The Impact on Morbidity and Length of Stay of Early Versus Delayed Complete Lymphadenectomy in Melanoma: Results of the Multicenter Selective Lymphadenectomy Trial (I)

Abstract

Background Complete lymph node dissection, the current standard treatment for nodal metastasis in melanoma, carries the risk of significant morbidity. Clinically apparent nodal tumor is likely to impact both pre-operative lymphatic function and extent of soft tissue dissection required to clear the basin. We hypothesized that early dissection would be associated with less morbidity than delayed dissection at the time of clinical recurrence. Methods The Multicenter Selective Lymphadenectomy Trial I randomized patients to wide excision of a primary melanoma with or without sentinel lymph node biopsy. Immediate completion lymph node dissection (early CLND) was performed when indicated in the SLN arm, while therapeutic dissection (delayed CLND) was performed at the time of clinical recurrence in the wide excision-alone arm. Acute and chronic morbidities were prospectively monitored. Results Early CLND was performed in 225 patients, and in the wide excision-alone arm 132 have undergone delayed CLND. The two groups were similar for primary tumor features, body mass index, basin location and demographics except age, which was higher for delayed CLND. The number of nodes evaluated and the number of positive nodes was greater for delayed CLND. There was no significant difference in acute morbidity, but lymphedema was significantly higher in the delayed CLND group (20.4% vs. 12.4%, p=0.04). Length of inpatient hospitalization was also longer for delayed CLND. Conclusion Immediate nodal treatment provides critical prognostic information and a likely therapeutic effect for those patients with nodal involvement. These data show that early CLND is also less likely to result in lymphedema.

Long-term follow-up reveals that ulceration and sentinel lymph node status are the strongest predictors for survival in patients with primary cutaneous melanoma

“…21,22 Although there is a slight risk of limb edema, the lymphedema after CLND is less than therapeutic lymph node dissection for palpable nodal disease according to data from the MSLT Cooperative Group. 23 Hospital length of stay was also significant longer in the delayed CLND compared to the early CLND. So early CLND, in addition to a tumor-positive SLN, is not only of prognostic value and beneficial in staging regional nodes, selecting patients for adjuvant therapy or clinical trials and above all, improving melanoma-specific survival, it also decreases both lymphedema and hospital length of stay.…”

Malignant Melanoma S3‐Guideline “Diagnosis, Therapy and Follow‐up of Melanoma”

“…Nashan, J. Hübner Relevant types of lymphedemas in melanoma are due to obstruction of lymph drainage by the tumor or secondarily as a result of treatment [685] such as e.g.  surgery, especially lymph node dissection [686],  radiation therapy [687],  isolated limb perfusion [688]. If left untreated, chronic persistent lymphedema may develop.…”

Mitose como fator prognóstico para biópsia de linfonodo sentinela em melanoma fino

“…Published data suggest that a biopsy combined with immediate lymphadenectomy may improve overall disease-free survival rates. 13 Mitosis in primary melanoma identifies patients with a high risk of recurrence, as can be clearly observed in the case described above. ❑ …”