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Long-Term Treatment Outcome after Only Popliteal Lymph Node Dissection for Nodal Metastasis in Malignant Melanoma of the Heel: The Only “Interval Node” Dissection Can Be an Adequate Surgical Treatment

Long-Term Treatment Outcome after Only Popliteal Lymph Node Dissection for Nodal Metastasis in... Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2013, Article ID 259326, 4 pages http://dx.doi.org/10.1155/2013/259326 Case Report Long-Term Treatment Outcome after Only Popliteal Lymph Node Dissection for Nodal Metastasis in Malignant Melanoma of the Heel: The Only ‘‘Interval Node’’ Dissection Can Be an Adequate Surgical Treatment 1 1 1 2 2 Kentaro Tanaka, Hiroki Mori, Mutsumi Okazaki, Aya Nishizawa, and Hiroo Yokozeki Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan Department of Dermatology, Graduate School of Medical Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan Correspondence should be addressed to Kentaro Tanaka; kenta.plas@tmd.ac.jp Received 26 March 2013; Accepted 20 April 2013 Academic Editors: G. Di Vagno and M. Ryberg Copyright © 2013 Kentaro Tanaka et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We present a patient with malignant melanoma on his heel. Wide local excision was performed, along with sentinel lymph node biopsy of the inguinal and popliteal lesions. The primary site was clear of tumor at all margins; the inguinal nodes were negative, but the popliteal node was positive for metastatic melanoma. Only radical popliteal lymph node dissection was performed. eTh patient went on to receive adjuvant chemoimmunotherapy. er Th e was no recurrence or complication until the long-term followup. Popliteal drainage from below the knee is uncommon, and the rate of popliteal-positive and inguinal-negative cases is estimated to be less than 1% of all melanomas. er Th e is no established evidence about how to treat lymph nodes in these cases. Because we considered popliteal nodes as a regional, not interval, lymph node basin, only popliteal lymph node dissection was performed, and good postoperative course was achieved. eTh first site of drainage is the sentinel node, and the popliteal node can be a sentinel node. eTh inguinal node is not a sentinel node in all lower extremity melanomas. This case illustrates the importance of individual detailed investigation of lymphatic drainage patterns from foot to inguinal and popliteal nodes. 1. Introduction the popliteal fossa, do not perform popliteal node biopsy, or consider the presence of popliteal metastasis positivity as an Sentinel lymph node biopsy is now an essential procedure indication for inguinal dissection. for the treatment of cutaneous malignant melanoma. Lym- We present a case of a patient with a malignant melanoma phoscintigraphy is commonly used for identification of on his left heel, who had positive popliteal node metastasis the sentinel lymph node, which is sometimes detected in and negative inguinal node. Only popliteal lymph node dis- unexpected areas, such as the popliteal fossa in distal lower section was performed, and there was no recurrence or com- extremity melanoma cases. These are called interval nodes. plication until long-term followup. This case study illustrates Popliteal drainage from below the knee is uncommon, and the importance of more detailed individual investigation of popliteal node metastasis cases are rare. In particular, the rate lymphatic drainage patterns from the foot to the inguinal and of popliteal-positive and inguinal-negative cases is estimated popliteal lymph nodes. to be less than 1% of all melanomas. In these cases, management of lymph node dissection is 2. Case Presentation necessary for den fi itive surgical treatment, but there are no clear answer and no established evidence about how to treat A 72-year-old man presented to the department of dermatol- lymph nodes in the literature. Some surgeons do not examine ogywitha2-week historyofgeographicalmelanotic lesion 2 Case Reports in Oncological Medicine (a) Figure 1: The findings of primary skin tumor when first diagnosed. The lesion was 55×40 mm in size with a 15 mm-diameter nonulcer- ated nodule in the center. of his left heel. eTh lesion was 55×40 mm in size with a 15 mm-diameter nonulcerated nodule in the center when rfi st diagnosed (Figure 1). The findings of dermoscopy confirmed the presence of malignant melanoma. Neither inguinal nor popliteal lymph node was palpable, and no distant metastasis or lymph node enlargement was found by contrast