Surgical wound complications after groin dissection in melanoma patients - A historical cohort study and risk factor analysis
European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology (Impact Factor: 3.01). 10/2014; 40(10). DOI: 10.1016/j.ejso.2014.01.019
Background and objectives: Wound complications occur frequently after inguinal lymph node dissection (ILND) in melanoma patients. Evidence on risk factors for complications is scarce and inconsistent. This study assessed wound complication rates after ILND and investigated associated risk factors, in the melanoma unit of a specialised cancer hospital. Methods: A chart review was conducted of all patients on whom inguinal lymph node dissection had been performed between 2003 and 2013. Wound infections, seroma formation and skin flap problems were assessed according to explicit definitions and graded through the modified Clavien system. Univariable and multivariable penalized logistic regression was used to identify risk factors. The primary factors of interest were body mass index, age, smoking, diabetes, cardiovascular and/or pulmonal comorbidity, palpable disease and postoperative bedrest. Additionally, the influence of incision-type, sartorius transposition, saphenous vein sparing and skin removal was examined. Results: A total of 145 procedures was examined. One or more complications occurred in 104 (72%) of the procedures; wound infection in 45%, seroma formation in 37% and skin flap problems in 26%. The only statistically significant risk factor was age (odds ratio for one standard deviation increase: 1.46, 95%CI 1.01-2.14, p = 0.05). Conclusions: Wound complication rates after ILND in melanoma patients are high. Age was the only predictor of complications in this cohort, other previously identified risk factors could not be confirmed.
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ABSTRACT: 30-44% of patients with clinical groin node melanoma have involved pelvic nodes. Clinical guidelines selectively target pelvic lymph node dissection (PLND) to those meeting radiological and clinico-pathological criteria, but we lack satisfactory diagnostic tools to preoperatively identify patients with pelvic node disease. We evaluate routine PLND for all patients undergoing superficial node dissection (SLND), performed as a combined single-stage ilioinguinal lymph node dissection (ILND). Retrospective analysis of 67 ILNDs in consecutive patients presenting with palpable, cytologically melanocytic groin nodes. We examine predictors of pelvic node status and determine efficacy of 2010 UK guidelines in patient selection for PLND. 28 patients (42%) had histologically positive pelvic nodes; half had just one involved node (53.6%). 43% of pelvic metastases were radiologically occult. Significant predictors of pelvic melanoma were stage N3 groin nodes (p=0.049), one third of groin nodes involved (p=0.0009), positive Cloquet’s node (p=0.005), previous in transit disease (p=0.001), and staging CT (p=0.007). UK guidelines, primarily reliant upon staging CT, were effective selection criteria (p=0.04), identifying 57% of pelvic metastases. CT and in-transit disease status in combination was the strongest predictor of pelvic disease (p=0.006, RR 4.5, PPV 0.75, NPV 0.83). A combined CT and in-transit disease status provides a potentially clinically useful preoperative selection tool for ILND. With a high prevalence of occult pelvic node involvement, potential to avoid the morbidity of untreated pelvic nodes, and 5 year survival figures of 24–35% following surgery, we advocate ILND in all patients with clinically evident melanoma in a single groin node.
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ABSTRACT: The optimal extent of the groin lymph node (LN) dissection for melanoma patients with positive sentinel LN biopsy is still debated and no agreement exist on dissection of pelvic LN. This study aimed at investigating predictors of pelvic LN metastasis and prognostic significance of having metastasis in the pelvic LNs. Clinicopathologic data of 740 patients with positive groin sentinel LN who underwent ilioinguinal completion LN dissection at four Italian centre were analysed. Multivariable logistic and Cox regression analysis was used to identify independent predictors of pelvic LN metastasis and to adjust prognostic significance of pelvic LN metastasis. More than a quarter (26%) of patients had positive non-SLNs after inguinal and pelvic lymphadenectomy, which were located in their pelvis in the 12% of cases. Older patients [(OR) 1.69; 95% confidence interval (CI) 1.02-2.78] having thick primary (OR 1.6; 95% CI, 1.01-2.53) and ≥ 2 positive SLNs (OR 2.5; 95% CI, 1.4-4.47) were more likely to harbour pelvic LN metastasis. Interestingly, 4% of all patients (34% of patients with positive pelvic LNs) had pelvic LN metastasis with negative inguinal LNs. Pelvic LN metastasis was independently associated with higher risk of recurrence and lower survival. 5-year disease free and overall survival was 30% and 50%, respectively, for patients with pelvic LN metastasis. Pelvic LNs are frequently positive after ilioinguinal lymphadenectomy and it should be considered for all patients, especially those who are older, have thick primary and ≥ 2 positive SLN. Patients with pelvic LN metastasis have worse prognosis. Copyright © 2015. Published by Elsevier Ltd.
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ABSTRACT: A 72-year-old woman underwent complete deep inguinal lymph node dissection on her right side subsequent to metastasis from malignant melanoma. On the second postoperative day, the patient reported of nausea and vomiting. She presented with a mass in the resected area that gradually increased in size to approximately 15×20 cm. The wound was opened a few hours after onset of symptoms and a large femoral hernia with 40 cm of small intestine was immediately revealed protruding in the groin. Prophylactic suturing of the inguinal ligament and Coopers ligament can reduce the risk of postoperative femoral hernia. Further, the authors argue that drainage for seroma and haematoma should be performed with utmost care, considering other possible causes and, if necessary, guided by ultrasonography. 2015 BMJ Publishing Group Ltd.
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