Annals of Surgical Oncology

, Volume 20, Issue 6, pp 2056–2064 | Cite as

How Often do Level III Nodes Bear Melanoma Metastases and does it Affect Patient Outcomes?

  • Carolyn Nessim
  • Calvin Law
  • Yarrow McConnell
  • Sade Shachar
  • Gregory McKinnon
  • Frances Wright



Limited data exist regarding the necessity of resecting level three nodes as part of an axillary dissection for melanoma. The objective of this study was to determine how often level III nodes have metastases, in patients with sentinel lymph node (SLN) positive, palpable and bulky axillary disease, and to determine patient outcomes.


A retrospective chart review was completed at two tertiary care centers of patients with melanoma that had level three axillary dissections. At the time of surgery, the level III nodes were sent as a separate specimen. Bulky disease was defined as a large mass in all three levels that could not be separated.


A total of 117 patients were identified. Three percent and 18 % of patients with SLN+ and palpable disease, respectively, had further disease in their level III nodes. All bulky patients had level III disease. Those with level III disease had a worse 3-year overall survival than those who did not (15.2 vs. 61.1 %, p < 0.001). For patients with palpable and bulky disease, systemic recurrence rate was 65 and 88 %, with a median time to metastases of 13.6 and 2 months, respectively.


Patients with SLN+ disease rarely have positive level III nodes, questioning the need for routine removal of these nodes. Patients with palpable and bulky lymph node disease have implied occult distant metastases at the time of diagnosis and treatment. With the advent of improved targeted therapies for melanoma, clinical trials evaluating their role in patients with stage III disease may be warranted to improve patient outcomes.


Melanoma Sentinel Lymph Node Lymphedema Axillary Dissection Vemurafenib 



The authors thank Dr. Jean-François Boileau for his support and advice throughout the project and the inclusion of his patients in this series. We also thank Dr. May Lynn Quan for her contribution and the inclusion of her patients in this series.

Conflict of interest

The authors of this paper do not have any disclosures to declare.


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Copyright information

© Society of Surgical Oncology 2013

Authors and Affiliations

  • Carolyn Nessim
    • 1
  • Calvin Law
    • 1
  • Yarrow McConnell
    • 2
  • Sade Shachar
    • 1
  • Gregory McKinnon
    • 2
  • Frances Wright
    • 1
  1. 1.Sunnybrook Health Sciences Center, Odette Cancer CenterUniversity of TorontoTorontoCanada
  2. 2.Alberta Health Services, Tom Baker Cancer CenterUniversity of CalgaryCalgaryCanada

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