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

Short- and long-term outcomes of surgical treatment for inguinal lymph node metastasis in rectal and anal canal adenocarcinoma

AIM

The significance of lymphadenectomy and its indications in patients with inguinal lymph node metastasis (ILNM) of anorectal adenocarcinoma is unclear. This study aimed to clarify the surgical outcomes and prognostic factors of inguinal lymphadenectomy for ILNM.

METHOD

This study included patients who underwent surgical resection for ILNM of rectal or anal canal adenocarcinoma with pathologically positive metastases between 1997 and 2011 at 20 participating centres in the Study Group for Inguinal Lymph Node Metastasis from Colorectal Cancer organized by the Japanese Society for Cancer of the Colon and Rectum. Clinicopathological characteristics and short- and long-term postoperative outcomes were retrospectively analysed.

RESULTS

In total, 107 patients were included. The primary tumour was in the rectum in 57 patients (53.3%) and in the anal canal in 50 (46.7%). The median number of ILNMs was 2.34. Postoperative complications of Clavien-Dindo Grade III or higher were observed in five patients. The 5-year overall survival rate was 38.8%. Multivariate analysis identified undifferentiated histological type (P < 0.001), pathological venous invasion (P = 0.01) and pathological primary tumour depth T0-2 (P = 0.01) as independent prognostic factors for poor overall survival.

CONCLUSION

The 5-year overall survival after inguinal lymph node dissection was acceptable, and it warrants consideration in more patients. Further larger-scale studies are needed in order to clarify the surgical indications.

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.

Predictors of complication after groin dissection: a single-centre experience

BACKGROUND

Inguinal lymphadenectomy (ILND) has historically been associated with substantial morbidity. The objective of this study was to obtain contemporary ILND morbidity rates and to identify potentially preventable risk factors.

METHODS

We carried out a retrospective review of medical records for all superficial, deep, and combination groin dissections performed at a single, high-volume academic centre between January 2007 and December 2020. We collected data points for patient, disease, and surgery characteristics, and cancer outcomes. The outcome of interest was any complication within 30 days of surgery. Complications included wound infection, wound necrosis or disruption, seroma, drainage procedure, hematoma, and lymphedema. We performed multivariate logistic regression using SAS version 9.4.

RESULTS

We identified 139 patients having undergone 89 superficial, 12 deep, and 38 combined dissection types, respectively. Melanoma accounted for 84.9% of cases. Of these patients, 56.1% had an adverse postoperative event within 30 days. Increasing age (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.07, p < 0.01) and number of positive lymph nodes harvested (OR 1.22, 95% CI 1.00-1.50, p = 0.05) were associated with more complications. Patients with deep dissection showed a lower likelihood of complications than those with superficial dissection (OR 0.15, 95% CI 0.03-0.84, p < 0.05).

CONCLUSION

Complication rates after ILND remain high. We identified a number of risk factors, providing opportunities for better selection and prevention.

The incidence and cost implications of surgical site infection following lymph node surgery for skin malignancy

BACKGROUND

Lymph node surgery is commonly performed in the staging and treatment of metastatic skin cancer. Previous studies have demonstrated sentinel lymph node biopsy (SLNB) and, particularly, lymph node dissection (LND) to be plagued by high rates of wound complications, including surgical site infection (SSI) and seroma formation. This study evaluated the incidence of wound complications following lymph node surgery and provided the first published cost estimate of SSI associated with lymph node surgery in the UK.

PATIENTS AND METHODS

A retrospective cohort study of 169 patients with a histological diagnosis of primary skin malignancy who underwent SLNB or LND of the axilla and/or inguinal region at a single tertiary centre over a 2 year period was conducted. Demographic, patient risk factor, and operation characteristics data were collected and effect on SSI and seroma formation was analysed. Cost-per-infection was estimated using National Health Service (NHS) reference and antibiotic costs.

RESULTS

A total of 146 patients underwent SLNB with a SSI rate of 4.1% and a seroma incidence of 12.3%. Twenty-three patients underwent LND with a SSI rate of 39.1% and a seroma incidence of 39.1%. Seroma formation was strongly associated with the development of SSI in both the SLNB (odds ratio (OR) = 18.0, p < 0.001) and LND (OR = 21.0, p = 0.007) group. The median additional cost of care events and treatment of SSI in the SLNB and LND groups was £199.46 and £5187.04, respectively.

CONCLUSION

SSI remains a troublesome and costly event following SLNB and LND. Further research into perioperative care protocols and methods of reducing lymph node surgery morbidity is required and could result in significant cost savings to the NHS.

Clinical outcomes of different muscle flap reconstruction after inguinal tumor resection: A case series

PURPOSE

To introduce the clinical outcomes of adductor longus and sartorius muscle transfer alone and combined application for reconstruction of the inguinal region.

METHODS

This is a retrospective study of patients between January 2019 and December 2022 who underwent adductor longus flap transfer, sartorius muscle flap transfer, and combined transfer of adductor longus and sartorius muscle. The demographic data and surgical details were recorded.

RESULTS

Sixteen patients were included, with a mean age of 57.5 years. Nine patients performed adductor longus flap transfers, three patients performed sartorius muscle flap transfers, and four patients performed combined transfers. The average operation time was 238 min. The average length of stay was 6.7 days. The average follow-up period was 9.6 months (range 6-16). The overall early postoperative complication rate was 12.5% (one patient had excessive wound exudation and one patient had a wound infection). No delayed postoperative complications occurred during the follow-up.

CONCLUSION

The sartorius muscle flap, the adductor longus flap, and the combined application are suitable techniques for inguinal region reconstruction under different conditions. The combined application of the two flaps can fill the dead space and cover the neurovascular bundle efficaciously.

Surgical outcomes of lymph node dissections for stage III melanoma after neoadjuvant systemic therapy are not inferior to upfront surgery

BACKGROUND

Neoadjuvant systemic therapy has shown promising results in the treatment of high-risk stage III melanoma; however, the effects on surgery are currently unknown. This study aims to compare the surgical outcomes, in terms of postoperative complications, postoperative morbidity, duration of surgery and textbook outcomes, of patients with high-risk stage III melanoma who received neoadjuvant systemic therapy followed by lymph node dissection with patients who received an upfront lymph node dissection.

METHODS

In this retrospective cohort study, patients with high-risk stage III melanoma treated with neoadjuvant anti-PD1 and anti-CTLA4 in the OpACIN (NCT02437279) and OpACIN-neo (NCT02977052) trial between October 2014 and August 2018 were included and compared to patients who received upfront surgery in the same time period.

