Axillary and Epitrochlear Lymph Node

Dissection for Melanoma

Sandra L. Wong, Douglas S. Tyler, Charles M. Balch,

John F. Thompson, and Kelly M. McMasters

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

© Springer Nature Switzerland AG 2019 1

C. Balch et al. (eds.), Cutaneous Melanoma,
https://doi.org/10.1007/978-3-319-46029-1_21-1
2 S. L. Wong et al.
Introduction
Indications for regional lymph node dissection in
melanoma have evolved over time. Previous debates
focused on the timing of lymphadenectomy: it could
be performed as a therapeutic lymph node dissection
for palpable nodal disease or expectantly as an elec-
tive lymph node dissection (ELND). The advent of
sentinel lymph node biopsy (SLNB) in the 1990s
puts to rest the prior debate regarding the merits of
elective vs. therapeutic lymph node dissection (Mor-
ton et al. 1992). Because SLNB detects early nodal
micrometastases, but also causes little morbidity,
ELND became irrelevant, and the predominant
indication for regional lymphadenectomy shifted to
patients with microscopic nodal disease.
For clinically detected, biopsy-proven nodal
disease, therapeutic lymph node dissection is
still a standard practice, following a comprehen-
sive staging evaluation and with due consider-
ation given to a multimodality treatment plan or
clinical trial enrollment. Completion lymph node
dissection (CLND) is the term used for
lymphadenectomy performed after SLNB detects
nodal micrometastases and is defined as removal
of the remaining nodes beyond the sentinel node
(s). The purported benefits of CLND following a
tumor-positive SLNB are improved regional
nodal basin disease control, more accurate stag-
ing, and, until 2017, a possible survival benefit.
More recently, the therapeutic utility of CLND,
coupled with considerations of associated mor-
bidity and cost, has been increasingly questioned,
especially given the option of nodal basin obser-
vation with delayed node dissection if regional
nodal disease becomes apparent.
Decision-making in this regard is discussed in
detail elsewhere (see also Biopsy of the Sentinel
Node). Briefly, the value of CLND has been
questioned, since only about 15–20% of these
specimens reveal evidence of additional disease
in the non-sentinel nodes. Two large prospective,
randomized trials have failed to demonstrate a
survival benefit (whether defined as overall sur-
vival or melanoma-specific survival) for CLND
(Faries et al. 2017; Leiter et al. 2016). These data
support both a therapeutic benefit for SLNB alone
(because the majority of patients with nodal
micrometastases will not have disease in non-sen-
tinel nodes) and a small but finite risk of regional
nodal basin recurrence even after CLND. There-
fore, either CLND or careful observation (clinical
follow-up in conjunction with nodal basin ultra-
sonography and other imaging studies) may be
considered for patients with low-risk micro-
metastatic disease. For higher risk patients, giving
due consideration to clinicopathological factors,
the potential risks and benefits of foregoing
CLND should be discussed. The role of (and
need for) CLND as it pertains to decision-making
around adjuvant therapy also needs to be
considered.
While the specifics of decision-making for
regional lymph node dissection are evolving, sur-
gery remains a cornerstone of management of
nodal metastases. Importantly, surgical principles
remain the same for therapeutic, elective, and
completion lymphadenectomy. Performed prop-
erly, regional lymphadenectomy offers excellent
locoregional disease control with acceptable mor-
bidity rates.
As such, the goal of axillary lymph node dis-
section for melanoma is complete resection of all
lymph nodes in the axillary basin. Skeletonization
of the axillary vein, thoracodorsal neurovascular
bundle, and long thoracic nerve and removal of all
levels I, II, and III lymph nodes should be accom-
plished during the course of the procedure. With
bulky or multiple metastatic nodes, the regional
nodal recurrence rates after axillary dissection can
exceed 20%, and postoperative adjuvant treat-
ment options may be considered (see also Adju-
vant Systemic Therapy for High-Risk Melanoma
Patients).
Metastasis to epitrochlear nodes is a rare event,
but can occur from melanomas of the distal upper
extremity. Knowledge of the anatomy of the
epitrochlear nodal basin is important for surgeons
who treat melanoma and find themselves faced
with palpable disease in the epitrochlear region
or with findings of a positive epitrochlear SLN.
