Combined inguinal and pelvic lymph node dissection for stage III melanoma

Leg Lymphoedema After Inguinal and Ilio-Inguinal Lymphadenectomy for Melanoma: Results from a Prospective, Randomised Trial

BACKGROUND

The Evaluation of Groin Lymphadenectomy Extent for Melanoma (EAGLE FM) study sought to address the question of whether to perform inguinal (IL) or ilio-inguinal lymphadenectomy (I-IL) for patients with inguinal nodal metastatic melanoma who have no clinical or imaging evidence of pelvic disease. Primary outcome measure was disease-free survival at 5 years, and secondary endpoints included lymphoedema.

METHODS

EAGLE FM was designed to recruit 634 patients but closed with 88 patients randomised because of slow recruitment and changes in melanoma management. Lymphoedema assessments occurred preoperatively and at 6, 12, 18, and 24 months postoperatively. Lymphoedema was defined as Inter-Limb Volume Difference (ILVD) > 10%, Lymphoedema Index (L-Dex®) > 10 or change of L-Dex® > 10 from baseline.

RESULTS

Prevalence of leg lymphoedema between the two groups was similar but numerically higher for I-IL at all time points in the first 24 months of follow-up; highest at 6 months (45.9% IL [CI 29.9-62.0%], 54.1% I-IL [CI 38.0-70.1%]) and lowest at 18 months (18.8% IL [CI 5.2-32.3%], 41.4% I-IL [CI 23.5-59.3%]). Median ILVD at 24 months for those affected by lymphoedema was 14.5% (IQR 10.6-18.7%) and L-Dex® was 12.6 (IQR 9.0-17.2). There was not enough statistical evidence to support associations between lymphoedema and extent of surgery, radiotherapy, or wound infection.

CONCLUSIONS

Despite a trend for patients who had I-IL to have greater lymphoedema prevalence than IL in the first 24 months after surgery, our study's small sample did not have the statistical evidence to support an overall difference between the surgical groups.

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.

Characteristics Associated with Pathologic Nodal Burden in Patients Presenting with Clinical Melanoma Nodal Metastasis

BACKGROUND

Nodal observation is safe for patients with microscopic melanoma metastasis in a sentinel lymph node (LN). Complete LN dissection (CLND) remains the standard of care for patients with clinically evident LN (cLN) metastases, even though about 40% have only one pathologic LN (pLN). We sought to identify clinical features associated with having one pLN among patients with cLNs.

METHODS

Patients at three melanoma centers who underwent CLND for cLNs were identified. Clinicopathologic and imaging characteristics associated with one pLN were determined by multivariable logistic regression and classification tree analysis.

RESULTS

Of 190 patients, 90 (47.4%) had one pLN and 100 (52.6%) had more than one pLN. By multivariable logistic regression, extremity versus truncal primary (odds ratio [OR] 2.15, p = 0.012), axillary versus superficial inguinal location (OR 3.89, p = 0.009), and preoperative cross-sectional imaging demonstrating more than one versus one cLN (OR 17.1, p < 0.001) were associated with more than one pLN. The negative predictive value for additional pathologic nodal disease of preoperative imaging was 70.9%, increasing to 74.4% for positron emission tomography/computed tomography. In the subgroup of patients with one cLN, the classification tree identified two groups with < 10% risk of additional pLNs: (1) Breslow thickness > 6.55 mm (n = 17); and (2) if unknown primary or Breslow thickness ≤ 6.55 mm, then LN diameter > 1.8 cm in the inguinal location (n = 22).

CONCLUSION

The majority of patients with one cLN from melanoma by preoperative imaging will harbor no additional pathologic nodes on CLND. Safety of nodal observation after clinical nodal excision in these patients, particularly in an era of effective adjuvant therapies, deserves prospective evaluation.

Reducing morbidity with surgical adhesives following inguinal lymph node dissections for the treatment of malignant skin tumors

Background: Inguinal lymph node dissection (ILND) is associated with a high rate of morbidity. To evaluate the clinical benefit of surgical adhesives to reduce complications in patients undergoing ILND, we compared the use of TissuGlu^® Surgical Adhesive and ARTISS^® fibrin sealant with a control population.

Material and methods: We conducted a retrospective analysis of patients undergoing ILND for metastatic malignant skin tumors at one hospital, Fachklinik Hornheide (Münster, Germany), from January 2011 through September 2013, assessing 137 patients with a total of 142 procedures.

Results: Complications occurred in 22/60 procedures in the TissuGlu group (TG), in 8/17 in the ARTISS group (AG), and in 29/65 in the control group (CG). Prolonged drainage and seroma were recorded in 16 (26.7%), four (23.5%), and 26 (40%) respectively (non-significant). TG showed less extended drainage vs. CG (p=0.082). Mean daily drain volumes were significantly lower in AG vs. CG (p=0.000). With regard to wound infection, there was a 15% reduction in TG and 74% increase in AG group. Revision surgery was reduced by 36% in TG and increased by 54% in AG. Mean daily drain volumes were significantly lower in AG vs. CG (p=0.000). Mean total post-operative drain volume was lower in TG and AG vs. CG (p<0.001 among groups, CG vs. TG p<0.001, CG vs. AG p<0.001). The mean body mass index (BMI) was significantly higher in patients with complications, 29.4±5.8 vs. 25.3±4.1 (p=0.000).

Conclusion: The use of TissuGlu in our ILND patients was associated with a reduction in post-operative wound related complications and the need for revision surgeries compared to the control group. Daily drainage was significantly lower within the first 7 post-operative days with the use of ARTISS, but the benefit was lost due to the higher occurrence of wound infection and revision surgery. BMI above 29 is a risk factor for complications following ILND.

