Comparison of lymphedema following incontinuity and discontinuity groin dissection

Immediate inguinal lymphaticovenous anastomosis following lymphadenectomy in skin cancer of lower extremities

BACKGROUND

Secondary lymphedema following inguinal lymph node dissection in lower extremities skin cancer reduce the patients' quality of life. Immediate lymphaticovenous anastomosis (LVA) at groin is a procedure intended to prevent secondary lymphedema. The data regarding the long-term efficacy and safety of this procedure was limited. Therefore, we evaluated the long-term outcomes of immediate LVA in patients with melanoma and non-melanoma skin cancer of the lower extremities.

METHODS

The retrospective data review of patients with melanoma or squamous cell carcinoma of the lower extremities underwent oncologic tumor resection with groin node dissection between December 2013 and December 2016 was performed. Seven patients underwent immediate LVA (intervention) at groin after node dissection and 22 acted as controls. The occurrence of lymphedema and oncologic outcomes were followed up to 7 years.

RESULTS

Fifteen patients (51.7%) developed postoperative lymphedema, which were three patients in the intervention group and twelve patients in the control group (p = 0.68). The intervention group had significant lower 2-year (57.1% versus 77.3%) and 5-year overall survival (14.3% versus 54.5%) (p = 0.035). The intervention group had reduced 2-year (28.6% versus 86.4%) and 5-year (28.6% versus 68.2%) Recurrence Free Survival (RFS) (p = 0.013). The intervention group also had reduced 2-year (0% versus 90%) and 5-year (0% versus 70%) Metastasis Free Survival (MFS) (p = 0.003).

CONCLUSION

Immediate inguinal LVA following groin node dissection in lower extremity skin cancer patients did not reduce the incidence of lymphedema. Unfortunately, it was associated with lower overall survival and an increase in tumor recurrence and metastasis.

The Use of Lympho-Venous Anastomoses to Prevent Complications from Ilio-Inguinal Dissection

Lympho-venous anastomoses (LVA) were performed in 30 patients, immediately after the completion of ilio-inguinal dissection for metastatic nodal involvement. This surgical procedure, originally devised to treat post-mastectomy lymphedema from radical mastectomy, was intended in this series of cases to prevent complications from ilio-inguinal nodal dissection. Actually, when compared to another group of 84 patients previously operated on by ilioinguinal nodal dissection without lympho-venous anastomoses, the series showed a lower rate of local-regional complications (38% vs 65.9%). The mean duration of hospital stay was also reduced (18.5 vs 34.7 days). Distant lymphedema of the lower limb was observed in 7 of 23 patients who had received LVA, whereas in the control group, lymphedema was recorded in 39 of 52 patients who were regularly followed-up (30% vs 75%). LVA should be routinely used, as a useful surgical procedure, to prevent or reduce the occurrence of local-regional complications following ilio-inguinal nodal dissections.

Recent progress in the treatment and prevention of cancer-related lymphedema

This article provides an overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema. Lymphedema incidence by tumor site is evaluated. Measurement techniques and trends in patient education and treatment are also summarized to include current trends in therapeutic and surgical treatment options as well as longer-term management. Finally, an overview of the policies related to insurance coverage and reimbursement will give the clinician an overview of important trends in the diagnosis, treatment, and management of cancer-related lymphedema.

Prospective assessment of lymphedema incidence and lymphedema-associated symptoms following lymph node surgery for melanoma

We aimed to prospectively assess limb volume change (LVC) and associated symptoms in patients with melanoma undergoing sentinel lymph node biopsy and/or therapeutic lymph node dissection. Limb volume was measured preoperatively and postoperatively at 6 and 12 months using a perometer (1000 mol/l). LVC was calculated and used to define three groups: less than 5%, 5-10%, and greater than 10%. A 19-item lymphedema symptom questionnaire was administered at baseline, 6, and 12 months. One hundred and eighty-two patients were enrolled. Twelve months after axillary surgery, 9% had LVC 5-10% and 13% had LVC greater than 10%. Twelve months after inguinofemoral surgery, 10% had LVC 5-10% and 13% had LVC greater than 10%. There was a significant seven- to nine-fold increase in symptoms for patients with LVC greater than 10% compared with those with LVC less than 5% (P<0.05). On multivariate analysis, therapeutic lymph node dissection versus sentinel lymph node biopsy (odds ratio=3.18; P<0.01) and borderline significance for lower-extremity versus upper-extremity procedures (odds ratio=1.72; P=0.07) were associated with LVC greater than 5%. LVC greater than 5% is common at 12 months following nodal surgery for melanoma and is associated with symptoms. Informed consent for melanoma patients undergoing lymph node surgery should include a discussion of the risks of postoperative lymphedema.

Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema

BACKGROUND

Secondary lymphedema is a debilitating, chronic, progressive condition that commonly occurs after the treatment of breast cancer. The purpose of the current study was to perform a systematic review and meta-analysis of the oncology-related literature excluding breast cancer to derive estimates of lymphedema incidence and to identify potential risk factors among various malignancies.

METHODS

The authors systematically reviewed 3 major medical indices (MEDLINE, Cochrane Library databases, and Scopus) to identify studies (1972-2008) that included a prospective assessment of lymphedema after cancer treatment. Studies were categorized according to malignancy, and data included treatment, complications, lymphedema measurement criteria, lymphedema incidence, and follow-up interval. A quality assessment of individual studies was performed using established criteria for systematic reviews. Bayesian meta-analytic techniques were applied to derive summary estimates when sufficient data were available.

RESULTS

A total of 47 studies (7779 cancer survivors) met inclusion criteria: melanoma (n = 15), gynecologic malignancies (n = 22), genitourinary cancers (n = 8), head/neck cancers (n = 1), and sarcomas (n = 1). The overall incidence of lymphedema was 15.5% and varied by malignancy (P < .001): melanoma, 16% (upper extremity, 5%; lower extremity, 28%); gynecologic, 20%; genitourinary, 10%; head/neck, 4%; and sarcoma, 30%. Increased lymphedema risk was also noted for patients undergoing pelvic dissections (22%) and radiation therapy (31%). Objective measurement methods and longer follow-up were both associated with increased lymphedema incidence.

CONCLUSIONS

Lymphedema is a common condition affecting cancer survivors with various malignancies. The incidence of lymphedema is related to the type and extent of treatment, anatomic location, heterogeneity of assessment methods, and length of follow-up.

Cutaneous melanoma in the elderly

The aim of this review was to analyze the difficulties in diagnosing and treating elderly patients with cutaneous melanoma. It focused on the main causes for late diagnosis and relatively poor prognosis in these patients. Early detection of melanoma is vital to reduce mortality in these patients and surgery is often curative. Adequate treatment of elderly patients with melanoma requires knowledge of the clinical features and histopathology of the disease, and the therapeutic options. This review also examined the main surgical procedures for primary melanoma and regional lymph node staging, and the curative and palliative procedures indicated for those elderly patients with advanced disease. It is expected that several molecular genetic factors will soon provide further prognostic information of possible benefit for elderly patients with melanoma.

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.

Diagnosis of melanoma in the elderly and surgical implications

The diagnosis of primary melanoma is mainly related to the precocity on which a patient is referred to the specialist, but in elderly patients this may present some peculiar characteristics, one is anatomical, a typical melanoma of the face, the lentigo maligna melanoma and the second is attitudinal, the fact that elderly patients often do not refer a changing cutaneous lesion to a doctor until becoming symptomatic. The therapeutic approach has to be discussed with an anaesthesiologist if the procedure has to be conducted under general anaesthesia or with a cardiologist if under local anaesthesia. Once there are no contraindications medically, a similar oncological approach should be proposed without any reduction in radicality due to the elderly age.

Surgical techniques of melanoma and sentinel node biopsy

The adequacy of surgical treatment of melanoma patients is the most important milestone in the natural history of the disease, once the diagnosis has been confirmed. Surgery plays a fundamental role in the initial stages of the disease, ie, to remove the primary lesion and to excise accurately the locoregional metastases. On the contrary, the impact of a surgical indication to treat distant metastases has never been confirmed in a prospective study; thus, there are no standard guidelines and it represents a decision to be discussed with each individual patient.