Axillary and Epitrochlear Lymph Node Dissection for Melanoma
Axillary Dissection
Anatomy
Melanomas involving the ipsilateral upper trunk
or upper extremity tend to drain to the axillary
nodal basin. Use of lymphoscintigraphy has
redefined classical anatomic studies because it
provides a functional picture of cutaneous lym-
phatic drainage (see also Lymphoscintigraphy in
Patients with Melanoma). Multiple nodal basin
drainage from the trunk is not uncommon, and
lymphoscintigraphy should be done to identify
all nodal basins at risk. Epitrochlear drainage is
seen in less than 5% of distal upper extremity
lesions, almost always with concomitant axillary
nodal drainage. Many shoulder and supra-
clavicular lesions have unexpected drainage pat-
terns and commonly drain to axillary as well as
supraclavicular or cervical nodal basins. Upper
trunk lesions may drain to bilateral axillae (espe-
cially if close to the midline) as well as to supra-
clavicular or cervical nodes (for more cephalad
primary tumor locations). Lesions of the lower
trunk may drain to bilateral axillae and/or to the
inguinal nodes.
The axilla is essentially pyramidal in shape,
with an apex, base, and four muscular walls. The
apex is formed by the clavicle, upper border of the
first rib, and the superior border of the scapula.
The boundary between the axilla and the supra-
clavicular fossa is at the level of the subclavius
tendon. The base of the axilla is made up of the
skin of the axilla, the superficial fascia, and the
pectoral fascia. The four walls of the axilla include
the anterior wall, the posterior wall, the lateral
wall, and the medial wall. The anterior wall con-
sists of the pectoralis major and minor muscles.
The posterior wall is comprised of the sub-
scapularis, teres major, and latissimus dorsi mus-
cles. The lateral wall muscles include the
coracobrachialis and short head of the biceps,
while the medial wall is formed by the upper
digitations of serratus anterior.
The axillary nodes are divided into levels I, II,
and III (Fig. 1). Level I nodes are lateral to the
3
Fig. 1 Lymphatic anatomy of the axilla shows three sub-
groups of axillary lymph nodes, levels I, II, and III (as
labelled in the diagram). All lymph nodes in the axilla
must be removed as part of the complete axillary lymph
node dissection for melanoma
pectoralis minor muscle. Level II nodes are deep
to the pectoralis minor. Classical surgical teaching
has long held that axillary dissection should not
include removal of tissue cephalad of the axillary
vein. However, some level II nodes actually reside
in a fat pad that predictably extends anterior to and
superior to the axillary vein. In fact, this is a com-
mon site of recurrence after incomplete axillary
dissection, and when bulky disease is present, it
may be mistakenly thought to represent supra-
clavicular nodal recurrence or may be termed by
radiologists on imaging studies as “infraclavicular”
or “subpectoral” nodal disease. In fact, there are no
“infraclavicular” or “subpectoral” nodal basins –
these misguided clinical terms refer to nodes that
are found in levels II and III of the axilla. Level III
nodes, by definition, are located medial to the
pectoralis minor muscle, in the apex of the axilla.
Complete clearance of level III nodes allows access
to the subclavius tendon (“Halsted’s ligament”),
beneath which the axillary vein enters the supra-
clavicular fossa to become the subclavian vein. For-
mal axillary lymph node dissection performed for
melanoma should always include levels I, II, and III
lymph nodes.
4 S. L. Wong et al.
Surgical Technique
Preoperative and Perioperative
Preparation
General anesthesia should be used for this proce-
dure, although paravertebral block anesthesia, as a
regional alternative to general anesthesia, has
been described (Conveney et al. 1998). Preopera-
tive antibiotics have been shown to reduce the rate
of postoperative wound infection, and a single
dose should be administered prior to skin incision
(Bold et al. 1998; Coit et al. 1991). The patient
should be supine with the arm extended on an arm
board. The scapula may be “bumped” on a rolled
sheet to elevate the axilla off the operating table.
Folded sheets or foam padding are placed on the
arm board to elevate the arm and to prevent hyper-
extension at the shoulder which may cause trac-
tion injury to the brachial plexus. The patient’s
ipsilateral chest, axilla, and entire arm down to the
wrist are included in the sterile preparation. Axil-
lary hair may be clipped as needed immediately
prior to this part of the prep. It is important that the
sterile preparation extends medially onto the
lower neck and includes the posterior shoulder.