(Level of evidence: level IV, retrospective case study)

Robotic-Assisted Transperitoneal Pelvic Lymphadenectomy for Metastatic Melanoma: Early Outcomes Compared with Open Pelvic Lymphadenectomy

BACKGROUND

In the absence of iliac or obturator nodal involvement, the role of pelvic lymphadenectomy (PLND) for melanoma is controversial, but for select patients, long-term survival can be achieved with the combination of superficial inguinal (inguinofemoral) and PLND. Open PLND (oPLND) is often limited in visual exposure and can be associated with considerable postoperative pain. Robotic PLND (rPLND) is a minimally invasive technique that provides excellent visualization of the iliac and obturator nodes. Outcomes comparing the open and robotic techniques have not been reported previously for patients with melanoma.

STUDY DESIGN

We reviewed our experience with rPLND for melanoma and compared clinical and pathologic results with oPLND. We evaluated operative times, nodal yield, and short-term oncologic outcomes.

RESULTS

Thirteen rPLND (2013 to 2015) (15 attempted, 87% success rate) and 25 oPLND (2010 to 2015) consecutive cases were completed. Pelvic lymphadenectomy was combined with an open inguinofemoral dissection in 8 of 13 (62%) robotic and 17 of 25 (68%) open cases. Median length of stay was shorter in the rPLND group, with 1.0 vs 3.5 days for pelvic-only cases (p < 0.001) and 2.5 vs 4.0 days (p < 0.001) for combined ilioinguinal cases. Median operative time (227 vs 230 minutes; p = 0.96) and nodal yield (11 vs 10 nodes; p = 0.53) were not different between rPLND and oPLND.

CONCLUSIONS

Robotic PLND offers a safe, effective, minimally invasive approach to resect the pelvic lymph nodes in patients with melanoma, with no significant difference in nodal yield or operative times, but a shorter length of stay compared with oPLND.

The nomenclature of groin dissection for melanoma - Time to simplify

INTRODUCTION

A wide variety of terms are used to describe different extents of groin dissection for stage 3 melanoma which may result in confusion and reduce effectiveness of research. We aim to evaluate the published terminology.

METHODS

A PubMed review was conducted using the terms 'melanoma' plus 'inguinal'; 'groin'; 'pelvic'; 'ilioinguinal' dissection. 63 papers were included from 1956 to March 2015. A review of anatomy and coding was also conducted.

RESULTS

Inguinal dissection was described using 8 terms from 56 papers with 7 papers using multiple terms for the same procedure. 'Superficial dissection' was the most common term despite inguinal-nodal tissue being separated into superficial and deep layers anatomically. ICD10PCS and OPSC code for 'inguinal' with no anatomical definition, CPT codes for 'inguinofemoral/superficial'. Combination inguino-pelvic dissection was described using 11 terms from 51 papers with 15 papers using multiple terms for the same procedure. 'Ilioinguinal' and 'Deep' were the most common despite most pelvic dissections including obturator nodes. ICD10PCS and OPSC code for 'pelvic' with no anatomical definition and CPT codes for 'superficial plus pelvic'.

CONCLUSION

Many different terms are used to describe the same procedures, often within the same article. The lack of clarity can confuse readers, hinder comparative research and jeopardise patient care. Imprecise documentation of anatomical definition limits surgical outcome reporting and can impede planning for revision surgery. Standardisation is necessary and groin dissection should be defined by anatomical boundaries e.g. 'superficial' and 'deep' inguinal; 'pelvic'; 'inguino-pelvic' with clear documentation of extent.

Risk Factors for Positive Deep Pelvic Nodal Involvement in Patients with Palpable Groin Melanoma Metastases: Can the Extent of Surgery be Safely Minimized? : A Retrospective, Multicenter Cohort Study

Background

Patients with palpable melanoma groin metastases have a poor prognosis. There is debate whether a combined superficial and deep groin dissection (CGD) is necessary or if superficial groin dissection (SGD) alone is sufficient.

Aim

The aim of this study was to analyze risk factors for deep pelvic nodal involvement in a retrospective, multicenter cohort of palpable groin melanoma metastases. This could aid in the development of an algorithm for selective surgery in the future.

Methods

This study related to 209 therapeutic CGDs from four tertiary centers in The Netherlands (1992–2013), selected based on complete preoperative imaging and pathology reports. Analyzed risk factors included baseline and primary tumor characteristics, total and positive number of inguinal nodes, inguinal lymph node ratio (LNR) and positive deep pelvic nodes on imaging (computed tomography [CT] ± positron emission tomography [PET], or PET − low-dose CT).

Results

Median age was 57 years, 54 % of patients were female, and median follow-up was 21 months (interquartile range [IQR] 11–46 months). Median Breslow thickness was 2.10 mm (IQR 1.40–3.40 mm), and 26 % of all primary melanomas were ulcerated. Positive deep pelvic nodes occurred in 35 % of CGDs. Significantly fewer inguinal nodes were positive in case of negative deep pelvic nodes (median 1 [IQR 1–2] vs. 3 [IQR 1–4] for positive deep pelvic nodes; p < 0.001), and LNR was significantly lower for negative versus positive deep pelvic nodes [median 0.15 (IQR 0.10–0.25) vs. 0.33 (IQR 0.14–0.54); p < 0.001]. A combination of negative imaging, low LNR, low number of positive inguinal nodes, and no extracapsular extension (ECE) could accurately predict the absence of pelvic nodal involvement in 84 % of patients.

Conclusions

Patients with negative imaging, few positive inguinal nodes, no ECE, and low LNR have a low risk of positive deep pelvic nodes and may safely undergo SGD alone.

Cloquet's node trumps imaging modalities in the prediction of pelvic nodal involvement in patients with lower limb melanomas in Asian patients with palpable groin nodes

Patients with clinically palpable lymph node metastases to the groin are treated with groin dissection to control local disease and stage the malignancy. However, the extent of nodal dissection required to optimize survival rate is controversial.

AIM

To evaluate the approach to the extent of nodal dissection in advanced lower limb melanomas with clinically palpable inguinal nodes; to review survival outcomes based on the extent of nodal dissection and nodal disease.