Lymphedema management training for physical therapy students in the United States

BACKGROUND

The objective of this study was to determine to what extent accredited physical therapy programs in the United States were presenting the principles of lymphedema management and whether regional differences existed.

METHODS

States were grouped into four geographic regions: Northeast, South, Midwest, and West. From mid-June to mid-July, 1997, 63 of 148 (42.6%) accredited physical therapy (PT) programs in the United States completed and returned the questionnaires. Participants received a cover letter, consent form, and lymphedema survey by e-mail, facsimile, or regular post. The lymphedema survey covered a wide variety of issues relating to five areas: 1) general and 2) specific anatomy and physiology of the lymphatic system, 3) pathogenesis of lymphedema, 4) traditional (compression pumps/garments), and 5) innovative (European/Australian) treatment techniques for lymphedema. "Yes" responses indicated that specific information was included in the curriculum. Frequency of yes responses for each of the five areas were counted and converted into percentages. Regional responses were compared with the total combined responses with a modified binomial technique.

RESULTS

PT programs in the United States were providing 89% of our designated content in the general anatomy and physiology of the lymphatic system, 73% in the pathogenesis of lymphedema, 65% in traditional treatment techniques, 48% in innovative treatment techniques, and 42% in the specific anatomy and physiology of the lymphatic system. No individual region differed significantly (P > 0.05) from the combined results.

CONCLUSIONS

The participating PT programs appeared to be providing instruction in general anatomy and physiology of the lymphatic system, pathogenesis of lymphedema, and traditional treatment techniques. However, far less instruction on the specific anatomy and physiology of the lymphatic system and innovative treatment techniques is offered. We believe that PT students would benefit with more curricular content in these latter two categories in order to acquire the knowledge and skills to combat the devastating effects of lymphedema.

Management of cutaneous melanoma M0: state of the art and trends

This article reviews the epidemiology, diagnosis and treatment of cutaneous melanoma, including the most recent developments. The combination of positive family history, fair complexion, number of nevi, exposure to sun and/or chromosomal alterations seem to be implicated in the pathogenesis of cutaneous melanoma. Melanomas can be classified according to their growth patterns, and tumour microstaging is of straightforward predictive value for survival and risk of metastasis, although new factors are also being investigated. As yet, surgical excision is the only effective treatment available for primary tumours, resection margins varying according to tumour thickness. Elective node dissection is, however, no longer advocated for melanomas thinner than 1.5 mm, and there is disagreement as to its role for thicker lesions. In contrast, selective node dissection at the time of definitive surgery is becoming more widely accepted, with regional node dissection being restricted to positive cases. Therapeutic dissection is required for lymph node involvement, the most common pattern of recurrence from melanoma, which affects nearly 30% of all patients. Complete remission rates from isolated limb perfusion, which has been employed in patients with multiple recurrences or in-transit metastases, range from 40 to 90%, depending on drugs and techniques used in different series; the best responses so far have been obtained with tumour necrosis factor in combination with melphalan. Patients with thick lesions (> 4 mm) or lymph node metastases have a high risk of micrometastases that would warrant adjuvant therapy. The only agent found to affect survival is interferon alpha-2.

Ilioinguinal block dissection for malignant melanoma

A retrospective analysis of 41 patients treated for metastatic inguinal lymph node malignant melanoma is presented: 16 underwent inguinal node excision and 25 ilioinguinal node excision. The two groups were well matched for age, sex and other characteristics. The mean time in hospital (inguinal 20 days, ilioinguinal 18 days) and the complication rates (inguinal, ten of 16 patients, ilioinguinal, 13 of 25) were similar in each group. The incidence of groin relapse, defined as the development of symptomatic melanoma in the region of the inguinal or iliac node basins following block dissection, was lower after ilioinguinal block dissection (inguinal, three patients; ilioinguinal, none). Histological examination demonstrated a high proportion of iliac node involvement (13 of 25 patients), even in those with a single mobile inguinal lymph node clinically and no clinical or computed tomographic evidence of iliac node involvement. This supports the value of ilioinguinal block dissection and suggests that the associated morbidity need not be greater than that associated with inguinal clearance alone.

