Inguinal node dissection for melanoma in the era of sentinel lymph node biopsy

doi:10.1016/j.surg.2006.12.018

Surgery

Volume 141, Issue 6, June 2007, Pages 728-735

https://doi.org/10.1016/j.surg.2006.12.018 Get rights and content

Background

With the introduction of sentinel lymph node (SLN) biopsy for melanoma, inguinal lymph node dissections (ILND) are more commonly performed for microscopic disease than for clinically palpable disease. We sought to examine the effect this change has on the morbidity of the operation.

Methods

A retrospective review was performed of all patients who underwent an ILND for melanoma between October 1997 and April, 2006. Clinical and pathologic data were collected and correlated by multivariate analysis with the incidence of a major wound complication.

Results

We identified 212 patients, 132 who underwent an ILND for a positive SLN and 80 for clinically palpable disease. Age, sex, and body mass index (BMI) were similar in both groups. Patients with clinically palpable disease had a significantly greater number of involved nodes (3.0 vs 1.96, P = .0013), more often had ≥4 involved nodes (29% vs 9%, P < .001), and a greater incidence of extranodal extension (47% vs 5%, P < .001). Of the 212 patients, 41 (19%) had a significant wound complication. This complication was significantly higher among patients with clinical disease compared to patients with a positive SLN (28% vs 14%, P = .02). Only BMI (odds ratio of 1.1) and the indication for the procedure (odds ratio of 2.2) were independent predictors of a major wound complication. Lymphedema occurred in 30% of the patients and was only significantly associated with clinical disease (41% vs 24%, P = .025). With a median follow-up of 2 years, regional recurrence was not significantly greater in patients with clinically palpable disease (13% vs 9%, P = not significant [ns]), although this result was possibly due to the significantly greater rate of distant recurrence (49% vs 18%, P < .001) and death (48% vs 21%) in these patients.

Conclusions

Patients undergoing an ILND for a positive SLN have a significantly lower risk of postoperative complication or lymphedema than do patients undergoing ILND for clinically palpable disease. There is a benefit in regard to the morbidity of treatment in surgically staging melanoma patients by SLN biopsy and preventing ILND for palpable disease.

Section snippets

Material and methods

Approval of the study was obtained from the University of Michigan Institutional Review Board. A retrospective review was performed of all patients who underwent an ILND between October 1997 and April 2006. Patients younger than 18 years of age were excluded, as were patients who underwent an ILND for histologies other than malignant melanoma. The clinical and pathologic data of the primary melanoma that were collected included age, sex, height, and body mass index (BMI). Breslow thickness

Results

Between October 1997 and April 2006, we identified 212 patients, 18 years of age and older, who underwent ILND for metastatic melanoma. The average age of the patients at the time of the ILND was 49.6 years (range, 17 to 92 years).

Of the 212 patients, 132 underwent ILND because of micrometastases detected on an SNL biopsy performed at the time of their local excision (Figure). A total of 80 patients underwent ILND because of clinically palpable disease. The majority of these patients, 49 (61%)

Conclusions

Inguinal groin dissection appears to carry an intrinsic risk of wound complication that is greater than that found in most other operations9, 10, 11, 12; reasons for this are multifactorial. Microorganisms in the groin area have been reported to be more numerous than the axilla and to harbor greater pathogenicity.13, 14 Thin flaps created in this area also are vulnerable to devascularization, leading to ischemia, wound edge necrosis, and creation of a portal of entry for infectious organisms.¹⁵

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Cited by (104)

