Regional Metastasis

On physical exam, the most common clinical manifestation of regional melanoma in the head and neck region is lymphadenopathy. This can involve the anterior and posterior cervical nodes, but can also include conventionally ignored nodal basins such as occipital, pre- and postauricular, intraparotid, and axillary basins. Prediction of the possibly involved nodal basin is complicated by the frequently unexpected lymph node drainage patterns of primary melanomas on the head, neck, and upper torso. Between 35% and 84% of patients have discordant drainage to unexpected lymph node basins (5,6). Almost 50% of patients with midline primary melanomas have lymph node drainage to both sides of the neck (6). Moreover, nonpalpable lymph nodes may contain significant melanoma metastases.

Another manifestation of regional spread is satellite and in-transit lesions. Satellite lesions are dermal or subcutaneous metastases within 2 cm of the primary lesion (Fig. 1D) (7). Melanoma can also form intralymphatic dermal or subcutaneous in-transit metastases extending from the primary lesion to the regional draining lymph node basin. These can be extensive and progressive, resulting in significant disease burden, particularly from primary melanomas on the scalp.

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