The hand and wrist are wrapped with sterile
towels or in stockinette to allow the entire upper
limb to be included in the field and moved during
the procedure to help with exposure of the upper
axilla (level III). Towel clips or staples are used to
secure sterile towels around the surgical field. An
Fig. 2 The lazy-S incision
provides excellent exposure
to the entire axilla (and is
shown here between
the marked border of the
pectoralis muscle and the
marked border of the
latissumus muscle). Here,
the prior incision is
intended to be included en
bloc
excellent sterile field is provided when the arm is
placed through the opening of a standard laparot-
omy or breast/chest drape.
Incision
While a short curvilinear incision at the inferior
aspect of the hairline is commonly used for axil-
lary dissection for breast cancer, extended expo-
sure is generally helpful in melanoma cases
(Balch 1990). A “lazy-S” incision, from the supe-
rior border of the pectoralis muscle, extended in a
caudal direction transversely over the fourth rib
across the axilla and then longitudinally over the
latissimus muscle, provides optimal access to the
entire axilla (Fig. 2). If a previous incision exists
from a SLNB, the resultant scar should be excised
en bloc with the specimen. (For this reason, the
placement of a SLNB of incision should be made
with care and along the course of a standard axil-
lary dissection incision if possible.)
Skin Flaps
The skin incision is made with a knife, and elec-
trocautery is used to incise the dermis and subcu-
taneous tissue. Electrocautery is then used to
develop the skin flaps within the subcutaneous
layer. Skin hooks and countertraction on the sub-
cutaneous tissue are used to assist with flap for-
mation. The plane of dissection is approximately
0.5–1.0 cm deep, depending on the amount of
subcutaneous tissue. The flap is made
Axillary and Epitrochlear Lymph Node Dissection for Melanoma
progressively thicker as its base is approached.
The anterior flap is raised first to expose the fascia
overlying the superior border of the pectoralis
major muscle. It is then easy to proceed inferiorly
along the pectoralis major muscle. A retrac-
tor along the lateral aspect of the pectoralis muscle
to guide the course of dissection can expedite this
portion of the exposure.
At this point, it is appropriate to divide the
clavipectoral fascia along the lateral edge of the
pectoralis major and minor muscles. Posteriorly,
flaps are raised until the latissimus dorsi muscle is
exposed, marking the lateral edge of the dissec-
tion. The inferior border of dissection is the level
of the fifth intercostal space or sixth rib. The
inferior border of the dissection is also more prac-
tically marked by the inferior extent of the
latissimus dorsi muscle where it meets the serratus
anterior muscle.
Dissection of Nodal Tissue
Many surgeons prefer to begin the dissection by
identifying the axillary vein, at the level of the
subclavius tendon, and then proceed with the dis-
section inferiorly from this structure. While this is
a useful technique that should be familiar to all
surgeons, an alternative is to approach the dissec-
tion from the lateral side. The clavipectoral fascia
along the medial edge of the latissimus dorsi is
incised. Proceeding cephalad, the main
intercostobrachial nerve will be encountered in
the fibrofatty tissue of the axilla first and is
divided. Preservation of this sensory nerve is not
considered a priority in axillary dissection for
melanoma. Next, the tendinous portion of the
latissimus will be encountered, and careful dissec-
tion will reveal the lateral portion of the axillary
vein anterior to the tendinous portion of latissimus
dorsi.
Dissection of the axillary nodal basin is facili-
tated throughout by traction and countertraction to
convert the relatively amorphous axillary contents
into a series of planes that can be dissected in a
linear fashion. Using a laparotomy sponge, the
axillary contents may be retracted medially
while also exerting similar traction inferiorly and
posteriorly along the inferior portion of the
latissimus dorsi muscle. This straightens the
5
course of the thoracodorsal nerve, artery, and
vein and, in almost all patients, allows this
neurovascular bundle to be identified and pro-
tected. The clavipectoral fascia just anterior to
the thoracodorsal neurovascular bundle is then
divided and can be followed up to the level of
the axillary vein. At its cephalad portion near the
axillary vein, the thoracodorsal nerve usually
curves medially, away from the artery and vein.
Recognition of this fact will prevent inadvertent
nerve injury.
