Videoscopic ilioinguinal lymphadenectomy for groin lymph node metastases from melanoma

Starting a minimally invasive inguinal lymphadenectomy program: Initial learning experience and outcomes

BACKGROUND

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.

METHODS

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.

RESULTS

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%).

CONCLUSION

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.

A single-center comparison of our initial experiences in treating penile and urethral cancer with video-endoscopic inguinal lymphadenectomy (VEIL) and later experiences in melanoma cases

Background

Video-endoscopic inguinal lymphadenectomy (VEIL) is a minimally invasive approach that is increasingly indicated in oncological settings, with mounting evidence for its long-term oncological safety.

Objectives

To present our single-center experience of treating penile and urethral cancer with VEIL, as well as its more recent application in melanoma patients.

Methods

We prospectively recorded our experiences with VEIL from September 2010 to July 2018, registering the patient primary indication, surgical details, complications, and follow-up.

Results

Twenty-nine patients were operated in one (24) or both (5) groins; 18 had penile cancer, 1 had urethral cancer, and 10 had melanoma. A mean 8.62 ± 4.45 lymph nodes were removed using VEIL and of these, an average of 1.00 ± 2.87 were metastatic; 16 patients developed lymphocele and 10 presented some degree of lymphedema; there were no skin or other major complications. The median follow-up was 19.35 months; there were 3 penile cancer patient recurrences in the VEIL-operated side. None of the melanoma patients presented a lymphatic inguinal recurrence.

Conclusions

VEIL is a minimally invasive technique which appears to be oncologically safe showing fewer complications than open surgery. However, complications such as lymphorrhea, lymphocele, or lymphedema were not diminished by using VEIL.

Combined robotic inguinal and iliac‐obturator lymphadenectomy for stage III skin cancers: Surgical technique and preliminary results

Background

Ilio‐inguinal lymphadenectomy for stage III melanoma and skin cancers still represents the best therapeutic option for a subset of patients, although the incidence of post‐operative complications is dramatically high. Only a paucity of papers on robotic approach have been published, reporting experiences on isolated pelvic or inguinal lymphadenectomy, and no series on combined dissections have been described yet. We present the preliminary results achieved with combined robotic approach, with special emphasis on lymph nodal mapping, dissection technique and postoperative complications linked with the lymphatic system.

Methods

Between September 2019 and September 2021, 10 patients were submitted to robotic inguinal and iliac‐obturator lymphadenectomy.

Results

Post‐operative course was characterised by early mobilisation and minimal post‐operative pain. Only one lymphoedema occurred and lymph nodal harvesting was more than satisfactory.

Conclusions

Robotic surgery provides meticulous lymph nodal dissections, with promising functional and oncologic outcomes. Further series are advocated to confirm these preliminary results.

Pelvic sentinel lymph nodes have minimal impact on survival in melanoma patients

Background

Lower limb or trunk melanoma often presents with femoral and pelvic sentinel lymph nodes (SLNs). The benefits of harvesting pelvic lymph nodes remain controversial. In this retrospective study, the frequency and predictors of pelvic SLNs (PSLNs), and the impact of PSLNs on survival and staging was investigated.

Methods

Altogether 285 patients with cutaneous melanoma located in the lower limb or trunk underwent sentinel lymph node biopsy of the inguinal/iliac lymph node basin at Helsinki University Hospital from 2009–2013. Patient characteristics, detailed pathology reports and follow-up data were retrieved from hospital files. Subgroups of patients categorized by presence of PSLNs were compared for outcome parameters including progression-free survival, melanoma-specific survival and groin recurrence.

Results

Superficial femoral/inguinal SLNs were present in all patients and 199 (69.8 per cent) also had PSLNs removed. Median number of SLNs per patient was five and median number of PSLNs was two. Sixty-three patients (22.1 per cent) had metastases in their SLNs and seven (2.5 per cent) had metastases in PSLNs. A single patient had metastases solely in PSLNs, while superficial SLNs remained negative. Harvesting PSLNs or the number of PSLNs retrieved had no impact on progression-free survival or overall survival. The removal of PSLNs did not affect the risk of postoperative seroma or lymphoedema. The only predictor of positive PSLNs was radioactivity count equal to or more than that of the hottest superficial SLNs.

Conclusion

Pelvic SLNs have minimal clinical impact on the outcome of melanoma patients especially in cases with negative superficial femoral/inguinal SLNs. Removal of PSLNs should be considered when they are the most radioactive nodes or equal to the hottest superficial femoral/inguinal SLNs in lymphoscintigraphy or during surgery.

Preliminary results were presented in part at the International Sentinel Node Society Biennial Meeting, Tokyo, Japan, 11–13 October 2018.