Starting a minimally invasive inguinal lymphadenectomy program: Initial learning experience and outcomes
2023, Surgery (United States)
There is promising data on minimally invasive inguinal lymphadenectomy indicating decreased wound complications compared with the standard open approach. We examined our institutional experience with starting a minimally invasive inguinal lymphadenectomy program.
This is a retrospective case series of consecutive patients undergoing videoscopic minimally invasive inguinal lymphadenectomy from August 2017 to March 2022 by a single surgeon. Patients meeting criteria for inguinal lymphadenectomy were considered for minimally invasive inguinal lymphadenectomy unless there was skin involvement by tumor or bulky disease. Data collected included patient characteristics, primary cancer, surgery, and postoperative complications.
There were 26 patients included. The mean age was 60.6 ± 16.2 years. Most patients were female (n = 17, 65.4%), and the primary diagnosis was melanoma (n = 21, 19.2%). In 6 cases (23.1%), minimally invasive inguinal lymphadenectomy was combined with deep pelvic node dissection, but most patients did not have a concurrent procedure (n = 15, 57.7%). The median operative time was 119.0 minutes (range, 89.0–160.0), or 130.5 minutes (range, 89.0–345.0) when including concurrent procedures. The mean number of nodes retrieved was 9.8 ± 3.7, with a positive node identified in 19 patients (73.1%) during minimally invasive inguinal lymphadenectomy. There were 12 (46.2%) patients experiencing at least one postoperative complication within 30 days of surgery, the most common being infection (n = 4, 15.4%). One patient required reoperation for infected hematoma washout. Postoperative intervention for seroma was undertaken in 3 patients (11.5%).
Minimally invasive inguinal lymphadenectomy is a safe approach to inguinal lymph node dissection, in terms of node retrieval and postoperative complications, and can feasibly be adopted into practice with minimal learning curve.
Immediate inguinal lymphaticovenous anastomosis following lymphadenectomy in skin cancer of lower extremities
2023, Asian Journal of Surgery
Secondary lymphedema following inguinal lymph node dissection in lower extremities skin cancer reduce the patients’ quality of life. Immediate lymphaticovenous anastomosis (LVA) at groin is a procedure intended to prevent secondary lymphedema. The data regarding the long-term efficacy and safety of this procedure was limited. Therefore, we evaluated the long-term outcomes of immediate LVA in patients with melanoma and non-melanoma skin cancer of the lower extremities.
The retrospective data review of patients with melanoma or squamous cell carcinoma of the lower extremities underwent oncologic tumor resection with groin node dissection between December 2013 and December 2016 was performed. Seven patients underwent immediate LVA (intervention) at groin after node dissection and 22 acted as controls. The occurrence of lymphedema and oncologic outcomes were followed up to 7 years.
Fifteen patients (51.7%) developed postoperative lymphedema, which were three patients in the intervention group and twelve patients in the control group (p = 0.68). The intervention group had significant lower 2-year (57.1% versus 77.3%) and 5-year overall survival (14.3% versus 54.5%) (p = 0.035). The intervention group had reduced 2-year (28.6% versus 86.4%) and 5-year (28.6% versus 68.2%) Recurrence Free Survival (RFS) (p = 0.013). The intervention group also had reduced 2-year (0% versus 90%) and 5-year (0% versus 70%) Metastasis Free Survival (MFS) (p = 0.003).
Immediate inguinal LVA following groin node dissection in lower extremity skin cancer patients did not reduce the incidence of lymphedema. Unfortunately, it was associated with lower overall survival and an increase in tumor recurrence and metastasis.
A Novel Fascial Flap Technique After Inguinal Complete Lymph Node Dissection for Melanoma
2022, Journal of Surgical Research
Inguinal complete lymph node dissection (CLND) for metastatic melanoma exposes the femoral vein and artery. To protect femoral vessels while preserving the sartorius muscle, we developed a novel sartorius and adductor fascial flap (SAFF) technique for coverage.
The SAFF technique includes dissection of fascia off sartorius and/or adductor muscles, rotation over femoral vasculature, and suturing into place. Patients who underwent inguinal CLND with SAFF for melanoma at our institution were identified retrospectively from a prospectively-collected database. Patient characteristics and post-operative outcomes were obtained. Multivariate logistic regression assessed associations of palpable and non-palpable disease with wound complications.
From 2008 to 2019, 51 patients underwent CLND with SAFF. Median age was 62 years, and 59% were female. Thirty-one (61%) patients were presented with palpable disease and 20 (39%) had non-palpable disease. Fifty-five percent (95% confidence interval CI: 40%-69%) experienced at least one wound complication: wound infection was most common (45%; 95% CI: 31%-60%), while bleeding was the least (2%; 95% CI: 0.05%-11%). Complications were similar, with and without palpable disease.
The SAFF procedure covers femoral vessels, minimizes bleeding, preserves the sartorius muscle, and uses standard surgical techniques easily adoptable by surgeons who perform inguinal CLND.
Feasibility, indications and complications of SCIP flap for reconstruction after extirpative surgery for vulvar cancer
2022, Journal of Plastic, Reconstructive and Aesthetic Surgery
Surgical therapy for vulvar cancer involves wide defects that often require flap-based reconstruction. The goal of the reconstruction is fast wound healing with low donor site morbidity.
This is a retrospective observational cohort study in which we reviewed all patients who underwent surgery for vulvar cancer followed by reconstruction using the Superficial Circumflex Iliac Artery Perforator (SCIP) flap between 2015 and 2020. The primary outcome measure of this investigation was the incidence of wound complications. The secondary outcomes were the surgical indications in terms of establishing the anatomical subunits involved in the resection that made us choose this flap for reconstruction. This study adheres to the STROBE guidelines.
Thirty-two patients were included; in two cases, the flap was performed bilaterally for a total of 34 SCIP flaps. The mean age of patients was 70.6 ± 8.6 years, and the mean BMI was 26.8 ± 4.7. The SCIP flap was always feasible. The mean flap size was 128.8 ± 74.3cm². Three patients showed wound complications. In every patient, the defect involved the vulva, perineum and inguinal area; in 18 patients, the mons pubis was also involved. The mean follow-up was 30 months. During the follow-up, six patients died, and four showed local or nodal cancer relapse.
Our results suggest that the advantages of SCIP flap for the reconstruction of vulvoperineal defects secondary to vulvar cancer surgery include low complication rate, minimal donor site morbidity, quick dissection, proximity of donor and recipient sites, possibility to harvest large skin islands of variable thickness and chimeric flaps.
Randomized Study of Wound Drainage on Early Complications After Lymph Node Dissection for Melanoma
2021, Journal of Surgical Research
Citation Excerpt :
Nonetheless, reduction of in-person care is desirable in settings with community transmission of infections. The present study found decreased risk of early complications in patients operated with CLND, which is in accordance with findings in a study of 212 patients,30 but in contrast to previous retrospective studies.30,31 The total number of removed lymph nodes was not significantly different for patients operated with CLND or TLND.
The complication rate after axillary lymph node dissection (ALND) and inguinal lymph node dissection (ILND) in melanoma patients is high. The aim of this randomized non-inferiority study was to evaluate the effect of postoperative wound drainage on early complications after ALND and ILND.
Between 2018 and 2020, 104 stage III melanoma patients operated on with ALND or ILND were randomized to a study group with complete wound drain removal 3 wk after surgery or a control group with progressive drain removal. The primary end point was overall early complications graded according to the modified Clavien-Dindo classification. Secondary endpoints were length of hospital stay and prognostic factors for early complications.
Of the 99 patients analyzed, ALND was performed in 58 patients and ILND in 41 patients. Overall, 62 patients (62.6%) developed early complications: 30 in the study group and 32 in the control group (P = 0.53). The confidence interval for the difference in proportions of patients without early complications in the two groups was −0.27 to 0.11 (P = 0.42), hence non-inferiority could be claimed. Length of hospital stay was 5 d in the study group compared to 6 in the control group (P < 0.01). ILND was associated with increased risk of early complications compared to ALND (75.6% versus 53.4%, P = 0.04).
Complete drain removal 3 wk after ALN and ILND in stage III melanoma patients did not increase the risk of early complications compared to progressive drain removal.
Risk Factors for Complications and Long-Term Outcomes Following Completion Lymph Node Dissection for Cutaneous Melanoma: A Retrospective Cohort Study
2020, Journal of Plastic, Reconstructive and Aesthetic Surgery
Completion lymph node dissection (CLND) for malignant melanoma is performed for regional cancer control and is associated with a high complication rate. It is unknown whether post-operative complications influence cancer recurrence or survival. Our aim was to evaluate the risk factors for short- and long-term complications after CLND, and to determine whether complications affect recurrence or survival.
We performed a retrospective cohort study including all melanoma patients who underwent CLND in the Stockholm region during 2005–2014. Patient and cancer characteristics were collected from medical records, as were clinical outcomes. Assessment was performed by multivariate logistic regression.
Among 144 patients, the risk of any post-operative one year complication was 68.8%. Lymphedema (41.0%), infection (37.5 %), and seroma (31.3 %) were the most common complications. Diabetes and inguinal CLND were associated with nine- and ten-fold increased risks of post-operative complications (p<0.05), respectively. Complications were linked to an increased risk of recurrent cancer (p<0.05), median follow-up time of 49 months, but did not appear to affect five-year survival.
Post-operative complications are common in melanoma patients undergoing CLND. Strong risk factors for complications are diabetes and inguinal CLND. Post-operative complications appear to be associated with increased risks of recurrent cancer, but the mechanism is unknown.

