Principles of the Lymph Node Dissection in Non-melanoma Skin Cancer and Cutaneous Melanoma

  • Steven D. Kozusko
  • Alireza Hamidian Jahromi
  • Grant Bond
  • Tyler D. Ragsdale
  • Robert D. Wallace
  • Petros KonofaosEmail author


Lymphadenectomy or lymph node dissection (LND) includes systematic dissection and biopsy of the regional lymph nodes. While LND is planned for staging purposes, it could also help with local control and systemic control of the cancers (prevention of other organs getting involved). The importance of the lymph node evaluation and surgical excision in the management of the cancers cannot be overemphasized. Due to its widespread list of possible early or late complications, LND is generally considered as a morbid procedure. Introduction of the sentinel lymph node biopsy (SLNB) in the last few years has been a wise attempt aiming in prevention of unnecessary morbidities associated with LND in the patients and at the same time trying to gain invaluable cancer staging data and even help in the local and systemic control of the cancers. Some of the consequences of these procedures (mostly LND but to a lesser degree SLNB) may take more than a decade to develop. Since its introduction, SLNB has been modified to help us in identification of the primary lymphatic drainage for skin and soft tissue malignancies. SLNB is supposed to give us regional information on cancerous lymph node involvement while avoiding the morbidity of the LND. The current chapter reviews the principles of the LND in simple terms with an overview of the lymph nodes regional anatomy. We will also discuss necessary preoperative evaluations, indications and the value of LND in the patients with different skin cancers, and possible complications of SLNB and LND.


Lymph node Lymph node dissection Principles Anatomy Complications 



Conflict of Interest: None of the authors have any conflict of interest to disclose.