MATERIALS AND METHODS

A prospectively maintained database of 12 patients with lower limb melanoma was analyzed. Cloquet's node was assessed based on the frozen section result which guided the decision to proceed to iliac-obturator dissection. The correlation of the results of the Cloquet's nodes and radiological imaging to the final histological outcome of groin nodal dissection were compared.

RESULTS

The positive predictive value (PPV) of radiological imaging in identifying pelvic nodal disease was 60%. PPV of a positive or indeterminate frozen section result of Cloquet's node was 71.4%. Notably, all patients with a positive frozen section result for the Cloquet's node had positive pelvic nodal disease. Median DFS for all patients is 26 months (range 3-68 months) and the median OS for all patients is 28.5 months (range 5-68 months). Median DFS for node negative patients was 28 months (range 24-68 months). Median DFS for node positive patients was 20 months (range 3-36 months).

CONCLUSION

Cloquet's node was shown to be superior to radiological imaging and should be preferentially used to decide on the extent of nodal dissection.

Outcomes of routine ilioinguinal lymph node dissection for palpable inguinal melanoma nodal metastasis

BACKGROUND

Patients who present with palpable inguinal melanoma nodal metastasis have two surgical options: inguinal or ilioinguinal lymph node dissection. Indications for either operation remain controversial. This study examined survival and recurrence outcomes following ilioinguinal dissection for patients with palpable inguinal nodal metastasis, and assessed the incidence and preoperative predictors of pelvic nodal metastasis.

METHODS

This was a retrospective clinicopathological analysis of consecutive surgical patients with stage III malignant melanoma. All patients underwent a standardized ilioinguinal dissection at a specialist tertiary oncology hospital over a 12-year period (1998-2010).

RESULTS

Some 38.9 per cent of 113 patients had metastatic pelvic nodes. Over a median follow-up of 31 months, the 5-year overall survival rate was 28 per cent for patients with metastatic inguinal and pelvic nodes, and 51 per cent for those with inguinal nodal metastasis only (P = 0.002). The nodal basin control rate was 88.5 per cent. Despite no evidence of pelvic node involvement on preoperative computed tomography (CT), six patients (5.3 per cent) with a single metastatic inguinal lymph node had metastatic pelvic lymph nodes. Logistic regression analysis showed that the number of metastatic inguinal nodes (odds ratio 1.56; P = 0.021) and suspicious CT findings (odds ratio 9.89; P = 0.001) were both significantly associated with metastatic pelvic nodes. The specificity of CT was good (89.2 per cent) in detecting metastatic pelvic nodes, but the sensitivity was limited (57.9 per cent).

CONCLUSION

Metastatic pelvic nodes are common when palpable metastatic inguinal nodes are present. Long-term survival can be achieved following their resection by ilioinguinal dissection. As metastatic pelvic nodes cannot be diagnosed reliably by preoperative CT, patients presenting with palpable inguinal nodal metastasis should be considered for ilioinguinal dissection.

Completion lymph node dissection after a positive sentinel node: no longer a must?

PURPOSE OF REVIEW

Sentinel node biopsy (SNB) for primary melanoma is accepted worldwide as a diagnostic procedure. When sentinel node positive, the invasive completion lymph node dissection (CLND) is usually performed. Approximately 20% of CLND patients have nonsentinel node (NSN) metastases. The therapeutic benefit is unknown. This review analyzed the necessity of CLND in sentinel node positive patients.

RECENT FINDINGS

Prognosis of sentinel node positive patients is highly heterogeneous. The Rotterdam and Dewar criteria and S-classification are important sentinel node tumor burden criteria to stratify melanoma patients for prognosis and risk of NSN metastases. Patients with less than 0.1 mm metastases seem to have similar prognosis as sentinel node negative patients, especially when located in the subcapsular area. This depends on the use of an extensive sentinel node pathology protocol identifying possibly clinically irrelevant micrometastases.

SUMMARY

Consensus on the sentinel node pathology work-up and analysis protocols are crucial for correct risk stratification and for clinical decision-making. Primary and sentinel node tumor burden parameters and patient comorbidities should be taken into consideration when offering CLND to an individual patient. In the future, prospective studies such as the MSLT-II and the EORTC 1208 (Minitub) will provide answers to whether CLND has a therapeutic benefit and to which patients might safely be spared CLND.

Superficial and deep lymph node dissection for stage III cutaneous melanoma: clinical outcome and prognostic factors

Background

The aims of this retrospective analysis were to evaluate the effect of combined superficial and deep groin dissection on disease-free and melanoma-specific survival, and to identify the most important factors for predicting the involvement of deep nodes according to clinically or microscopically detected nodal metastases.

Methods

Between January 1996 and December 2005, 133 consecutive patients with groin lymph node metastases underwent superficial and deep dissection at the National Cancer Institute, Naples. Lymph node involvement was clinically evident in 84 patients and detected by sentinel node biopsy in 49 cases.

Results

The 5-year disease-free survival was significantly better for patients with superficial lymph node metastases than for patients with involvement of both superficial and deep lymph nodes (34.9% vs. 19.0%; P = 0.001). The 5-year melanoma-specific survival was also significantly better for patients with superficial node metastases only (55.6% vs. 33.3%; P = 0.001).

Conclusions

Metastasis in the deep nodes is the strongest predictor of both disease-free and melanoma-specific survival. Deep groin dissection should be considered for all patients with groin clinical nodal involvement, but might be spared in patients with a positive sentinel node. Prospective studies will clarify the issue further.

The addition of the surgical robot to skin cancer management

We present the introduction of the surgical robot for pelvic lymphadenectomy for skin cancer through a cross-specialty collaboration. In this prospective series, we include the first report of cases undergoing robot-assisted pelvic lymph node dissection for Merkel cell carcinoma and melanoma in the recognised scientific literature.

Inguinopelvic lymphadenectomy following positive inguinal sentinel lymph node biopsy in melanoma: true frequency of synchronous pelvic metastases

BACKGROUND

True frequency of synchronous pelvic metastases with positive inguinal sentinel lymph node (SLN) biopsy is unknown. Role of pelvic dissection in the SLN era is unclear.