Groin dissection in malignant melanoma

BACKGROUND

There is controversy about the extent of groin dissection necessary (whether superficial or radical) and about its utility when the deep nodes are affected.

METHODS

A total of 198 groin dissections (1977-1991) were reviewed; 94 (48%) were superficial and 104 (52%) were radical dissections. Of 72 patients with palpable positive inguinal nodes, 31 (43%) had involvement of the deep nodes; of 39 patients with nonpalpable, histologically positive inguinal nodes, seven (18%) had or later manifested involvement of the deep nodes.

RESULTS

The mean number of positive nodes (median) in the group with clinically palpable disease was six (two), and in the group with occult disease the number was two (one). The estimated overall (disease-free) 5-year and 10-year survival rates for patients with negative nodes were 73% (67%) and 64% (58%), respectively, and for those with positive nodes they were 36% (27%) and 30% (23%), respectively. Survival was significantly poorer for patients with positive nodes (p < 0.0001). The respective 5-year and 10-year survival rates for patients with positive nodes and involvement of the inguinal nodes only were 41% (33%) and 36% (29%), and for those with involvement of the inguinal and deep nodes the rates were 28% (17%) and 19% (13%). Survival was significantly poorer for patients with deep node involvement (p = 0.006).

CONCLUSIONS

The survival rates after therapeutic groin dissection are substantial and unattainable with any other treatment at the present time. Incontinuity dissection of the deep nodes is advisable in the presence of palpable inguinal nodes, since the incidence of deep node involvement is considerable and the survival rate appreciable after removal of involved deep nodes.

Elective lymph node dissection for melanoma

The role of elective lymph node dissection (ELND) in the management of primary melanoma of the skin is a controversial subject. Some authorities consider the indications for this procedure to be broad, whereas others rarely recommend ELND. Voluminous literature reflects these divergent opinions. Unfortunately, this can be confusing for the practitioner advising a patient with melanoma. We review arguments for and against ELND and review some of the most important studies of the effects of ELND on survival. We attempt to elucidate the sources of controversy inherent in these survival studies. Criteria for the selection of appropriate candidates for ELND are discussed. ELND with hyperthermic limb perfusion is also briefly reviewed.

Treatment of regional nodes

The appearance of nodal metastases from cutaneous melanoma represents a poor prognosis. Surgery is the only possible treatment for these patients since chemotherapy or immunotherapy have no confirmed specific efficacy in adjuvant or therapeutic schedules. If, for clinically metastatic regional nodes, there is complete agreement on the opportunity of dissection, in the case of clinically uninvolved nodes some controversy exists. For melanomas of the extremities, two different randomized studies have demonstrated no difference in the long-term outcome of patients with stage I melanoma, whether immediate or delayed node dissection is performed. For axial melanomas, although definitive data are not available, there are preliminary statistical results as well as anatomical and technical reasons, suggesting an identical surgical approach to that performed for primaries of other sites. Therefore, apart from specific cases, there is good evidence that node dissection should be planned only for patients with clinically involved regional nodes.

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

A series of 168 patients who underwent 177 inguinal lymph node dissections from 1979 to 1989 were retrospectively reviewed to determine the incidence and severity of postoperative complications as well as the perioperative risk factors associated with them. Operative mortality was 0%, whereas the incidence of moderate to severe wound infection was 11%, skin flap problems 0%, seromas 6%, and hemorrhage 3%. The occurrence of a wound complication increased the average hospital stay from 11 to 12 days. Multivariate risk factor analysis revealed age older than 50, male sex, and smoking to be significant risk factors for developing a wound infection. The use of prophylactic antibiotics and the duration of closed suction catheter drainage were not predictive of wound complications. Overall, 44% of patients experienced some postoperative edema, with only 7% of patients having 1+ edema that lasted longer than 6 months. Combined ilioinguinal lymph node dissection increased the chance of developing moderate to severe edema. These risk factors identify patients at high risk for morbidity, which should lead to improved perioperative care.