RESULTS

A total of 120 patients were included in this study, of whom 44 received neoadjuvant systemic therapy and 76 underwent upfront surgery. There was no significant difference in the overall rate of postoperative complications between the neoadjuvant group and the upfront surgery group (31.8% versus 36.8%, p = 0.578) and neither in rate of postoperative morbidity (seroma 56.8% versus 57.9%, p = 0.908) (lymphedema 22.7% versus 13.2%, p = 0.175). There was a non-significant difference towards a slightly longer duration of surgery after neoadjuvant immunotherapy (105 versus 90 min, p = 0.077). There were no differences in textbook outcomes (50% versus 49%, p = 0.889).

CONCLUSION

This study shows that the surgical outcomes for patients who underwent a lymph node dissection after neoadjuvant systemic immunotherapy or underwent upfront lymph node dissection for high-risk stage III melanoma are comparable.

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.

Classification of Metastatic Lymph Nodes In Vivo Using Quantitative Ultrasound at Clinical Frequencies

Quantitative ultrasound (QUS) methods characterizing the backscattered echo signal have been of use in assessing tissue microstructure. High-frequency (30 MHz) QUS methods have been successful in detecting metastases in surgically excised lymph nodes (LNs), but limited evidence exists regarding the efficacy of QUS for evaluating LNs in vivo at clinical frequencies (2-10 MHz). In this study, a clinical scanner and 10-MHz linear probe were used to collect radiofrequency (RF) echo data of LNs in vivo from 19 cancer patients. QUS methods were applied to estimate parameters derived from the backscatter coefficient (BSC) and statistics of the envelope-detected RF signal. QUS parameters were used to train classifiers based on linear discriminant analysis (LDA) and support vector machines (SVMs). Two BSC-based parameters, scatterer diameter and acoustic concentration, were the most effective for accurately detecting metastatic LNs, with both LDA and SVMs achieving areas under the receiver operating characteristic (AUROC) curve ≥0.94. A strategy of classifying LNs based on the echo frame with the highest cancer probability improved performance to 88% specificity at 100% sensitivity (AUROC = 0.99). These results provide encouraging evidence that QUS applied at clinical frequencies may be effective at accurately identifying metastatic LNs in vivo, helping in diagnosis while reducing unnecessary biopsies and surgical treatments.

Completion Lymph Node Dissection for Melanoma Before and After the Multicenter Selective Lymphadenectomy Trial-II in the United States

BACKGROUND

The Multicenter Selective Lymphadenectomy Trial-II (MSLT-II) revealed completion lymph node dissection (CLND) after positive sentinel lymph node biopsy (SLNB) did not improve melanoma-specific survival compared with surveillance. Given these findings and the morbidity associated with CLND, this study investigated trends in rates and predictors of CLND after MSLT-II.

METHODS

Analysis of the National Cancer Database was performed for all patients aged ≥18 years with melanoma and a positive SLNB for 2012-2019. Rates of CLND before and after publication of MSLT-II were identified and logistic regression used to identify factors associated with CLND.

RESULTS

Patients undergoing CLND declined from 55.9% pre-MSLT-II (n = 9725) to 19.5% post-MSLT-II (n = 9419) (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.29-0.35). CLND was less likely in females (OR 0.83; 95% CI 0.78-0.89), older patients (vs. 18-39 yr; 40-64 yr OR 0.80, 95% CI 0.65-0.98; 65-79 yr OR 0.67, 95% CI 0.53-0.84; >80 yr OR 0.38, 95% CI 0.30-0.49), sicker patients (Deyo category ≥2 OR 0.85, 95% CI 0.73-0.99), thinner primary lesions (vs. 0.01-0.79 mm; 1.01-4.00 mm OR 1.16, 95% CI 1.01-1.33; ≥4.01 mm OR 1.31, 95% CI 1.08-1.59), patients from metro areas (Rural OR 1.31, 95% CI 1.00-1.70; Urban OR 1.15, 95% CI 1.03-1.29), and those treated at lower-volume centers (vs. lowest-volume; highest-volume OR 1.31, 95% CI 1.14-1.50; high-volume OR 1.40, 95% CI 1.24-1.57).

CONCLUSIONS

MSLT-II has impacted clinical care; however, male gender, thicker lesions, rural/urban residence, younger age, fewer comorbidities, and treatment at higher-volume centers confer a greater likelihood of undergoing CLND. Further investigations should focus on whether these populations benefit from more aggressive surgical care.

Lymphoscintigraphy Using Tilmanocept Detects Multiple Sentinel Lymph Nodes in Melanoma Patients

BACKGROUND

Technetium-99m-labeled Tilmanocept, a multivalent mannose, is readily internalized by the CD206 surface receptor on macrophages and dendritic cells which are abundantly present in lymph nodes. We want to examine the drainage patterns of Technetium-99m-labeled Tilmanocept to sentinel lymph nodes (SLNs) in melanoma patients following the 10% rule.

METHODS

Multi-center retrospective review of patients with cutaneous melanoma undergoing SLN biopsy using Technetium-99m-labeled Tilmanocept between 2008 and 2014 was conducted. Statistical methods were used for data analyses.

RESULTS

Of the 564 patients (mean age of 60.3 and 62% male) with preoperative lymphoscintigraphy showing at least one SLN, several primary tumor sites were included: 27% head/neck, 33% trunk, 21% upper extremity and 19% lower extremity. For the head/neck primary site, 36.5% of patients had multiple draining basins; for the trunk site, 36.4% of patients; for the upper extremity site, 13% of patients; and for the lower extremity, 27.4% of patients. A median of 3 (range 1-18) SLNs were identified and resected. Overall, 78% of patients had >1 SLN identified by Technetium-99m-labeled Tilmanocept. In a multivariate model, patients with >1 SLN were significantly associated with age, Breslow depth, tumor location and higher AJCC tumor stage. A total of 17.7% of patients (100/564) had a positive SLN identified. A total of 145 positive SLNs were identified out of 1,812 SLNs with a positive SLN rate of 8%. Positive SLN status was significantly associated with younger age, greater Breslow depth, mitosis rate, higher AJCC tumor stage, presence of ulceration and angiolymphatic invasion.

CONCLUSIONS

Using the 10% rule, Technetium-99m-labeled Tilmanocept detects multiple SLNs in most melanoma patients.

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.

Inguinal lymph node dissection in the era of minimally invasive surgical technology

BACKGROUND

Inguinal lymph node dissection (ILND) is an essential step in both treatment and staging of several malignancies including penile and vulvar cancers. Various open, video endoscopic, and robotic-assisted techniques have been utilized so far. In this review, we aim to describe available minimally invasive surgical approaches for ILND, and review their outcomes and complications.

METHODS

The PubMed, Wiley Online Library, and Science Direct databases were reviewed in February 2020 to find relevant studies published in English within 2000-2020.