com- puterized tomography scanning and F-u fl orodeoxyglucose positron emission tomography. eTh depth of tumor invasion was evaluated to be the superficial layer of subcutaneous fatty tissue by magnetic resonance imaging. The patient was referred to the department of plastic and reconstructive surgery for surgical treatment. eTh day before surgery, lymph nodes were detected in inguinal and popliteal lesions by lymphoscintigraphy (Figure 2). Prior to excision, 1 mL of patent blue was injected intradermally around the (b) primary tumor. A wide local excision with 1.5 cm margin including plantar fascia was performed, along with sentinel Figure 2: Lymphoscintigraphy on the day before surgery. Lymph lymph node biopsy of the inguinal and popliteal lesions nodes were detected in both (a) inguinal and (b) popliteal lesions. using a combination of a gamma probe and the highlighted lymphatics obtained from the patent blue dye. Aeft r excision of the malignant melanoma from the left heel, the defect was covered with medial plantar flap and split-thickness skin Examination of the specimen showed that the nodes were grafting from the left femur. positive (2/2). The AJCC/UICC clinical stage was T4aN2aM0, The specimen was confirmed to be a 4.2 mm-thick, acral stage IIIA. The patient went on to receive adjuvant chemoim- lentiginous melanoma, Clark’s level IV, on pathologic exam- munotherapy with vfi e courses of DAV-feron therapy (con- ination. The primary site was clear of tumor at all margins; sisting of dacarbazine, nimustine hydrochloride, vincristine, the inguinal nodes were negative (0/3), but the popliteal node and interferon beta) and a monthly local injection of inter- was positive (1/1) for metastatic melanoma. Therefore, radical feron beta to the left heel and popliteal space performed by popliteal lymph node dissection was performed [1]. A fat pad dermatologists. and lymphatic tissue under popliteal fascia were dissected from around the popliteal vessels and major nerve trunks to The patient had an uneventful postoperative recovery. the lower leg with an S-shaped incision. Although the lesser All wounds healed in a satisfactory fashion. There were no saphenous vein was sacrificed, the other vessels (popliteal local or systemic signs of recurrence until his 33-month artery and vein) and nerves (tibial, common peroneal, and followup, and lymphedema was not seen in the left lower leg medial sural cutaneous nerves) were preserved (Figure 3). (Figure 4). Case Reports in Oncological Medicine 3 (a) (a) (b) (b) Figure 3: (a) eTh operative findings of radical popliteal lymph node Figure 4: eTh 33-month postoperative findings of the patient’s lower dissection. A fat pad and lymphatic tissue under the popliteal fascia extremity. eTh re were no local or systemic signs of recurrence, and were dissected from around the popliteal vessels and major nerve lymphedema was not seen in the left lower leg. trunkstothelowerlegwithanS-shapedincision.(b)Poplitealartery andveinand tibial,commonperoneal, andmedialsural cutaneous nerves were preserved, although the lesser saphenous vein was epitrochlear region or popliteal fossa [2]. Lymph nodes in sacrificed. these lesions have been described as interval or in-transit nodes, including drainage to the popliteal nodes for a distal lower extremity. According to classical anatomical theory, drainage from the dorsum and medial aspect of the foot 3. Discussion passes parallel to the course of the great saphenous vein to the The most effective treatment of malignant melanoma is inguinal lesion, and drainage from the posterolateral aspect of thought to be a surgical excision of primary tumor and meta- the heel, sole, and lateral malleolus follows the lesser saphe- static lesion. eTh extent of excision should be necessary and nous vein to the popliteal legion. om Th pson et al. [ 3]showed sufficient from the perspective of tumor recurrence and post- that positive nodes in the popliteal fossa can occur from operative complications, and the determination of indication a lesion anywhere below the knee. Biopsy of these interval for lymph node dissection is sometimes difficult. nodes in melanoma indicates that they are as frequently Lymphatic drainage of cutaneous melanoma targets cer- involved with metastatic disease as the nodes in the conven- vical, axillary, or inguinal lesions in many cases, but some tional lymph node basin [4]. However, the rate of popliteal melanomas initially drain to unexpected areas, such as the nodes detection was reported [2–8]tobefrom1.8%to 4 Case Reports