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Original communicationInguinal node dissection for melanoma in the era of sentinel lymph node biopsy

Background

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Conclusions

Lancet

Am J Surg

Validation of the accuracy of intraoperative lymphatic mapping and sentinel lymphadenectomy for early-stage melanoma: a multicenter trial

Ann Surg

Technical details of intraoperative lymphatic mapping for early stage melanoma

Arch Surgery

Delayed regional lymph node dissection in stage I melanoma of the skin of the lower extremities

Cancer

Efficacy of an elective regional lymph node dissection of 1 to 4 mm thick melanomas for patients 60 years of age and younger

Ann Surg

Morbidity following prophylactic and therapeutic lymph node dissection for melanoma- A comparison

Tumori

Morbidity, mortality and local recurrence following regional node dissection for melanoma

Br J Surg

Operative morbidity associated with groin dissections

Surg Today

Operative morbidity and risk factor assessment in melanoma patients undergoing inguinal lymph node dissection

Am J Surg

Groin dissection in the treatment of lower-extremity melanomaShort term and long term morbidity

Arch Surg

Groin dissection in malignant melanoma

Br J Surg

Primary postoperative wound infection due to Staphylococcus pyogenes

Curr Probl Surg

Original communication
Inguinal node dissection for melanoma in the era of sentinel lymph node biopsy