FINDINGS

There are different minimally invasive platforms available to accomplish dissection of inguinal nodes without jeopardizing oncological results while minimizing postoperative complications. Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy are safe and achieve the same nodal yield, a surrogate metric for oncological adequacy. When compared to open technique, Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy may offer faster postoperative recovery and fewer postoperative complications including wound dehiscence, necrosis, and infection. The relatively high rate and severity of postoperative complications hinders utilization of recommended ILND for oncologic indications. Minimally invasive approaches, using laparoscopic or robotic-assisted platforms, show some promise in reducing the morbidity of this procedure while achieving adequate short and intermediate term oncological outcomes.

Wound Complication Rates after Inguinal Lymph Node Dissection: Contemporary Analysis of the NSQIP Database

BACKGROUND

Inguinal lymph node dissection (ILND) is used for diagnosis and treatment in penile cancer (PC), vulvar cancer (VC), and melanomas draining to the inguinal lymph nodes. However, ILND is often characterized by its morbidity and high wound complication rate. Consequently, we aimed to characterize wound complication rates after ILND.

STUDY DESIGN

The NSQIP database was queried for ILND performed from 2005 to 2018 for melanoma, PC, or VC. Thirty-day wound complications included wound disruption and superficial, deep, and organ-space surgical site infection. Multivariable logistic regression was performed with covariates, including cancer type, age, American Society of Anesthesiologists score ≥3, BMI ≥30, smoking history, diabetes, operative time, and concomitant pelvic lymph node dissection.

RESULTS

A total of 1,099 patients had an ILND with 92, 115, and 892 ILNDs performed for PC, VC, and melanoma, respectively. Wound complications occurred in 161 (14.6%) patients, including 12 (13.0%), 17(14.8%), and 132 (14.8%) patients with PC, VC, and melanoma, respectively. Median length of stay was 1 day (interquartile range 0 to 3 days), and median operative time was 152 minutes (interquartile 83 to 192 minutes). Readmission rate was 12.7%. Wound complications were associated with longer operative time per 10 minutes (odds ratio 1.038, 95% CI 1.019 to 1.056, p < 0.001), BMI ≥30 (odds ratio 1.976, 95% CI 1.386 to 2.818, p < 0.001), and concomitant pelvic lymph node dissection (odds ratio 1.561, 95% CI 1.056 to 2.306, p = 0.025).

CONCLUSIONS

Predictors of wound complications after ILND include BMI ≥30, longer operative time, and concomitant pelvic lymph node dissection. There have been efforts to decrease ILND complication rates, including minimally invasive techniques and modified templates, which are not captured by NSQIP, and such approaches may be considered especially for those with increased complication risks.

A Novel Fascial Flap Technique After Inguinal Complete Lymph Node Dissection for Melanoma

INTRODUCTION

Inguinal complete lymph node dissection (CLND) for metastatic melanoma exposes the femoral vein and artery. To protect femoral vessels while preserving the sartorius muscle, we developed a novel sartorius and adductor fascial flap (SAFF) technique for coverage.

METHODS

The SAFF technique includes dissection of fascia off sartorius and/or adductor muscles, rotation over femoral vasculature, and suturing into place. Patients who underwent inguinal CLND with SAFF for melanoma at our institution were identified retrospectively from a prospectively-collected database. Patient characteristics and post-operative outcomes were obtained. Multivariate logistic regression assessed associations of palpable and non-palpable disease with wound complications.

RESULTS

From 2008 to 2019, 51 patients underwent CLND with SAFF. Median age was 62 years, and 59% were female. Thirty-one (61%) patients were presented with palpable disease and 20 (39%) had non-palpable disease. Fifty-five percent (95% confidence interval CI: 40%-69%) experienced at least one wound complication: wound infection was most common (45%; 95% CI: 31%-60%), while bleeding was the least (2%; 95% CI: 0.05%-11%). Complications were similar, with and without palpable disease.

CONCLUSIONS

The SAFF procedure covers femoral vessels, minimizes bleeding, preserves the sartorius muscle, and uses standard surgical techniques easily adoptable by surgeons who perform inguinal CLND.

Adapted Physical Activity Protocol for Lower Limb Functional and Strength Recovery in a Young Athlete with Cutaneous Melanoma: Feasibility and Efficacy during COVID-19 Pandemic

Adapted physical activity (APA) can improve psychophysical wellbeing and quality of life (QoL) in cancer survivors, a vulnerable population requiring a global management, especially during the recent pandemic. On this basis, we investigated for the first time the impact of a tailored APA intervention on a melanoma-affected 18-year-old female athlete to counteract treatment sequelae and promote lower limb functional and strength recovery. Patient was evaluated at baseline and post-protocol by a test battery focusing on mobility, muscle strength measured by dynamometry, and lower limb girths assessed at specific anatomical points. Moreover, health-related QoL, depression/anxiety, psychological distress and pain intensity were evaluated by Functional Assessment of Cancer Therapy–Melanoma (FACT-M), Hospital Anxiety and Depression Scale (HADS), distress thermometer, and numerical rating scale (NRS) questionnaires, respectively. An almost doubled up increase in lower limb strength, along with hip mobility improvement, and post-surgical edema and pain reduction were observed following the protocol. Concerning the QoL assessment, a moderate post-intervention improvement in physical and emotional wellbeing was detected, while depression state worsened though remaining within the normality range. Our findings show that a specialist-supervised structured APA protocol based on a patient-centered multidisciplinary approach may represent an effective strategy to recover functional and psychophysical efficiency, thus promoting a quick return to daily life activities and offering a concrete chance of resuming competitive sport practice.

Fluoreszenzgesteuerte Lymphgefäßversiegelung bei der systematischen Lymphknotendissektion zur Vermeidung von Lymphfisteln und Lymphozelen

Hintergrund Die wichtigsten Morbiditäten der systematischen inguinalen und axillären Lymphknotendissektion sind Lymphfisteln und Serome. Die intraoperative, fluoreszenzgesteuerte Versiegelung der Lymphgefäße könnte die Häufigkeit dieser postoperativen Komplikationen verringern.

Methoden Vor der Lymphadenektomie erfolgte die Intrakutaninjektion von Indocyanin-Farbstoff im Bereich der distalen Extremität. Die Lymphadenektomie wurde nach Standardprotokollen durchgeführt. Während des gesamten Eingriffs wurde Nahinfrarot-Bildgebung eingesetzt, und es wurde eine fluoreszenzgesteuerte Lymphgefäßversiegelung in Echtzeit durchgeführt (Videopräsentation).

Ergebnisse Die fluoreszenzgesteuerte Lymphgefäßversiegelung wurde bei 3 Patienten durchgeführt, die sich einer axillären systematischen Lymphknotendissektion unterzogen. Nach der Injektion des Fluoreszenzfarbstoffs traten keine unerwünschten Ereignisse auf. Alle Patienten konnten ohne Wundkomplikationen entlassen werden.