With more firm medial retraction of the axillary
contents, an inferior tributary of the thoracodorsal
vein is usually apparent and can be followed to the
chest wall. Just posterior to this vessel, along the
chest wall, lies the long thoracic nerve. In most
patients, this nerve can then be traced cephalad, as
the fascial layer just anterior the nerve is divided
up to and just beneath the axillary vein. Alterna-
tively, the long thoracic nerve may be exposed by
distracting the nodal contents laterally as the
clavipectoral fascia along the lateral border of
the pectoralis major and minor muscles is
exposed, and dissection is carried out more deeply
along the edge of the serratus anterior muscle. In
other cases, exposure of the long thoracic nerve
can wait until the axillary vein is fully exposed.
Dissection is then carried out to expose the
axillary vein. Using sharp dissection, the fascia
overlying the mid-portion of the axillary vein is
divided from lateral to medial, and small vessels
from the inferior surface of the axillary vein
should be carefully dissected, ligated or clipped,
and divided. The thoraco-epigastric vein is the
most sizable tributary to be divided; it enters the
axillary vein anteriorly in the mid-portion of the
dissection and should not be mistakenly identified
as the thoracodorsal vein, which enters the axil-
lary vein more posteriorly. If the axillary vein is
invaded or encased by tumor, the vein can and
should be ligated and resected along with the
nodal metastases, often with surprisingly little
consequence in terms of lymphedema
(Karakousis et al. 1990). Alternatively, an autolo-
gous or synthetic interposition graft can be placed
between the divided ends of the vein though this is
not commonly done.
6 S. L. Wong et al.
At this point, the medial extent of the dissec-
tion is approached. The arm is abducted, bent at
the elbow, and brought anteriorly so as to bring the
hand in the approximate position of a military
salute. This maneuver takes tension off the
pectoralis muscles and greatly facilitates exposure
of levels II and III of the axilla. A handheld
medium-sized Richardson or Fritsch retractor is
used to retract the pectoralis major to better
expose the interpectoral groove. Alternatively, a
self-retaining retractor system may be used to
provide excellent exposure of the field. The dis-
section continues along the undersurface of the
pectoralis major muscle. The medial pectoral
neurovascular bundle is identified as it emerges
through or just medial to the pectoralis minor
muscle and should be preserved when possible
to prevent partial atrophy of the pectoralis major
muscle. The medial pectoralis nerve innervates
the clavicular and sternal origins of the pectoralis
major muscle. This neurovascular bundle can usu-
ally be preserved by ligating and dividing a tribu-
tary that extends laterally and inferiorly into the
axilla, allowing this bundle to be retracted medi-
ally and anteriorly along with the pectoralis mus-
cles; however, if there is any question that
preservation of this nerve will compromise the
completeness of nodal clearance, it should be
sacrificed. The specimen is dissected off the lat-
eral edge of the pectoralis minor muscle. The
lateral pectoralis nerve emerges more medially,
usually immediately medial to the medial border
of pectoralis minor, descends along the edge of the
pectoralis minor muscle, crosses it, and then
courses between the two pectoral muscles to sup-
ply innervation to the lower third and
costoabdominal insertions of the pectoralis major
muscle. The relation of the branches of the lateral
pectoral nerve to the pectoralis minor muscle can
be quite variable.
Generally, vessels and lymphatics should be
ligated or clipped and divided. Interpectoral
nodes should be included in the specimen. At
this point, depending on the patient’s body habitus
and the extent of the nodal disease, it may be
helpful to divide the pectoralis minor muscle. If
necessary (and for some surgeons routinely), the
pectoralis minor may be detached from its
insertion point on the coracoid process by bluntly
hooking an index finger around the insertion point
of the muscle and using electrocautery to com-
plete the dissection. This results in excellent expo-
sure of the apex of the axilla and may be done
when necessary for the clearance of bulky nodal
metastasis from levels II and III because of the risk
of damage to the pectoral nerves.
Attention is now focused on dissection of the
level II axillary lymph nodes. As mentioned pre-
viously, several of the level II nodes are usually
contained in a fat pad that extends cephalad to the
axillary vein. This supraaxillary fat pad, found
above the axillary vein directly overlying the bra-
chial plexus, is removed en bloc with the speci-
men. Karakousis et al. showed that its dissection
did not result in increased complications such as
lymphedema (Karakousis et al. 1990). Gentle
retraction of this fat pad and incision of the tissue
around it will allow these nodes to be brought
inferiorly into the specimen. The dissection is
then continued medially, where level III nodes
are dissected from subclavius tendon, laterally to
the medial border of the pectoralis minor muscle
(if it has not been previously detached from the
coracoid process).
