersurface of the axillary vein. This supraaxillary fat pad, found
pectoralis major muscle. The medial pectoral above the axillary vein directly overlying the bra-
neurovascular bundle is identified as it emerges chial plexus, is removed en bloc with the speci-
through or just medial to the pectoralis minor men. Karakousis et al. showed that its dissection
muscle and should be preserved when possible did not result in increased complications such as
to prevent partial atrophy of the pectoralis major lymphedema (Karakousis et al. 1990). Gentle
muscle. The medial pectoralis nerve innervates retraction of this fat pad and incision of the tissue
the clavicular and sternal origins of the pectoralis around it will allow these nodes to be brought
major muscle. This neurovascular bundle can usu- inferiorly into the specimen. The dissection is
ally be preserved by ligating and dividing a tribu- then continued medially, where level III nodes
tary that extends laterally and inferiorly into the are dissected from subclavius tendon, laterally to
axilla, allowing this bundle to be retracted medi- the medial border of the pectoralis minor muscle
ally and anteriorly along with the pectoralis mus- (if it has not been previously detached from the
cles; however, if there is any question that coracoid process).
preservation of this nerve will compromise the The lower axillary nodes are removed as the
completeness of nodal clearance, it should be specimen is brought out of the incision. Starting as
sacrificed. The specimen is dissected off the lat- the apex of the axilla, all fatty and lymphatic
eral edge of the pectoralis minor muscle. The tissues anterior and inferior to the axillary vein
lateral pectoralis nerve emerges more medially, are divided. The long thoracic and thoracodorsal
usually immediately medial to the medial border nerves should be clearly visualized at this point. If
of pectoralis minor, descends along the edge of the the long thoracic nerve has not been identified
pectoralis minor muscle, crosses it, and then previously, it can now be identified by retracting
courses between the two pectoral muscles to sup- the specimen anteriorly, thus thinning out the tis-
ply innervation to the lower third and sue along the chest wall. The long thoracic nerve
costoabdominal insertions of the pectoralis major lies in a groove alongside the chest wall superfi-
muscle. The relation of the branches of the lateral cial (lateral) to the investing fascia of the serratus
pectoral nerve to the pectoralis minor muscle can anterior muscle, in the same horizontal plane as
be quite variable. the thoracodorsal nerve. The tissue along the chest
Generally, vessels and lymphatics should be wall is divided in a longitudinal direction using a
ligated or clipped and divided. Interpectoral scalpel or electrocautery, and the nerve can usu-
nodes should be included in the specimen. At ally then be identified beneath a thin adventitial
this point, depending on the patient’s body habitus layer. Another way to identify the nerve is to
and the extent of the nodal disease, it may be retract the specimen in a posterolateral direction
helpful to divide the pectoralis minor muscle. If and gently divide the tissues along the chest wall.
necessary (and for some surgeons routinely), the The nerve can then be found as a taut “piano wire”
pectoralis minor may be detached from its palpable along the chest wall.
Axillary and Epitrochlear Lymph Node Dissection for Melanoma 7
Finally, the specimen is retracted inferiorly and disease is left behind. Portions of the skin,
laterally, allowing for sharp dissection of tissue off pectoralis major and minor muscles, and
the underlying subscapularis muscle, including latissimus dorsi may be resected if necessary to
the tissue between the long thoracic and remove all disease. In the setting of bulky nodal
thoracodorsal nerves. The specimen is removed disease, preservation of the medial pectoral, lat-
from the chest wall, and the intercostobrachial eral pectoral, thoracodorsal, and long thoracic
nerve(s) are divided as they come off the chest nerves is not as important as complete extirpation
wall and course directly through the axillary of disease (Moosman 1980). Further, if there is
contents. tumor involvement of the axillary vein, it should
be resected en bloc with the nodal specimen,
Closure taking care to ligate the proximal and distal
Once the axillary contents have been removed, the stumps of the axillary vein, if reconstruction of
entire axilla should be examined to be sure hemo- the vein is not performed.
stasis is complete. A large, closed-suction drain is This clinical presentation often requires a mod-
inserted through the inferior skin flap and into the ified approach that involves an incision across the
axilla. The drain should be positioned below the anterior chest wall in a direction that parallels the
axillary vein and secured to the skin using a stout, clavipectoral groove. The incision is carried down
nonabsorbable suture. The incision is closed in through the subcutaneous tissues, and flaps are
multiple (at least two) layers: the subcutaneous/ raised to expose the pectoralis major muscle on
deep dermal layers are approximated using 2-0 or either side of the clavipectoral groove. The dis-
3-0 synthetic absorbable sutures in an interrupted section then proceeds by splitting the pectoralis
or continuous fashion; the subcuticular layer may muscle between the two heads of the muscle. With
then be closed using a running 4-0 synthetic retraction, the pectoralis minor muscle and the
absorbable suture, or alternatively the skin may level II and III lymph nodes are exposed. Some
be approximated with suture and/or staples. In routinely or ultimately find it necessary to transect
difficult cases requiring extensive en bloc resec- the pectoralis minor muscle at its insertion into the
tion, plastic surgical consultation may be helpful coracoid process or to formally resect pectoralis
for closure of large skin and soft tissue defects. minor to gain access to the nodes. The muscle may
be removed as part of the surgical specimen when it
is involved by the underlying metastatic tumor(s).
