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Advanced melanoma that has spread to lymph nodes may be treated by radical lymphadenectomy, which can in some cases be curative or at least extend disease-free survival. However, such radical lymphadenectomy can produce serious morbidity, including problems in wound healing and lymphatic drainage. As noted by editorialists Sondak and Sarnaik, 51% of 127 patients who underwent inguinal lymphadenectomy in the Sunbelt Melanoma Trial had a significant postoperative complication (Ann Surg Oncol 2003; 10:676), and the Multicenter Selective Lymphadenectomy Trial (Ann Surg Oncol 2010; 17:3324) demonstrated postsurgical lymphedema rates of 21.9% to 34.7%. In addition, procedure-associated deep vein thrombosis can be life-threatening. The authors of two recent studies examine the value and efficacy of altering the surgical process to minimize such damage.
Spillane and colleagues assessed whether two short incisions that avoided the inguinal crease would permit technically proficient dissection while reducing morbidity. They found that this small-incision approach was feasible, providing the same lymph node yield as the standard approach, without significant differences in the number or severity of immediate postoperative complications.
Delman and colleagues assessed the use of a minimally invasive, videoscopic inguinal lymphadenectomy (VIL). They reported a reduced rate of complications. However, as the editorialists point out, VIL deviates from the standard of care in leaving the sentinel node biopsy scars intact, which may increase the risk for recurrence.
Sondak VK and Sarnaik AA. Minimizing morbidity while preserving outcome after inguinal lymphadenectomy: Navigating between Scylla and Charybdis. Ann Surg Oncol 2011 Apr; 18:909.
Spillane AJ et al. A pilot study reporting outcomes for melanoma patients of a minimal access ilio-inguinal dissection technique based on two incisions. Ann Surg Oncol 2011 Apr; 18:970.
Delman KA et al. Initial experience with videoscopic inguinal lymphadenectomy. Ann Surg Oncol 2011 Apr; 18:977.
Comment
The current trend toward obtaining sentinel lymph node biopsies for ever-thinner melanomas is, on the one hand, a patient-friendly measure that seeks to detect even small risks for tumor spread. On the other hand, lymph node biopsies and the more radical procedures they may motivate can cause problems, including chronic pain and loss of function: For instance, the sentinel lymph node can be hard to localize on the head and neck, and multiple basins close to vital structures may need to be sampled. The dangers of lymph node procedures must be weighed against their potential benefits. When radical lymph node resection is determined to be necessary, however, there appears to be room for improvement. Smaller incisions, and perhaps video guidance, may not eliminate morbidity but may reduce it. Cancer surgeons need to be reminded that maximizing postoperative quality of life is almost as important as maximizing the likelihood of cure.