Schlussfolgerung Die fluoreszenzgesteuerte Lymphgefäßversiegelung könnte eine vielversprechende neue Technik zur Verhinderung von Lymphfisteln nach systematischer Lymphadenektomie sein.

Immediate Lymphatic Reconstruction to Prevent Breast Cancer-Related Lymphedema: A Systematic Review

Significance: Lymphedema is chronic limb swelling from lymphatic dysfunction. The condition affects up to 250 million people worldwide. In breast cancer patients, lymphedema occurs in 30% who undergo axillary lymph node dissection (ALND). Recent Advances: Immediate lymphatic reconstruction (ILR), also termed Lymphatic Microsurgical Preventing Healing Approach (LyMPHA), is a method to decrease the risk of lymphedema by performing prophylactic lymphovenous anastomoses at the time of ALND. The objective of this study is to assess the risk reduction of ILR in preventing lymphedema. Critical Issues: Lymphedema has significant effects on the quality of life and morbidity of patients. Several techniques have been described to manage lymphedema after development, but prophylactic treatment of lymphedema with ILR may decrease risk of development to 6.6%. Future Directions: Long-term studies that demonstrate efficacy of ILR may allow for prophylactic management of lymphedema in the patient undergoing lymph node dissection.

The Pedicled Flap of Adductor Longus, a New Technique for Inguinal Reconstruction

Introduction: Reconstruction surgeries of the inguinal area pose a challenge for oncological and orthopedic surgeons, especially after radical local resection (RLR), radical inguinal lymph node dissection (RILND), or both. Although numerous surgical procedures have been reported, there is no report about a pedicle adductor longus flap method. The aim of this work is to show our experience about inguinal reconstruction with pedicled adductor longus flap and associated outcomes. Patients and Methods: A retrospective study of 16 patients with localized inguinal region interventions and reconstructed by adductor longus flap from March 2016 to July 2020. Patients' average age was 60.0 years (range = 38-79 years) and had postoperative follow-up of 10 months (ranging 2-19 months). All patients had unilateral inguinal region involvement-seven cases on the left and nine cases on the right. The patients' clinical course, operative course, and postoperative follow-up data were evaluated. Results: All 16 patients recovered well post-operatively and did not require any re-intervention. Four patients experienced negligible discomfort around the groin area. Five patients experienced a minor strength deficit in thigh adduction compared with that of preoperative strength in the same or contralateral leg. The aforementioned complications resolved during the postoperative course and had no functional impact on their activity of daily living. All adductor longus flaps survived, completely filled the inguinal dead space, and wounds healed uneventfully within 3 weeks except for three patients who suffered delayed wound healing for more than 4 weeks. Other common complications such as infection, seroma, or wound dehiscence were not encountered in this series. Conclusion: The adductor longus flap is a reliable alternative method for inguinal region reconstruction following radical local resection (RLR), radical inguinal lymph node dissection (RILND), or both.

Feasibility, indications and complications of SCIP flap for reconstruction after extirpative surgery for vulvar cancer

INTRODUCTION

Surgical therapy for vulvar cancer involves wide defects that often require flap-based reconstruction. The goal of the reconstruction is fast wound healing with low donor site morbidity.

MATERIALS AND METHODS

This is a retrospective observational cohort study in which we reviewed all patients who underwent surgery for vulvar cancer followed by reconstruction using the Superficial Circumflex Iliac Artery Perforator (SCIP) flap between 2015 and 2020. The primary outcome measure of this investigation was the incidence of wound complications. The secondary outcomes were the surgical indications in terms of establishing the anatomical subunits involved in the resection that made us choose this flap for reconstruction. This study adheres to the STROBE guidelines.

RESULTS

Thirty-two patients were included; in two cases, the flap was performed bilaterally for a total of 34 SCIP flaps. The mean age of patients was 70.6 ± 8.6 years, and the mean BMI was 26.8 ± 4.7. The SCIP flap was always feasible. The mean flap size was 128.8 ± 74.3cm². Three patients showed wound complications. In every patient, the defect involved the vulva, perineum and inguinal area; in 18 patients, the mons pubis was also involved. The mean follow-up was 30 months. During the follow-up, six patients died, and four showed local or nodal cancer relapse.

CONCLUSION

Our results suggest that the advantages of SCIP flap for the reconstruction of vulvoperineal defects secondary to vulvar cancer surgery include low complication rate, minimal donor site morbidity, quick dissection, proximity of donor and recipient sites, possibility to harvest large skin islands of variable thickness and chimeric flaps.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

Randomized Study of Wound Drainage on Early Complications After Lymph Node Dissection for Melanoma

INTRODUCTION

The complication rate after axillary lymph node dissection (ALND) and inguinal lymph node dissection (ILND) in melanoma patients is high. The aim of this randomized non-inferiority study was to evaluate the effect of postoperative wound drainage on early complications after ALND and ILND.

MATERIALS AND METHODS

Between 2018 and 2020, 104 stage III melanoma patients operated on with ALND or ILND were randomized to a study group with complete wound drain removal 3 wk after surgery or a control group with progressive drain removal. The primary end point was overall early complications graded according to the modified Clavien-Dindo classification. Secondary endpoints were length of hospital stay and prognostic factors for early complications.

RESULTS

Of the 99 patients analyzed, ALND was performed in 58 patients and ILND in 41 patients. Overall, 62 patients (62.6%) developed early complications: 30 in the study group and 32 in the control group (P = 0.53). The confidence interval for the difference in proportions of patients without early complications in the two groups was -0.27 to 0.11 (P = 0.42), hence non-inferiority could be claimed. Length of hospital stay was 5 d in the study group compared to 6 in the control group (P < 0.01). ILND was associated with increased risk of early complications compared to ALND (75.6% versus 53.4%, P = 0.04).

CONCLUSIONS

Complete drain removal 3 wk after ALN and ILND in stage III melanoma patients did not increase the risk of early complications compared to progressive drain removal.

Sentinel Lymph Node Biopsy, Lymph Node Dissection, and Lymphedema Management Options in Melanoma

Melanoma tumor thickness and ulceration are the strongest predictors of nodal spread. The recommendations for sentinel lymph node biopsy (SLNB) have been updated in recent American Joint Committee on Cancer and National Comprehensive Cancer Network guidelines to include tumor thickness ≥0.8 mm or any ulcerated melanoma. Mitotic rate is no longer considered an indicator for determining T category. Improvements in disease-specific survival conferred from SLNB were demonstrated through level I data in the Multicenter Selective Lymphadenectomy Trial (MSLT) I. The role for completion lymph node dissection has evolved to less surgery in lieu of recent domestic (MSLT II) and international (Dermatologic Cooperative Oncology Group Selective Lymphadenectomy Trial [DeCOG-SLT]) level I data having similar melanoma-specific survival. Treatment options for the prevention of treatment of lymphedema have progressed to include immediate lymphatic reconstruction, lymphovenous anastomosis, and vascularized lymph node transfer.