in Oncological Medicine 9.6%, so popliteal nodal metastasis is relatively uncommon. pp. 543–549, 2002. Furthermore, the popliteal metastasis-positive and inguinal- [5] B. Morcos and F. Al-Ahmad, “Metastasis to the popliteal lymph negative rate of all melanomas located below the knee is nodes in lower extremity melanoma and their management,” Surgical Oncology,vol.20, no.2,pp. e119–e122, 2011. estimatedtorange from 0.16%to0.94% [2–7]. In these popliteal-positive and inguinal-negative cases, [6] S. T. Steen, H. Kargozaran, C. J. Moran, M. Shin-Sim, D. L. Mor- the issue of which lesions should be dissected is important. ton, and M. B. Faries, “Management of popliteal sentinel nodes in melanoma,” Journal of the American College of Surgeons,vol. There is no established evidence on this subject. Because we 213, no. 1, pp. 180–186, 2011. considered popliteal nodes as a regional, not interval, lymph [7] N.Hatta,R.Morita, M. Yamada,K.Takehara, K. Ichiyanagi,and node basin and defined the popliteal status independent K. Yokoyama, “Implications of popliteal lymph node detected of the inguinal nodal status, only popliteal lymph node by sentinel lymph node biopsy,” Dermatologic Surgery,vol.31, dissection without dissection of the next nodal basin was per- no.3,pp. 327–330, 2005. formed. As a result, good postoperative course with no recur- [8] R.F.Uren, R. Howman-Giles,J.F.Thompson et al., “Interval rence or complication was achieved in our institution. Lym- nodes: the forgotten sentinel nodes in patients with melanoma,” phedema is an unpleasant complication of inguinal and ilio- Archives of Surgery,vol.135,no. 10,pp. 1168–1172, 2000. inguinal lymph node dissection, which may cause a chronic [9] A. J. Spillane, R. P. M. Saw, M. Tucker, K. Byth, and J. F. o Th mp- feeling of heaviness, discomfort, and pain, sometimes result- son, “Defining lower limb lymphedema aer ft inguinal or ilio- ing in limitation of patient activity. This is reported to occur inguinal dissection in patients with melanoma using classifica- in 9% to 55% of patients, but lymphedema is rarely seen aeft r tion andregressiontreeanalysis,” Annals of Surgery,vol.248, only popliteal lymph node dissection [9, 10]. In our case, only no. 2, pp. 286–293, 2008. “interval” node dissection is thought to be an adequate treat- [10] S. Abbas and M. Seitz, “Systematic review and meta-analysis of ment. Because Steen et al. reported that two popliteal node- the used surgical techniques to reduce leg lymphedema follow- positive and inguinal-negative cases had nodal recurrences ing radical inguinal nodes dissection,” Surgical Oncology,vol. in the groin aer ft disease-free intervals of about 60 months 20,no. 2, pp.88–96,2011. [6], further long-term followup and prompt treatment for recurrence are necessary in our patient. Lymphoscintigraphy is now used routinely for sentinel lymph node biopsy and sometimes identifies popliteal nodal drainage,which canbethe only site of nodalmetastasisin some cases [4]. The first site of drainage of a lesion is the sentinel node by definition, so the popliteal node can be a sen- tinellymph node,not an “intervalnode.”Theinguinalnode is not the sentinel node in all lower extremity melanomas, and all sentinel nodes identified by a lymphoscintigram should be removed. There are thought to be some patterns of lymphatic drainage from the foot to the inguinal and popliteal lymph nodes [5]. More detailed investigation of anatomical predictions of nodal drainage should be performed, and more appropriate surgical treatment is expected to improve patient’s quality of life. Conflict of Interests eTh authors declare that they have no conflict of interests. References [1] A. Sholar, R. C. G. Martin 2nd, and K. M. McMasters, “Popliteal lymph node dissection,” Annals of Surgical Oncology,vol.12, no. 2, pp. 189–193, 2005. [2] W. E. Sumner 3rd, M. I. Ross, P. F. Mansfield et al., “Implications of lymphatic drainage to unusual sentinel lymph node sites in patients with primary cutaneous melanoma,” Cancer,vol.95, no. 2, pp. 354–360, 2002. [3] J.F.Thompson,J.A.Hunt, G. Culjak,R.F.Uren, R. Howman- Giles,andC.R.Harman,“Popliteallymphnodemetastasisfrom primary cutaneous melanoma,” European Journal of Surgical Oncology,vol.26, no.2,pp. 172–176, 2000. [4] K. M. McMasters, C. Chao, S. L. Wong et al., “Interval sentinel lymph nodes in melanoma,” Archives of Surgery,vol.137,no. 5, MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Oncological Medicine Hindawi Publishing Corporation