METHODS

From 1994 to 2004, 1 surgeon routinely performed nonselective, complete inguinopelvic lymphadenectomy after positive inguinal SLN biopsy. All cases were identified from a prospectively maintained database. Clinicopathologic features associated with pelvic disease were assessed.

RESULTS

A total of 40 patients with positive inguinal SLN underwent, without additional selection, 42 complete inguinopelvic lymphadenectomies. Median age was 46.5 years (range 25-79 years); 79% had lower extremity primaries. Median Breslow depth was 2.3 mm (range 1.0-10.0 mm), Clark's IV/V 98%, ulceration 26%. Frequency of synchronous pelvic disease upon completion lymphadenectomy was 5 of 42 (11.9%). Patients with and without pelvic disease were similar in age, sex, Breslow depth, Clark's level, ulceration, and mitoses. All 5 cases with pelvic metastases had extremity primaries (4 distal, 1 proximal). Of the 5, 3 (60%) had ≥3 total involved inguinal nodes, compared with only 1 (2.7%) of the 37 cases without pelvic disease (P=.003). Ratio of positive to total number inguinal nodes retrieved was >0.20 in 80% of cases with pelvic disease and 8.6% of cases without (P=.002). Upon lymphoscintigraphy review, secondary pelvic drainage was present in 80% of cases with pelvic disease compared with 56% of cases without pelvic disease, though the trend was statistically insignificant (P=.63).

CONCLUSIONS

In this cohort of unselected, SLN-positive patients with complete inguinopelvic lymphadenectomy, frequency of synchronous pelvic disease was 11.9%. Patients with ≥3 total involved inguinal nodes or inguinal node ratio >0.20 appear more likely to harbor pelvic disease.

Therapeutic surgical management of palpable melanoma groin metastases: superficial or combined superficial and deep groin lymph node dissection

Background

Management of patients with clinically detectable lymph node metastasis to the groin is by ilioinguinal or combined superficial and deep groin dissection (CGD) according to most literature, but in practice superficial groin dissection (SGD) only is still performed in some centers. The aim of this study is to evaluate the experience in CGD versus SGD patients in our center.

Methods

Between 1991 and 2009, 121 therapeutic CGD and 48 SGD were performed in 169 melanoma patients with palpable groin metastases at our institute. Median follow-up was 20 and, for survivors, 45 months.

Results

In this heterogeneous group of patients, overall (OS) and disease-free survival, local control rates, and morbidity rates were not significantly different between CGD and SGD patients. However, CGD patients had a trend towards more chronic lymphedema. Superficial lymph node ratio, the number of positive superficial lymph nodes, and the presence of deep nodes were prognostic factors for survival. CGD patients with involved deep lymph nodes (24.8%) had estimated 5-year OS of 12% compared with 40% with no involved deep lymph nodes (p = 0.001). Preoperative computed tomography (CT) scan had high negative predictive value of 91% for detection of pelvic nodal involvement.

Conclusions

This study demonstrated that survival and local control do not differ for patients with palpable groin metastases treated by CGD or SGD. Patients without pathological iliac nodes on CT might safely undergo SGD, while CGD might be reserved for patients with multiple positive nodes on SGD and/or positive deep nodes on CT scan.

Initial experience with videoscopic inguinal lymphadenectomy

BACKGROUND

Inguinofemoral lymphadenectomy is associated with frequent and marked incision-related morbidity. Our initial feasibility study of videoscopic inguinal lymphadenectomy (VIL) for melanoma showed appropriate nodal yield and anatomic dissection. Although a limited suprafascial dissection has been reported in the urologic literature, we report our growing experience with VIL applying a comprehensive approach to dissection.

METHODS

Patients with inguinal metastases from varied malignancies were offered VIL. With institutional review board approval, procedures were performed via three ports: one at the apex of the femoral triangle, a second medial to the adductor, and a third lateral to sartorius. Femoral vessels were skeletonized, and all lymphatic tissue within the femoral triangle to 5 cm up onto the external oblique aponeurosis was resected. Specimens were removed through the apical port via a specimen bag. Clinicopathologic and perioperative outcome data were recorded.

RESULTS

Forty-five VILs were performed in 32 patients: 19 had unilateral VILs, and 13 had bilateral VILs for neuroendocrine, extramammary Paget disease, or varied genitourinary malignancies. Nine procedures (20%) were performed in women. Median age was 61 (range 16-87) years. Median body mass index was 30 (range 19-53). Median operative time was 165 (range 75-245) minutes, median length of stay was 1 (range 1-14) day, and median drain duration was 15 days. Median number of collected nodes was 11 (range 4-24), and the largest node removed was 5.6 cm in size. Wound complications were observed in 8 cases (18%). Six patients (13%) developed cellulitis without any wound dehiscences, 1 patient developed a seroma, and 1 patient with diabetes had mild skin flap necrosis, which resolved with minimal local care.

CONCLUSIONS

VIL is an alternative approach to traditional open inguinal lymphadenectomy. In our growing experience, node retrieval is appropriate and wound complications are substantially fewer than reported via an open approach. Further comparative analysis of VIL and traditional inguinofemoral lymphadenectomy is being pursued in a randomized, prospective trial.

Feasibility of a novel approach to inguinal lymphadenectomy: minimally invasive groin dissection for melanoma

INTRODUCTION

Inguinal lymphadenectomy for metastatic melanoma is reported to have a complication rate as high as 50%. Wound dehiscence has been reported to occur in more than half of these patients, and as a result many surgeons routinely use sartorius muscle transposition to protect against the potential for exposed vessels. We report feasibility of minimally invasive inguinal lymphadenectomy intended to minimize wound complications inherent to this procedure.

