At one time, melanoma was a rare form of cancer. Since the mid-1950s, however, its incidence is increasing faster than any other form of cancer. For some, melanoma is a chronic disease that portends a lifetime of risk factor mitigation and careful surveillance. For intermediate and thick tumors, the likelihood of lymph node metastasis is much more frequent, and when the disease is located on the lower extremities or trunk, regional spread to the inguinal nodes must be evaluated.

In the past, inguinal lymph node dissections (ILND) were performed in either an elective setting (ILND done preemptively to diagnose and treat) or a therapeutic setting (ILND done in the setting of diagnosed (palpable) disease). The presumed trade-offs of elective ILND were early removal of disease at a microscopic level versus unnecessary removal of nodes that never would have developed disease. With the advent of sentinel lymph node biopsy (SLNB), the rates of ILND decreased, since such a procedure was reserved for those with known disease, presumably found at a much earlier stage. Current controversies around the need for completion ILND revolve around the question of whether there is any therapeutic effect of ILND following SLNB.

While many studies considered surgical complications, data on the dimensions of QoL were lacking. The surgical management of metastatic disease to the groin is fraught with morbidity and complications. Overall, wound complication rates following inguinal lymph node dissections are reported in up to 71% of patients [5]. Frequent complications include seroma (17%), wound infection (9%), wound necrosis (3%), and edema (20%) [6]. Fortunately, complications appeared to decline with more minimally invasive procedures. The complication rate for a SLNB is between 4.6 and 10.1% [7]. Several studies, including the Sunbelt Melanoma Trial, have demonstrated that the morbidity with SLNB is less than compared to SLNB plus CLND. Further, surgical techniques that utilize a minimally invasive approach have shown some promise to reduce complications, particularly wound-related ones [8, 9]. Additional longitudinal QoL data will be important as approaches to inguinal nodal disease are continuously evaluated.

Bulky adenopathy of the iliac and inguinal nodes can result in lymphedema, vascular compromise, neuropathy/pain, or locoregional wound complications (either associated with involvement of nearby structures or overlying skin). Similarly, feared complications resulting from inguinal node dissections include lymphedema, ranging from relatively asymptomatic edema based on serial leg measurements to massive lymphedema which limits physical functioning; vascular compromise, including venous thrombosis; neuropathy from direct damage to nerves; or nonhealing wounds/infectious complications. Several techniques accompanying ILND include preservation of the muscle fascia, pedicled omentoplasty, sartorius transposition, and saphenous vein sparing and have been developed in an attempt to mitigate complications, without much improvement. Despite all of the above data around morbidity of groin dissections, studies have shown that the QoL of survivors is essentially comparable to the general population [7, 10]. The exact reason for this lack of impact is unknown though possible explanations include concepts such as response shift, survival bias, as well as a selection bias.

Because the majority of patients have a good functional outcome, many believe that the major impact on QoL is psychological. A systematic review of QoL in melanoma patients supports this claim. Approximately a third of all patients will experience a significant level of distress. This effect peaks around the time of diagnosis and shortly after treatment but then decreases with time. Poor preoperative health status and psychological illness are predictors of postoperative QoL impairment [11]. Even worse, studies have shown an association between QoL impairment, psychological factors, and personality structure that may affect survival [11, 12]. The cause for such psychological distress is largely unknown. The finding that approximately 85% of patients did not receive adequate treatment or assessment for psychological distress during surveillance, however, is equally concerning. Like all of the diseases reviewed here, this highlights the need and importance of continued work with QoL in patients. It also shows how important preoperative and continued postoperative psychosocial care is to QoL.