  1. 1.
  2. 2.
    Baroody FM, Naclerio RM. Allergy and immunology of the upper airway. In: Cummings otolaryngology. 6th ed: Elsevier Inc; 2015. p. 593–625.Google Scholar
  3. 3.
    Armitage JO, Bierman PJ. Approach to the patient with lymphadenopathy and splenomegaly. In: Goldman-Cecil Medicine. 25th ed: Elsevier Inc; 2016. p. 1138–42.Google Scholar
  4. 4.
    Shah JP, Patel SG, Singh B. Cervical lymph nodes. In: Jatin Shah’s head and neck surgery and oncology. 4th ed: Elsevier Inc.; 2012. p. 426–70.Google Scholar
  5. 5.
    Robbins KT, Samant S, Ronen O. Neck dissection. In: Cummings otolaryngology. 6th ed: Elsevier Inc; 2015. p. 1837–61.Google Scholar
  6. 6.
    Lee J, Sung TY, Nam KH, Chung WY, Soh EY, Park CS. Is level IIb lymph node dissection always necessary in N1b papillary thyroid carcinoma patients? World J Surg. 2008;32(5):716–21.CrossRefGoogle Scholar
  7. 7.
    Tanabe KK. Lymphatic mapping and epitrochlear lymph node dissection for melanoma. Surgery. 1997;121(1):102–4.CrossRefGoogle Scholar
  8. 8.
    McCartan D, Gemignani ML. The management of the axilla in breast. In: Current surgical therapy. 12th ed: Elsevier; 2017. p. 690–5.Google Scholar
  9. 9.
    Carter CL, Allen C, Nenson DE. Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer. 1989;63:181–7.CrossRefGoogle Scholar
  10. 10.
    Siegal B, Mayzel K, Love S. Level I and II axillary dissection in the treatment of early stage breast cancer. Arch Surg. 1990;125:1144.CrossRefGoogle Scholar
  11. 11.
    Rockson SG. Anatomy and structural physiology of the lymphatic system. In: Principles and practices of lymphedema surgery: Elsevier Health Sciences; 2015. p. 25–31.Google Scholar
  12. 12.
    Kaur P, Puleo CA, Cox CE. Lymphedema in the postmastectomy patient: pathophysiology, prevention and management. In: Breast: comprehensive management of benign and malignant diseases. 4th ed: Elsevier Inc; 2009. p. 897–913.Google Scholar
  13. 13.
    Paulsen F. Lower Extremity. In: Sobotta atlas of human anatomy, vol. 1. 15th ed: Elsevier GmbH; 2013. p. 243–374.Google Scholar
  14. 14.
    Spratt J. Groin dissection. J Surg Oncol. 2000;73(4):243–62.CrossRefGoogle Scholar
  15. 15.
    Swan MC, Furniss D, Cassell OC. Surgical management of metastatic inguinal lymphadenopathy. BMJ. 2004;329(7477):1272–6.CrossRefGoogle Scholar
  16. 16.
    Zhang SH, Sood AK, Sorosky JI, Anderson B, Buller RE. Preservation of the saphenous vein during inguinal lymphadenectomy decreases morbidity in patients with carcinoma of the vulva. Cancer. 2000;89(7):1520–5.CrossRefGoogle Scholar
  17. 17.
    Iannotti JP, Parker R. Ankle and foot. In: Netter collection of medical illustrations: spine and lower limb. 2nd ed: Elsevier Inc.; 2013. p. 195–244.Google Scholar
  18. 18.
    Teixeira F, Moutinho V Jr, Akaishi E, Mendes G, Perina A, Lima T, Lallee M, Couto S, Utiyama E, Rasslan S. Popliteal lymph node dissection for metastases of cutaneous malignant melanoma. World J Surg Oncol. 2014;12:135. Scholar
  19. 19.
    Marone U, Caracò C, Chiofalo MG, Botti G, Mozzillo N. Resection in the popliteal fossa for metastatic melanoma. World J Surg Oncol. 2007;5:8.CrossRefGoogle Scholar
  20. 20.
    Standring S, MBE PD. Posterior abdominal wall and retroperitoneum. In: Gray’s anatomy: Elsevier Limited; 2016. p. 1083–97.Google Scholar
  21. 21.
    Large MC, Sheinfeld J, Eggener SE. Retroperitoneal lymph node dissection: reassessment of modified templates. BJU Int. 2009;104(9 Pt B):1369–75. Scholar
  22. 22.
    Syan-Bhanvadia S, Bazargani ST, Clifford TG, Cai J, Miranda G, Daneshmand S. Midline extraperitoneal approach to retroperitoneal lymph node dissection in testicular cancer: minimizing surgical morbidity. Eur Urol. 2017;
  23. 23.
    Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician. 1998;58(6):1313–20.PubMedGoogle Scholar
  24. 24.
    Ferrer RL, Aronson MD, Freedman AS, Sullivan DJ (2016). Evaluation of peripheral lymphadenopathy in adults. Retrieved from
  25. 25.
    Kambadakone A, Grajo JR, Sahani DV. Lymph node imaging techniques and clinical role. In: Abdominal imaging. 2nd ed: Elsevier Inc.; 2017. p. 701–25.Google Scholar
  26. 26.
    Kostakoglu L. PET/CT imaging. In: Head and neck imaging. 5th ed: Mosby, Inc, Elsevier Inc.; 2011. p. 2825–91.Google Scholar
  27. 27.
    Gratzinger D, Natkunam Y. Processing of the lymph node biopsy specimen. In: Hematopathology. 2nd ed: Elsevier Inc.; 2017. p. 3–13.Google Scholar
  28. 28.
    Franco R. Lymph nodes. In: Point of care ultrasound: Elsevier Inc; 2015. p. 262–8.Google Scholar
  29. 29.
    Kimbrough CW, Urist MM, McMasters KM. Melanoma and cutaneous malignant neoplasms. In: Sabiston textbook of surgery. 12th ed: Elsevier Inc; 2017. p. 724–53.Google Scholar
