Morbidity and prognosis after therapeutic lymph node dissections for malignant melanoma

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Abstract

Melanoma patients with clinically evident regional lymph node metastases are treated with therapeutic lymph node dissections (TLNDs). The aim of this study was to evaluate morbidity and mortality following TLND in our institution. Moreover, disease-free (DFS) and overall (OS) survival were evaluated and factors that influence prognosis after TLND were assessed.

Between 1982 and 2005, 236 patients underwent a TLND. Patients, who received a palliative LND or a sentinel node procedure, were not included. The median Breslow thickness was 2.4 mm. Ulceration was present in 23% of patients and unknown in 66%. 37 patients had unknown primary tumors. There were 129 ilio-inguinal, 50 axillary and 61 cervical dissections performed. 37% of the patients experienced at least one operation related complication. The most frequently seen complications were wound infections/necrosis and chronic lymph edema. Ilio-inguinal dissection patients experienced significantly more complications and a longer duration of hospitalization compared to axillary or cervical patients. The duration of hospitalization has been reduced in recent years from 12 to 5 days. The mean follow-up was 29 months. Kaplan–Meier estimated 5-year regional control was 79%, 5-year DFS was 19% and 5-year OS was 26%. The number of positive lymph nodes, the site of the primary tumor and extra capsular extension (ECE) were independent prognostic factors for DFS and only site and ECE for OS.

In conclusion, TLND for stage III melanoma is accompanied with considerable short-term complications, and can achieve regional control and potential curation in approximately one in every four patients.

Introduction

Melanoma incidence has increased 3–7% on average over the last several decades and even more rapidly among Caucasian men and the elderly.1 Clinical outcome in melanoma patients is strongly correlated with primary tumor characteristics such as tumor thickness and ulceration. However, the presence or absence of lymph node metastasis is the most significant prognostic factor for survival, as survival rates are approximately halved by the presence of nodal metastasis.2

The question whether early removal of clinically occult lymph node metastases by performing an elective lymph node dissection (ELND) improves survival has been addressed in a number of randomized trials that overall have failed to demonstrate a survival benefit by ELND.3, 4, 5, 6 Nowadays, the sentinel node (SN) procedure developed by Morton and colleagues7 is commonly used for the accurate staging of patients without clinically detectable lymph node metastases. Nevertheless, there are numerous patients that present with clinically evident regional lymph node metastases. For these patients, therapeutic lymph node dissections (TLNDs) are indicated to achieve regional tumor control, and to potentially achieve cure and survival benefit. The 5-year overall survival rates for TLND described in the literature range from 13 to 46%.2, 4, 8, 9, 10, 11, 12

The prognostic factors analysis undertaken by the American Joint Committee on Cancer (AJCC) showed that prognosis for patients with regional lymph node metastases was not only depended on the number of involved lymph nodes, but also on whether this involvement was microscopic or macroscopic. Primary tumor ulceration was also found to be a independent prognostic factor.2 In addition to above mentioned prognostic factors, extra capsular extension (ECE) has been cited as an adverse prognostic indicator in other studies.9, 10, 13

TLNDs are associated with several postoperative complications such as wound infections and lymph edema. However, only a few authors have reported elaborately on morbidity and mortality associated with lymph node dissections.12, 14, 15, 16, 17 Wound complications including hematoma, seroma, dysfunction or pain and wound infections are frequently seen after lymph node dissections for melanoma. Especially following ilio-inguinal dissections, wound complication rates up to 71% have been reported.17 Furthermore, chronic lymph edema is a serious complication of axillary and ilio-inguinal dissections. The prevalence of chronic lymph edema after axillary dissections ranges from 0% to 12%14, 15, 18, 19, 20 and after ilio-inguinal dissections the prevalence is even higher, ranging from 30% to 44%.12, 16, 21

The aim of this study was to evaluate morbidity and mortality following TLND in our institution. Moreover, regional control, disease-free and overall survival were evaluated and factors that influence prognosis after TLND were assessed.

Section snippets

Patients and methods

A retrospective review was performed on 236 consecutive patients who underwent TLND for palpable lymph node metastases at our institution from 1982 through 2005. In most patients, treatment of the primary tumor was performed elsewhere. Patients who underwent palliative lymph node dissection (PLND) or sentinel node (SN) procedure were excluded from the study. PLNDs were defined as macroscopically irradical or debulking dissections. Patients were all staged through diagnostic imaging prior to the

Results

This study included 236 patients (120 males and 116 females) with a median age of 54 years (range 2–84 years). Four patients underwent two simultaneous lymph node dissections for palpable nodal disease in two basins. Thus, the total number of therapeutic lymph node dissections was 240. Patient, tumor and dissection characteristics are summarized in Table 1. The mean and median Breslow thicknesses of the primary tumors were 3.9 mm and 2.4 mm (range 0.4–52.0 mm), respectively. In 37 patients the

Discussion

Therapeutic lymph node dissections are performed for patients with proven regional lymph node metastases of malignant melanoma to achieve regional control. The estimated 5-year overall survival rate after TLND in this study was 26%, which is comparable with 13–46% described in the literature.2, 4, 8, 9, 10, 11, 12, 25

Conclusions

Therapeutic lymph node dissections in stage III melanoma patients achieve regional control and a potential chance of curation in one in every four patients. The site of the primary tumor and extra capsular extension of a metastasis in the lymph node dissection specimen are prognostic factors for overall survival in the present study. TLNDs are not without complications; most frequently wound infections and chronic lymph edema are seen. There are significantly more complications and longer

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