METHODS

Five patients with histologically confirmed inguinal metastases from melanoma underwent minimally invasive inguinal lymphadenectomy. Procedures were performed via three ports: one at the apex of the femoral triangle, a second two fingerbreadths medial to the adductors, and the third two fingerbreadths lateral to the sartorius. No inguinal incision was utilized for the purpose of surgery. A standard melanoma dissection was performed through these ports: contents of the femoral triangle and 5 cm up onto the external oblique aponeurosis were removed. To validate this technique, sentinel node biopsy scars were excised to permit visual confirmation of adequate anatomic dissection.

RESULTS

Five patients underwent minimally invasive inguinal lymphadenectomy for metastatic melanoma. Median operative time was 180 (range, 142-223) min, median hospital stay was 1 day, and two patients developed cutaneous erythema but neither suffered wound dehiscence. Median nodal yield was 10 (range, 4-13). Blood loss was <100 ml for all procedures. Median duration of drain usage was 8 (range 7-19) days.

CONCLUSIONS

Minimally invasive inguinal lymphadenectomy is feasible for patients with melanoma as demonstrated by nodal yield and visual inspection. This technique may reduce complication rates and wound dehiscence, and the risk of exposed vessels is minimized by eliminating the inguinal incision. This obviates the need for routine sartorius muscle transposition. A prospective, randomized trial comparing the open versus the videoscopic approach is currently in progress.

Prospective assessment of postoperative complications and associated costs following inguinal lymph node dissection (ILND) in melanoma patients

BACKGROUND

We prospectively assessed the incidence, risk factors, and costs associated with wound complications and lymphedema in melanoma patients undergoing inguinal lymph node dissection (ILND).

MATERIALS AND METHODS

A total of 53 melanoma patients were accrued to 2 trials (June 2005 to July 2008) that included prospective evaluations of postoperative complications; 30-day wound complications included infection, seroma, and/or dehiscence. There were 20 patients who underwent limb volume measurement and completed a 19-item lymphedema symptom assessment questionnaire preoperatively and 3 months postoperatively. A multivariate analysis was performed to evaluate potential risk factors for complications. A microcosting analysis was also performed to evaluate the direct costs associated with wound complications.

RESULTS

The 30-day wound complications were noted in 77.4% of patients. A BMI ≥ 30 (n = 28) increased the risk for wound complications (odds ratio [OR] = 11.4, 95% confidence interval [95%CI] 1.6-78.5, P = .01), while advanced nodal disease approached significance (OR = 9.0, 95%CI: 0.79-103.1, P = .08). Other risk factors, including diabetes, smoking, and the addition of a deep pelvic (iliac/obturator) dissection to ILND, were not significant. Of 20 patients, 9 (45%) developed limb volume change (LVC) ≥5% at 3 months, with associated mean symptom scores of 6.1 versus 4.6 for those without LVC. Costs for patients with wound complications were significantly higher than for those without wound complications.

CONCLUSIONS

Postoperative wound complications and early onset lymphedema occur frequently following ILND for melanoma. Obesity is an adverse risk factor for 30-day wound complications that can significantly increase postoperative costs, as is likely the case for advanced disease. Risk reduction practices and novel treatment approaches are needed to reduce postoperative morbidity.

Imaging in cutaneous melanoma

Cutaneous melanoma (CM) is a common malignancy and imaging, particularly lymphoscintigraphy (LS), positron-emission tomography with 2-fluoro-2-deoxyglucose (FDG-PET), ultrasound, radiography computed tomography (CT) and magnetic resonance imaging have important roles in staging and restaging, surgical guidance, surveillance and assessment of recurrent disease. This review aims to summarize the available data regarding these and other imaging modalities in CM and provide the basis for subsequent formulation of guidelines regarding the use of imaging in CM. PubMed and Medline searches were performed and reference lists from publications were also searched. The published data were reviewed and tabulated. There is level I evidence supporting the use of LS and sentinel lymph node biopsy in nodal staging for CM. There is level III evidence demonstrating the superiority of ultrasound to palpation in the assessment of lymph nodes in CM. There is level IV evidence supporting FDG-PET in American Joint Committee on Cancer stage III/IV and recurrent CM and that FDG-PET/CT may be superior to FDG-PET. Level IV evidence also supports the use of CT in the same group of patients and the role of CT appears to be complementary to FDG-PET. Various imaging modalities, especially LS/sentinel lymph node biopsy and FDG-PET/CT, add incremental information in the management of CM and the various modalities have complementary roles depending on the clinical situation.

Defining lower limb lymphedema after inguinal or ilio-inguinal dissection in patients with melanoma using classification and regression tree analysis

OBJECTIVE

This study aims to objectively define the criteria for assessing the presence of lymphedema and to report the prevalence of lymphedema after inguinal and ilio-inguinal (inguinal and pelvic) lymph node dissection for metastatic melanoma.

SUMMARY BACKGROUND DATA

Lymphedema of the lower limb is a common problem after inguinal and ilio-inguinal dissection for melanoma. The problem is variably perceived by both patients and clinicians. Adding to the confusion is a lack of a clear definition or criteria that allow a diagnosis of lymphedema to be made using the various subjective and objective diagnostic techniques available.

METHODS

Lymphedema was assessed in 66 patients who had undergone inguinal or ilio-inguinal dissection. Nine patients received postoperative radiotherapy. Assessment was performed by limb circumference measurements at standardized intervals, volume displacement measurements, and volumetric assessment calculated using an infrared optoelectronic perometer technique. Comparisons were made with the contralateral untreated limb. Patient assessment of the severity of lymphedema was compared with objective measures of volume discrepancy. Classification and regression tree analysis was used to determine a threshold fractional leg volume or circumference increase above which patients could self-detect volume changes that they reliably considered to indicate lymphedema.