Long-Term Treatment Outcome after Only Popliteal Lymph Node Dissection for Nodal Metastasis in Malignant Melanoma of the Heel: The Only “Interval Node” Dissection Can Be an Adequate Surgical Treatment

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Copyright © 2013 Kentaro Tanaka et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2013, Article ID 259326, 4 pages http://dx.doi.org/10.1155/2013/259326 Case Report Long-Term Treatment Outcome after Only Popliteal Lymph Node Dissection for Nodal Metastasis in Malignant Melanoma of the Heel: The Only ‘‘Interval Node’’ Dissection Can Be an Adequate Surgical Treatment 1 1 1 2 2 Kentaro Tanaka, Hiroki Mori, Mutsumi Okazaki, Aya Nishizawa, and Hiroo Yokozeki Department of Plastic and Reconstructive Surgery, Graduate School of Medical Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan Department of Dermatology, Graduate School of Medical Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan Correspondence should be addressed to Kentaro Tanaka; kenta.plas@tmd.ac.jp Received 26 March 2013; Accepted 20 April 2013 Academic Editors: G. Di Vagno and M. Ryberg Copyright © 2013 Kentaro Tanaka et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We present a patient with malignant melanoma on his heel. Wide local excision was performed, along with sentinel lymph node biopsy of the inguinal and popliteal lesions. The primary site was clear of tumor at all margins; the inguinal nodes were negative, but the popliteal node was positive for metastatic melanoma. Only radical popliteal lymph node dissection was performed. eTh patient went on to receive adjuvant chemoimmunotherapy. er Th e was no recurrence or complication until the long-term followup. Popliteal drainage from below the knee is uncommon, and the rate of popliteal-positive and inguinal-negative cases is estimated to be less than 1% of all melanomas. er Th e is no established evidence about how to treat lymph nodes in these cases. Because we considered popliteal nodes as a regional, not interval, lymph node basin, only popliteal lymph node dissection was performed, and good postoperative course was achieved. eTh first site of drainage is the sentinel node, and the popliteal node can be a sentinel node. eTh inguinal node is not a sentinel node in all lower extremity melanomas. This case illustrates the importance of individual detailed investigation of lymphatic drainage patterns from foot to inguinal and popliteal nodes. 1. Introduction the popliteal fossa, do not perform popliteal node biopsy, or consider the presence of popliteal metastasis positivity as an Sentinel lymph node biopsy is now an essential procedure indication for inguinal dissection. for the treatment of cutaneous malignant melanoma. Lym- We present a case of a patient with a malignant melanoma phoscintigraphy is commonly used for identification of on his left heel, who had positive popliteal node metastasis the sentinel lymph node, which is sometimes detected in and negative inguinal node. Only popliteal lymph node dis- unexpected areas, such as the popliteal fossa in distal lower section was performed, and there was no recurrence or com- extremity melanoma cases. These are called interval nodes. plication until long-term followup. This case study illustrates Popliteal drainage from below the knee is uncommon, and the importance of more detailed individual investigation of popliteal node metastasis cases are rare. In particular, the rate lymphatic drainage patterns from the foot to the inguinal and of popliteal-positive and inguinal-negative cases is estimated popliteal lymph nodes. to be less than 1% of all melanomas. In these cases, management of lymph node dissection is 2. Case Presentation necessary for den fi itive surgical treatment, but there are no clear answer and no established evidence about how to treat A 72-year-old man presented to the department of dermatol- lymph nodes in the literature. Some surgeons do not examine ogywitha2-week historyofgeographicalmelanotic lesion 2 Case Reports in Oncological Medicine (a) Figure 1: The findings of primary skin tumor when first diagnosed. The lesion was 55×40 mm in size with a 15 mm-diameter nonulcer- ated nodule in the center. of his left heel. eTh lesion was 55×40 mm in size with a 15 mm-diameter nonulcerated nodule in the center when rfi st diagnosed (Figure 1). The findings of dermoscopy confirmed the presence of malignant melanoma. Neither inguinal nor popliteal lymph node was palpable, and no distant metastasis or lymph node enlargement was found by contrast com- puterized tomography scanning and F-u fl