The lower axillary nodes are removed as the
specimen is brought out of the incision. Starting as
the apex of the axilla, all fatty and lymphatic
tissues anterior and inferior to the axillary vein
are divided. The long thoracic and thoracodorsal
nerves should be clearly visualized at this point. If
the long thoracic nerve has not been identified
previously, it can now be identified by retracting
the specimen anteriorly, thus thinning out the tis-
sue along the chest wall. The long thoracic nerve
lies in a groove alongside the chest wall superfi-
cial (lateral) to the investing fascia of the serratus
anterior muscle, in the same horizontal plane as
the thoracodorsal nerve. The tissue along the chest
wall is divided in a longitudinal direction using a
scalpel or electrocautery, and the nerve can usu-
ally then be identified beneath a thin adventitial
layer. Another way to identify the nerve is to
retract the specimen in a posterolateral direction
and gently divide the tissues along the chest wall.
The nerve can then be found as a taut “piano wire”
palpable along the chest wall.
Axillary and Epitrochlear Lymph Node Dissection for Melanoma
Finally, the specimen is retracted inferiorly and
laterally, allowing for sharp dissection of tissue off
the underlying subscapularis muscle, including
the tissue between the long thoracic and
thoracodorsal nerves. The specimen is removed
from the chest wall, and the intercostobrachial
nerve(s) are divided as they come off the chest
wall and course directly through the axillary
contents.
Closure
Once the axillary contents have been removed, the
entire axilla should be examined to be sure hemo-
stasis is complete. A large, closed-suction drain is
inserted through the inferior skin flap and into the
axilla. The drain should be positioned below the
axillary vein and secured to the skin using a stout,
nonabsorbable suture. The incision is closed in
multiple (at least two) layers: the subcutaneous/
deep dermal layers are approximated using 2-0 or
3-0 synthetic absorbable sutures in an interrupted
or continuous fashion; the subcuticular layer may
then be closed using a running 4-0 synthetic
absorbable suture, or alternatively the skin may
be approximated with suture and/or staples. In
difficult cases requiring extensive en bloc resec-
tion, plastic surgical consultation may be helpful
for closure of large skin and soft tissue defects.
Operative Considerations for Recurrent
or Bulky Axillary Metastases in the Upper
Axilla
While the use of neoadjuvant radiotherapy in this
clinical scenario is infrequently and rarely indi-
cated, there are some emerging strategies for neo-
adjuvant immunotherapy and/or targeted
molecular therapies when clinical presentation
includes bulky axillary disease (Amaria et al.
2018; Keung et al. 2018).
In these cases of advanced nodal metastases,
the traditional boundaries of the axillary dissec-
tion should not be an impediment to complete
removal of all gross disease. Incomplete lymph
node dissection should be avoided since postop-
erative radiation therapy is rarely effective at pro-
viding regional disease control when gross
7
disease is left behind. Portions of the skin,
pectoralis major and minor muscles, and
latissimus dorsi may be resected if necessary to
remove all disease. In the setting of bulky nodal
disease, preservation of the medial pectoral, lat-
eral pectoral, thoracodorsal, and long thoracic
nerves is not as important as complete extirpation
of disease (Moosman 1980). Further, if there is
tumor involvement of the axillary vein, it should
be resected en bloc with the nodal specimen,
taking care to ligate the proximal and distal
stumps of the axillary vein, if reconstruction of
the vein is not performed.
This clinical presentation often requires a mod-
ified approach that involves an incision across the
anterior chest wall in a direction that parallels the
clavipectoral groove. The incision is carried down
through the subcutaneous tissues, and flaps are
raised to expose the pectoralis major muscle on
either side of the clavipectoral groove. The dis-
section then proceeds by splitting the pectoralis
muscle between the two heads of the muscle. With
retraction, the pectoralis minor muscle and the
level II and III lymph nodes are exposed. Some
routinely or ultimately find it necessary to transect
the pectoralis minor muscle at its insertion into the
coracoid process or to formally resect pectoralis
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).
Branches coursing inferiorly from the axillary vein
and artery into the specimen are ligated and divided
as needed.