RESULTS

Based on classification and regression tree analysis, both the whole limb perometer volume percentage change > or = 15% and the sum of circumferences (of 6 defined sites along the limb) percentage change > or = 7% performed well overall in predicting moderate or severe perceived swelling (defined as "lymphedema"). Both definitions predicted lymphedema in approximately the same fraction of patients with misclassification rates of 16% and 15%, sensitivity 56% and 50%, specificity 95% and 100%, respectively. Using > or = 15% of whole perometer volume percentage change, 12% of patients with inguinal dissection had lymphedema compared with 23% of patients with ilio-inguinal dissection. Combining both groups, 18% of patients had lymphedema, positive and negative predictive values 82% and 84%. Using the definition > or = 7% of the sum of circumferences percent change, 7% of patients with inguinal dissection had lymphedema compared with 19% of patients with ilio-inguinal dissection (overall 14% had lymphedema, positive and negative predictive values 100% and 82%, respectively). Of the variables assessed, only radiotherapy was significantly associated with predicted lymphedema (OR 12.6; 95% CI 1.7 to > 100; P = 0.001 using whole perometer change > or = 15%; and OR 13.0; 95%CI 1.4 to > 100; P = 0.021 using sum circumference change > or = 7%).

CONCLUSIONS

A whole limb perometer volume percentage change of > or = 15% and increase in the sum of circumferences of the defined points along the limb > or = 7% provide robust definitions of lower limb lymphedema.

Complete lymph node dissection for sentinel node-positive melanoma: assessment of practice patterns in the United States

BACKGROUND

Currently, complete lymph node dissection (CLND) is recommended after identification of a metastatic lymph node by sentinel lymph node biopsy (SLNB). Guidelines suggest that CLND should be performed as a separate procedure, and a sufficient number of nodes should be examined. Our objective was to examine the utilization, timing, and adequacy of CLND for melanoma in the United States.

METHODS

From the National Cancer Data Base, patients diagnosed with stage I to III melanoma during 2004-2005 were identified. Multiple logistic regression was used to assess factors associated with CLND utilization, timing (separate operation from SLNB), and adequacy (examination of > or = 10 nodes).

RESULTS

Of the 44,548 patients identified, 47.5% were pathologic stage IA, 23.8% stage IB, 14.1% stage II, and 14.6% stage III. Of the 17% (2942 of 17,524) with nodal metastases on SLNB, only 50% underwent a CLND. Patients were significantly less likely to undergo a CLND after SLNB if > 75 years old or had lower extremity melanomas. Of the patients who underwent a CLND, only 42% underwent the CLND at a separate procedure after the SLNB. Of those who underwent a CLND, 69.2% had > or = 10 nodes examined. Patients were significantly less likely to have > or = 10 nodes examined if they were > 75 years old or had lower extremity melanomas. Patients treated at NCCN/NCI-designated centers were significantly more likely to undergo nodal evaluation in concordance with established guidelines.

CONCLUSIONS

Only half of patients with sentinel node-positive melanoma underwent CLND. Quality surveillance measures are needed to monitor, standardize, and improve the care of patients with malignant melanoma.

Measurement of limb volume: laser scanning versus volume displacement

BACKGROUND

Determining the prevalence and treatment success of surgical lymphedema requires accurate and reproducible measurement. A new method of measurement of limb volume is described.

METHODS

A series of inanimate objects of known and unknown volume was measured using digital laser scanning and water displacement. A similar comparison was made with 10 human volunteers. Digital scanning was evaluated by comparison to the established method of water displacement, then to itself to determine reproducibility of measurement.

RESULTS

(1) Objects of known volume: Laser scanning accurately measured the calculated volume but water displacement became less accurate as the size of the object increased. (2) Objects of unknown volume: As average volume increased, there was an increasing bias of underestimation of volume by the water displacement method. The coefficient of reproducibility of water displacement was 83.44 ml. In contrast, the reproducibility of the digital scanning method was 19.0 ml. (3) Human data: The mean difference between water displacement volume and laser scanning volume was 151.7 ml (SD +/- 189.5). The coefficient of reproducibility of water displacement was 450.8 ml whereas for laser scanning it was 174 ml.

CONCLUSION

Laser scanning is an innovative method of measuring tissue volume that combines precision and reproducibility and may have clinical utility for measuring lymphedema.

[Cutaneous malignant melanoma. Excision margins and lymph node dissections]

Excision is the treatment of choice in stage I malignant melanoma. As supported by several controlled clinical studies, reduced safety surgical margins from 0.5 to 2 cm are sufficient. Most surgical defects can be closed by simple skin flap techniques. In critical anatomic sites (e. g. face, hand, foot) micrographic surgery is the therapy of choice. Sentinel lymph node biopsy (SLNB) was proposed as a minimally-invasive procedure for the histopathologic staging of the regional lymph nodes. Today SLNB is standard in the diagnostic approach to melanomas thicker than 1 mm. The therapeutic relevance of SLNB is unclear. The most common sign of tumor progression is involvement of regional lymph nodes. The treatment of choice in patients with neck metastases is the radical, modified or selective neck dissection. In the case of axillary metastases, levels I-III of the axillary lymph nodes are excised. With groin metastases, superficial inguinal dissection is usually preferred. There are no randomized controlled trials comparing the outcome of combined inguinal and pelvic lymph node dissection and superficial inguinal lymph node dissection.

Lymphoedema: estimating the size of the problem

Lymphoedema is a problem frequently encountered by professionals working in palliative care. This article reviews the evidence on the magnitude of the problem of lymphoedema in the general population and provides evidence on specific high risk groups within it. Prevalence is a good indicator of the burden of disease for chronic problems such as lymphoedema, as it indicates the numbers of patients who require care. Incidence is indicative of changes in the causes of lymphoedema and the success of any prevention programmes. Both are important means of assessing the current level of need and the potential for the changing needs in managing this condition. Problems exist in all studies in relation to precise definitions of lymphoedema, inconsistent measures to assess differential diagnosis and poorly defined populations. While there is some evidence of high rates in relation to breast cancer therapy, the total burden of lymphoedema in the general population is largely unknown.

