Training High-Volume Melanoma Surgeons to Perform a Novel Minimally Invasive Inguinal Lymphadenectomy: Report of a Prospective Multi-Institutional Trial

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.

Surgical Management of Melanoma: Advances and Updates

PURPOSE OF REVIEW

To review and update surgeons about the evolving complexities in the surgical management of melanoma including lymph node staging and treatment.

RECENT FINDINGS

Primary resection with adequate margins continues to be the standard of care for localized cutaneous melanoma. Sentinel lymph node biopsy is confirmed to be a powerful tool due to its prognostic value and informative guidance for adjuvant treatments and surveillance. Due to the lack of benefit in melanoma-specific survival and distant metastasis-free survival, completion lymph node dissection is not performed routinely after a positive sentinel lymph node biopsy. Neoadjuvant systemic treatment approaches for advanced loco-regional disease show promise in phase I and II clinical trial data, and phase III studies. The surgical management of cutaneous melanoma continues to evolve with further de-escalation of the extent of excision of primary melanomas and the management of lymph node disease.

Oncologic Outcomes of Multi-Institutional Minimally Invasive Inguinal Lymph Node Dissection for Melanoma Compared with Open Inguinal Dissection in the Second Multicenter Selective Lymphadenectomy Trial (MSLT-II)

BACKGROUND

Minimally invasive inguinal lymphadenectomy (MILND) is safe and feasible, but limited data exist regarding oncologic outcomes.

METHODS

This study performed a multi-institutional retrospective cohort analysis of consecutive MILND performed for melanoma between January 2009 and June 2016. The open ILND (OILND) comparative cohort comprised patients enrolled in the second Multicenter Selective Lymphadenectomy Trial (MSLT-II) between December 2004 and March 2014.The pre-defined primary end point was the same-basin regional nodal recurrence, calculated using properties of binomial distribution. Time to events was calculated using the Kaplan-Meier method. The secondary end points were overall survival, progression-free survival, melanoma-specific survival (MSS), and distant metastasis-free survival (DMFS).

RESULTS

For all the patients undergoing MILND, the same-basin regional recurrence rate was 4.4 % (10/228; 95 % confidence interval [CI], 2.1-7.9 %): 8.2 % (4/49) for clinical nodal disease and 3.4 % (6/179) for patients with a positive sentinel lymph node (SLN) as the indication. For the 288 patients enrolled in MSLT-II who underwent OILND for a positive SLN, 17 (5.9 %) had regional node recurrence as their first event. After controlling for ulceration, positive LN count and positive non-SLNs at the time of lymphadenectomy, no difference in OS, PFS, MSS or DMFS was observed for patients with a positive SLN who underwent MILND versus OILND.

CONCLUSION

This large multi-institutional experience supports the oncologic safety of MILND for melanoma. The outcomes in this large multi-institutional experience of MILND compared favorably with those for an OILND population during similar periods, supporting the oncologic safety of MILND for melanoma.

Robotic-Assisted Video-Endoscopic Inguinal Lymphadenectomy (RAVEIL) and Video-Endoscopic Inguinal Lymphadenectomy (VEIL) versus Open Inguinal Lymph-Node Dissection (OILND) in carcinoma of penis: Comparison of perioperative outcomes, complications and oncological outcomes. A systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis evaluating the peri-operative outcomes, complications, and oncological outcomes of Robotic-Assisted Video-Endoscopic Inguinal Lymphadenectomy (RAVEIL)/Video-Endoscopic Inguinal Lymphadenectomy (VEIL) with Open Inguinal Lymph-Node Dissection (OILND) for management of inguinal lymph-nodes in carcinoma of the penis.

METHODS

A comprehensive literature search was performed in January 2021 using the PubMed, Embase, and Cochrane databases. Data from human studies comparing RAVEIL/VEIL vs. OILND in carcinoma of penis published in English was extracted and analyzed by two independent authors.

RESULTS

Two Randomised Controlled Trials and 6 cohort studies were included in the meta-analysis. RAVEIL/VEIL group exhibited increased operative time (Mean Difference [MD] = 15.28 [14.19; 16.38], P < 0.001), shorter hospital stay (MD = -1.06 [-1.14; -0.98], P < 0.001), and decreased duration of drainage (MD = -2.82 [-3.21; -2.43], P < 0.001), wound infection (Odds Ratio [OR] = 0.15 [0.08; 0.27], P < 0.001), skin necrosis (OR = 0.12 [0.05; 0.28], P < 0.001), lymphedema (OR = 0.41 [0.24; 0.72], P = 0.002), and major complications (OR = 0.11 [0.05; 0.24], P < 0.001) as compared to OILND group. Recurrence rate and number of deaths were comparable in both the groups. RAVEIL/VEIL groups showed slightly larger lymph-node yield (MD = 0.44 [0.18; 0.70], P < 0.001) as compared to OILND group.