In circumstances where extensive exposure is
necessary for bulky disease at levels II or III, it
may be necessary to split the entire length of the
pectoralis major muscle along the clavipectoral
groove. This maneuver provides excellent expo-
sure of the entire axillary contents. After the nodal
dissection, the two portions of the pectoralis major
muscle (i.e., clavicular and pectoral segments) are
re-approximated. The surgeon may need to be
prepared to deal with supraclavicular extension
as well and a combined, in continuity ipsilateral
neck and axillary lymphadenectomy via the
cervicoaxillary canal (with or without clavicular
osteotomy or claviculectomy) may be necessary
in occasional cases (Goodenough et al. 2013).
8 S. L. Wong et al.
Postoperative Management
Postoperatively, patients may be discharged on
the same day, although some surgeons prefer
overnight observation. Closed suction drainage
is continued until the output is less than
25–30 ml/day; drains are usually removed
10–21 days postoperatively. Routine drain care
includes “stripping” or “milking” of the drainage
catheter to maintain patency, with appropriate
cleansing of the drain exit site and a sterile dress-
ing changed daily. Caution must be exercised if
drains are left in place for longer than 3–4 weeks
following surgery because of the risk of prolonged
drainage or wound infection. Immediately post-
operatively, patients are unlikely to require more
than just a few doses of narcotic pain medicine,
and many have adequate pain relief with nonste-
roidal anti-inflammatory agents only; this avoids
the risk of ensuing persistent opioid use (Hill et al.
2017; Lee et al. 2017).
Gentle range of motion exercises can begin in
the early postoperative period, but should not be
too vigorous until a few days after drain removal.
Early mobilization of the arm and range of motion
exercises help prevent long-term restriction of
shoulder motion. Physical therapy is rarely
needed if adequate patient instruction for arm
mobilization is given. The arm should not be
immobilized in a sling.
Complications
The complication rate following axillary lymph
node dissection is relatively low. The most com-
mon complications are minor (Bland et al. 1981;
Bowsher et al. 1986; Urist et al. 1983). A small
seroma, the most common problem, usually does
not require treatment and can be managed expec-
tantly, but needle aspiration could be considered;
repeated needle aspiration or drain replacement
may be necessary in persistent cases. Wound
infections are usually caused by Staphylococcus
aureus and can be treated with antibiotics in most
cases. If an infected seroma or fluid collection is
present concomitantly, drainage is usually neces-
sary. Nerve dysfunction/pain, hemorrhage, skin
necrosis, and other complications have been
reported to be uncommon, but better collection
of patient-reported outcomes will give us better
data in the future.
Long-term complications are also uncommon,
but potentially debilitating. Lymphedema is per-
haps the most troublesome complication. Early
postoperative lymphedema of the arm may
resolve with extremity elevation, but chronic
lymphedema often results in functional deficits
and discomfort. At the first sign of lymphedema,
aggressive lymphedema therapy should be initi-
ated; this may include massage, a compression
garment, and other techniques.
The reported incidence of lymphedema follow-
ing axillary dissection ranges from 0% to 30% and
may depend on how it is measured, taking both
quantitative and qualitative data into account.
Postoperative radiotherapy and wound complica-
tions are thought to be independent risk factors for
the development of lymphedema. Arms may be
measured circumferentially, or arm volumes can
be measured by using a water displacement tech-
nique (Starritt et al. 2004), with lymphedema
defined as an increase in arm volume greater
than 16% relative to the volume of the control
arm. Many have found that subjective functional
deficit or pain after level I–III axillary dissection is
a distinct entity and does not correlate with degree
of lymphedema (Neuss et al. 2010).
In more contemporary series, the incidence of
lymphedema is reported as 8–24% (Faries et al.
2017; Leiter et al. 2016) again with a lower rate if
only more serious cases are counted (here, 8% is
cited when lymphedema is reported as a Grade 3
or 4 complication). Paresthesias, chronic pain, and
restricted arm mobility are sometimes difficult to
manage and can severely affect the quality of life
for patients.
After axillary dissection, patients should be
cautioned about the increased risk of infection in
that arm. Even minor skin infections (e.g.,
resulting from an insect bite or cat scratch) can
occasionally result in severe lymphangitis or cel-
lulitis requiring antibiotic treatment or even hos-
pitalization. Sometimes such an infection will
worsen lymphedema or trigger lymphedema that
Axillary and Epitrochlear Lymph Node Dissection for Melanoma
was not previously noticeable. Fortunately, such
complications from infections are rare.