  30. 30.
    Morton DL, Wen DR, Wong JH, Economou JS, Cagle LA, Storm FK, Foshag LJ, Cochran AJ. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg. 1992;127(4):392–9.CrossRefGoogle Scholar
  31. 31.
    Reintgen D, Cruse CW, Wells K, Berman C, Fenske N, Glass F, Schroer K, Heller R, Ross M, Lyman G, et al. The orderly progression of melanoma nodal metastases. Ann Surg. 1994;220(6):759–67.CrossRefGoogle Scholar
  32. 32.
    Nathanson SD, Nelson L, Karvelis KC. Rates of flow of technetium 99m: labeled human serum albumin from peripheral injection sites to sentinel lymph nodes. Ann Surg Oncol. 1996;3(4):329–35.CrossRefGoogle Scholar
  33. 33.
    Rutkowski P, Nowecki ZI, Zurawski Z, Dziewirski W, Nasierowska-Guttmejer A, Switaj T, Ruka W. In transit/local recurrences in melanoma patients after sentinel node biopsy and therapeutic lymph node dissection. Eur J Cancer. 2006;42(2):159–64.CrossRefGoogle Scholar
  34. 34.
    Leilabadi SN, Chen A, Tsai S, Soundararajan V, Silberman H, Wong AK. Update and review on the surgical management of primary cutaneous melanoma. Healthcare (Basel). 2014;2(2):234–49. Scholar
  35. 35.
    Arens A, Osinga J, Schwipper V, Schober O, Tilkorn H, Liebau J. Sentinel lymph node dissection in patients with malignant melanoma. Diagnostic and therapeutic standards. Chirurg. 2003;74(7):665–70.CrossRefGoogle Scholar
  36. 36.
    Georgeu G, El-Muttardi N, Mercer D. Malignant melanoma metastasis to the sentinel node in the popliteal fossa. Br J Plast Surg. 2002;55(5):443–5.CrossRefGoogle Scholar
  37. 37.
    Cheah WK, Arici C, Ituarte PH, et al. Complications of neck dissection for thyroid cancer. World J Surg. 2002;26:1013–6.CrossRefGoogle Scholar
  38. 38.
    Kuroda K, Yamamoto Y, Yanagisawa M, Kawata A, Akiba N, Suzuki K, Naritaka K. Risk factors and a prediction model for lower limb lymphedema following lymphadenectomy in gynecologic cancer: a hospital-based retrospective cohort study. BMC Womens Health. 2017;17(1):50. Scholar
  39. 39.
    Basta MN, Wu LC, Kanchwala SK, Serletti JM, Tchou JC, Kovach SJ, Fosnot J, Fischer JP. Reliable prediction of postmastectomy lymphedema: the risk assessment tool evaluating lymphedema. Am J Surg. 2017;213(6):1125–1133.e1. Scholar
  40. 40.
    Litrowski N, Duval Modeste AB, Coquerel D, Courville P, Milliez PY, Joly P. Complication of radical lymph node dissection following sentinel lymph node biopsy in patients with melanoma. Ann Dermatol Venereol. 2013;140(6-7):425–30. Scholar
  41. 41.
    Shaha AR. Complications of neck dissection for thyroid cancer. Ann Surg Oncol. 2008;15(2):397–9.CrossRefGoogle Scholar
  42. 42.
    Jeffrey SS, Goodson WH 3rd, Ikeda DM, Birdwell RL, Bogetz MS. Axillary lymphadenectomy for breast cancer without axillary drainage. Arch Surg. 1995;130(8):909–12; discussion 912-913CrossRefGoogle Scholar
  43. 43.
    Perlmutter GS, Leffert RD. Results of transfer of the pectoralis major tendon to treat paralysis of the serratus anterior muscle. J Bone Joint Surg Am. 1999;81(3):377–84.CrossRefGoogle Scholar
  44. 44.
    Petrek JA, Heelan MC. Incidence of breast carcinoma-related lymphedema. Cancer. 1998;83(12 Suppl American):2776–81.CrossRefGoogle Scholar
  45. 45.
    Petrek JA, Senie RT, Peters M, Rosen PP. Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer. 2001;92:1368.CrossRefGoogle Scholar
  46. 46.
    Tonouchi H, Ohmori Y, Kobayashi M, Konishi N, Tanaka K, Mohri Y, Mizutani H, Kusunoki M. Operative morbidity associated with groin dissections. Surg Today. 2004;34(5):413–8.CrossRefGoogle Scholar
  47. 47.
    van der Velden K, Ansink A. Primary groin irradiation vs primary groin surgery for early vulvar cancer. Cochrane Database Syst Rev. 2001;(4):CD002224. Review. Update in: Cochrane Database Syst Rev 2011;(5):CD002224.Google Scholar
  48. 48.
    Donohue JP, Foster RS, Rowland RG, Bihrle R, Jones J, Geier G. Nerve-sparing retroperitoneal lymphadenectomy with preservation of ejaculation. J Urol. 1990;144(2 Pt 1):287–91. discussion 291–2.CrossRefGoogle Scholar
  49. 49.
    Baniel J, Sella A. Complications of retroperitoneal lymph node dissection in testicular cancer: primary and post-chemotherapy. Semin Surg Oncol. 1999;17(4):263–7.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Steven D. Kozusko
    • 1
  • Alireza Hamidian Jahromi
    • 1
  • Grant Bond
    • 2
  • Tyler D. Ragsdale
    • 1
  • Robert D. Wallace
    • 1
  • Petros Konofaos
    • 1
    Email author
  1. 1.Department of Plastic SurgeryUniversity of Tennessee Health Science Center (UTHSC)MemphisUSA
  2. 2.Department of SurgeryUniversity of Tennessee Health Science Center (UTHSC)MemphisUSA

Personalised recommendations