Minimizing Morbidity while Preserving Outcome after Inguinal Lymphadenectomy: Navigating between Scylla and Charybdis

Abstract

Radical lymphadenectomy for microscopic or macroscopic metastases from cutaneous melanoma is associated with cure rates higher than many other widely performed radical procedures, such as radical pancreaticoduodenectomy or esophagectomy, that are associated with higher morbidity and mortality rates. Nonetheless, the morbidity associated with lymphadenectomy, especially inguinal or ilioinguinal lymphadenectomy, leads some patients to refuse—and even leads many surgical oncologists to discourage their patients from undergoing—this potentially curative procedure. However, the past few decades have seen substantial advances in our ability to identify the patients who are most appropriate for inguinal or ilioinguinal lymphadenectomy. These advances include the widespread adoption of sentinel node biopsy to identify microscopic nodal metastases, and the use of ultrasound and PET scanning to identify macroscopic nodal metastases before they become palpable or symptomatic. Whereas earlier detection in and of itself can lower operative morbidity, there has been much less attention paid to decreasing the morbidity of inguinal lymphadenectomy by altering the actual surgical technique. Fortunately for our patients, this has begun to change. In this issue of the Annals of Surgical Oncology, two articles describe efforts to decrease the morbidity of inguinal node dissection by performing the procedure through less invasive approaches than typically employed. Before we discuss these two papers, however, an examination of what is already known about the morbidity of inguinal node dissection is in order. Inguinal node dissection is associated with substantive short-term and chronic morbidity. Wound complications and prolonged lymphatic drainage are common short-term problems, whereas deep venous thrombosis is rare but potentially life-threatening. In prospective data collected from 127 patients who underwent complete inguinal lymphadenectomy as part of the Sunbelt Melanoma Trial, 51.2% developed a significant postoperative complication. Minimizing acute complications begins with the initial diagnosis of metastatic disease. The sentinel node biopsy site should be positioned and oriented to facilitate using the smallest possible incision should a subsequent inguinal lymphadenectomy prove necessary, and we strongly believe that the groin crease itself should be avoided for sentinel node biopsy incisions so that the lymphadenectomy incision need not involve or cross the groin. Equally importantly, when palpable nodes are encountered in the groin, fine-needle aspiration should be utilized to establish the diagnosis, because open biopsy is associated with higher acute morbidity during the subsequent lymphadenectomy. For all the consternation surgeons show when primary melanomas are diagnosed by the expedient shave biopsy, we should be collectively ashamed at how routinely we employ open node biopsy when needle aspiration would suffice and be far better for the patient. In the same vein, although preoperative node ultrasonography has to date not been shown to be a satisfactory substitute for sentinel node biopsy on a routine basis, we do use preoperative inguinal nodal ultrasonography for our patients with T4 lesions. In the event of detecting an abnormal node, this is followed by fine-needle aspiration biopsy to allow for a one-stage procedure combining wide excision and lymphadenectomy, eliminating the sentinel node biopsy incision entirely in a small subset of patients at high risk of needing a lymphadenectomy. Society of Surgical Oncology 2011