Epitrochlear Dissection
Rationale
Melanomas of the distal upper extremity, specifi-
cally those found on the hand (including sub-
ungual), forearm, or elbow region, can drain to
the epitrochlear nodal basin. The reported inci-
dence of epitrochlear lymph node metastases
from these primaries ranges from 2.4% to 18%
(Hunt et al. 1998; Kidner et al. 2012; Smith et al.
1983). When epitrochlear nodes are involved,
they are infrequently obvious clinically; thus dil-
igence in examination of the area is important.
Lymphoscintigraphy will identify patients who
may need SLNB of the epitrochlear basin, and
decision-making around the need for completion
dissection is as previously described for axillary
lymph node dissection.
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
9
Anatomy and Surgical Technique
The superficial subdermal lymphatic plexuses of
the hand and forearm unite in the subcutaneous
tissues to form a number of trunks that pass up the
limb in medial and lateral groups (Tanabe 1997).
The lymphatics of the forearm anastomose exten-
sively. The medial groups may pass through the
epitrochlear basin en route to joining the deep
lymphatic system, which runs with the brachial
artery. The lateral group passes up the forearm
along the course of the cephalic vein; some of
these lymphatics may pass medially and join the
medial group via an epitrochlear node. The
epitrochlear nodal basin is defined by the medial
head of the triceps, the short head of the biceps,
the musculature overlying the medial epicondyle,
and the brachialis muscle.
The epitrochlear lymph nodes are located in
the distal medial upper arm and the medial ante-
cubital fossa. To clear them, a curvilinear incision
is made from a point approximately 5 cm proxi-
mal to the medial epicondyle and extended trans-
versely across the antecubital region down to the
10
brachioradialis muscle (Fig. 3a). If prior node
excision has been performed, the scar should be
included in the incision. Skin flaps are raised to
identify the following muscles: biceps, short head
of triceps, brachioradialis, and flexor carpi
radialis.
The anatomic confines of the basin are as fol-
lows: the superior aspect is defined by the biceps
muscle/tendon anteriorly and the medial
intermuscular septum adjacent to the medial
head of the triceps and the medial epicondyle
posteriorly, noting that the proximal margin is
where the brachial artery crosses the medial
intermuscular septum. The inferior aspect is
defined by the proximal lateral edge of the prona-
tor teres/flexor carpi radialis and the medial edge
of the brachioradialis, noting that the distal aspect
of the space is the brachialis muscle. The lymph
nodes lie deep to the muscular fascia/bicipital
aponeurosis.
Any superficial veins encountered should be
ligated or clipped and divided. The basilic vein is
typically preserved, but superficial tributaries of
the basilic vein will frequently require division to
fully access the lymphoareolar tissue. Branches of
the medial antebrachial cutaneous nerves also
pierce the muscular fascia adjacent to the main
basilic vein. If the median antebrachial cutaneous
nerves are transected, there will be a loss of sen-
sation to the C8 and T1 dermatomes, so attempts
at preservation may be worthwhile.
Dissection proceeds proximally, with en bloc
resection of lymphatic tissue found within the
confines of the biceps muscle, triceps muscle,
and medial epicondyle. There exist only a few
epitrochlear nodes, and they are found lying
upon the brachialis muscle. Typically, the nodes
are found adjacent to the medial epicondyle of the
humerus within a groove formed by the origin of
the forearm flexor muscles and the short head of
the biceps (Fig. 3b). The proximal extent of dis-
section is defined as the point where the brachial
artery crosses over the medial intermuscular sep-
tum. The inferior ulnar collateral artery and vein,
which lie superficial to the brachialis muscle, may
need to be ligated and divided in order to remove
all lymphoareolar tissue.
S. L. Wong et al.
The brachial artery and median nerve lie deep
to the biceps muscle and tendon and should be
identified and preserved unless there is encase-
ment or direct invasion by nodal metastatic dis-
ease. Occasionally, superior cubital fossa lymph
nodes may be found at or just deep to the bicipital
aponeurosis at the bifurcation of the brachial
artery. These nodes may also be resected in the
course of the epitrochlear lymph node dissection.
Once hemostasis is obtained, the wound is
closed in layers, leaving a small, closed suction
drain in the dissected basin. Consideration should
be given to concomitant axillary lymph node dis-
section for patients with palpable epitrochlear
nodal metastases, because up to 50% of these
patients have subclinical involvement of their
axillary nodes (Hunt et al. 1998; Kidner et al.
2012; Smith et al. 1983).
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