Lessons learned from the Sunbelt Melanoma Trial

The Sunbelt Melanoma Trial is an ongoing multicenter prospective randomized trial that involves 79 centers and over 3600 patients from across the United States and Canada. This is one of the first large randomized studies to incorporate molecular staging using reverse transcriptase polymerase chain reaction (RT-PCR). While the results related to the primary endpoints of the study are not yet available, several analyses have shed light on many aspects of sentinel lymph node (SLN) biopsy and melanoma prognostic factors. In particular, we have developed a practical definition of sentinel nodes based on the degree of radioactivity. We have established the low rate of postoperative complications associated with SLN biopsy as compared to complete lymph node dissection. We have identified factors that predict the presence of SLN metastases. In contrast, we have been unable to identify factors that indicate a low risk of non-sentinel node metastases in patients with a positive sentinel node, suggesting that completion lymphadenectomy is appropriate for such patients. We have further established the value of identifying interval or in-transit sentinel nodes, which can be the only site of nodal metastasis. We have evaluated the particular challenges associated with SLN biopsy of head and neck melanomas, have evaluated the patterns of early recurrence, and have identified an interesting correlation between increasing patient age and a number of prognostic factors. Future analyses will evaluate the benefit of early therapeutic lymphadenectomy and early institution of adjuvant interferon alfa-2b therapy, as well as the validity of molecular staging.

Management of in-transit metastases from cutaneous malignant melanoma

Background

In-transit metastases from cutaneous malignant melanoma (cutaneous or subcutaneous deposits between the primary melanoma and regional lymph nodes) represent late-stage disease, and their treatment should be tailored accordingly. This article reviews the pathology, clinical significance and treatment options for in-transit disease from melanoma.

Methods

An initial Medline search was undertaken using the keywords ‘melanoma and in-transit’ and ‘melanoma and non-nodal regional recurrence’. Additional original articles were obtained from citations in articles identified by the initial search.

Results and conclusion

In-transit metastases carry a poor prognosis. The method of treatment should be tailored to the extent of cutaneous disease. The first line of treatment remains complete excision with negative histopathological margins. There is no need for wide excision. Carbon dioxide laser therapy is valuable for multiple small cutaneous deposits. Isolated limb perfusion has a role for numerous or bulky advanced in-transit metastases in the limbs that are beyond the scope of simpler techniques. Systemic chemotherapy has response rates of about 25 per cent and is reserved for patients for whom surgery is no longer feasible.

Controversies in the management of metastatic melanoma to regional lymphatic basins

The primary management of lymph nodes involved with metastatic melanoma is regional lymphadenectomy. Many controversies of regional lymph node dissection exist including extent and nature of the lymphadenectomy, treatment of lymphatic metastases in unusual locations and the role of adjuvant radiotherapy. Although radical neck dissection has been the gold standard for cervical disease, modified dissections do not seem to compromise regional control in appropriately selected patients. In the axilla, a Level I, II, and III dissection is most commonly performed. Combined superficial and deep groin dissection is justified for clinically palpable disease although management of patients with histologically positive yet clinically non-palpable disease is more controversial. Burden of disease, imaging, patient co-morbidity, and Cloquet nodal status must be considered. Many technical variations exist in an attempt to improve morbidity rates secondary to lymphadenectomy. Unfortunately, complication rates are difficult to compare secondary to variable study designs, definitions, and patient populations. Adjuvant radiation therapy appears warranted in patients with high risk of regional recurrence including bulky disease, extracapsular extension or cervical location.

Complications associated with sentinel lymph node biopsy for melanoma

BACKGROUND

Sentinel lymph node (SLN) biopsy has become widely accepted as a method of staging the regional lymph nodes for patients with melanoma. Although it is often stated that SLN biopsy is a minimally invasive procedure associated with few complications, a paucity of data exists to specifically determine the morbidity associated with this procedure. This analysis was performed to evaluate the morbidity associated with SLN biopsy compared with completion lymph node dissection (CLND).

METHODS

Patients were enrolled in the Sunbelt Melanoma Trial, a prospective multi-institutional study of SLN biopsy for melanoma. Patients underwent SLN biopsy and were prospectively followed up for the development of complications associated with this technique. Patients who had evidence of nodal metastasis in the SLN underwent CLND. Complications associated with SLN biopsy alone were compared with those associated with SLN biopsy plus CLND.

RESULTS

A total of 2120 patients were evaluated, with a median follow-up of 16 months. Overall, 96 (4.6%) of 2120 patients developed major or minor complications associated with SLN biopsy, whereas 103 (23.2%) of 444 patients experienced complications associated with SLN biopsy plus CLND. There were no deaths associated with either procedure.

CONCLUSIONS

SLN biopsy alone is associated with significantly less morbidity compared with SLN biopsy plus CLND.

Radical lymph node dissection for melanoma

BACKGROUND

Therapeutic lymph node dissection for melanoma aims to achieve regional disease control. Radical lymphadenectomy (RLND) can be a difficult procedure associated with significant postoperative morbidity. The aims of the present study were to review regional disease control and morbidity in a series of lymphadenectomies performed within a specialist unit.

METHODS

The present study involved the analysis of 73 lymphadenectomies in 64 patients, from 1995 to 2001.

RESULTS

The overall wound complication rate after inguinal lymphadenectomy (71%) was higher than after axillary lymphadenectomy (47%; P = 0.05). After inguinal lymphadenectomy, the wound infection rate was higher (25.0%vs 5.9%; P = 0.03), delayed wound healing was more frequent (25.0%vs 5.9%; P = 0.03), and the mean time that drain tubes remained in situ was longer (12.5 vs 8.2 days; P = 0.05). There were no significant differences in seroma (46%vs 32%) rates. Lymphoedema was more common after inguinal lymphadenectomy (P < 0.02). Multivariate analysis identified inguinal RLND (P = 0.002) and increasing tumour size (P = 0.045) as predictors of wound morbidity. More patients received postoperative radiotherapy after neck RLND compared to inguinal or axilla RLND (P = 0.03). Six (8%) patients developed local recurrence after lymphadenectomy. At a median follow up of 22 months, 34 (53%) patients have died, from disseminated disease.