One-Year Morbidity Following Videoscopic Inguinal Lymphadenectomy for Stage III Melanoma

Simple Summary

Inguinal lymphadenectomy (the removal of lymph nodes in the groin) is currently part of the treatment options for stage III melanoma patients. Surgery can be performed using one large inguinal incision (open approach) or a few smaller incisions (videoscopic approach). Previous research has already shown less severe complications and comparable oncologic outcomes after the videoscopic approach. Postoperative lymphedema following inguinal lymphadenectomy is a well-known problem which can potentially decrease quality of life. With the arrival of adjuvant systemic treatment options, less invalidating surgery is highly desirable. However, lymphedema and quality of life have only been investigated after the open approach. Therefore, we evaluated lymphedema and quality of life following videoscopic inguinal lymphadenectomy for stage III melanoma. The videoscopic inguinal lymphadenectomy is a feasible approach due to the comparable lymphedema incidence and normalization of quality of life during follow-up.

Abstract

Purpose: We aimed to elucidate morbidity following videoscopic inguinal lymphadenectomy for stage III melanoma. Methods: Melanoma patients who underwent a videoscopic inguinal lymphadenectomy between November 2015 and May 2019 were included. The measured outcomes were lymphedema and quality of life. Patients were reviewed one day prior to surgery and postoperatively every 3 months for one year. Results: A total number of 34 patients were included for participation; 19 (55.9%) patients underwent a concomitant iliac lymphadenectomy. Lymphedema incidence was 40% at 3 months and 50% at 12 months after surgery. Mean interlimb volume difference increased steadily from 1.8% at baseline to 6.9% at 12 months (p = 0.041). Median Lymph-ICF-LL total score increased from 0.0 at baseline to 12.0 at 3 months, and declined to 8.5 at 12 months (p = 0.007). Twelve months after surgery, Lymph-ICF-LL scores were higher for females (p = 0.021) and patients that received adjuvant radiotherapy (p = 0.013). The Median Distress Thermometer and EORTC QLQ-C30 summary score recovered to baseline at 12 months postoperatively (p = 0.747 and p = 0.203, respectively). Conclusions: The onset of lymphedema is rapid and continues to increase up to one year after videoscopic inguinal lymphadenectomy. Quality of life recovers to the baseline value.

Minimally invasive inguinal lymph node dissection: initial experience and reproducibility in a limited resource setting-with technique video

BACKGROUND

Conventional inguinal lymph node dissection comes with a high wound complication rate which increases hospital stay and may delay adjuvant treatment. Minimally invasive lymph node dissection (MILND) is a novel endoscopic technique which aims to minimize complications of lymphadenectomy. Herein we present our technique and experience with MILND to examine safety, feasibility and reproducibility in a setting of limited resources.

METHODS

All patients undergoing MILND in the National Cancer Institute, Cairo were prospectively included following informed consent, IRB and ethical committee approval. Demographics, clinical, pathological data and postoperative complications according to Clavien-Dindo classification were recorded. Footage collected was used to create a step-by-step video demonstrating the technique.

RESULTS

Twenty-seven procedures were included in the study. The most common indications were vulval cancer (44%) and skin melanoma (19%). There were 5 (18%) conversions to open procedure, all of them in the first 10 cases of the learning curve. The median (range) operative time was 120 (45-240) min and there was a trend towards shorter operative time after the first 5 cases. Wound dehiscence occurred in 4 cases (15%). Three of them (11%) required reoperation (grade III). Grade I/II complications in the form of seroma and wound infection occurred in 34%. The median (range) postoperative hospital stay was 2 (1-14). The median (range) number of retrieved lymph nodes was 12 (3-19). No grade III/IV lymphedema was recorded at 90 days after surgery.

CONCLUSION

MILND is a safe, feasible technique associated with relatively low postoperative wound complications even when performed in a centre with relatively limited resources.

Laparoscopically assisted ilio-inguinal lymph node dissection versus inguinal lymph node dissection in melanoma

Aim

Morbidity of open inguinal lymphadenectomy (OIL) is high. We use laparoscopy for pelvic time, preservation of the greater saphenous vein and transverse inguinal incisions (laparoscopically assisted ilio-inguinal lymphadenectomy, LIIL) to improve postoperative outcomes.

Patients & methods

Retrospective comparison of 14 patients who underwent LIIL and seven patients who underwent OIL.

Results

Fourteen LIIL compared with seven OIL showed a statistically significant reduction in morbidity (15.3 vs 75%) and hospital stay (7 vs 15.7 days). Pelvic lymph node involvement (27%) was not detected preoperatively. With a mean follow-up of 36.2 (range: 3-137) months, local recurrence rate was 58.3% in LIIL and 40% in OIL. Overall survival was significantly higher in OIL than in LIIL.

Conclusion

Compared with OIL, LIIL reduced postoperative complications and hospital stay.