Predictive factors of neoadjuvant immune checkpoint blockade in melanoma

This review describes the current body of literature and ongoing clinical trials examining neoadjuvant immune checkpoint inhibitors (ICI) for patients with resectable stage III and IV melanoma. Based on prior success in treating metastatic melanoma and as adjuvant therapy, ICIs are being explored in the neoadjuvant setting. There have been initial trials and there are many ongoing trials examining neoadjuvant ICI. Herein, we will review the clinical feasibility and efficacy of various neoadjuvant ICI regimens, explore pathologic and cellular responses, and present factors associated with predictive tumor response.

Role for fibrin glue (sealant) in seroma reduction after inguinal lymphadenectomy; a randomized controlled trial

BACKGROUND

Seroma is one of the most commonly encountered morbidities after inguinal lymph node dissection (ILND). It causes much nuisance to both patients and doctors and its presence can lead to many complications. This study aimed to evaluate the role and impact of using fibrin glue to decrease seroma formation in patients undergoing ILND.

MATERIALS AND METHODS

Thirty-two patients underwent ILND for various reasons. The patients were randomly divided into two groups; 16 in each group. In one group, fibrin glue sealant was applied with a dosage of 2 ml per 100 cm² surface area. Drain placement was then performed. In the control group, only drain placement was used. Preoperative, operative and postoperative data were recorded and analyzed.

RESULTS

There was a significant reduction in the incidence of seroma formation favoring the fibrin glue group when compared to the control group (P = 0.022). There was also a significant reduction of total cumulative amount of serous fluid (P < 0.001), time to remove drains (P < 0.001), and hospital stay (P = 0.012). There was no significant difference between the two groups in occurrences of hematoma, infection or superficial skin edge necrosis.

CONCLUSION

Fibrin glue sealant has a role to play in ILND as it significantly reduced the incidence of seroma formation. Standardization of definition of seroma as well as dosage and technique of fibrin glue have to be reached in future studies to determine the true role of fibrin glue in ILND.

Current practice patterns of society of urologic oncology members in performing inguinal lymph node staging/therapy for penile cancer: A survey study

OBJECTIVES

Inguinal lymph node (ILN) staging and therapeutic procedures are important for the diagnosis and management of suspected Inguinal lymph node metastasis in the setting of penile cancer. Morbidity associated with inguinal lymph node dissection (ILND) and the lack of standardization in its perioperative management are both significant. In this study, we aimed to define current management approaches and potential opportunities for improving outcomes.

METHODS AND MATERIALS

A questionnaire was developed with 16 questions regarding pre, peri, and postoperative management of patients undergoing ILND. The questionnaire was approved by the Society of Urologic Oncology (SUO) Questionnaire Committee, which facilitated its dissemination through an initial email and a follow-up reminder to 1,003 members. The study was conducted from July to August, 2020.

RESULTS

Of the 1,003 SUO members invited to participate, 93 responded (9.3% response rate); 49% performed 1 to 2 ILNDs annually, and 60% chose open ILND for high-risk primary cancer cN0. For suspicious lymph nodes > 2 cm, 69% preferred ILND, 86% preoperative systemic neoadjuvant chemotherapy, followed by surgery for bulky inguinal metastasis, and 84% used perioperative antibiotics (ABX), 53% of whom discontinued ABX 24 hours after surgery. Prophylactic anticoagulation was used by 78% of respondents, and 60% stopped it after ambulation. Specific ligation of lymphatics (versus none) was used by 82% of respondents, 55% obtained frozen sections, and 94% used inguinal drains. A saphenous sparing technique was used by 75% of respondents. An incisional wound vacuum device was used by 17% of respondents. Compression stockings and/or referral to a lymphedema specialist were used to manage postoperative lymphedema by 61% of respondents.

CONCLUSIONS

Responses to a penile lymphadenectomy survey were relatively low and were primarily from the academic surgeon subset of the SUO. Significant consensus ( ≥ 70%) was noted for neoadjuvant chemotherapy for bulky nodal metastasis prior to surgery, perioperative antibiotic use, ligation of lymphatics, drain placement, and saphenous sparing dissection techniques. Other evidenced-based strategies that could decrease morbidity were rarely used, including dynamic sentinel node biopsy, incisional wound vacuums, and lymphedema prevention. Prospective trials are needed to validate and resolve existing treatment paradigms and to optimize perioperative pathways to reduce complications in penile cancer management.

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

Simple Summary

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

Abstract

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

Survival and Operative Outcomes After Salvage Surgery for Recurrent or Persistent Anal Cancer

Anal squamous cell carcinoma (SCC) is a relatively rare cancer comprising less than 2.5% of all gastrointestinal malignancies. The standard treatment for anal SCC is primary chemoradiation therapy which can result in complete regression. After successful treatment, the 5-year survival is approximately 80%. However, up to 30% of patients experience recurrent persistent or recurrent disease. The role of surgery in the treatment of anal cancer, therefore, is limited to the management of recurrent or persistent disease with abdominoperineal resection and/or en bloc adjacent organ excision. Salvage surgery after irradiated anal cancer can be technically demanding in terms of acquisition of oncologically safe surgical margins and minimization of postoperative morbidity. In addition, 5-year survival outcomes after salvage resection have been reported to vary from 23% to 69%. Positive resection margins are generally regarded as the important risk factor associated with poor survival outcome. Perineal wound complications are the most common major postoperative morbidity. Because of the challenges of primary wound closure after salvage abdominoperineal resection, myocutaneous flap reconstruction has been performed to reduce the severity of perianal would complications. We, therefore, descriptively reviewed contemporary published evidence describing the treatment and outcomes after salvage surgery for persistent or recurrent anal SCC.

Groin dissections in skin cancer: Effect of a change in prophylactic antibiotic protocol

OBJECTIVES

To determine whether groin dissection surgical site infection (SSI) incidence changed with shorter post-operative antibiotic prophylaxis.

BACKGROUND

Post-operative prophylaxis changed due to antimicrobial stewardship, from regular oral antibiotics until drain removal, to three intravenous doses. Both groups had a single intravenous dose at induction.

METHODS

A prospective database of groin dissections for metastatic skin cancer was retrospectively reviewed for SSI according to Public Health England criteria. Eighty groin dissections in 79 consecutive patients were included: 40 had oral antibiotics until drain removal [mean 26±7 (range 19-36) days] and 39 had three post-operative intravenous doses.

