Conformal 3D planned radiotherapy for pelvic lymphoceles following surgery for urological cancer: A case study

Radiotherapy of Lymphatic Fistulas after Vascular Surgery in the Groin

PURPOSE

Lymphatic fistulas are common complications after vascular surgery especially in the groin, which can lead to a prolongation of the inpatient stay, wound infections and follow-up operations. Radiotherapy is one of the non-surgical treatment options. However, there is limited evidence and discussion about the ideal dosage and timing.

METHODS AND MATERIALS

The analysis was performed on patients from a German university hospital and included 191 patients with 206 lymphatic fistulas from 2005 to 2016. Four different endpoints were analyzed. The patients were irradiated with a fraction dose of 3 Gy up to a cumulative dose of 9 Gy (94/206 cases) or 18 Gy (112/206 cases). The median age of the patients was 70.5 years with 74% male and 26% female patients. Vascular surgery included bypass grafts (52%), thrombendarterectomy/patch angioplasty (26%), and vascular access for aortic endografts (22%).

RESULTS

The response to radiotherapy for the four different endpoints was 88% (25% decrease in secretion volume), 80% (secretion below 50 ml/24 hours), 81% (removal of the drainage) and 75% (freedom from any intervention), respectively. The overall response for all four endpoints was 63% (129/206) after completion of radiotherapy, and 34% (70/206) after one course with a total dose up to 9 Gy. The median lymphatic secretion was 150 ml/24 hours before radiotherapy and 60 ml/24 hours one day after the end of therapy. The drainage could be removed a median of 3 days after radiotherapy completion. There was no significant difference between patients starting the radiation within 5-9 days or ≥10 days postoperatively (p = .971 OR = 0.99; 95%-CI: 0.56 to 1.74). No relevant factors influencing the response rate could be identified. Re-operation was required in 50/206 cases (25%), in 24/206 cases (12%) due to persistent lymphatic fistula and complications and in 26/206 cases (13%) due to wound and/or vascular complications.

CONCLUSION

Radiotherapy seems to be an effective, non-surgical treatment option for reducing lymphatic secretion after vascular surgery in the groin. Starting radiation early (≤9 days) or late (≥10 days) postoperatively does not affect the success rate.

[Radiotherapeutic management of lymphatic fistulas : An effective but disregarded therapy option]

BACKGROUND

Lymphatic fistulas and lymphoceles are known complications after vascular surgery of the groin and after extended surgical interventions in the pelvic region. Unfortunately, conservative standard therapies are not always successful.

OBJECTIVES

Evaluation of the therapeutic efficacy and related side effects of percutaneous low-dose irradiation in patients with lymphorrhea and definition of its importance.

MATERIAL AND METHODS

Current presentation of previously published case series, reviews and guidelines.

RESULTS

The use of low-dose irradiation therapy with single doses of 0.3-0.5 Gy leads to a cessation of the lymphatic flow in a high percentage of patients when standard therapies do not show a sufficient effect. With cessation of lymphorrhea irradiation should be terminated. Acute side effects have not been reported and the risk of tumor induction is almost negligible.

CONCLUSION

Low-dose irradiation is an effective and very well-tolerated therapeutic alternative in the treatment of lymphatic fistulas and lymphorrhea when conservative therapies are unsuccessful.