Oncological outcome of videoscopic groin dissection for lymph node metastasis from melanoma

BACKGROUND

Videoscopic inguinal lymphadenectomy (VIL) represents an innovative approach for patients with melanoma lymph node (LN) metastases, mainly aimed at lowering wound-related morbidity. However, long-term data on oncologic safety are still lacking. The aim of this study is to review the oncologic outcome of videoscopic groin dissection in a single institution caseload.

METHODS

Data were prospectively gathered on patients with inguinal melanoma metastasis who underwent VIL. Clinical data included age, race, sex, tumor histology, node counts and number of metastatic nodes. Disease-free survival and overall survival were monitored based on an institutional follow-up schedule. The study was approved by the local ethics committee (Video-SIIO II study).

RESULTS

We analyzed 48 videoscopic groin dissections performed in 50 patients (2 patients underwent bilateral VIL). Median age was 54.5 years. Female/male ratio was 15/33. Indication for surgery was positive inguinal sentinel biopsy and cytological confirmed clinical disease in 40 and 10 cases, respectively. Median LN retrieval count was 19. After a median follow-up of 28 months, groin recurrence (lymphatic basin) was observed in one single case.

CONCLUSIONS

VIL for melanoma LN metastases is associated with a favorable oncologic outcome. In particular, LN yield and locoregional recurrence rate obtained with videoscopic dissection are comparable to those reported with the open technique. Prospective studies are needed to confirm these results in a larger cohort of patients.

Indocyanine green-enhanced fluorescence-guided video-assisted axillary surgery for chronic lymphocele

INTRODUCTION

Lymphocele occurs frequently after regional lymph node dissection. Surgery with multiple lymphatic ligation represents the only reliable treatment for long-standing chronic lymphocele.

MATERIALS AND SURGICAL TECHNIQUE

We report the case of a man with chronic axillary seroma after axillary lymphadenectomy for melanoma. The lymphocele was unresponsive to conservative management and successfully treated with indocyanine green lymphography-guided video-assisted axillary surgery.

DISCUSSION

Indocyanine green-enhanced fluorescence video-assisted identification and ligation of lymph vessels can simply and effectively treat recurrent chronic lymphocele after axillary or groin lymphadenectomy.

Evaluation of the videoscopic inguinal lymphadenectomy in melanoma patients

INTRODUCTION

A completion or therapeutic inguinal lymph node dissection is a procedure accompanied with a high rate of postoperative complications. A novel, minimally invasive alternative has been developed; the videoscopic inguinal lymphadenectomy. The aim of this study is to present our first experience with the videoscopic inguinal lymphadenectomy among melanoma patients with inguinal metastases.

METHODS

Melanoma patients with a histologically confirmed inguinal metastases who underwent a videoscopic inguinal lymphadenectomy between November 2015 and January 2018 were included. Outcome measures were operation time, nodal yield, and postoperative complications. Furthermore, lymphedema measurements were performed both subjectively and objectively.

RESULTS

A total of 20 patients (3 males and 17 females) underwent a videoscopic inguinal lymphadenectomy. In 75% of patients the procedure was combined with an open iliac lymphadenectomy. Median operation time of the videoscopic procedure was 110 min (range, 79-165). There were no perioperative complications or conversions. In 12 patients (60%) there was ≥1 postoperative complication. The most frequent complications were seroma and wound infection. All complications were treated conservatively without the need for a surgical re-intervention. The median nodal yield of the videoscopic procedure was 9 (range, 1-19). Lymphedema was present in nine patients (45%) after three months of follow-up.

CONCLUSION

Our initial results show that the videoscopic inguinal lymphadenectomy is an attractive alternative to the conventional open technique. The number of complications is comparable with the complication rate reported for the conventional open procedure, but they are less severe and there is no need for a surgical re-intervention.

The possible role of the da Vinci robot for patients with vulval carcinoma undergoing inguinal lymph node dissection

Inguinal lymph node dissection represents the gold standard of treatment for patients with vulval carcinoma. The application of minimally invasive techniques, such as robotics, in the surgical treatment of gynecologic cancer, reduced the rate of postoperative complications, which has an important impact on the quality of patients’ life. Robotic inguinal lymph node dissection is a safe and oncologically effective but expensive and time-consuming approach in patients with penile cancer or melanoma. However, it is related with less postoperative complications, especially less lymphocele or lymphedema rates, and can improve the patients’ quality of life while minimizing cost for health systems. The introduction of robot- assisted inguinal lymph node dissection in the treatment of vulval carcinoma may be identified as a provisional option for the gynecologic oncologist. Our intention was to present a brief review/commentary on the possible use of a robot-assisted technique on inguinal lymphadenectomy for patients with vulval cancer.