CONCLUSION

RAVEIL/VEIL has lesser skin complications, lymphedema, and better lymph-node yield as compared to OILND. It is comparable in terms of lymphocele and recurrence. It has lesser hospital stay and duration of drainage but owing to heterogeneity, the results should be interpreted with caution. Further studies are required to determine long-term oncological outcomes like overall survival and disease-specific survival.

Introducing minimally invasive inguinal lymph node dissection in a UK tertiary skin cancer service: Initial experience & outcomes

AIMS

We report the first UK case series of minimally invasive inguinal lymphadenectomy (MILND) for patients with metastatic cutaneous pathology.

METHODS

This was a retrospective, single-centre, single-surgeon cohort study. Twenty-one patients who underwent MILND from May 2015 to February 2019 were included. Demographic data, disease burden, and surgical quality assurance parameters were analysed.

RESULTS

Median age was 69 (IQR: 58-76) with 14 women (66%) and 7 men (33%). Eighteen (85%) patients had melanoma with the rest having other skin malignancies. The median number of nodes resected was eight (IQR:6-11) and the median N-ratio was 0.18 [0.05-1.00]. The median surgical time for the procedure was 180 minutes (IQR: 147-225) Seven (33%) patients had complications--three trivial and four (19%) grade IIIB. Only one case (the first) was converted to an open procedure.

CONCLUSIONS

We report the first UK series of MILND in a cutaneous oncology service. Our results show that MILND is a safe technique that can be introduced into a busy NHS practice with a structured training program, with surgical quality assurance outcomes identical to open inguinal lymphadenectomy. Our learning curve was similar to previously published data.

Technical management of inguinal lymph-nodes in penile cancer: open versus minimal invasive

Inguinal lymphadenectomy (ILND) remains the standard of care for patients with invasive squamous cell carcinoma of the penis, dictating patient prognosis, adjuvant therapies, and surveillance strategies. Importantly the performance of an ILND has been shown to improve cancer-specific outcomes, providing a modifiable factor for patients with an aggressive malignancy. Surprisingly, the procedure remains underutilized, mainly due to the high surgical morbidity associated with the procedure. The open lymphadenectomy technique has undergone several modifications over the last 30 years to minimize its associated surgical morbidity, but wound-related complications remain significant. Minimally invasive surgery (MIS) techniques have been recently introduced to help mitigate wound-related complications associated with open lymphadenectomy, with promising results. In this review, we highlight the importance of ILND, present a detail review of the surgical and oncological outcomes associated with open, laparoscopic and robotic ILND for patients with penile cancer.

Safety and feasibility of single-incision radical vulvectomy: a novel approach for the treatment of vulvar cancer

Background

In the process of decreasing the morbidity of wound-related complications after vulvectomy and IL for treating vulvar malignancy, we performed a novel surgical procedure—single-incision radical vulvectomy (SIRV). Here, we share our initial experience and report its safety and feasibility.

Methods

Patients with advanced local vulvar tumors were sequentially enrolled in this prospective cohort study to undergo SIRV. While performing SIRV, routine radical vulvectomies were performed first. Subsequently, the flaps of the bridge area between the vulvectomy incisions and femoral triangles were separated and the lymph nodes underneath were removed. Anterior working spaces (AWS) before the femoral triangle were then made. The saphenous vein was carefully identified and retained, while the superficial and deep inguinal lymph nodes were removed from the medial to the lateral sides. After careful hemostasis, the wounds were sutured. Patient demographics, clinical data, pathologic data, operation time, node count, and complications were recorded.

Results

Ten patients underwent SIRV for vulvar cancer. Average hospital stay was 11.70±3.16 (range, 9–13) days. The average number of harvested lymph nodes was 7.59±3.62 (range, 3–15) and 15.14±3.63 (range, 11–20) for per side or both sides of the groin. Blood loss was ≤35 mL. Three patients developed inguinal lymphoceles and underwent needle aspirations. Two patients had impaired wound healing and achieved healing after dressing change. No other postoperative complications were noted during follow-up.