RESULTS

Longer prophylaxis was associated with lower SSI incidence [10 (25%) versus 21 (54%), odds ratio (OR) 3.50, 95% confidence interval (CI) 1.34-9.08, p = 0.009], fewer deep infections [5 (13%) versus 16 (41%), OR 4.89, 95% CI 1.57-15.13, p = 0.004], fewer readmissions for infection [5 (13%) versus 15 (38%), OR 4.38, 95% CI 1.40-13.65, p = 0.008], but similar seroma incidence [18 (45%) versus 16 (41%), OR 0.85, 95% CI 0.35-2.07, p = 0.72] and wound dehiscence [7 (18%) versus 5 (13%), OR 0.69, 95% CI 0.20-2.40, p = 0.56]. BMI ≥30 (n = 21) was associated with SSI, occurring in 13 of 21 (62%) (OR 3.859, 95% CI 1.34-11.10, p = 0.01). Median infection onset was 22 days (IQR 12-27) versus 17 (IQR 13-22), (p = 0.53). Multiple organisms were cultured in 21 of 31 (68%) patients with positive microbiological samples.

CONCLUSIONS

SSI rates doubled with shorter prophylaxis; deep infections and readmissions for infection tripled. Obesity was independently associated with infection. Seroma and wound dehiscence incidence were unchanged. Infections mainly occurred in the third week after surgery and were polymicrobial.

Complications and outcomes following inguinal lymphadenectomy for malignant melanoma in an Asian population

Purpose

Melanoma is a potentially fatal cutaneous malignancy and regional lymph node (LN) metastases are the most important predictors of mortality. This study aimed to analyze clinical features and risk factors of complications associated with inguinal LN dissection (LND) to establish treatment protocols.

Methods

This single-center retrospective study (2000 to 2018) consisted of patients who underwent inguinal area sentinel LN biopsy (SLNB) or LND due to malignant melanoma. Risk factors and outcomes were analyzed.

Results

One hundred patients underwent SLNB alone (n=67; patients with negative SLNB), complete LND (CLND) after positive SLNB (n=19), or radical LND without SLNB (n=14). Five-year overall survival and disease-free survival rates among these groups were 87.3%, 57.4%, and 61.9%, and 59.0%, 22.7%, and 28.1%, respectively. The complication rate in the SLNB alone group was lower than the other groups (22.4% vs. 47.4% and 35.7%, respectively; P=0.048). Seroma was the most common complication in the SLNB alone group (15.0%); lymphedema was most common in the CLND after SLNB group (21.1%). Multivariate analysis of risk factors for postoperative complications found the hazard ratio for body mass index >28 kg/m² was 4.376 (95% confidence interval [CI], 1.243-15.401; P=0.022). The hazard ratio for LND (including CLND after SLNB and radical LND without SLNB) was 3.263 (95% CI, 1.248-8.529; P=0.016).

Conclusion

Inguinal LND is a higher risk procedure compared to SLNB and other sites for postoperative complications, irrespective of meticulous surgical techniques. More studies are needed to establish treatment protocols (e.g., observation vs. CLND after a positive SLNB result) and the risks and benefits in Asian populations.

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.

Anatomical characterization of the inguinal lymph nodes using microcomputed tomography to inform radical inguinal lymph node dissections in penile cancer

BACKGROUND & OBJECTIVES

Radical inguinal lymph node dissections (rILND) for penile cancer risk significant postoperative lymphocele and lymphedema. However, reducing the risk of lymphatic complications is limited by our understanding of lymphatic anatomy. Therefore, this study aims to elucidate the lymphatic anatomy within the current surgical borders of a rILND.

METHODS

To visualize the position of the lymph nodes, tissue packets excised from the inguinal region of five fresh, male cadavers were imaged using microcomputed tomography (µCT). To standardize the position, rotation and size between specimens, each lymph node packet was aligned using a Generalized Procrustes analysis.

RESULTS

There was a median of 13.5 lymph nodes (range = 8-18) per packet, with the majority (99%) clustered within a 6 cm radius of the saphenofemoral junction; a region 39%-41% smaller than current surgical borders. No difference existed between the number of nodes between sides, or distribution around the saphenofemoral junction.

CONCLUSIONS

This study provides the first 3D, in situ, standardized characterization of lymph node anatomy in the inguinal region using µCT. By using knowledge of the normal lymphatic anatomy, this study can help inform the reduction in borders of rILND to limit disruption and ensure a complete lymphadenectomy.

Robot-assisted endoscopic inguinal lymphadenectomy: A review of current outcomes

Objective

To review the role of robot-assisted endoscopic inguinal lymphadenectomy (RAIL) in the management of penile cancer.

Methods

A PubMed search for all relevant publications regarding RAIL series up until August 2019 was performed using the keyword “robotic”, “inguinal lymph node dissection”, and “penile cancer”. Weighted mean was calculated in the largest series for all outcomes using the number of patients included in each study as the weighting factor.

Results

We identified 23 articles, of note the three largest series that included 102, 27, and 20 RAIL in 51, 14, and 10 patients, respectively. Saphenous vein was spared in 88.93% of RAIL cases in these series and node yield was 11.42 per groin; 35.28% of patients had positive pathological nodes. The weighted mean of operative time was 87.98 min per RAIL and the estimated blood loss was 37.08 mL per patient. The mean length of hospital stay was 1.29 days and the drain was kept in place for 17.02 days; the major complication rate was only 5.31% in these series. The mean follow-up was 33.46 months with a recurrence-free survival of 96.33%.

Conclusion

The literature regarding RAIL describes promising results, although it has shorter follow-up and higher costs when compared to historically series from the open approach. Initials series reported lower cutaneous complications compared to conventional approach, without compromising oncological outcomes. However, long-term results and larger trials are crucial to validate those findings.

Closed-incision negative-pressure wound management in surgery—literature review and recommendations

Background

Wound healing deficits and subsequent surgical site infections are potential complications after surgical procedures, resulting in increased morbidity and treatment costs. Closed-incision negative-pressure wound therapy (ciNPWT) systems seem to reduce postoperative wound complications by sealing the wound and reducing tensile forces.

Materials and methods

We conducted a collaborative English literature review in the PubMed database including publications from 2009 to 2020 on ciNPWT use in five surgical subspecialities (orthopaedics and trauma, general surgery, plastic surgery, cardiac surgery and vascular surgery). With literature reviews, case reports and expert opinions excluded, the remaining 59 studies were critically summarized and evaluated with regard to their level of evidence.

Results

Of nine studies analysed in orthopaedics and trauma, positive results of ciNPWT were reported in 55.6%. In 11 of 13 (84.6%), 13 of 15 (86.7%) and 10 of 10 (100%) of studies analysed in plastic, vascular and general surgery, respectively, a positive effect of ciNPWT was observed. On the contrary, only 4 of 12 studies from cardiac surgery discovered positive effects of ciNPWT (33.3%).

Conclusion

ciNPWT is a promising treatment modality to improve postoperative wound healing, notably when facing increased tensile forces. To optimise ciNPWT benefits, indications for its use should be based on patient- and procedure-related risk factors.

