Abstract | December 20, 2022

Palliative Right Hip Disarticulation for Bulky Ulcerating Metastatic Melanoma to Inguinal Lymph Nodes

Presenting Author: Leila Rezaian-Yazdi, BS, Medical Student, 4th Year, Department of Surgery, University of South Carolina School of Medicine, Columbia, South Carolina

Coauthors: Michael Gibbons, MD, General Surgery, PGY5, Prisma Health-Midlands, Columbia, SC; Neelam Mulji, MD, General Surgery, PGY2, Prisma Health-Midlands, Columbia, SC; Kevin Choong, MD, Surgical Oncologist, Department of Surgery, Prisma Health-Midlands, Columbia, SC; Julian Kim, MD, Chair, Department of Surgery, Prisma Health-Midlands, Columbia, SC

Learning Objectives

  1. Identify clinical cases where palliative surgery may be a viable treatment option for complex symptom management.
  2. Discuss the benefits of palliative surgery and how it may improve the patient's quality of life.

Introduction: We present a case of an 86 year old male who presented for treatment of a large right inguinal mass from recurrent melanoma.

 

Case Presentation: The patient’s melanoma was initially diagnosed in 2015 on his right heel as acral lentiginous melanoma, stage pT3b (Breslow thickness of 2.8 mm, ulceration present). He had previously undergone a right above the knee amputation in 2018 and had recovered well, demonstrating good mobility with a prosthesis. The patient subsequently developed recurrence in his right inguinal lymph nodes refractory to checkpoint inhibitors with rapid progression between May and June of 2022. The recurrence resulted in a large ulcerating tumor with bleeding, odor, need for extensive wound care, and inability to wear a prosthesis. On imaging, there was extensive right inguinal lymphadenopathy with the lesion measuring 20 cm. Additionally, there was no evidence of additional metastatic disease. Goals of care were discussed with the patient and his family, and a palliative right hip disarticulation was planned. 

 

Management: During the operation, a standard circumferential hip disarticulation incision was made. The femoral artery, vein, and nerve were carefully dissected free and ligated. Relevant proximal thigh musculature was then divided to dissect down to the hip joint. The femur was sawed at the femoral neck to expose the posterior compartment of the thigh and posterior musculature. The sciatic nerve was then divided. The femoral head was then disarticulated from the acetabulum and the ligamentum teres was divided. The gluteal muscle was rotated over to fill the space and the incision was closed in layers with underlying drains. The patient was discharged after overnight observation. He returned 2 weeks later to the clinic for a post-op evaluation and his drains were removed. It was noted that the patient’s pain had substantially improved, wound care has become less challenging, and his mobility had increased after the surgery. 

 

Conclusion: In conclusion, palliative surgery is a reasonable option in appropriately selected patients with the potential for significant improvement in quality of life. Palliative surgery helped this patient regain his mobility, independence, and relieved his daily pain from the metastatic lesion.

 

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