orodeoxyglucose positron emission tomography. eTh depth of tumor invasion was evaluated to be the superficial layer of subcutaneous fatty tissue by magnetic resonance imaging. The patient was referred to the department of plastic and reconstructive surgery for surgical treatment. eTh day before surgery, lymph nodes were detected in inguinal and popliteal lesions by lymphoscintigraphy (Figure 2). Prior to excision, 1 mL of patent blue was injected intradermally around the (b) primary tumor. A wide local excision with 1.5 cm margin including plantar fascia was performed, along with sentinel Figure 2: Lymphoscintigraphy on the day before surgery. Lymph lymph node biopsy of the inguinal and popliteal lesions nodes were detected in both (a) inguinal and (b) popliteal lesions. using a combination of a gamma probe and the highlighted lymphatics obtained from the patent blue dye. Aeft r excision of the malignant melanoma from the left heel, the defect was covered with medial plantar flap and split-thickness skin Examination of the specimen showed that the nodes were grafting from the left femur. positive (2/2). The AJCC/UICC clinical stage was T4aN2aM0, The specimen was confirmed to be a 4.2 mm-thick, acral stage IIIA. The patient went on to receive adjuvant chemoim- lentiginous melanoma, Clark’s level IV, on pathologic exam- munotherapy with vfi e courses of DAV-feron therapy (con- ination. The primary site was clear of tumor at all margins; sisting of dacarbazine, nimustine hydrochloride, vincristine, the inguinal nodes were negative (0/3), but the popliteal node and interferon beta) and a monthly local injection of inter- was positive (1/1) for metastatic melanoma. Therefore, radical feron beta to the left heel and popliteal space performed by popliteal lymph node dissection was performed [1]. A fat pad dermatologists. and lymphatic tissue under popliteal fascia were dissected from around the popliteal vessels and major nerve trunks to The patient had an uneventful postoperative recovery. the lower leg with an S-shaped incision. Although the lesser All wounds healed in a satisfactory fashion. There were no saphenous vein was sacrificed, the other vessels (popliteal local or systemic signs of recurrence until his 33-month artery and vein) and nerves (tibial, common peroneal, and followup, and lymphedema was not seen in the left lower leg medial sural cutaneous nerves) were preserved (Figure 3). (Figure 4). Case Reports in Oncological Medicine 3 (a) (a) (b) (b) Figure 3: (a) eTh operative findings of radical popliteal lymph node Figure 4: eTh 33-month postoperative findings of the patient’s lower dissection. A fat pad and lymphatic tissue under the popliteal fascia extremity. eTh re were no local or systemic signs of recurrence, and were dissected from around the popliteal vessels and major nerve lymphedema was not seen in the left lower leg. trunkstothelowerlegwithanS-shapedincision.(b)Poplitealartery andveinand tibial,commonperoneal, andmedialsural cutaneous nerves were preserved, although the lesser saphenous vein was epitrochlear region or popliteal fossa [2]. Lymph nodes in sacrificed. these lesions have been described as interval or in-transit nodes, including drainage to the popliteal nodes for a distal lower extremity. According to classical anatomical theory, drainage from the dorsum and medial aspect of the foot 3. Discussion passes parallel to the course of the great saphenous vein to the The most effective treatment of malignant melanoma is inguinal lesion, and drainage from the posterolateral aspect of thought to be a surgical excision of primary tumor and meta- the heel, sole, and lateral malleolus follows the lesser saphe- static lesion. eTh extent of excision should be necessary and nous vein to the popliteal legion. om Th pson et al. [ 3]showed sufficient from the perspective of tumor recurrence and post- that positive nodes in the popliteal fossa can occur from operative complications, and the determination of indication a lesion anywhere below the knee. Biopsy of these interval for lymph node dissection is sometimes difficult. nodes in melanoma indicates that they are as frequently Lymphatic drainage of cutaneous melanoma targets cer- involved with metastatic disease as the nodes in the conven- vical, axillary, or inguinal lesions in many cases, but some tional lymph node basin [4]. However, the rate of popliteal melanomas initially drain to unexpected areas, such as the nodes detection was reported [2–8]tobefrom1.8%to 4 Case Reports in Oncological Medicine 9.6%, so popliteal