Malignant melanoma and lymph nodes

A total of 226 cases of malignant melanoma of the skin (MM), clinical stage I disease, located on the leg (87), arm (36), or trunk (103), were treated with elective regional node dissection (ERND). The axillary lymph nodes were dissected by a T-shaped skin incision line, whereas the inguinal nodes were removed with the help of a spindle-shaped skin excision. Both techniques, without mortality, offered the precondition for extirpation of the lymph nodes en bloc and guaranteed well-healing wounds.

Lymphedema after groin dissection

Groin dissection was performed in 67 patients, of whom 40 had superficial groin dissection and 27 had ilioinguinal dissection. The incidence of overall lymphedema of a mild to moderate degree was 21 percent. Lymphedema was observed more frequently (26 percent) in patients with primary lesions in the leg when compared with those with lower trunk lesions (6 percent, p less than 0.001), and in those who did not follow a prophylactic regime of leg elevation and use of a fitted elastic stocking (45.8 percent) when compared with those who adhered to the regime (7 percent, p less than 0.004). Sex, age, wound problems, histologic status of lymph nodes, and the duration of follow-up did not significantly affect the occurrence of lymphedema.

Epidermoid carcinoma of the anus

Twenty five patients with epidermoid carcinoma of the anus, representing 1.5% of all large bowel malignancies, were seen over a 33 year period. Most patients presented with an advanced lesion which gave rise to a fungating mass, bleeding or pain. Nearly all patients who received either palliative irradiation or refused treatment died within a year of diagnosis. Abdominoperineal resection in 12 patients yielded an encouraging five year survival rate of 68.5%. Therapeutic groin node dissection performed on six occasions led to only one late recurrence. The surgical literature on sphincter saving local excision and therapeutic radiotherapy is reviewed. Currently, radical resection remains the most appropriate treatment for the majority of patients with epidermoid anal cancer.

The surgical management of anorectal malignant melanoma

The biological vagaries of anal malignant melanoma are illustrated by four cases in Chinese patients. All four died within five years. Their poor prognosis emphasizes the value of preoperative studies to detect clinically occult metastases and obviate futile radical surgery. Many patients already have disseminated disease at the time of diagnosis, and local excision of the tumour provides acceptable palliation. For localized disease, abdominoperineal resection prevents local recurrence and removes the mesenteric nodes which are frequently involved. Palpable inguinal nodes necessitate therapeutic groin dissection, but we perform elective resection only when affected nodes are found at laparotomy. Pelvic lymphadenectomy should be performed in conjunction with abdominoperineal resection. The efficacy of chemotherapy for anorectal melanoma remains uncertain.

Lymph node dissection in malignant melanoma

Regional node dissection was performed in 120 patients with malignant melanoma. Patients with clinically negative nodes had a 90% survival, whereas patients with enlarged nodes had a 15% survival. In 45 inguinal dissections, usually associated with a high morbidity, there was only a 4.5% incidence of infection and a 6.5% incidence of skin edge necrosis. For all types of node dissection, the overall incidence of wound infection was 5.8%, and that of necrosis of skin edges was 5%.

A rational approach to the surgical management of melanoma

Our experience with 294 regional lymph node dissections in 250 patients are reviewed. The relationship between the Clark's level of invasion and the thickness of the primary is related to regional lymph node metastases. Patients with Clark's Level III melanoma had a 29% incidence of regional lymph node metastases, Clark's Level IV had a 42% incidence of regional lymph node metastases and Clark's Level V a 58% incidence of regional lymph node metastases. Primary melanomas greater than 1.5 mm in thickness had a 38% incidence of positive regional lymph nodes. We therefore recommend a regional lymphadenectomy in patients with Clark's Levels III, IV and V and all melanomas that are greater than 1.5 mm in thickness. A new technique is described which is helpful in localizing the direction of ambiguous lymphatic drainage in patients with truncal melanoma. The use of radioactive colloidal gold scanning has been useful in predicting lymphatic shed in these ambiguous truncal melanomas. Certain technical aspects of inguinal lymph node dissection are emphasized in an attempt to reduce the morbidity of these dissections. It is emphasized that iliac-obturator lymph node dissections are not performed unless the inguinal lymph nodes are found to be involved by frozen section examination at the time of surgery.