Multiple lymphatic-venous anastomoses in reducing the risk of lymphedema in melanoma patients undergoing complete lymph node dissection. A retrospective case-control study

doi:10.1016/j.bjps.2019.01.023

Journal of Plastic, Reconstructive & Aesthetic Surgery

Volume 72, Issue 4, April 2019, Pages 642-648

https://doi.org/10.1016/j.bjps.2019.01.023 Get rights and content

Summary

Background

Sentinel lymph node biopsy (SLNB) is an indispensable surgical procedure in staging and management of intermediate-to-thick melanomas. Although recent studies have demonstrated that complete lymph node dissection (CLND) does not improve 3-year specific survival, its utility in increasing the disease-free period and the control of local disease remains confirmed. The most frequent complication related to CLND is lymphedema, which may affect up to 20% of patients undergoing CLND. The preventive use of lymphatic-venous micro-anastomoses could avoid this complication.

Materials and methods

We performed a single-institution retrospective case-control study. CLND was proposed to all subjects with positive-SLNB; a preventive procedure involving multiple lymphaticovenular anastomoses (PMA) was performed in a cohort of subjects undergoing CLND. Frequency of lymphedema was compared among subjects undergoing and not-undergoing PMA during CLND.

Results

We selected patients affected by melanoma of the trunk and with a minimum follow-up of 3 years, identifying 23 patients who underwent PMA during CLND (PMA group) and 120 subjects who underwent CLND without PMA (control group). The frequency of lymphedema was significantly lower in the PMA group than in the control group (4.3% vs. 24.2%, p = 0.03). Patients of the PMA group and the control group showed similar 3-year recurrence-free period (65.2% vs. 62.5%, log-rank test p = 0.88) and 3-year overall survival (73.9% vs. 72.5%, log-rank test p = 0.97) and frequency of nonsentinel-node metastases (26.7% vs. 30.4%, p = 0.71).

Conclusion

PMA appear to represent a useful and safe procedure in reducing the risk of lymphedema in patients with melanoma undergoing CLND.

Section snippets

Background

Cutaneous melanoma (CM) is the most common skin cancer whose incidence is rapidly increasing across the developed world. Survival rates have improved greatly over the last 30 years, with a current 10-year disease specific survival rate of 90%. Mortality is reduced worldwide – patients with regional lymph node metastasis show a 5-year survival rate ranging from 40% to 78% – although it remains elevated in patients with advanced disease.¹ Sentinel lymph node biopsy (SLNB) is the standard

Methods

This research protocol was approved by our local Ethical Committee. Electronic medical records of clinical data of patients with melanoma were collected from a single institution during July 1994 to March 2018. We identified patients with CM of the trunk and a SLNB located in axilla or groin. Patients with stage IV melanoma, affected by other carcinomas, or with prior procedures, which might have compromised lymphatic drainage of the primary site, were excluded.

All patients with suspicious skin

Patients and survival analysis

The database evaluation revealed 656 patients who had been treated with a previous complete local excision and a subsequent SLNB. The clinical and demographic characteristics of the population in study are presented in Table 1. Positive SLBNs were detected in 185 (28.2%) subjects (146 with micrometastatic SLNBs and 39 with macrometastatic SLNBs). CLND was performed in 182 subjects with positive SLNBs. Lymphadenectomy of axilla or groin was performed in 143 patients with melanoma of the trunk,

Discussion

CLND is quite a safe procedure used to control lymphatic metastatic dissemination in patients with melanoma. In the prophylactic lymph node dissection era, there was a high frequency of dissections in patients without lymph nodal disease because of the low frequency of lymphatic involvement in intermediate-thickness melanomas. For this reason, only a minority of patients did benefit from CLND, while all were exposed to complications related to this surgical procedure.⁶ The deployment of SLNB

Conclusion

Lymphedema is a common acute and/or chronic complication of CLND. The usefulness of immediate CLND on disease-specific survival in patients with melanoma-positive SLNB is debated, but its utility in the control of local disease is still confirmed. In addition, delayed CLND is strongly recommended in patients with ultrasonography and/or clinical evidence of nodal metastasis. The execution of PMA during lymphadenectomy is a safe procedure that could sensibly reduce frequency of lymphedema both in

Conflict of interest

None.