Conclusions

Compared with conventional open inguinal lymphadenectomy (COIL) and video endoscopic inguinal lymphadenectomy (VEIL), SIRV is a more minimally invasive procedure. Our short-term observations showed that SIRV is safe and feasible and has good future application prospects for vulvar cancer. However, definitive conclusions cannot be made. Therefore, long-term oncologic outcomes and large-scale clinical trials are warranted.

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.

Safety and Feasibility of Minimally Invasive Inguinal Lymph Node Dissection in Patients With Melanoma (SAFE-MILND): Report of a Prospective Multi-institutional Trial

BACKGROUND

Minimally invasive inguinal lymph node dissection (MILND) is a novel approach to inguinal lymphadenectomy. SAFE-MILND (NCT01500304) is a multicenter, phase I/II clinical trial evaluating the safety and feasibility of MILND for patients with melanoma in a group of surgeons newly adopting the procedure.

METHODS

Twelve melanoma surgeons from 10 institutions without any previous MILND experience, enrolled patients into a prospective study after completing specialized training including didactic lectures, participating in a hands-on cadaveric laboratory, and being provided an instructional DVD of the procedure. Complications and adverse postoperative events were graded using the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events Version 4.0.

RESULTS

Eighty-seven patients underwent a MILND. Seventy-seven cases (88.5%) were completed via a minimally invasive approach. The median total inguinal lymph nodes pathologically examined (SLN + MILND) was 12.0 (interquartile range 8.0, 14.0). Overall, 71% of patients suffered an adverse event (AE); the majority of these were grades 1 and 2, with 26% of patients experiencing a grade 3 AE. No grade 4 or 5 AEs were observed.

CONCLUSIONS

After a structured training program, high-volume melanoma surgeons adopted a novel surgical technique with a lymph node retrieval rate that met or exceeded current oncologic guidelines and published benchmarks, and a favorable morbidity profile.

Laparoscopic skill assessment of practicing surgeons prior to enrollment in a surgical trial of a new laparoscopic procedure

BACKGROUND

Outcomes of surgical trials hinge on surgeon selection and their underlying expertise. Assessment of expertise is paramount. We investigated whether surgeons' performance measured by the fundamentals of laparoscopic surgery (FLS) assessment program could predict their performance in a surgical trial.

METHODS

As part of a prospective multi-institutional study of minimally invasive inguinal lymphadenectomy (MILND) for melanoma, surgical oncologists with no prior MILND experience underwent pre-trial FLS assessment. Surgeons completed MILND training, began enrolling patients, and submitted videos of each MILND case performed. Videos were scored with the global operative assessment of laparoscopic skills (GOALS) tool. Associations between baseline FLS scores and participant's trial performance metrics were assessed.

RESULTS

Twelve surgeons enrolled patients; their median total baseline FLS score was 332 (range 275-380, max possible 500, passing >270). Participants enrolled 87 patients in the study (median 6 per surgeon, range 1-24), of which 72 (83%) videos were adequate for scoring. Baseline GOALS score was 17.1 (range 9.6-21.2, max possible score 30). Inter-rater reliability was excellent (ICC = 0.85). FLS scores correlated with improved GOALS scores (r = 0.57, p = 0.05) and with decreased operative time (r = -0.6, p = 0.02). No associations were found with the degree of patient recruitment (r = 0.02, p = 0.7), lymph node count (r = 0.01, p = 0.07), conversion rate (r = -0.06, p = 0.38) or major complications(r = -0.14, p = 0.6).

CONCLUSIONS

FLS skill assessment of surgeons prior to their enrollment in a surgical trial is feasible. Although better FLS scores predicted improved operative performance and operative time, other trial outcome measures showed no difference. Our findings have implications for the documentation of laparoscopic expertise of surgeons in practice and may allow more appropriate selection of surgeons to participate in clinical trials.

Weighing the value of completion nodal dissection for melanoma

In the United States, approximately half of patients with a positive sentinel lymph node biopsy undergo a completion lymphadenectomy. Because of the equivocal survival benefits in pursuing a completion lymphadenectomy in these patients, surgeons must weigh the postoperative morbidity of the operation with concerns facing a patient's quality of life and risk of tumor recurrence. We discuss the value of a completion lymphadenectomy in light of the uncertainties facing this management strategy for melanoma. J. Surg. Oncol. 2016;114:281-287. © 2016 Wiley Periodicals, Inc.