nodal metastasis is relatively uncommon. pp. 543–549, 2002. Furthermore, the popliteal metastasis-positive and inguinal- [5] B. Morcos and F. Al-Ahmad, “Metastasis to the popliteal lymph negative rate of all melanomas located below the knee is nodes in lower extremity melanoma and their management,” Surgical Oncology,vol.20, no.2,pp. e119–e122, 2011. estimatedtorange from 0.16%to0.94% [2–7]. In these popliteal-positive and inguinal-negative cases, [6] S. T. Steen, H. Kargozaran, C. J. Moran, M. Shin-Sim, D. L. Mor- the issue of which lesions should be dissected is important. ton, and M. B. Faries, “Management of popliteal sentinel nodes in melanoma,” Journal of the American College of Surgeons,vol. There is no established evidence on this subject. Because we 213, no. 1, pp. 180–186, 2011. considered popliteal nodes as a regional, not interval, lymph [7] N.Hatta,R.Morita, M. Yamada,K.Takehara, K. Ichiyanagi,and node basin and defined the popliteal status independent K. Yokoyama, “Implications of popliteal lymph node detected of the inguinal nodal status, only popliteal lymph node by sentinel lymph node biopsy,” Dermatologic Surgery,vol.31, dissection without dissection of the next nodal basin was per- no.3,pp. 327–330, 2005. formed. As a result, good postoperative course with no recur- [8] R.F.Uren, R. Howman-Giles,J.F.Thompson et al., “Interval rence or complication was achieved in our institution. Lym- nodes: the forgotten sentinel nodes in patients with melanoma,” phedema is an unpleasant complication of inguinal and ilio- Archives of Surgery,vol.135,no. 10,pp. 1168–1172, 2000. inguinal lymph node dissection, which may cause a chronic [9] A. J. Spillane, R. P. M. Saw, M. Tucker, K. Byth, and J. F. o Th mp- feeling of heaviness, discomfort, and pain, sometimes result- son, “Defining lower limb lymphedema aer ft inguinal or ilio- ing in limitation of patient activity. This is reported to occur inguinal dissection in patients with melanoma using classifica- in 9% to 55% of patients, but lymphedema is rarely seen aeft r tion andregressiontreeanalysis,” Annals of Surgery,vol.248, only popliteal lymph node dissection [9, 10]. In our case, only no. 2, pp. 286–293, 2008. “interval” node dissection is thought to be an adequate treat- [10] S. Abbas and M. Seitz, “Systematic review and meta-analysis of ment. Because Steen et al. reported that two popliteal node- the used surgical techniques to reduce leg lymphedema follow- positive and inguinal-negative cases had nodal recurrences ing radical inguinal nodes dissection,” Surgical Oncology,vol. in the groin aer ft disease-free intervals of about 60 months 20,no. 2, pp.88–96,2011. [6], further long-term followup and prompt treatment for recurrence are necessary in our patient. Lymphoscintigraphy is now used routinely for sentinel lymph node biopsy and sometimes identifies popliteal nodal drainage,which canbethe only site of nodalmetastasisin some cases [4]. The first site of drainage of a lesion is the sentinel node by definition, so the popliteal node can be a sen- tinellymph node,not an “intervalnode.”Theinguinalnode is not the sentinel node in all lower extremity melanomas, and all sentinel nodes identified by a lymphoscintigram should be removed. There are thought to be some patterns of lymphatic drainage from the foot to the inguinal and popliteal lymph nodes [5]. More detailed investigation of anatomical predictions of nodal drainage should be performed, and more appropriate surgical treatment is expected to improve patient’s quality of life. Conflict of Interests eTh authors declare that they have no conflict of interests. References [1] A. Sholar, R. C. G. Martin 2nd, and K. M. McMasters, “Popliteal lymph node dissection,” Annals of Surgical Oncology,vol.12, no. 2, pp. 189–193, 2005. [2] W. E. Sumner 3rd, M. I. Ross, P. F. Mansfield et al., “Implications of lymphatic drainage to unusual sentinel lymph node sites in patients with primary cutaneous melanoma,” Cancer,vol.95, no. 2, pp. 354–360, 2002. [3] J.F.Thompson,J.A.Hunt, G. Culjak,R.F.Uren, R. Howman- Giles,andC.R.Harman,“Popliteallymphnodemetastasisfrom primary cutaneous melanoma,” European Journal of Surgical Oncology,vol.26, no.2,pp. 172–176, 2000. [4] K. M. McMasters, C. Chao, S. L. Wong et al., “Interval sentinel lymph nodes in melanoma,” Archives of Surgery,vol.137,no. 5, MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal

Case Reports in Oncological MedicineHindawi Publishing Corporation

Published: May 12, 2013

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