Funding sources

None.

Financial disclosures

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

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Also, from our analysis, the procedure adds an average of 95 min to the total operation time, which is more than twice of upper extremity LYMPHA. Nacchiero et al. concluded that PMA is a safe procedure that reduces lymphedema and allowed for better control of local disease without any risks of complication.31 Gentileschi et al. described their ILR technique as having the lymphatic flap pedicled on the distal perforator of the deep branch of the superficial circumflex iliac vessels.
Secondary lymphedema remains one of the most notorious complications of axillary and pelvic lymph node surgery following mastectomy. There is a lack of high-level evidence found on the effectiveness of immediate lymphatic reconstruction (ILR) in preventing secondary lymphedema. This meta-analysis evaluates the outcomes of ILR for prevention of secondary lymphedema in patients undergoing different surgeries, and provides suggestions for lymphatic microsurgical preventive healing approach (LYMPHA).
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The protocol for the SEROMA trial, outlining use of post-operative negative pressure wound therapy to reduce complications in groin dissections in Denmark has been published recently27, from which early results indicate a significant reduction in seroma (from 90.3% to 28.6%), and a downtrend in SSI (from 65.9% to 42.9%)9, similar to its use in vascular surgery28,29. Multiple lymphatic-venous anastomoses performed as part of completion lymph node dissections also show some promising results for lymphoedema, but no reduction in SSI30. Minimally invasive inguinal lymph node dissection shows some promise, however in a prospective multi-institutional trial infection rates were still around 20 of 87 (23%) including those converted to open31, and a sub-group analysis of those not converted to open (n = 77) found that those prescribed antibiotic prophylaxis on discharge had a lower wound infection rate, 1 of 23 (4%), versus those who had no antibiotic prophylaxis on discharge 15 of 54 (28%)31.
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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.
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.
Evaluation of modulation of immunity by lymph node transfer: A preliminary histological evidence in lymphedema patients
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Surgical Prevention of Lymphedema
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The Current Treatment Trends and Survival Patterns in Melanoma Patients with Positive Sentinel Lymph Node Biopsy (SLNB): A Multicenter Nationwide Study
2023, Cancers

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View full text

Multiple lymphatic-venous anastomoses in reducing the risk of lymphedema in melanoma patients undergoing complete lymph node dissection. A retrospective case-control study

Summary

Background

Materials and methods

Results

Conclusion

Section snippets

Background

Methods

Patients and survival analysis

Discussion

Conclusion

Conflict of interest

Funding sources

Financial disclosures

Ann Oncol

Lancet Oncol

Int J Surg Case Rep

J Am Coll Surg

Surgery

Impact of national comprehensive cancer network guidelines on case selection and outcomes for sentinel lymph node biopsy in thin melanoma

Dermatol Surg

Reply to "melanoma pattern of care in ontario: a call for strategic alignment of multidisciplinary care)"

J Surg Oncol

Completion dissection or observation for sentinel-node metastasis in melanoma

N Engl J Med

Morbidity following prophylactic and therapeutic lymph node dissection for melanoma–a comparison

Tumori

Quality of life after axillary or groin sentinel lymph node biopsy, with or without completion lymph node dissection, in patients with cutaneous melanoma

Ann Surg Oncol

MSLT cooperative group. The impact on morbidity and length of stay of early versus delayed complete lymphadenectomy in melanoma: results of the multicenter selective lymphadenectomy trial (I)

Ann Surg Oncol

Sequential anastomosis for lymphatic supermicrosurgery; multiple lymphaticovenular anastomoses on 1 venule

Ann Plast Surg

Double gastroepiploic vascularized lymph NDE transfers to middle and distal limb for the treatment of lymphedema

Microsurgery

Surgical prevention and treatment of lymphedema after lymph node dissection in patients with cutaneous melanoma

Lymphology

LYMPHA technique to prevent secondary lower limb lymphedema

Ann Surg Oncol

Single-stage excision and sentinel lymph node biopsy in cutaneous melanoma in selected patients: a retrospective case-control study

Melanoma Res