CONCLUSIONS

Radical lymphadenectomy for melanoma is associated with significant morbidity. Inguinal node dissection has a higher rate of complications than axillary dissection. Low local recurrence rates can be achieved, limiting the potential morbidity of uncontrolled regional metastatic disease.

Combined endoscopic and open inguinal dissection for malignant melanoma

BACKGROUND

Positive sentinel node biopsy or clinically/radiologically demonstrable lymph node metastases in patients with malignant melanoma establishes the indication for inguinal dissection. Currently the deep (pelvic) part of the dissection is the subject of lively discussion. For the past 3 years we have been carrying out all pelvic lymph node dissections using an endoscopic extraperitoneal approach in combination with conventional superficial inguinal dissection.

METHODS

In analogy to endoscopic extraperitoneal hernia repair we open the extraperitoneal space with the aid of a dissection balloon and then perform a complete dissection of the para-iliac and obturator lymph nodes. The superficial part of inguinal dissection is then carried out in the conventional manner.

RESULTS

Among a total of 31 consecutive dissections performed on 30 malignant melanoma patients between April 1999 and June 2002 neither intraoperative nor postoperative complications of the endoscopic part of the dissection were observed.

CONCLUSIONS

While enabling better local tumor control as a result of the complete dissection, this modification entailing the use of endoscopic pelvic dissection also appreciably reduces the extent of operative trauma without compromising oncological radicalness or increasing morbidity. We recommend this approach to all surgeons with experience with endoscopic extraperitoneal procedures for use in patients requiring inguinal dissection.

Dynamic lymphoscintigraphy and image fusion of SPECT and pelvic CT-scans allow mapping of aberrant pelvic sentinel lymph nodes in malignant melanoma

To date, there are no reliable criteria to identify those patients with melanoma-infiltrated sentinel lymph nodes (SLNs) of the groin who might benefit from an extended lymphadenectomy, including the pelvic lymph nodes. We hypothesised that there are pelvic lymph nodes that receive lymph directly from the primary tumour, thus being at an increased risk for metastasis. In order to determine the frequency of radioactively labelled pelvic lymph nodes and the kinetics of their appearance, we introduce here a combination of dynamic lymphoscintigraphy, single photon emission computed tomography (SPECT) and image fusion of SPECT and pelvic Computed Tomography (CT)-scans. By dynamic lymphoscintigraphy and intraoperative gamma probe detection, superficially located inguinal SLNs (median 2 nodes) could be identified in all of the 51 patients included in this analysis. The histological search for micrometastases was positive in 16 patients (median Breslow thickness of the primary melanoma 2.5 mm). In 29 patients, SPECT and the image fusion technique were additionally performed. Radioactively labelled pelvic lymph nodes were detected in 20 individuals, 6 of them presenting aberrant pelvic SLNs that, on dynamic lymphoscintigraphy, had appeared simultaneously with the superficial SLN(s). Of the 6 patients in whom radioactive pelvic lymph nodes were excised together with the superficial SLN(s), only one had positive superficial SLNs. In this patient, the aberrant pelvic SLN proved to be tumour-positive. In 9 patients, there was no radiotracer uptake in the pelvic lymph nodes at all. Image fusion of SPECT and pelvic CT-scans is an excellent tool to localise exactly the pelvic tumour-draining nodes. The significance of radioactively labelled pelvic lymph nodes for the probability of pelvic metastases should be analysed further.

Lymph node dissection for clinically evident lymph node metastases of malignant melanoma

AIMS

A considerable number of melanoma patients present with clinically evident regional lymph node metastases. Factors influencing prognosis following therapeutic lymph node dissection (TLND) were evaluated.

METHODS

In total 140 patients (68 women, 72 men, median age 53 years) with established regional lymph node metastases, but without clinically detectable distant metastases, received cervical, axillary or ilioinguinal TLND between 1978 and 1997 and were retrospectively reviewed. Uni- and multivariate survival analysis was performed.

RESULTS

Median survival for all 140 patients was 25 months; the observed overall 5 year survival rate was 30%. Age greater than 50 years, primary tumour site on the trunk, more than three lymph node metastases and extracapsular spread were associated with a poor prognosis. In multivariate analysis age (< or =50 years vs >50 years, P=0.02), location of the primary tumour (non-truncal vs truncal, P=0.005), number of lymph nodes involved ( n< or =3 vsn >3, P=0.01) and extracapsular spread (none vs present, P=0.04) proved to be independent prognostic factors.

CONCLUSIONS

TLND is worthwhile and offers a potential chance of cure in about one-third of melanoma patients with established regional lymph node metastases. There are subgroups with a particularly poor prognosis in whom the benefit of radical surgery alone is limited.

Prognosis and surgical management of patients with palpable inguinal lymph node metastases from melanoma

BACKGROUND

The appropriate management of melanoma metastatic to inguinal lymph nodes remains controversial. The aim of this study was to identify disease- and treatment-related factors that influence the outcome of patients undergoing therapeutic groin dissection for clinically detectable melanoma lymph node metastases.

METHODS

A retrospective analysis was performed on data collected from the case records of patients who had a therapeutic inguinal lymph node dissection performed between 1984 and 1998.

RESULTS

Some 132 patients were suitable for inclusion. Sixty patients had superficial inguinal lymph node dissection (SLND) and 72 had combined superficial inguinal and pelvic lymph node dissection (CLND). There was no difference in postoperative morbidity or major lymphoedema between SLND and CLND. The overall survival rate was 34 per cent at 5 years. On univariate analysis, age (P = 0.003), the number of involved superficial lymph nodes (P = 0.001) and the presence of extracapsular spread (P = 0.003) were found to have a significant impact on survival. The presence or absence of pelvic lymph node metastases in patients who had CLND was a significant prognostic factor for survival (5-year survival 19 versus 47 per cent; P = 0.015).

CONCLUSION

The prognosis of patients with clinically detectable melanoma metastases to the groin is variable and related to the biological characteristics of each case. CLND provided additional prognostic information and optimal regional control with no increased morbidity compared with SLND.