Definition and severity grading of postoperative lymphatic leakage following inguinal lymph node dissection

Purpose

Lymphatic complications occur frequently after radical inguinal lymph node dissection (RILND). The incidence of lymphatic leakage varies considerably among different studies due to the lack of a consistent definition. The aim of the present study is to propose a standardized definition and grading of different types of lymphatic leakage after groin dissection.

Methods

A bicentric retrospective analysis of 82 patients who had undergone RILND was conducted. A classification of postoperative lymphatic leakage was developed on the basis of the daily drainage output, any necessary postoperative interventions and reoperations, and any delay in adjuvant treatment.

Results

In the majority of cases, RILND was performed in patients with inguinal metastases of malignant melanoma (n = 71). Reinterventions were necessary in 15% of the patients and reoperations in 32%. A new classification of postoperative lymphatic leakage was developed. According to this definition, grade A lymphatic leakage (continued secretion of lymphatic fluid from the surgical drains without further complications) occurred in 13% of the patients, grade B lymphatic leakage (persistent drainage for more than 10 postoperative days or the occurrence of a seroma after the initial removal of the drain that requires an intervention) in 28%, and grade C lymphatic leakage (causing a reoperation or a subsequent conflict with medical measures) in 33%. The drainage volume on the second postoperative day was a suitable predictor for a complicated lymphatic leakage (grades B and C) with a cutoff of 110 ml.

Conclusion

The proposed definition is clinically relevant, is easy to employ, and may serve as the definition of a standardized endpoint for the assessment of lymphatic morbidity after RILND in future studies.

Utility of Minimally Invasive Technology for Inguinal Lymph Node Dissection in Penile Cancer

Our aim is to review the benefits as well as techniques, surgical outcomes, and complications of minimally invasive inguinal lymph node dissection (ILND) for penile cancer. The PubMed, Wiley Online Library, and Science Direct databases were reviewed in March 2020 for relevant studies limited to those published in English and within 2000–2020. Thirty-one articles describing minimally invasive ILND were identified for review. ILND has an important role in both staging and treatment of penile cancer. Minimally invasive technologies have been utilized to perform ILND in penile cancer patients with non-palpable inguinal lymph nodes and intermediate to high-risk primary tumors or patients with unilateral palpable non-fixed inguinal lymph nodes measuring less than 4 cm, including videoscopic endoscopic inguinal lymphadenectomy (VEIL) and robotic videoscopic endoscopic inguinal lymphadenectomy (RVEIL). Current data suggest that VEIL and RVEIL are feasible and safe with minimal intra-operative complications. Perhaps the strongest appeal for the use of minimally-invasive approaches is their faster post-operative recovery and less post-operative complications. As a result, patients can tolerate this procedure better and surgeons can offer surgery to patients who otherwise would not be a candidate or personally willing to undergo surgery. When compared to open technique, VEIL and RVEIL have similar dissected nodal count, a surrogate metric for oncological adequacy, and a none-inferior inguinal recurrence rate. Larger randomized studies are encouraged to investigate long-term outcome and survival rates using these minimally-invasive techniques for ILND.

Risk Factors for Complications and Long-Term Outcomes Following Completion Lymph Node Dissection for Cutaneous Melanoma: A Retrospective Cohort Study

BACKGROUND

Completion lymph node dissection (CLND) for malignant melanoma is performed for regional cancer control and is associated with a high complication rate. It is unknown whether post-operative complications influence cancer recurrence or survival. Our aim was to evaluate the risk factors for short- and long-term complications after CLND, and to determine whether complications affect recurrence or survival.

METHOD

We performed a retrospective cohort study including all melanoma patients who underwent CLND in the Stockholm region during 2005-2014. Patient and cancer characteristics were collected from medical records, as were clinical outcomes. Assessment was performed by multivariate logistic regression.

RESULTS

Among 144 patients, the risk of any post-operative one year complication was 68.8%. Lymphedema (41.0%), infection (37.5 %), and seroma (31.3 %) were the most common complications. Diabetes and inguinal CLND were associated with nine- and ten-fold increased risks of post-operative complications (p<0.05), respectively. Complications were linked to an increased risk of recurrent cancer (p<0.05), median follow-up time of 49 months, but did not appear to affect five-year survival.

CONCLUSION

Post-operative complications are common in melanoma patients undergoing CLND. Strong risk factors for complications are diabetes and inguinal CLND. Post-operative complications appear to be associated with increased risks of recurrent cancer, but the mechanism is unknown.

Treatment of Upper Extremity Lymphedema following Chemotherapy and Radiation for Head and Neck Cancer

In the industrialized world, the most common cause of secondary lymphedema is iatrogenic. The inciting event is generally a combination of lymph node resection, chemotherapy, and radiation therapy. Although a regional nodal dissection is often the primary risk factor, lymphedema can also result from sentinel node dissections, or as in the case presented without any surgical resection. Here, we present a unique case of upper extremity lymphedema resulting from definitive chemoradiation for squamous cell carcinoma of the head and neck. The patient was treated using a combined approach with a lymphaticovenular anastomosis and a free vascularized inguinal lymph node transfer.

Inguinal Lymph Node Dissection Does Not Improve Overall Survival in Anal Cancer Nodal Disease

BACKGROUND

Anal SCC is a rare disease mainly treated with chemoradiation. Abdominoperineal resection (APR), once the mainstay of treatment for anal cancer, now serves a role as salvage therapy for persistent or recurrent disease after chemoradiation. In addition, clinically positive nodes are currently treated by extending the radiation field to the groin. The role of inguinal lymph node dissection in recurrent or persistent anal SCC is unclear. The aim of the study is to determine the role of inguinal lymph node dissection in the management of inguinal lymph node metastasis for anal squamous cell carcinoma (SCC).

METHODS

Retrospective analysis of patients with anal SCC in the National Cancer Database with positive inguinal nodes undergoing salvage APR between 2004 and 2014 was performed. A comparison of overall survival between patients who underwent APR with lymph node dissection versus APR only was analyzed using Kaplan-Meier plot.

RESULTS

A total of 3424 patients underwent salvage APR, with 274 (8%) having clinically positive nodes. Within the subgroup that had clinically positive nodes, 195 (71%) underwent APR, whereas 79 (29%) underwent both APR and node dissection. Kaplan-Meier analysis demonstrates no difference in overall survival in the two groups (P = 0.99). Five-year survival for both groups was similar (36% versus 42%; P = 0.987). No significant difference was found when adjusted for age, gender, and Tumor Node Metastasis staging.