Operative Considerations for Recurrent Branches coursing inferiorly from the axillary vein
or Bulky Axillary Metastases in the Upper and artery into the specimen are ligated and divided
Axilla as needed.
In circumstances where extensive exposure is
While the use of neoadjuvant radiotherapy in this necessary for bulky disease at levels II or III, it
clinical scenario is infrequently and rarely indi- may be necessary to split the entire length of the
cated, there are some emerging strategies for neo- pectoralis major muscle along the clavipectoral
adjuvant immunotherapy and/or targeted groove. This maneuver provides excellent expo-
molecular therapies when clinical presentation sure of the entire axillary contents. After the nodal
includes bulky axillary disease (Amaria et al. dissection, the two portions of the pectoralis major
2018; Keung et al. 2018). muscle (i.e., clavicular and pectoral segments) are
In these cases of advanced nodal metastases, re-approximated. The surgeon may need to be
the traditional boundaries of the axillary dissec- prepared to deal with supraclavicular extension
tion should not be an impediment to complete as well and a combined, in continuity ipsilateral
removal of all gross disease. Incomplete lymph neck and axillary lymphadenectomy via the
node dissection should be avoided since postop- cervicoaxillary canal (with or without clavicular
erative radiation therapy is rarely effective at pro- osteotomy or claviculectomy) may be necessary
viding regional disease control when gross in occasional cases (Goodenough et al. 2013).
8 S. L. Wong et al.
was not previously noticeable. Fortunately, such Anatomy and Surgical Technique
complications from infections are rare.
The superficial subdermal lymphatic plexuses of
the hand and forearm unite in the subcutaneous
Epitrochlear Dissection tissues to form a number of trunks that pass up the
limb in medial and lateral groups (Tanabe 1997).
Rationale The lymphatics of the forearm anastomose exten-
sively. The medial groups may pass through the
Melanomas of the distal upper extremity, specifi- epitrochlear basin en route to joining the deep
cally those found on the hand (including sub- lymphatic system, which runs with the brachial
ungual), forearm, or elbow region, can drain to artery. The lateral group passes up the forearm
the epitrochlear nodal basin. The reported inci- along the course of the cephalic vein; some of
dence of epitrochlear lymph node metastases these lymphatics may pass medially and join the
from these primaries ranges from 2.4% to 18% medial group via an epitrochlear node. The
(Hunt et al. 1998; Kidner et al. 2012; Smith et al. epitrochlear nodal basin is defined by the medial
1983). When epitrochlear nodes are involved, head of the triceps, the short head of the biceps,
they are infrequently obvious clinically; thus dil- the musculature overlying the medial epicondyle,
igence in examination of the area is important. and the brachialis muscle.
Lymphoscintigraphy will identify patients who The epitrochlear lymph nodes are located in
may need SLNB of the epitrochlear basin, and the distal medial upper arm and the medial ante-
decision-making around the need for completion cubital fossa. To clear them, a curvilinear incision
dissection is as previously described for axillary is made from a point approximately 5 cm proxi-
lymph node dissection. mal to the medial epicondyle and extended trans-
versely across the antecubital region down to the
Fig. 3 (a) Skin incision for a left epitrochlear lymph node dissection is shown by the dotted line. (b) Region anatomy of
the epitrochlear lymph nodes
10 S. L. Wong et al.
brachioradialis muscle (Fig. 3a). If prior node The brachial artery and median nerve lie deep
excision has been performed, the scar should be to the biceps muscle and tendon and should be
included in the incision. Skin flaps are raised to identified and preserved unless there is encase-
identify the following muscles: biceps, short head ment or direct invasion by nodal metastatic dis-
of triceps, brachioradialis, and flexor carpi ease. Occasionally, superior cubital fossa lymph
radialis. nodes may be found at or just deep to the bicipital
The anatomic confines of the basin are as fol- aponeurosis at the bifurcation of the brachial
lows: the superior aspect is defined by the biceps artery. These nodes may also be resected in the
muscle/tendon anteriorly and the medial course of the epitrochlear lymph node dissection.
intermuscular septum adjacent to the medial Once hemostasis is obtained, the wound is
head of the triceps and the medial epicondyle closed in layers, leaving a small, closed suction
posteriorly, noting that the proximal margin is drain in the dissected basin. Consideration should
where the brachial artery crosses the medial be given to concomitant axillary lymph node dis-
intermuscular septum. The inferior aspect is section for patients with palpable epitrochlear
defined by the proximal lateral edge of the prona- nodal metastases, because up to 50% of these
tor teres/flexor carpi radialis and the medial edge patients have subclinical involvement of their
of the brachioradialis, noting that the distal aspect axillary nodes (Hunt et al. 1998; Kidner et al.
of the space is the brachialis muscle. The lymph 2012; Smith et al. 1983).
nodes lie deep to the muscular fascia/bicipital
aponeurosis.
Any superficial veins encountered should be References
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