CONCLUSIONS

Inguinal lymph node dissection does not appear to improve overall survival in patients with advanced-stage anal cancer requiring salvage APR. Proper patient selection for node dissection is essential to spare patients from additional morbid procedures.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The utility of surgical and conservative combination therapy for advanced stage lymphedema

BACKGROUND

In the treatment of lymphedema, a plastic surgeon carries out only surgical treatment, whereas a therapist performs only complex physical therapy. Therefore, a combination treatment strategy is not performed in most cases. Our institution combines a lymphaticovenular anastomosis (LVA) operation with complex physical therapy during the same hospitalization.

METHODS

From advanced cases of lymphedema of stage II or higher, we included patients who were hospitalized for 2 weeks or more for combined LVA and complex physical therapy. Of the 28 cases studied, 26 were secondary lymphedema and two were primary lymphedema. There were seven upper limb cases and 21 lower limb cases. The mean length of hospital stay was 12 days (7-14 days). We performed a multisite LVA in all 28 patients. The mean number of anastomoses in each case (the side with the most edema for bilateral cases) was 3.96 (2-6). During hospitalization, lymphatic therapists who were familiar with complex physical therapy for lymphedema were trained to provide total care for lymphedema. The content of the education was applied according to the individual patient's status, and an emphasis was placed on development of a treatment regimen that patients could perform continuously by themselves after discharge.

RESULTS

The average volume reduction in seven patients with upper limb lymphedema was 15.1%; the average in 18 patients with lymphedema of the lower limbs was 13.1%. The average volume reduction in eight patients at stage II was 14.1%; stage II late was 13.0%, and stage III was 14.7%. The other three cases had suffered an exacerbation, and the mean exacerbation was 3.2%. Among the 12 patients who had cellulitis preoperatively, an episode of cellulitis was detected in only two patients during follow-up postoperatively. These two patients were those at late stage II and stage III. The frequency of onset decreased in these two cases.

CONCLUSIONS

In this study, combination therapy was administrated for lymphedema. We obtained good results in the diseased limbs, including volume reduction and prevention of cellulitis. Therefore, combination therapy might be useful for lymphedema cases at advanced stages.

Skin Cancer Prevention: Psychosocial Predictors of Sunscreen Use in University Students

Skin cancer has the most prevention potential among all cancers. Sunscreen use is an effective method in reducing the risk prevalence of skin cancer. The aim of this study was to determine the cognitive determinants of sunscreen use among university students based on the health belief model (HBM). This cross-sectional study was conducted among 301 university students in the west of Iran. Students were randomly selected to participate voluntarily in the study. Participants filled out a self-administered questionnaire. Data were analyzed by SPSS version 16 using appropriate statistical tests including correlation and logistic regression at 95% significance level. Our results indicated 44.2% of participants reported had always sunscreen use. Among the HBM constructs, cues to action with odds ratio estimate of 1.146 (95% CI 1.061, 1.239) and perceived self-efficacy with odds ratio estimate of 1.131 (95% CI 1.036, 1.234) were the more influential predictors on always sunscreen use. Female students and high levels of mother's education were significant predictors of sunscreen use. It seems these findings are useful in planning health promotion programs aimed at increasing self-efficacy for sunscreen use.

Japanese Dermatological Association Guidelines: Outlines of guidelines for cutaneous melanoma 2019

With consideration of the ongoing developments in treatment options for cutaneous melanoma, the Japanese Skin Cancer Society published the first guidelines for cutaneous melanoma in 2007 and later revised them in 2015. Here, we report on an English version of the 2019 Japanese Melanoma Guidelines. In this latest edition, all processes were carried out according to the Grading of Recommendations, Assessment, Development and Evaluation system. A comprehensive published work search, systematic review and determination of recommendations in each clinical question were performed by a multidisciplinary expert panel consisting of dermatologists, a plastic and reconstructive surgeon, and a radiation oncologist. The advent of novel agents, such as immune checkpoint inhibitors and molecular-targeted agents, has drastically changed the nature of treatment for adjuvant and advanced-stage diseases among melanoma patients worldwide. Additionally, recent reports of clinical trials regarding surgical procedures and a better understanding of molecular biology and tumor immunology in clinical types of melanoma have had an impact on clinical practise. Based on these viewpoints, eight relevant clinical questions were raised in this report that aim to help clinicians select the appropriate therapeutic approach.

Sensitivity of Preference-Based Quality-of-Life Measures for Economic Evaluations in Early-Stage Melanoma

Importance

The diagnosis of a life-threatening disease like melanoma can affect all aspects of a person's life, including health-related quality of life (HRQOL) and psychological aspects of melanoma such as fear of cancer recurrence (FCR). Economic evaluations of psychological interventions require preference-based (utility) instruments that are sensitive to changes in well-being and HRQOL; however, very few studies have evaluated the sensitivity of these instruments when used for people with melanoma.

Objective

To compare utility scores from the multiple-attribute instrument Assessment of Quality of Life-8-Dimension Scale (AQoL-8D) with the mapped utility scores of the Functional Assessment of Cancer Therapy-Melanoma (FACT-M) and to investigate the sensitivity of both instruments in identifying the influence of FCR on HRQOL.

Design, Setting, and Participants

This assessment of data from a randomized clinical trial of a psychoeducational intervention to reduce FCR, conducted at 3 high-risk melanoma clinics in Australia, evaluated 164 patients with early-stage melanoma and a high risk of developing a second primary melanoma.

Main Outcomes and Measures

The FACT-M and AQoL-8D were used to assess HRQOL and FCR among the study participants. Concurrent validity was assessed by comparing the total and subdomain scores of the 2 instruments, and the strength of associations was assessed using Pearson correlation coefficient. Convergent validity was assessed by comparing participants' HRQOL, demographic, and clinical characteristics using the χ2 test and F statistic. Both the FACT-M and AQoL-8D utilities were regressed on FCR Inventory (FCRI) severity scores to estimate the effect of elevated FCR on HRQOL.

Results

A total of 164 participants completed the baseline questionnaires, but only 163 met all inclusion criteria and underwent the full analysis: 72 were women; 91 were men; and mean (SD) age was 58.2 (12.1) years. Both the AQoL-8D and FACT-M instruments showed good concurrent validity and could differentiate between relevant subgroups including level of FCRI severity. The AQoL-8D and FACT-M utilities were strongly correlated (r2 = 0.57). Respondents had a mean (SD) AQoL-8D utility of 0.77 (0.2), and a mean (SD) FACT-M utility score of 0.76 (0.07). High levels of FCRI severity were associated with a decrease in utility of 0.12 (95% CI, -0.19 to -0.05) as measured by AQoL-8D, and a decrease of 0.03 (95% CI, -0.05 to -0.01) as measured by the FACT-M.

Conclusions and Relevance

For economic evaluations of psychological interventions in melanoma, the AQoL-8D and FACT-M are valid measures of utility; however, the AQoL-8D demonstrates greater sensitivity to FCRI severity. Our results suggest a significant association between FCR and HRQOL.